This document discusses trends and drivers of change in European primary care. It outlines that primary care serves as the first point of access to health services through generalist clinicians working in teams. The scope of primary care is expanding to include care coordination, specialist services, and new forms of access like e-consultations. There are multiple drivers of increasing demand, like aging populations and rising chronic disease prevalence. Primary care systems vary significantly across Europe in inputs like physician numbers and expenditures. The document examines political, economic, and policy trends shaping primary care reforms around integration, new payment models, and delivery innovations.

1. Trends and Drivers of Change in European
Primary Care
Dr Rebecca Rosen
Senior Fellow
The Nuffield Trust
29th Jan 2013
© Nuffield Trust

2. Primary care as first point of access to health services
• First-line clinical care for undifferentiated health problems
• Increasing focus on prevention and screening
• May be founded on general practice, but is more than the work
of generalist doctors, and may include other disciplines
• Provided by generalist clinicians, sometimes working as part of
a multi-professional team (doctors, nurses, pharmacists or
other community health workers)
• Is typically a level of care between self care and specialist care
• May be designed around a registered population
© Nuffield Trust

3. Changing scope of primary care
• Traditionally including:
• assessment of undifferentiated symptoms;
• diagnosis, triage and onward referral;
• treatment of episodic illness
• provision of palliative care
• prevention and health promotion .
• Increasingly likely to involve:
• care coordination for people with complex problems;
• areas of ‘specialist’ care (eg endoscopy, minor surgery.
diagnostics ) enabled by new medical technologies
• new forms of access such e consultations
© Nuffield Trust

4. Multiple drivers of demand
Lack of access Rising patient
to social care expectations
New providers/ Primary Aging
supply induced care populations
demand
Rising New
prevalence of medical
chronic disease technologies
© Nuffield Trust

5. Wide variations in inputs across Europe
Relative provision of GPs, specialists and other doctors in Europe No. of doctors per 1000 population in
Europe
Public expenditure on health as a % of GDP in EU member states (2008)
© Nuffield Trust

6. Primary care ‘fit for the future’
Attributes Sustainability
• Comprehensive • Financial
• Patient-centred • Workforce
• Co-ordinated • Public trust
• Continuous if required • Fit with wider health system
• Accessible
• Safe and High Quality
• Population focused
•Adapted from Agency for Healthcare
© Nuffield Trust
Research and Quality 2013

7. The Primary Care Paradox....
‘... a paradoxical situation: the tension
between the relative weakness and un-
attractiveness of this level of care versus the
intention to assign critical strategic functions
to it’
From:Primary Care In The Driver’s Seat? Saltman, Rico and Boerma (eds) 2006
© Nuffield Trust

8. Drivers of change: political and policy trends
• Significant regional variations across Europe
• Political and economic foundations of health systems
• Impact of financial crisis on health sector
• Interactions between health and other sectors (eg social care)
• Some overarching themes
• Coordination of care
• Diversification of providers/growing role for private sector and
increasing use of choice and competition
• Experiments with primary care purchasing and new payment
mechanisms
© Nuffield Trust
• Care delivery innovations

9. Mechanisms for change: Integration and coordination
• Croatia: GP led polyclinics.
• GPs employed under contract (health insurance funds) renting
space to specialists with whom they can make shared care
decisions about complex patients
• Germany: Disease management programmes (DMPs)
• Lead doctors (usually a family physician) coordinate care
related to selected chronic conditions.
• Evidence based criteria for referral to specialists
• Patient self-management support
• Financial incentives to providers to deliver DMPs
© Nuffield Trust

10. Mechanisms for change: Privatisation, markets and new
business models
• Large scale privatisation of
family medicine clinics in CEE
• Pluralisation of provision and
new primary care providers
• Corporatisation of primary care
• New ‘convenience clinics’ and
walk-in centres
• New business models for
blending primary and specialist
services (polyclinics, integrated
care pathways)
© Nuffield Trust

11. Mechanisms for change: payment innovation
• Dutch DBC payments for chronic conditions
• Integrated payments for selected chronic conditions
• Payment for a year of care delivered to specified standards
• Negotiated with groups of practices
• Clinical commissioning in the English NHS
• Compulsory GP membership of budget holding clinical
commissioning croups
• Influencing primary care practice and buying other services
© Nuffield Trust

12. Mechanisms for change: delivery innovations
Electronic and telephone access
to primary care
• NHS Direct :
• 24 hour telephone advice from
nurses following algorithms
• NHS Direct web site
- symptom checker
- patient information pages
- healthy living advice
© Nuffield Trust

13. Challenges for the Eurosummit
• What are the essential characteristics of a primary care
system that is fit for the future?
• Which emerging business models for primary care
organisations are best supporting the development of
services that are fit for the future
• What is enabling primary care reform in European countries
• Can we replicate and embed these factors
• What does this offer to European health policy and
management practice?
© Nuffield Trust

14. www.nuffieldtrust.org.uk
Sign-up for our newsletter
www.nuffieldtrust.org.uk/newsletter
Follow us on Twitter
(http://twitter.com/NuffieldTrust)
© Nuffield Trust