In the Netherlands, changes in the payment system for diabetes care stimulated individual GPs to group together into local networks. In Sweden, national policy to improve access through greater competition has introduced new private providers and encouraged service innovation. In England, national policy to shift care from hospital to community settings and promote integration has triggered the emergence of larger practices combining primary care with specialist services.
In addition to national policies, local context and professional enthusiasm can be important drivers of change. In the Belgian case study a new philosophy of care based on individual patient goals has emerged in response to the health needs of a deprived local population. In contrast, ParkinsonNet was driven by a new professional vision of the relationships between generalists and specialists combined with innovative use of technology and a focus on patient involvement and choice. The UK case studies illustrate how national policy can create a supportive context for change, but engaging local clinicians in services transformation requires a compelling local story about why change is needed.
||Key drivers for change|
- Two private primary care clinics established by doctors and dentists who form the Praktikertjänst company.
- This has been enabled by legislation opening up the primary care market in Sweden.
- 12 doctors, 10 nurses, allied health professionals, nurse assistants, clerical staff, social worker.
- Serves 12,600 people and has an electronic patient record.
- A network with specialist outpatient services and the local hospital.
Reforms to increase access and innovation through competition were introduced in Sweden in 2008.
The reforms created new entrepreneurial opportunities for primary care and has led come GPs to expand the scope and scale of their practices.
|Community Health Centre Botermarkt, Ghent, Belgium|
- Not-for-profit multi-disciplinary health center in a deprived area of Ghent, for 6,000 patients from over 70 countries.
- 9 doctors, 4.5 nurses and 8 staff including: health promoters, dieticians, social work and ancillary staff.
- There is an electronic and interdisciplinary record.
- Aims to deliver integrated primary healthcare: prevention, curative care, palliative care, rehabilitative care and health promotion.
- Works within philosophy of Community Oriented Primary Care and co-designs care objectives with patients who have multi-morbidity, and tailors services accordingly.
Based on a philosophy of meeting the goals of the patient rather than focusing on the process and biomedical indicators. What does the patient need to improve their life?
This becomes much more relevant for patients with multiple problems as the guidelines developed for single diseases are of limited help and applying them all would mean that the patient’s life would be dominated by managing their health.
|Vitality Partnership, Birmingham UK|
- Super-partnership formed of practice mergers, serving 50,000 patients across seven sites.
- 27 doctors and 23 nurses and 137 employed staff in total.
- A single IT system and integrated electronic patient record.
- Aims to deliver high quality population-based primary care with in-house provision of specialist services.
- Specialist services include dermatology, rheumatology, orthopedics and diagnostics.
- Aims to grow to a population of 100,000.
- New career options for doctors and nurses, strong focus on organizational development.
Downward pressure on practice incomes provides an additional incentive to scale up.
|Whitstable Medical Practice, UK|
- NHS general practice and community integrated healthcare for 34,000 patients.
- 19 doctors and 34 nurses and 130 other staff, and plans to integrate social care (Whitstable Integrated Social and Health care pilot – WISH).
- Electronic patient record.
- Provides a wide range of preventative healthcare, screening, exercise programs, smoking cessation programs.
- Redesigned care pathways as basis for developing new primary care services: long-term condition management, urgent care, elective care and diagnostics; and community hospital.
Building on national policy to create integrated services in community settings, the Whitsable Medical Practice built a new health center to combine primary and specialist care.
Professional management also makes a big difference in this model – the large scale allows a higher calibre manager to be employed than is possible in most smaller practices.
|Zorg in Ontwikkeling (ZIO) Netherlands|
- General practice network of 90 GPs covering a population of 170,000.
- Physiotherapists, dieticians, nurses and also members of the network.
- Multidisciplinary primary care organization focused on delivery of coordinated chronic care.
- Disease management programs delivered by all member practices under network contracts to health insurers.
- Integrated payments for a year of care for long term conditions.
- Members receive education, quality systems and IT support, real estate development etc. from the network.
- Piloting population-based budgets.
A requirement that all residents in Dutch nursing homes should have a regular medicines review led to nursing homes ensuring that their residents were only registered with one or two practices rather than the many that was usually the case.
This allowed some specialization in this complex type of care to develop with good results on reduced admissions to hospital, reduced falls and so on.
Case study: ParkinsonNet
ParkinsonNet is a vision of the future for the management of a complex disease and illustrates the power of the patient as a participant in their own care. The model was built by Professor Bas Bloem. His goal was to create a model that met the needs of the patient while dealing with some of the institutional challenges inherent in the system such as: poor referrals being made to specialists, overtreatment, under treatment, the wrong treatments being used, a lack of specific expertise and poor communication between professionals about patient care. His research led him to believe that the overall gap between evidence and actual clinical practice needed to be closed.
In redesigning his services, he identified five areas that were key to success:
- helping to create an active patient able to manage their care and take key decisions;
- defining what value based care would look like from the perspective of the patient;
- changing the way that doctors and other clinicians work with patients from ‘god to guide’ by shifting to a partnership approach with patients to identify the regimen that works best for them;
- creating a network of experts; and
- linking all of these together with information technology tools.
Based on these assumptions, Professor Bloem worked with patients to develop a set of comprehensive guidelines including a special version geared towards patients’ use. Interestingly, a key part of the guidelines involved patients telling their professionals what they needed to stop doing rather than what they should be doing.
Using these guidelines Professor Bloem identified all the professionals working with Parkinson’s patients in his region, and trained a selected group of these in the most up to date approach to management of the condition including the provision of physical therapy, symptom control etc.
The next step was to provide these specialists with tools that could facilitate greater communication and the sharing of best practices, new approaches and data about patient outcomes.
With this infrastructure in place, Professor Bloem was able to enroll patients through a web portal, allowing patients to choose an accredited provider, confident in the knowledge that they would be using the same approach as other professionals in the network. Patients are able to set their own priorities and build their own networks of care supported by electronic tools which also allow them to set their own priorities and goals for their care, exchange information with professionals and connect to other patients. The same tools are used to connect the professionals to each other.
Patient outcomes and satisfaction have seen enormous improvements and the initiative has led to reduced hospital visits, a 50 percent reduction in hip fractures and substantial savings for payers valued at US $27 million across the Netherlands.