From Policy to Practice and back

to PolicyProf. Dr. J. De Maeseneer, MD, PhD

Department of Family Medicine and PHC- Ghent University, BelgiumGeneral Practitioner (part-time), Community Health Centre ,

Ledeberg-Ghent (Belgium)Chairman European Forum for Primary Care

Chairman Expert Panel on Effective Ways of Investing in Health-EC

Director International Centre for PHC and FM – Ghent University, BelgiumWHO-Collaborating Centre on PHC

Paris, 9.04.2014

• No conflict of interest

1. Expert Panel on Innovative Ways of Investing in Health

2. The model of PHC-Centres in Belgium

3. Policy:strategies for change

From Policy to Practice and back to Policy

Expert Panel on effective ways of investing in Health (EXPH)

• * To provide independent non-binding advice on matters related to health care modernisation, responsiveness, and sustainability

• * Set up by Commission Decision of 5 July 2012• http://ec.europa.eu/health/healthcare/docs/dec_panel2012_en.pdf

• * 12 members, nominated for 3 years, by Decision 21 May 2013• http://ec.europa.eu/health/healthcare/docs/dec_members_expert_panel_20

13_en.pdf

• * Started its activities on 11 July 2013

The public consultation has been launched (deadline: 11 May 2014).http://ec.europa.eu/health/expert_panel/consultations/primarycare_en.htm

Opinion on Definition primary care – Definition

• History• Alma-Ata / Vuori / Tarimo / Starfield / IOM

• Core-definition• 'The Expert Panel considers that primary care is the provision of

universally accessible, person-centered, comprehensive health and community services provided by a team of professionals accountable for addressing a large majority of personal health needs. These services are delivered in a sustained partnership with patients and informal caregivers, in the context of family and community, and play a central role in the overall coordination and continuity of people’s care.'

Opinion on Definition primary care – Main points

• 3. Referral systems (including gatekeeping)

- Emphasises the importance of using primary care as the preferred entry point into the health system

- To be effective, referral systems (gatekeeping) must involve:• - a strong and responsive high-quality primary care system

- a patient-centered approach- timely access to medical imaging results (by primary care providers)- a prompt response by secondary care- maximal subsidiarity to avoid long waiting terms- electronic referral processes as much as possible- interactions between referral and payment systems

Opinion on Definition primary care –Main points

• 4. Financing primary care

• The opinion recommends- to ensure an adequate level of financing for primary care,- to promote equitable access to primary care(when user charges -> protecting mechanisms needed for people with low incomes or regular users)- to provide incentives for efficiency and quality in primary care delivery, including care coordination

• (trend towards blended provider payment systems can be effective when financial incentives are integrated)

1. Expert Panel on Innovative Ways of Investing in Health

2. The model of PHC-Centres in Belgium

3. Policy:strategies for change

From Policy to Practice and back to Policy

The changing society

a. Demographical and epidemiological developments

b. Scientific and technological developments

c. Cultural developments

d. Socio-economical developments

e. Globalisation and “glocalisation”

‘By 2030, 70% of the world population will live in an urban context’ (Castells, 2002)By 2100, 85%?

Healthy life expectancy in Belgium, 25 years, men

28,1

3842,6

45,9

2025303540455055

basic secundaryschool: 1st cycle

secundaryschool: 2nd

cycle

university/highereducation

Socio-economic inequalities in health

Healthy life expectancy in Belgium

(Bossuyt, et al. Public Health 2004)

http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf

Primary Care delivery in Belgium: type IIPrimary Health Care Centres

Type of Services:• Patient-list: territorial; “referral”• Reactive care: broad-spectrum: physical, mental, social,…• Diagnostic (Imaging, lab): outsourced, GP-controlled• Comprehensive home care (incl. palliative)• Prevention and screening: call-recall; contract for health promotion towards the local community• Community Oriented Primary Care (COPC)• Training of GPs

16

Primary Care deliveryin Belgium: type II

Primary Health Care CentresTypes of payment:• Integrated mixed needs-based capitation (since 01.05.2013) negotiated PHC-Insurance companies• Allowances (informatics, GMR, Impulseo, care trajectories diabetes and CRF,…)• No co-payment for patients• Incentives for prevention (regions, municipalities)

17

Integrated mixed needs-based capitation: the “needs-variables” Demographic variables Social-economic variables Morbidity variables Contextual variables

Age/sex (41 combinations) Widow Low income: < 15 000,00EUR Self-employed workers Deceased in that year Disability Urbanization index in the

neighbourhood Medical supply index in the

neighbourhood Handicap Help from public welfare centres Impaired functional status Cardiac diseases COPC Asthma Cystic Fibrosis Diabetes combined with chronic

cardiac condition IDD

NIDD Exocrine pancreatic diseases Psoriasis Rheumatoid arthritis, Crohn’s disease,

ulcero-hemorragic recto-colitis Psychosis: young adults Psychosis: elderly people Parkinson’s disease Epilepsy HIV Chronic hepatitis B & C Multiple sclerosis Post-transplant immunosuppression Alzheimer Thyroid diseases Thrombosis Coagulation disorders Protected habitat

ImplementationBased on an (electronic) “photograph” of the population on the list of the different PHCC’s

→ photograph made annuallyEach PHCC receives a specific “capitation” for the patients on the list

The integrated needs-based mixed capitation system:stimulates prevention, health promotion and self-reliance of the people,

as there is a global payment for all disciplines, there is an incentive to task-shifting and subsidiarity,

Prevents risk selectionStimulates a global approach to a broad range of problems, avoiding the fragmentation and disease-orientation

Study: comparison payment systems

Study: comparison payment systems2008: Federal Knowledge Center for Health Care

Fee-for-service ↔ Capitation

Strengths capitation system high degree of accessibility, especially for

vulnerable groups no risk selection patients in the capitated system use:

• less resources in the secondary care• less medications

the quality of care was at least as good or better

Primary Health Care Centre:

- Family Physicians; nurses; dieticians; health promotors; social workers; …

- 5800 patients; 60 nationalities

- Integrated needs based mixed capitation; no co-payment

- COPC-strategy

• 1978 family practice in poor neighbourhood

• 1980 first nurse and foundation of the community health centre

• 1986 interprofessional team• 1995 capitation financed system

Community Health Care Centre Botermarkt: history

ACCESSIBLE• Geographical context• Notwithstanding ethnicity, culture,

income, administrative status,…• No risk selection <> high prevalence of

multiproblem patients• Patients on the list

The 19th

century “belt” around Ghent

The 19th

century “belt” around Ghent

Wgc Kapellenberg

WGC Watersportbaan 01.04.2010

WGC Rabot

INTERPROFESSIONAL TEAM

• Family physicians

• Nurses

• Social work

• Health Promotion

• Dietician

• Administratieve staff and receptionist

• Ancillary staff

• Podologist

• External health care workers : physiotherapists,

psychologists

INTERPROFESSIONAL ELECTRONIC PATIENT

RECORD

• Family physicians

• Nurses

• Social work

• Dieticians

International Classification of Primary Care (ICPC-2);

Future: + International Classification of Function (ICF)

Family Physicians• During the day

– consultations – appointments– home visits

• At night (from 19.00 until 08.00)

– Cooperation with local GP-service

• During the weekend (Friday 19.00 pm to Mo 08.00 a.m.)

– Three “on call” GP-posts in Ghent

Nursing

• Appointments at the health centre– Daily direct access – Referral by GPs or receptionists

• Home visits– Daily – Referral by GPs or receptionists– Only when indicated by the medical and

functional condition

Nursing

Prevention• Follow – up blood pressure• Family-planning management• Participatory patient management

– Diabetic consultation: 3-monthly– COPD, asthma: Spirometry

• Diabetes clinic

• Objectives:– Improving the care for diabetes type 2 patients

through a structured multidisciplinary follow-up and health education

– To help patients to cope with their condition (“empowerment”)

– Improve self-efficacy of patients– To tackle social inequalities in relation to chronic

diseases

• Diabetes clinic• Programme:

– biomedical and behavioural follow-up by nurse and family physician, following guidelines

– exchange of experiences by the patients– contact with dietician (2 x / year)– “diabetes-cooking” (3 x / year)

Social Work

• social workers• Social work in the health centre includes :

– first intake, exploring the problem– information and counseling– advocating, mediating– supporting, psychosocial guidance– referral to specialised services– administrative support, application for allowances,

budgetplanning– establishing patient centered networks of care

Social Work

• Problems situated on different domains of life

• Multiproblem cases• Not (yet) reached by other social

services • Undocumented residents• On appointment or crisis intervention• No waiting lists

Dietician

• Gives information about healthy food and counsels :– Patients with general dietary problems– Patients with gastro-intestinal problems– Patients with cardiovascular problems– Patients with diabetes– Patients with kidney-problems– Children with obesity

• Only on appointment

Reception and administration

• First contact of patients

• Organisation of the surgery

• Dispatching of incoming phone-

calls

• Information to the patients

• General administration

• Handling of the capitation-system

Health promotion

• Health as a resource for social, economic and personal development / important aspect of quality of life

• Achieving equity in health and reducing socioeconomic differences in health.

Health promotion

• Mission statement Health Centre Botermarkt“Prevention of illness and health promotion as very important aspects in the daily routine of a primary health care centre”

• 2 levels:– Patient – centred– Community - centred

Interdisciplinary work -Internal meetings

• Weekly disciplinary teams• Interdisciplinary meeting for care-providers

with • case-discussions• worker-oriented discussions• community and policy oriented themes

• Monthly planning-meeting with the whole team

• Executive committee

External meetings

• Platform of providers and services – 3-monthly meetings, trainings, lunchdebates,…– Meeting, detecting problems, signalize problems

to stakeholders, working on projects,…

• Committee of Flemish Health Centres

• Local medical quality circle

• City Committee on health problems of asylum seekers and ‘people without papers’

• Local Social Policy Advisory board (city of Ghent)• ...

COMMUNITY ORIENTED

COPC-example: dental problems: periodontal disease in childhood

Risk factor for:

• Diabetes

• Coronary Heart Disease

• Preterm birth and low birth weight

• Osteoporosis

Identifying health problem: Family physicians/nurses: problematic oral condition of todlers, leading to feeding problems, crying, not

sleeping,...

COPC-project : from individual care to community health care

Results research children 30 months old:

• 18,5 % early symptoms of childhood caries (7,4 % – 29,6 %)

• 100% need for treatment!

Correlation with• deprivation

• nationality (Eastern-Europe)• no previous dentist consultations

COPC-project : DENTAL FITNESS

Childhood caries:

• Information and Sensibilisation

• Involving providers, social workers, parents, schools…

Strategies:

Community oriented, intersectoral, participation.

Educational platform for students in dentistry

COPC-project : DENTAL FITNESS

Accessible primary dental care

Centre for Primary Oral Health Care

Botermarkt Ledeberg (CEMOB)Started 01/09/2006

Towards accessible oral health care !

Ghent University

COPC-project : DENTAL FITNESS

Integration of personal and community health care

The Lancet 2008;372:871-2

Education and training

• Training for :– undergraduatie medical students

– family physician trainees

– nursing students

– social work students

– ...

The future: WHO-six star provider

- assess and improve the quality of care

- make optimal use of new technologies

- promote healthy lifestyles

- reconcile individual and community health

requirements

- work efficiently in teams

THE SIX STAR PROVIDER

- leadership attributes and acts as change agent

The Lancet 2010;376:1923-58

Universitiesshould investin strong departments offamily medicineand PHC

Integrationof family medicinein the undergraduatecurriculum

1. Expert Panel on Innovative Ways of Investing in Health

2. The model of PHC-Centres in Belgium

3. Policy:strategies for change

From Policy to Practice and back to Policy

Created in 2005

EFPC Multi-CountryStudy-Visits

Barcelona 2014 September 1/2

Website: www.euprimarycare.org

Tel: +31 30 272 96 11E-mail: info@euprimarycare.org

Improving health and primary health care around the world

through Primary Health Care Centres

Learn more at: www.ifchc2013.org

Debate:SCORE the PHC-practice in your country/region in comparison with the PHC-centres model in Belgium: use a comparative score (--;-;0;+;++) looking at:

°RELEVANCE (CARE THAT REALLY MATTERS…)

°EQUITY (INCL. ACCESSABILITY)

°QUALITY

°COST-EFFECTIVENESS

°PERSON- AND PEOPLE- CENTREDNESS

°SUSTAINABILITY

Debate:What would be the most important policy-measure to improve the quality of PHC in your country/region?

What is/are the most important obstacle(s) to make change happen?

What could be appropriate advocacy-strategies?

Management versus leadership

Management versus Leadership

• Planning and budgetting • Establishing direction

• Organizing and staffing • Aligning people

• Controlling and problem solving

• Motivating and inspiring

Source: J.P. Kotter. A force for change: How leadership differs from management (1990)

Thank you… jan.demaeseneer@ugent.be

WHO Collaborating

Centre on PHC

Ghent University Jan.DeMaeseneer@ugent.be