Data and statistics
Trends in primary care: western Europe
Western European countries base their primary care (PC) systems largely on physicians who deal with disease. People take responsibility for managing their health problems or diseases by referring themselves for help when they are ill. This may be to a team consisting of many health professionals, or to a solo or group practice. The facilities may be funded from social insurance or from public funds, or may be part of a private practice.
Disease prevention and health promotion are therefore not central features of these forms of PC. These modes of practice traditionally do not imply governmental acceptance of responsibility for the health of all those entitled to a service (as opposed to the treatment of disease) and arrangements for remuneration not been designed with this in mind. There have been some exceptions, such as the 1991 amendments to the United Kingdom general practitioner (GP) contract, which were designed to expand the role in this direction – as well as aspects of secondary prevention relating to the early diagnosis of diseases that has routinely become part of the task profiles of PC professionals in many countries. How to encourage even more public health elements into primary care practices in western Europe is a rather recent and ongoing discussion.
Beyond the issue of how much public health to include in primary care, there have been many reforms and changes in the delivery framework for primary care over the past 30 years. Some of the typical features include:
- introduction of general practice or family medicine as a medical specialty in some countries;
- encouragement of the establishment of group practices;
- encouragement of teamwork between different health professionals; delegating tasks traditionally carried out by physicians to nurses and professions allied to medicine;
- introduction of additional payment for particularly desirable services (for instance, immunization) and partial capitation payment to supplement fee-for-service;
- increase in the range of services provided by PC professionals (e.g., community-based mental health services and minor surgery);
- strengthening of the gate-keeping role (e.g., by making primary care providers budget holders responsible for purchasing services for their patients; introducing the “money follows the patient” principle; or restricting access to secondary and tertiary care without referral).
This refers especially to the reforms introduced in the United Kingdom in the 1990s when the “fund holding” principle transferred responsibilities for purchasing certain services to GP. This has since evolved through the creation of more complex organizational entities, the so-called PC trusts. These bring together all health care professionals involved in providing services, and have a responsibility for commissioning a larger range of services than did fund holders, including health improvement for larger given populations.
When specifically comparing the different models, one of the major differences is certainly that countries with a national health service model, such as the United Kingdom and the Scandinavian states, have stronger control over the system: The demarcation between PC and secondary care is usually clear and primary care is an effective gatekeeper. PC facilities are usually the patients’ first point of call, although direct access to specialists may be possible.
Traditionally, these systems have left little space for entrepreneurship by the health professional. Public authorities often control the number, distribution, hours of work and salaries or fee schedules of the health personnel, but their control over the quality of work is limited (hence the introduction of the Quality and Outcome Framework (QoF) within GP contracts in the United Kingdom in 2004). In sum, the trade-off between equity, efficiency and choice is mostly characterized by rather good access/equity and rather less choice and efficiency.
In many countries with private practice and health insurance, primary care continues to be physician-centred and oriented towards curative services. Group practices and teamwork are emerging, but most GPs still work alone. They often compete with specialists for patients. Their gate-keeping role is limited if patients can go freely and without additional financial cost directly to a specialist or to a hospital outpatient department. A general trend has been to introduce market elements (for example in Germany, Greece, the Netherlands), along with elements of integrated care. Traditionally, the trade-off between equity, efficiency and choice in these countries is bent towards more choice and efficiency and less equity.
Trends in primary care: eastern Europe, the newly independent states and central Asia
Before the early 1990s there were clear similarities in the organization and provision of primary care in the eastern half of the European region, based on the Semashko model. The development of the model started with an early emphasis on prevention to combat serious epidemics threatening the very existence of the new USSR. With rapid industrialization, the focus quickly shifted to curative specialized medicine with a focus on hospital-based services.
The system was state run, highly centralized and chronically underfunded in real terms. Compared to primary and secondary production, tertiary productions such as health care services had low esteem, which was reflected in the funds allocated to health and the socioeconomic status of its employees, the health professionals. While all services were free in theory, under-the-table payments to low-earning health professionals or in-kind contributions occurred in practice: a barrier to seeking care that existed well before the 1990s.
PC was (and in some countries still is) organized largely around three medical specialties: internist/therapist, paediatrician and obstetrician/gynaecologist. Only the former Yugoslavia had a very early tradition of GP specialization. Medical education focused mainly on treatment with very little emphasis on promotion and prevention. Compared to specialists, PC medical doctors had lower prestige, accompanied by lower salary and few incentives to perform better. Consequently, referral rates to specialists were usually high. The role of nurses was primarily to serve the physician, not to have independent responsibility. Their training was in vocational schools only.
In urban areas, it was difficult to distinguish between the primary and secondary levels of care. Polyclinics had the role of diagnosing and treating common problems and to undertake preventive activities. Service delivery was usually fragmented with separate facilities for adults, children and for women’s health (reproductive) services. Specialized dispensaries provided outpatient care in vertical programmes e.g. tuberculosis, sexually transmitted infections, cardiology, etc. Specific occupation groups had their own services (e.g. the military, railway workers). In rural areas, primary care was provided in health posts staffed by a nurse, midwife or feldsher in the USSR, or in ambulatory locations by a district internist and nurses – all accountable to the central rayon hospitals. A widely developed network of sanepid facilities at the republic, oblast, city and rayon levels and anti-plague and disinfection stations provided public health services.
While many system components are common, the reform experience of central and eastern Europe differs considerably from that of the successor states since the dissolution of the USSR. This is probably mainly due to being relatively more prosperous and having had experience with private practice and social health insurance before the Second World War. Accordingly, central and eastern European countries moved faster and were more radical in breaking with the old model. The new health politicians, leading clinicians who had no previous political role, saw how their colleagues in western countries prospered and wanted to emulate their model. The result was a rapid conversion to a predominantly privatized system. In the more distant newly independent states, progress was much slower – and the legacy of the old model is often still present as heavy baggage.