Primary health care: no more hype!

Pere Vivó

We live in convulsive times in terms of the health care system and especially in primary health care (PHC), this represents an opportunity for reflection and the construction of a substantially different model. The PHC constitutes the citizen's first contact with health care services and is a primary focus in the health care of a country. Aspects such as health promotion, attention to health needs throughout life or disease prevention contribute (sometimes silently) to progress and social spreading. For that reason, no one doubts that a health system is stronger if investments in PHC are enhanced and its resolving capacity and infrastructure are strengthened.

However, despite this strategic role, there is still a journey in the construction and deployment of an integrated model focused on the person who in turn is efficient and stimulates innovation and professional motivation. But, will that alone be enough? The answer is definitely NO. The structural transformation should be complemented by professional initiatives with a real impact on the system that helps consolidate the leadership of the PHC. Let's see an example:

Last December, British Journal of General Practice published an interesting experience carried out in a sector of the PHC of Barcelona of the Catalan Institute of Health (ICS), the main provider of health services public in Catalonia, which has led to two significant advances in prescription management and patient safety: on the one hand, a significant reduction in the number of patients treated with an active principle of low pharmacological inherent value (mostly induced by specialized focal attention) and, on the other, the drastic break of said induction through a unitary positioning of the entire PHC.

The intervention was carried out throughout 2017 and was designed within a commission formed by two technicians and two managers whose objectives are the analysis of the indicators and goals established by the regulatory body of the health system in Catalonia (CatSalut), the analysis of results at territorial level and the definition of the operational strategy.

The strategy, extrapolated to any environment with prescription-induced problems, was based on four main axes and the deployment of actions included in each of them:

1. Simplified information. To empower the 227 family doctors of the territory where the intervention was performed, an infographic was designed and distributed, indicating, through schematic information, the indications of the drug, its potential side effects and its positioning in therapeutics. The infographic was disseminated through the internal communication channels and presented a double function: on the one hand, the purely formative and, on the other, offering the possibility of being used as an informative element to the patient and of converting the drug review process is a tool for shared decision making.

2. Management and professional support. In the process of reviewing the adequacy of the prescription of a drug, the existence of evidence does not solve the multitude of clinical and casuistic situations that are observed with patients, so a technical consultation channel was offered to both physicians as to the PHC team directors to encourage decision making in the clinical setting and the deployment of the strategy within each participating team.

3. Unified positioning. Through the coordination between those responsible for the PHC commission, executives, service managers and technical staff of the reference hospital, a positioning of territorial PHC was carried out to communicate the multicenter strategy, its clinical foundations and the existing evidence. Both the infographics and the reports of the new drug evaluation committee related to the drug were made available to hospital services. This positioning was the key to achieving a negative inverse induction on potential new prescriptions in the 28 urologists and 23 gynaecologists of the reference hospital, compared to other sectors of the city of Barcelona, which maintained an upward trend.

4. Follow up. A periodic monitoring sequence of territorial scope was defined, offering raw data by PHC team and by professional, under the premise that knowledge of evolution could constitute a periodic reminder of the intervention and a stimulus factor for its continuity, thus as an element of clinical debate.

Beyond the benefit obtained in terms of patient convenience and safety, this type of initiative arising from the clinical and middle management areas will be essential for a strong health care system led by the PHC. We should not fall into the hype that sometimes the justified historical claims of the sector since nobody doubts them and their implementation, will arrive safely or at least reflect the strategies designed to reorient the PHC.

We should avoid universal formulas, so typical in the past, and be able to generate a change based on the talent of our professional networking, focusing on the collective effort to enhance and share knowledge and skills that will allow initiatives to be adjusted to each territory.

This motivating path is also the key to enhancing working conditions, stimulate professionals and, finally, improve the provision of services and results in health care focused on the person.