Primary care: reforms based on innovation

The primary care reform initiated in Spain in 1985 was inspired by the Alma-Ata statement that WHO had proclaimed a few years earlier. The need for change was evident since the previous model was characterized by access difficulties, the predominance of curative care, medical orientation focused on diseases and the absolute lack of teamwork. Thirty years later, primary care is in a crisis of exhaustion due to multiple factors, of which the lack of budgetary endowment, the ageing of the population and the rigidities and bureaucracies of which it has been endowed stand out, and for a long time the call for reforming the reformed has been heard and create a new model more appropriate to the present day.

The King's Fund, in a situation of the British primary care very similar to ours, rather than discussing a general reform, to "Innovative models of general practice" reviewed the innovations that are helping to readjust and strengthen the essential values of primary care. Following the terminology from Víctor Lapuente, the researchers of this London institution flee from the models and the proclamations of the "shamans", and instead, they adopt the "explorers" approach.

The five essences of primary care

Since the purpose of primary care is to provide people with the promotion of health and health services with a general and effective vision in their family environment, the King's Fund report believes that there are five essences that every innovation should preserve or boost These essences are: accessibility, community environment, continuity, coordination of care received and people-centred care, which requires that doctors and nurses have the time and the appropriate attitude to listen and involve patients in clinical processes that affect them.

What are the most effective innovations according to this review?

Organization of multidisciplinary teams. Many innovative projects have left behind the traditional individual assignment and created small teams of professionals: doctors, nurses, and case managers, social and administrative assistants, who work together for a defined population. These experiences are showing that they improve the continuity, access and monitoring of complex cases. In these team environments, the demand is distributed more appropriately to each professional, family doctors have more time to visit the patients who need them most and nurses have a more genuine competence space.

Involvement of patients and communities. The researchers say that they have observed many innovative projects that enhance the involvement of patients in the design of community health models and the reformulation of the care offered to them, so, if this occurs, the offer can go adapting to each social reality.

Proactive attitude in the follow-up of chronic patients. Many teams have opted to be proactive in the follow-up of chronic patients, with specific strategies, the support of dedicated administrative staff and the complement of electronic medical records, with the use of secure e-mails and remote consultations, among other technological innovations

Segmentation of the most complex and vulnerable population groups. Some innovative models are generating segments of population groups with special needs, such as fragile and vulnerable or homeless people. The report believes that focusing the work of the neediest segments is a cost-effective decision. In this field, to address the complexity in the community itself, there is no ideal model, but what is clear is that this is a decision that places primary care at the centre of the system in a collaborative framework between social and health services.

Expand the service portfolio and reduce transfers. The more varied the supply of primary care services, the more decisive its action needs to be. The report sees the incorporations of the services of pharmacists, physiotherapists, psychotherapists, nutritionists, etc as a positive. It also says we must ensure that all the reference specialist act under the same roof of the health centre as would be the case of the most common: paediatrics, maternal and child health, mental health, addictions; In addition to the very frequent: orthopaedics, geriatrics, internal medicine, cardiology, neurology, etc. It is an obvious fact that it is much more satisfying and efficient for professionals from multiple disciplines to work together in informal environments than not have to send patients to several specialists through the traditional bureaucratic channels.

The evaluation of the innovative experiences of King's Fund teaches us that primary care teams should evolve from a gatekeeper position, which overwhelms family doctors and leaves nursing staff with a limited content, to a collaborative one, which requires the creation of multidisciplinary teams, efficient demand distribution, patient involvement and leadership in the coordination of social and health services in the community.

Jordi Varela

Editor