Monday 19 September 2022

How to get the most out of virtual primary care?

José Cerezo

From the onset, the pandemic has acted as a powerful catalyst, accelerating the introduction of reforms and the experimentation with new models of care, many of which had long been simmering in the labs of European health systems. These transformations have quickly and deeply affected primary care due to the indispensable – and little recognized – role it has played during the pandemic.

Primary care, on many occasions in a chronic context of precariousness and lack of resources, has played a dual role: diagnosing and monitoring COVID-19 patients who did not require hospitalization (the vast majority) and maintaining the rest of the essential services, being of special importance the follow-up of patients with chronic diseases and non-delayable and urgent cases. Among these transformations, the most radical was the overnight change in the conditions of access to primary care services. In a matter of weeks, primary care went from being fundamentally face-to-face to being almost exclusively virtual with the aim to preventing infections in health centres and protecting both patients and health professionals.

Virtual primary care is here to stay

The combination of various modes of provision of primary care services is a reality. These include face-to-face visits, both in health centres and in homes or community activities; face-to-face visits by mobile teams, especially in rural settings; and virtual visits (online appointment systems, telephone consultations, videoconferences, SMS, emails). All of them constitute a fundamental feature of primary care for the present and the future.

For this reason, and after more than two years of the pandemic, it is more important than ever to analyze international experiences to ensure that virtual primary care contributes to reducing inequalities in access to primary care services and to improving its quality.

This is the intention of an outstanding report published earlier this year by the Nuffield Trust and written by Dr Charlotte Paddison and Isabelle McGill entitled "Digital primary care: Improving access for all?". The authors carried out a quick review of the national (United Kingdom) and international evidence published during the years 2020 and 2021, which yields a series of important messages, which are highlighted below.

First, patients with the least need for health care, young people and people of high socioeconomic status are the most likely to benefit from virtual access to primary care. This constitutes a new form of the "inverse care law" and can enhance health inequalities since those groups that have worse health and greater health needs (people with socio-economic vulnerability, ethnic minorities and people with cognitive or communication difficulties) can see their access negatively affected. Regarding Catalonia, a recently published study concluded that remote consultations tripled during the first three months of the pandemic. Most users were predominantly female, systematically younger, more actively employed, and with less complex pathologies. This helped mitigate, to some extent, the decline in face-to-face visits in younger age groups, but also suggests that profiles with greater clinical and social complexity benefit less from non-face-to-face visits.

Secondly, virtual primary care may lead to the replacement of some access barriers (distance, time, transport problems) by others (internet access, digital skills, device capacity). The report includes an staggering fact about the United Kingdom: almost two million people do not have access to the internet and cannot afford it, so they are automatically excluded from online care.

However, the review also shows optimistic results. In situations where digital tools improve the accessibility of primary care, such tools can lead to improvements not only in access but also in the quality of care. Choosing between different consultation modalities can benefit patients who were previously disadvantaged in face-to-face primary care in two ways: by overcoming geographic barriers to access and by promoting patient autonomy. Particularly in the field of mental health, evidence shows that remote consultations increase the contact time that these patients can have with their primary care provider, in addition to expanding the scope of programs run by specialized mental health services.

Three recommendations to overcome the digital divide

The report also points out a series of recommendations for decision-makers interested in getting the most out of digital tools in primary care, while also addressing inequalities in access.

  • Commit to the right goal: to ensure that all citizens can access primary care under equal conditions.
  • Asses the impact that the change in access conditions may have on different groups of patients and clearly, identify potential “winners and losers”.
  • Introduce virtual primary care, so that it never reduces the possibilities of access but rather contributes to increasing and personalizing them based on the individual characteristics of each patient and the dynamics of use by different groups. In this sense, studies such as the one cited above from Catalonia, which characterize the profiles that most actively use teleconsultation and other virtual care tools, are essential.

In this process, primary care professionals must play a fundamental role in three areas: understanding the needs of their population, addressing access barriers by co-designing inclusive access to clinical circuits, and ensuring that access modalities are customised appropriately.

Virtuality must be a means to reduce inequalities and increase the quality

Although not mentioned in the report, it is vitally important for policymakers to study the context in which primary care services operate, before jumping into the introduction of digital solutions. Virtual primary care should never be seen as an alternative to strengthening primary care with sufficient human resources. In addition, there is a sort of magical thinking about the time that digital tools and telematic care can save health professionals. This can end up overloading, even more, the workload of primary care professionals  that isin a state of chronic unsustainability in many European countries. In Spain, the expansion of the use of remote care not only did not decrease but rather increased the work of primary care professionals. For example, since September 2020, the increase in e-consultations has not been associated with a decrease in face-to-face consultations. This increases the total number of consultations and the workload of PC professionals by adding telematic attention to the face-to-face consultations already existing. In addition, increased accessibility often goes hand in hand with increased demand, which in turn requires increased triage and demand management efforts (and resources) to prevent delays in the attention of the most relevant problems. Finally, the digital skills of professionals must be at the centre of any virtual care development strategy.

Virtual primary care should never be an end in itself, but rather a means to a greater purpose: to reduce inequalities in access to the health system and improve the quality of service provision.

José Cerezo Cerezo is health policy analyst and works as a consultant for the WHO European Center for Primary Health Care and the WHO Barcelona Office for the Financing of Health Systems.

Monday 12 September 2022

Why do good deeds sometimes fail to work?

Joan Escarrabill

Cities are looking for elegant solutions for severe and complex problems. Barcelona's Eixample can be a good example of an elegant solution. But in cities, sometimes, there are also critical points for which a good solution is never found. Glòries Square in Barcelona can be one of those critical points of bad solution: heavy traffic in all directions and subway and railway tunnels that pass very close to the water table. Many solutions have been proposed in recent years and the latest one has taken more than six years to come true. I do not know engineering or urban planning, but I am sure that the proposed design has been carried out by competent professionals who have sought the best solution or, at least, the best viable solution or the one that most minimizes the negative impact. I am also sure that the designers have thought about the needs of all the people who will be using the infrastructure. But from the very moment it opened, in early April, it hasn't worked and nobody seems to be happy about it. In real life, we have a difficult problem with the best possible solution and a bad result. How can it be that things well done sometimes don't work? I don't know, but I think the metaphor of Glòries Square in Barcelona helps me to comment on three articles I've recently read.

Monday 5 September 2022

Value-based healthcare: what comes next?

Alexandre Lourenço

More than 15 years have passed since the publication of Michael Porter and Elizabeth Teisberg's iconic book Redefining Health Care.

As a seasoned consultant, Porter delivered a simple message: Value-Based Healthcare (VBHC), an attractive concept to healthcare professionals, providers and payers. Presented as a solution to the health care crisis in the United States, the concept of value – the relationship between results and the cost to achieve them – quickly spread throughout Europe, South America and Australia. Like a magic potion, it provided a solution for almost all health-system problems: addressed fragmentation, variation, over-provision of care, financial lack of sustainability, medical errors, clinical compromise, lack of trust, patient disengagement, etc.

Monday 29 August 2022

Ten attributes of future healthcare according to McKinsey

Tino Martí

In late March, McKinsey published "The next frontier of care delivery in healthcare," an analysis of the trends that will define healthcare delivery in the United States in the coming years, drawn from expert input and led by Shubham Singhal, Mathangi Radha, and Nithya Vinjamoori.

According to McKinsey, there are ten attributes of future health care, defined below and displayed in the accompanying infographic:
  1. Patient-centred: this attribute brings together various aspects such as a holistic and personalized vision, accessibility to health services and data, the use of wellness services and user satisfaction.
  2. Virtual: the pandemic has triggered the use of remote health and has predisposed providers and patients to new models of care that combine virtual care with face-to-face care in services such as urgent care, scheduled consultation, home care or medication administration at home.
  3. Ambulatory: care provided in health centres represents a third of the activity invoiced in the United States. Outpatient care is associated with shorter waiting and visit times and lower complication rates.
  4. Home care: care provided at home expands to new models such as home dialysis or home hospitalization. The combination of the above attributes allows the redefinition of care processes.
  5. Based on value and risk-taking: the expectation of growth in value-based contracts in the coming years is associated with the prevention orientation of services and the role of primary care.
  6. Driven by data and technology: digital health and the use of data for decision-making and personalization of care can change the trend of healthcare costs, improve productivity and facilitate the deployment of value-based healthcare.
  7. Transparent and interoperable: new regulations force the publication of rates, restrict the blocking of data between providers and facilitate access to health data.
  8. Facilitated by new medical technologies: self-service opportunities for the management of chronic pathologies, remote monitoring, home telemetry or robotics are examples of technologies applied to the transformation of care models that include outpatient, home and virtual care.
  9. Financed by private investors: Private investment in healthcare is growing significantly and is geared towards new models of care that take advantage of the trends described above to overhaul the patient experience.
  10. Integrated despite being fragmented: the integration of care is based on the coordination of ecosystem agents through technological platforms.

Despite being predictions based on and directed to the United States healthcare sector, most of the attributes described are directly applicable to our European context with certain nuances. It‘s worth retaining as positive the consolidation of new models of care around the needs of the person, the value of care and the possibilities of de-concentration provided by technologies and data. The centrifugal trend toward more ambulatory, home and virtual care draws a substantial paradigm shift in the provision of services with deep consequences on how these services should be purchased, managed and provided. This new constellation leads to prevention and care but requires fundamental changes in the messages that are transferred to health providers.

In the "difficult to transfer" chapter, the increase in private investment in the health sector arouses opposing sentiments. On the one hand, the social centrality of health caused by the pandemic and shaken by technological innovation offers the opportunity to join forces to improve, from within and from outside, systems with a tendency to immobility. On the other hand, the expectation of suggestive returns on investment – explains the investors' interest and can aggravate existing inequalities.

Everything indicates that guiding the future of health care through these consolidated trends will be a challenge full of balances and compromises between the necessary change and the undesirable consequences that will require decision-makers to have a sophisticated compass.

Monday 22 August 2022

Ageism and risk of technological Darwinism

Glòria Galvez

Image by Flickr
According to the Spanish National Institute of Statistics (INE), in 2020 about half of the people over 75 years of age-connected to the internet daily. The pandemic and the need to feel integrated into society have forced them to enter the digital world, although their opinions, aptitudes or preferences have not been taken into account in the design of the tools used.

Monday 15 August 2022

Request and exercise economic evaluation

Cristina Adroher

Even before COVID-19, OECD countries allocated an average of 7.9% of their GDP to public spending on health (6.1% in Spain) [see Government at a Glance report, OECD 2019]. After pensions and social benefits, health spending is the most important item of public spending in all countries. For responsibility, transparency and common sense, it is important to know and analyze what health resources are used for and evaluate the results obtained thanks to your investment.

Monday 8 August 2022

War stress

Andrés Fontalba


Stress is an adaptive reaction. When a change occurs, an effort is made to face the new challenge and, thus the organism itself adapts and can experience emotions, even pleasant ones, in the face of this process. In this case, stress is stimulating and motivating. Unfortunately, in situations as distressing as those caused by the current war, stress becomes so intense that it is seriously detrimental to health and one of its most severe consequences is post-traumatic stress disorder, a disease that arises as a delayed reaction to extremely threatening or catastrophic situations. This disorder is characterized by repeated episodes in which the traumatic event is relived in the form of dreams, flashbacks, or intrusive memories, often accompanied by emotional numbing and dissociation. It may involve detachment from others and avoidance of activities that are reminiscent of the event. Anxiety and depression may also be present, and substance abuse and suicidal thoughts are common.