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Zdrav Var 2008; 47: 102-103
HOW CAN EUROPEAN QUALITY PRIMARY HEALTH CARE SYSTEMS ADDRESS THE CHALLENGES OF THE 21ST CENTURY?
Jan De Maeseneer1
Introduction                                                        Quality of care
The changing society in the 21st century, will confront health systems with important challenges. First of all there are the demographic and epidemiological developments. The percentage of older people in the population will continue to increase in all EU-mem-ber states in the period up to 2020 by 3 to 6 percentage points in most cases (1). At the same time, the percentage young people in the overall population will gradually decline. In 2003, the percentage of the population accounted for by children up to the age of 14 ranges from 14 or 15% in Italy, Spain, Greece, Slovenia and Germany, to 21% in Ireland and on Cyprus (2). In almost all EU-countries, this fgure will fall by a further one to 4 percentage points between now and 2020. This demographic change will be accompanied by an epidemiological transition with increasing chronic illnesses, mental disorders, … Moreover, the socio-cultural developments will lead to individualisation and rising expectations of the public towards the health care system. Ethnic and cultural diversity will increase in Europe over the decades ahead. This will have implications for health problems presented to the health system. Within the European countries there are major social-economic inequalities in the likelihood of suffering illness and premature mortality: on average, people of high socio-economic status remain in good health 12 years longer than people of low socio-economic status (3). Scientifc and technological developments will raise expectations (e.g. in the feld of genomics) and home care technology will create new opportunities for community based ambulatory care. Finally, both political decision-makers and the public are increasingly concerned about the prevention of or the appropriate response to disease outbreaks and disasters. This will require “preparedness” of the health system (4).
Health systems that want to be responsive to these challenges will have to take into account the following principles: relevance, equity (including accessibility), quality and effciency.
In order to demonstrate their social accountability, health systems have to make clear how they strive for and achieve quality.
Quality of care has 3 components: structure, process and outcome (5). Structure consists of 3 interrelated components: society, the individual and the health care system. For the health care system, organisational aspects (accessibility, continuity, comprehensiveness) and characteristics of health care providers (competence, empathy) affect quality of care. Process refers to all interventions and interactions between patients and providers. Process quality largely depends on adequate communication, medical decision making, and management of care. Guidelines, protocols and algorithms that underpin process are increasingly based on scientifc evidence (6). Outcome is defned by how patient and doctor perceive health and disease, and this perception has shifted from problem-orientation to goal orientation (7). As a result - e.g. for a patient with chronic pulmonary disease - the patients’ ability to participate in social life is more important than their change in long-function test.
This consideration results in a range of relevant outcome indicators that can be measured, from signs and symptoms, physical functioning, quality of life, patient satisfaction and social equity. Improving quality will require, interventions at different levels of structure and process, and will need medical, contextual and policy evidence (6).
How can European quality primary health care systems address the challenges?
There is growing evidence that comprehensive primary health care systems are able to provide relevant, equitable, quality, cost-effective health care (8). Star-feld at all fnd a rationale for the benefts for primary health care in greater access to needed services, better quality of care, a greater focus on prevention, early management of health problems and the role of
1Chairman European Forum for Primary Care [www.euprimarycare.org], Department of General Practice, and Primary Health Care, UZ - 1K3 - De Pintelaan 185, B-9000 Gent, Belgium Correspondence to: e-mail: jan.demaeseneer@ugent.be
De Maeseneer J. How can European quality primary health care systems address the challenges of the 21st century?
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primary care in reducing unnecessary and potentially harmful specialist care. Primary health care should act as the frst point of contact for the population, and is able to deal with more than 90% of all the presented problems, acting as a flter and helping patients to navigate in a cost-effective and high-quality way through the health care system. The primary health care team has an interdisciplinary composition, including family physicians, nurses, health promotion-workers, social workers, nutritionists, … and addresses the physical, psychological and social needs of patients, their families and the communities they live in. Through intersectoral cooperation, they may contribute to a “community diagnosis”, illustrating the underlying structural problems that contribute to ill health. The role of primary health care in the process of clarifying the importance of social structures and in understanding the social determinants of health, may contribute to the transformation of the social quality of the lives of individuals and communities (9). There is a need for integration between public health and primary health care, because primary health care integrates in a comprehensive way the messages and interventions from the public health approach. Health systems should be organised in an intersectoral network, with crosslinks to environment, economy, work and education at the different institutional levels (national, province, district, …). For primary health care, the full participation of the local community in the designing of services is of utmost importance, which requires a bottom-up approach. Such a primary health care system could contribute to eradication of diseases and, through its effect on social cohesion and empowerment, decrease the vulnerability of populations and strengthen communities in addressing the social determinants of health.
Today the question arises how primary health care and family medicine can be best organised in the health care system? The debate is whether it should be in the private sector, or in the public sector. Certainly in Eastern Europe, there is an increasing tendency to establish private primary health care practices, with family physicians functioning in a fee-for-service system. Certainly, when out-of-the-pocket-payments by the patients at the point of service delivery are high, this model may affect negatively accessibility of the health care system. Advocates of private practice as the organisational model, emphasize the high degree of fexibility and patient orientation of this kind of service. Those who defend primary health care as a public service, stress the importance of a comprehensive interdisciplinary team-based approach, and the need
for integration of preventive activities, having a focus not only at the health of the individual, but also at the population health. The evolution in Eastern Europe towards more private practices in family medicine is opposite to the fact in Western Europe, the family physician has switched from a private entrepreneur, towards a comprehensive health care provider, working in team and being socially accountable for a defned population or patient list at the level of e.g. continuity of care, quality of care, cost-effectiveness. For a public primary health are system to be performant, suffcient funding is needed, in order to attract skilled family physicians, nurses, and to assure their retention in the primary health care system. The European Forum for Primary Care (10) may offer the Platform to integrate experiences in designing Primary Health Care Systems in different European countries.
Finally, addressing the challenges of the 21st century will require an empowered citizen and patient, enabled to take adequate decisions in relation to his or her health, underpinned by evidence based information. To integrate health promotion and patient empowerment in primary health care is therefore a very important topic, and I want to congratulate the organisers of the international conference “Quality of primary health care, the perspective of patients” (Ljubljana - 28-29.03.2008) for having chosen this theme.
References
1.   Social and cultural Planning Offce. The Netherlands in Europe. The Hague: Social and Cultural Planning Offce, 2000.
2.   Eurostat. People by age classes. Available 26.8.2004 on: http://europa.eu.int/comm/eurostat/newcronos.
3.   Mackenbach J P, Kunst AE, Cavelaars AE, Groenhof F, Geurts JJ. Socioeconomic inequalities in Health. Lancet 1997; 349: 1655-959.
4.   Health Council of the Netherlands. European primary care. Publication n°. 2004/20E. The Hague: Health Council of the Netherlands, 2004.
5.   Donabedian A. The quality of care. How can it be assessed. JAMA 1988; 260: 1743-8.
6.   De Maeseneer JM, van Driel ML, Green LA, van Weel C. The need for research in primary care. Lancet 2003; 362: 1314-9.
7.   Mold J, Blake G, Becker L. Goal-oriented medical care. Fam Med 1991; 23: 46-51.
8.   Starfeld B, Shi L, Macinko J. Contribution of Primary Care to health systems and health. The Millbank Quarterly 2005; 83(3): 457-502.
9.   De Maeseneer J, Willems S, De Sutter A, Van de Geuchte I, Billings M. Primary Health Care as a strategy for achieving equitable care: a literature review commissioned by the Health systems Knowledgde Network. Available on 26.3.2008: http://www.who.int/social_determinants/resources/csdh_media/ primary_health_care_2007_en.pdf.
10. Available 26.3.2008 on: http://www.euprimarycare.org.
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Zdrav Var 2008; 47: 104-105
KAK[EN NAJ BO ODGOVOR EVROPSKIH SISTEMOV KAKOVOSTNEGA PRIMARNEGA ZDRAVSTVENEGA VARSTVA
NA IZZIVE 21. STOLETJA?
Jan De Maeseneer1
Uvodnik
Uvod
Dru`ba sprememb 21.stoletja postavlja zdravstveno varstvo pred vrsto pomembnih izzivov. Najprej gre za demografske in epidemiolo{ke spremembe. Dele` starej{ega prebivalstva bo do leta 2020 v vseh dr`avah ~lanicah EU ve~inoma narasel za 3 do 6 odstotne to~ke (1) ob postopnem zmanj{evanju dele`a mladih. Leta 2003 se je gibal dele` otrok, mlaj{ih od 14 let med 14 in 15 % v Italiji, [paniji, Gr~iji, Sloveniji in Nem~iji in 21 na Irskem in na Cipru (2). V skoraj vseh dr`avah ~lani-cah EU se bo to {tevilo zmanj{alo do leta 2020 {e za 4 odstotne to~ke. Te demografske spremembe bodo prinesle s seboj tudi druga~no epidemiolo{ko situacijo s pove~anim dele`em kroni~nih bolezni, du{evnih obolenj itd. Poleg tega vodijo dru`beno-kulturne spremembe v individualizacijo in ve~ja pri~akovanja javnosti v zvezi z zdravstvenim varstvom. V prihodnjih desetletjih se bo pove~ala etni~na in kulturna raznolikost Evrope, kar bo prineslo s seboj tudi vrsto zdravstvenih problemov, s katerimi se bo sre~eval sistem zdravstvenega varstva. Zaradi bistveno razli~nega dru`beno-ekonomskega polo`aja so med posameznimi evropskimi dr`avami velike razlike v stopnji obolevnosti in prezgodnje umrljivosti: tako posamezniki visoko na dru`beno-ekonom-ski lestvici ostanejo zdravi kar 12 let dlje, kot tisti z ni`jim dru`benoekonomskim statusom (3). Z napredkom znanosti in tehnologije se bodo pove~evala pri~akovanja uporabnikov (npr. na podro~ju genomike), tehnolo{ki dose`ki na podro~ju oskrbe na domu pa bodo prinesli nove mo`nosti zdravstvene obravnave bolnikov zunaj zdravstvenih ustanov. Odlo~ujo~i v politiki in {ir{a javnost se vedno bolj zavedajo, kako pomembno je prepre~evanje bolezni oziroma pravilno ukrepanje ob izbruhih bolezni in nesre~ah. Zato je nujna stalna pripravljenost sistema zdravstvenega varstva (4). Vsak zdravstveni sistem, ki se `eli ustrezno odzivati na te izzive, mora upo{tevati na~ela relevantnosti, enakosti (v dostopnosti), kakovosti in u~inkovitosti.
Kakovost zdravstvenega varstva
Svojo dru`beno odgovornost lahko zdravstveni sis-
temi doka`ejo s prikazom prizadevanj za kakovost in na~ina, kako kakovost dose`ejo. Kakovost zdravstvene nege sestavljajo struktura, proces in izid (5). Struktura je sestavljena iz treh, med seboj povezanih, elementov; to so: dru`ba, posameznik in zdravstveni sistem. Na kakovost nege vplivajo organizacijski vidiki (dostopnost, trajnost, celovitost) in zna~ilnosti izvajalcev zdravstvene nege (usposobljenost, empatija). Proces obsega vse postopke in interakcijo med bolniki in izvajalci. Kakovost procesa je v veliki meri odvisna od ustrezne komunikacije, zdravnikovih odlo~itev in vodenja zdravstvene oskrbe. Smernice, protokoli in algoritmi, na katerih sloni proces, se v vedno ve~ji meri oblikujejo na osnovi znanstvenih dokazov (6). Izid dolo~a na~in bolnikovega in zdravnikovega zaznavanja zdravja in bolezni, to razumevanje pa je vse manj usmerjeno k problemu in vse bolj k cilju (7). Tako je npr. pri kroni~nem plju~nem bolniku njegova zmo`nost delovanja v dru`benem `ivljenju bolj pomembna kot izvidi testov plju~nih funkcij. Iz tega pristopa izhaja vrsta pomembnih izmerljivih kazalcev izida, od znakov in simptomov, telesne funkcije, kakovosti `ivljenja, zadovoljstva bolnika do dru`bene enakosti. Kakovost lahko izbolj{amo z ukrepi na razli~nih ravneh strukture in procesa, podani pa morajo biti tudi medicinski, kontekstualni in politi~ni dokazi. (6)
Kako se lahko evropski sistemi primarnega zdravstvenega varstva odzovejo na izzive?
Vedno ve~ je dokazov, da celoviti sistemi primarnega zdravstvenega varstva lahko ponudijo ustrezno, pravi~no, kakovostno in stro{kovno u~inkovito zdravstveno nego (8). Starfeld in sod. ugotavljajo, da morajo biti prednosti primarnega zdravstvenega varstva: la`ja dostopnost do potrebnih storitev, bolj{a kakovost storitev, ve~ji poudarek na prepre~evanju bolezni, zgodnje zdravljenje in vloga primarnega zdravstvenega varstva v zmanj{evanju {tevila nepotrebnih in potencialno {kodljivih specialisti~nih storitev. Storitve primarnega zdravstvenega varstva predstavljajo prvi stik prebivalstva z zdravstveno os-
'Predsednik European Forum for Primary Care [www.euprimarycare.org], Department of General Practice, and Primary Health Care, UZ - 1K3 - De Pintelaan 185, B-9000 Gent, Belgium Kontaktni naslov: e-pošta: jan.demaeseneer@ugent.be
De Maeseneer J. Kak{en naj bo odgovor evropskih sistemov kakovostnega primarnega zdravstvenega varstva na izzive 21. stoletja?    105
krbo. Predstavljajo re{itev za kar 90 % zdravstvenih problemov, imajo zato vlogo fltra in bolnike na kakovosten in stro{kovno u~inkovit na~in usmerjajo skozi zdravstveni sistem. Zdravstveni tim sestavljajo strokovnjaki razli~nih podro~ij: dru`inski zdravniki, medicinske sestre, strokovnjaki za krepitev zdravja, socialni delavci, strokovnjaki za prehrano. Vsi ti skupaj re{ujejo telesne, du{evne in socialne probleme bolnika, njegove dru`ine in skupnosti, v kateri `ivi. Medsektor-sko sodelovanje pomembno prispeva k t. i. »skupnos-tni diagnozi» in opredeli strukturne vzroke obolevnosti. Vloga, ki jo ima primarno zdravstveno varstvo pri opozarjanju na pomen dru`benih struktur in razumevanja dru`benih determinant zdravja lahko prispeva k preobrazbi socialne kakovosti `ivljenja posameznika in skupnosti (9). Nujno je povezovati javno zdravje in primarno zdravstveno varstvo in s tem integrirati vse javnozdravstvene ukrepe in napotke v primarno zdravstveno varstvo. Zdravstveni sistemi morajo biti organizirani v medsektorski mre`i in povezani z okoljskim gospodarstvom, delom in izobra`evanjem na razli~nih ravneh (pokrajine, okraji itd). Pri na~rtovanju storitev primarnega zdravstvenega varstva je bistvenega pomena polno sodelovanje lokalne skupnosti, in sicer po na~elu od spodaj navzgor. Tak{en sistem primarnega zdravstvenega varstva lahko prispeva k izkoreninjanju bolezni, s tem, da prispeva k povezanosti in krepitvi mo~i v dru`bi, pa zmanj{uje ogro`enost prebivalstva in pomaga skupnostim pri re{evanju dru`benih vpra{anj zdravja.
Danes se spra{ujemo, kako najbolje organizirati primarno zdravstveno varstvo in dru`insko medicino v zdravstvenem sistemu: v okviru zasebnega ali v okviru javnega sektorja? Vzhodnoevropske dr`ave te`ijo k ustanavljanju zasebne zdravstvene slu`be s pla~ljivimi storitvami dru`inskih zdravnikov. Jasno je, da bi visoke cene, ki jih bi morali za storitve pla~evati bolniki sami, negativno vplivale na dostopnost zdravstvenega varstva. Zagovorniki zasebne prakse kot organizacijskega modela v zdravstvu poudarjajo visoko stopnjo feksibilnosti tak{nih storitev in njihovo usmerjenost k bolniku. Tisti, ki zagovarjajo javno primarno zdravstveno varstvo, pa se sklicujejo na pomen celostnega interdisciplinarnega timskega pristopa in povezovanja preventivnih dejavnosti, ki niso usmerjene le k zdravju posameznika, temve~ k zdravju vsega prebivalstva. Razvoj v smeri zasebnega zdravstvenega varstva, ki smo mu pri~a v vzhodni Evropi, je v nasprotju s polo`ajem v zahodnoevropskih dr`avah. Dru`inski
zdravnik se je iz podjetnika-zasebnika preobrazil v izvajalca celostnega zdravstvenega varstva, v ~lana tima, ki je dru`beno odgovoren za dolo~eno populacijo oz. skupino bolnikov, ob upo{tevanju stalnosti, kakovosti in stro{kovne u~inkovitosti zdravstvenih storitev. Za uspe{no delovanje javnega primarnega zdravstvenega varstva so potreba zadostna denarna sredstva, s katerimi je mo~ pritegniti k delu sposobne dru`inske zdravnike in medicinske sestre in jih zadr`ati v sistemu primarnega zdravstvenega varstva. Evropski forum za primarno zdravstveno varstvo (European Forum for Primary Care) (10) lahko ponudi platformo za povezovanje izku{enj pri oblikovanju sistemov primarnega zdravstvenega varstva v razli~nih evropskih dr`avah.
Ob zaklju~ku bi poudaril, da bo naloge, ki jih prina{a 21. stoletje, mogo~e re{evati le s krepitvijo vloge prebivalstva, ki bo znalo na osnovi informacij, temelje~ih na znanstvenih dokazih, sprejemati prave odlo~itve v zvezi s svojim zdravjem. Povezovanje krepitve zdravja in krepitev vloge prebivalstva v primarnem zdravstvenem varstvu je zato zelo pomembna naloga in rad bi ~estital organizatorjem mednarodne konference »Kakovost primarnega zdravstvenega varstva, perspektiva bolnika«, (Ljubljana, 28. – 29. marec 2008), da so za sre~anje izbrali prav to temo.
Literatura
1.   Social and cultural Planning Offce. The Netherlands in Europe. The Hague: Social and Cultural Planning Offce, 2000.
2.   Eurostat. People by age classes. Pridobljeno 26.8.2004 s spletne strani: http://europa.eu.int/comm/eurostat/newcronos.
3.   Mackenbach J P, Kunst AE, Cavelaars AE, Groenhof F, Geurts JJ. Socioeconomic inequalities in Health. Lancet 1997; 349: 1655-959.
4.   Health Council of the Netherlands. European primary care. Publication n°. 2004/20E. The Hague: Health Council of the Netherlands, 2004.
5.   Donabedian A. The quality of care. How can it be assessed. JAMA 1988; 260: 1743-8.
6.   De Maeseneer JM, van Driel ML, Green LA, van Weel C. The need for research in primary care. Lancet 2003; 362: 1314-9.
7.   Mold J, Blake G, Becker L. Goal-oriented medical care. Fam Med 1991; 23: 46-51.
8.   Starfeld B, Shi L, Macinko J. Contribution of Primary Care to health systems and health. The Millbank Quarterly 2005; 83(3): 457-502.
9.   De Maeseneer J, Willems S, De Sutter A, Van de Geuchte I, Billings M. Primary Health Care as a strategy for achieving equitable care: a literature review commissioned by the Health systems Knowledgde Network. Available on 26.3.2008: http://www.who.int/social_determinants/resources/csdh_media/ primary_health_care_2007_en.pdf.
10. Pridobljeno 26.3.2008 s spletne strani: http://www.euprimary-care.org.