Transitional Primary Care

Salvador Casado

Edward Coley-Jones
Head study of Perseus 1875

If even a pandemic like the current one has not been able to strengthen and improve Primary Care many wonder if anything will. And it will not be for money, given the generosity of European funds. With the devastation and the enormous burden it has assumed, it has become clear that the system has neither the capacity to adapt nor the energy to take on inexpected situations. Any increase in voltage overheats professionals who are already being pressed by high voltage. Those who attend to patients over forty every day are likely to move into the next hellish circle with ten or twenty more. 

What is certain is that in misfortunes, everyone show who really is. Some work hard, others mess up and some get out of the way. And the picture we have of the organisation is even more sinister than it seemed, with politicians who do not move a finger, health managers who have disappeared and fellow health workers who hide themselves saying "this is not my business". And to top it off, the citizens are fed up and angry that the open bar health system they used to have has been swiped by someone. Well, you know, especially those who do not have a private plan B are protesting, which once again highlights what some of the powerful interests in government want: two-speed health care, two education, etc. The opposite of universal quality health care that promotes social cohesion, solidarity and reduces inequalities.

Between the protests of health administrators who see that they have more telephone work when the call centre is closed and the web appointment too, of nurses for taking over the covid tests and other additions and of doctors for seeing their agendas go up as smoke, nobody seems to realise the obvious: the health centre is empty. Well, there are some people there, but in no case is it the usual crowd. The emperor is naked and does not know it.

The lines of improvement that already exist can be expected to bring about changes several years down the line but do not expect anything to affect the structure. The political and health management level is what it is, and as has been shown it has little capacity and humanity after letting its professionals burn like fire. To speak of what I know the reinforcement in the Community of Madrid has been some joung R0 in the summer without any function, covid managers in November (nursing assistants, physiotherapists...) who positioned themselves at the door with a merely informative function and a promise of polar liners with a logo. Well promises have been quite a few more, you know, but like so many they are already in the bin. 

The result of having a template on fire is that the function is lost. You stop doing important things. This will mean increased morbidity and mortality on the one hand and hospital saturation and increased expenditure on the other. It will also cause enormous damage to the mental health of a majority of doctors who are now forced to take anti-anxiety drugs, anti-depressants or other methods of covering up clearly unbearable suffering. We enter a dangerous dynamic where we go from a win-win to a lose-lose situation. And the crux of the matter is extremely simple, it has to do with mathematics with a number: the maximum number of patients a family doctor sees per day. 

Any health manager knows this number. They know that it can be optimal, suboptimal, overloaded and unacceptable. They know that it varies throughout the year with peak demand times. They know that their objectives, quality, patient safety and well-being depend on it. And finally, it knows that it can do little to improve it. 

The rigidity of the system means that there are places with better care pressure than others and that the only way to improve for professionals is to move to a better destination. This is a terrible misfortune for rural areas, working-class districts or territories with social problems that see their professionals marching at an ever-increasing speed. But it is the only real solution provided by a health organisation that literally suffocates its doctors. 

Inexplicably, some of them remain in their posts given the benefit that the longitudinal nature of the care gives to both the professional and the population. But this balance is increasingly polarised towards professional suffering. When we look at the data on consumption of psycho-pharmaceuticals, sick leave and surveys of discomfort carried out by health professionals, we see this. 

If in the current circumstances we do not manage to create a momentum to get Primary Care out of the situation of shock and cardio-respiratory arrest it is suffering from, we will be left with a corpse or a zombie forever. Entering a transition phase that follows a line of adaptive change is today an urgency. Where should the shots be fired to get out of the current situation? Many analyses can be made but I will only propose a few lines that seem to me to be practical.

1. Improve the filters, protocolise the triage.

When a patient requests care, he or she must explain their needs so that they can be weighed and the most appropriate response offered. This implies the creation of decision trees and general heuristic procedures that can be adapted to each centre and situation, including both bots or automatic programmes and conversation guides for administrators.

2. Promotion of demand management by nurses.

A large number of patient needs can be perfectly met by nurses, as experience in other countries and in some national centres tells us. In any case, the peaks in demand of a health centre should be assumed by nurses and doctors in order to avoid a chronic asymmetry in the size of the agendas that highlights poor organization and luck of solidarity.

3. Improve information and communication systems.

It is important that communication between health centres and the rest of the system is improved, including the community dimension. It is also important to adapt the electronic medical record to make it more clinical and less bureaucratic. And to promote communication systems with patients that allow instant messaging, e-mail, voice and video.

4. Make agendas more flexible.

An imposed and rigid agenda ends up being non-functional in the practice of medicine. This is not just a matter of putting the screws on and it is necessary that this working tool be intelligent and at the service of the professional who uses it and his or her patients. It should include a safety valve to avoid situations of maintained high pressure and probably an algorithm to help the user to advise on measures to manage it.

5. Work in teams with sufficient independence and safety. 

Without management capacity at team level little can be done. This is well known both by those responsible for the councils and by the professionals themselves. The current chains of command are not functional when it comes to transmitting, communicating and leading. The situation is one of blockage, given that the manager does not have real management capacity and everything has to be referred to higher levels. 

As you can see, it is possible to glimpse horizons that give us hope. The truth is that this should be a joint effort between citizens, professionals, managers and politicians. Only with a high degree of collective intelligence and creativity will we be capable of the most difficult thing, which is not to theorise but to implement. We have tools in the hands of enormous power and social conditioning factors that allow us to do great things. It will be possible if everyone dares to step out of their comfort zone of thought and action and step out into the open where the answers are.