Three axes for primary care reforms (with Decalogue included)

Jordi Varela
Editor

 

From the Alma-Ata declaration of 1978 to the Astana declaration of 2018

In 1978, through the Alma-Ata declaration, the WHO recommended that all countries should deploy universal access to primary health care, appropriate to the needs of each territory. The health of the communities should be attended to with a proactive attitude as it was the gateway to a healthy system. Countries that followed these recommendations, including the United Kingdom and Spain, have achieved more equitable and orderly services than those that have not, such as Germany and the United States. At the same time the waste was reduced, given that their services are more tailored to the characteristics of each person and each family.

Forty years later, at the Astana meeting, a new WHO declaration has opted for strengthened and inclusive primary care with sufficient capacity to lead the renewal of health systems, today too fragmented and far removed from the reality of patients they serve. The point is that the current demographic and epidemiological circumstances make it necessary to tighten coordination between levels and to promote work in multidisciplinary teams, especially when it comes to serving the most vulnerable and frail people.

Despite the new WHO recommendations, both in the UK and Spain, primary care is showing signs of exhaustion, and now these two countries are seeking reforms, as can be seen in the "NHS Long Term Plan" or in the document that SERGAS (Galicia) has just published "For a primary care backbone of the health system", in which I have had the opportunity to participate. Let no one think that, beyond the plans, changing structures and dynamics will be easy. In case it can be of help, from these two documents I have extracted the three axes (and the 10 actions) essential to have some possibility of getting ahead with the reforms.

Axis 1: any reform must have principles

The reforms should be based on principles shared among the actors, of which it should be highlighted: universal access, the co-responsibility of citizens and communities in the promotion and prevention of their health, care centred on people, clinical practice and innovations based on evidence and the structuring, coordination and integration of services.

Axis 2: a Decalogue of necessary measures

1) Increase management autonomy. The management teams of the health centres must have sufficient competencies to draw up work plans adjusted to the real needs of their territory. For this reason, primary care managers should have a high degree of autonomy concerning the management of resources, especially in the configuration of professional teams.

2) Manage demand with professional criteria. Given the current collapse, the centres should avoid that the agendas of family doctors act as a funnel where any request for service ends up. We need concrete actions such as nursing demand management, the expansion of functions of administrative and review of induced demand, routines and unnecessary bureaucracy.

3) Adopt a community health model. According to the health assets of each specific territory and the evidence shown in the community health programs, it would be necessary for each centre to adopt its model of community health and to define the resources it intends to allocate to it.

4) Create teamwork. Multidisciplinary teamwork is much more than organizing clinical sessions. It requires that several doctors, nurses, social workers and clerks collaborate, share resources, redefine functions and set organizational and care objectives together. These teams should bet on an increase in competencies, especially for nurses and clerks.

5) Reorganize services according to population needs. Segmentation studies usually highlight three segments with different needs: a technically healthy population that requires rapid resolution of their specific problems, a population at risk or with chronic diseases in early stages for which the continuity of the supply is key, and a small group of people with complex social and health needs that requires the creation of multidisciplinary units of attention to complexity with the capacity to offer intensively in homes and residencies.

6) Standardize processes and generate value chains. Standardizing practices is a fundamental dynamic for the structuring between primary care and the hospital, which must be given at various levels, from referral circuits, telematic consultations and rapid cancer diagnosis, to the transformation of clinical trajectories into chains of the value of the most frequent processes such as diabetes, COPD, heart failure, chronic coronary disease, depression, dementia, polyarthritis and chronic kidney failure.

7) Promote valuable clinical practices. The creation of local right care commissions should be the engine to standardize clinical activities according to the value they provide. In this sense, the most successful experiences are those that analyze the performance profiles of each professional and adjust them in a formative and cooperative climate.

8) Expand the portfolio of services. To the extent that budgetary possibilities allow, health centres should expand their services, especially, but not only, in psychology, pharmaceutical, odontology, podiatry, rehabilitation, and nutritionist.

9) Create a territorial network of services. Primary care must have the capacity to generate (and lead) a local network with public health services, mental health services, addiction services, sexual and reproductive health care programs and also paediatrics.

10) Integrate social and health services. This is a very complex issue, but it's necessary to find bridges, through the Chronic Care Model, which should be the basic methodology of the teams that, from primary care, deal with the home care of the most complex patients. Therefore, the appropriate instruments are the integral evaluation and the elaboration of individualized plans elaborated jointly between the patients, their families, the social services and the health.

Axis 3: a well-directed, gifted and evaluable implementation plan

Structural changes need a push if they want to move from the documentary phase to that of organizational change. Therefore, after agreeing on principles and actions, each health system should appoint a management team for the reform of primary care with explicit competencies; it should approve a specific and sufficient budget to invest strategically in promoting reforms and should design an evaluation system based on indicators that analyze the real value of the progress made.

To move towards primary care that should be the backbone of the health care system, it's necessary to review its principles, apply a set of necessary measures and approve a well-directed, financially endowed, and evaluable implementation plan. Any other dynamic, no matter how participatory, ends up being a dead letter.