The Future of Primary Care in Europe

1. The Future of Primary Care in Europe Nick Goodwin, PhD Senior Fellow, Health Policy, King�s Fund & Chair, INIC Paper to The Future of Primary Health Care in Europe II, University of Southampton, UK, 17th September 2008

2. Three Key Challenges for Primary Care Ageing populations

3. Ageing Populations: Long Term Care Comparative analyses of LTC policies in Europe - funding mechanisms and levels of entitlement to LTC - play a crucial role in defining the setting for service provision (informal; in-home; institutions). 1. Projected demographic change will see dramatic increase in numbers of dependent older people (first highlight) 2. Predicted future costs and service provision needs � if nothing changes � immense BUT also - informal care (cheapest) likely to decline in all the countries as a result of a downward trend in co-residence of older people with their children, an upward trend in older people living alone, a decline in female care-giving potential and rising female employment rates. Reduction in informal care would generate greater demand for formal care, thereby inflating LTC expenditures [4]. RESPONSE - an emerging European trend exists in attempting to reduce the rise in the level of institutionally-based care (residential and nursing home care) whilst promoting care provided in the home or home environmentComparative analyses of LTC policies in Europe - funding mechanisms and levels of entitlement to LTC - play a crucial role in defining the setting for service provision (informal; in-home; institutions). 1. Projected demographic change will see dramatic increase in numbers of dependent older people (first highlight) 2. Predicted future costs and service provision needs � if nothing changes � immense BUT also - informal care (cheapest) likely to decline in all the countries as a result of a downward trend in co-residence of older people with their children, an upward trend in older people living alone, a decline in female care-giving potential and rising female employment rates. Reduction in informal care would generate greater demand for formal care, thereby inflating LTC expenditures [4]. RESPONSE - an emerging European trend exists in attempting to reduce the rise in the level of institutionally-based care (residential and nursing home care) whilst promoting care provided in the home or home environment

4. Ageing Populations: Chronic Disease Age-related medical care represents the major disease burden on costs and use of medical services globally � over 60% Chief driver is growing numbers of older people living with one or more long-term conditions Older people, and especially the very old, are high users of health (medical) care. (Age-related) chronic disease now represents the major disease burden on cost and use of medical care services globally and a chief driver is the growing numbers of older people living and coping with one, or more often multiple, long-term chronic conditions Trends in institutional (hospital) capacity and utilization across Europe since the early 1990s have consistently shown the more intensive use of facilities, the presence of fewer hospital beds, and shorter lengths of stay. Changes in the nature and pattern of care provided to older people. This includes a common policy of earlier discharge to nursing homes /own homes with help from community-based health and social care services. One of the most comprehensive analyses of international trends and consequences in care for older people was undertaken in England. The Review found that, in England, older people (age 65+) account for nearly two-thirds of bed days whilst the rate of emergency admission growth was highest in older age groups. Significantly, the Review found a growing body of evidence internationally that hospital admissions and lengths of stay could be reduced by a range of social care interventions such as early transfers of people from hospital to the community, and the provision of ongoing home-based care. Good nutrition, hygiene, support with mobility, help with medications and reducing environmental hazards will all help limit some of the common causes of hospital admission among more dependent older people. Support with morale and confidence, and in combating depression are other examples.Older people, and especially the very old, are high users of health (medical) care. (Age-related) chronic disease now represents the major disease burden on cost and use of medical care services globally and a chief driver is the growing numbers of older people living and coping with one, or more often multiple, long-term chronic conditions Trends in institutional (hospital) capacity and utilization across Europe since the early 1990s have consistently shown the more intensive use of facilities, the presence of fewer hospital beds, and shorter lengths of stay. Changes in the nature and pattern of care provided to older people. This includes a common policy of earlier discharge to nursing homes /own homes with help from community-based health and social care services. One of the most comprehensive analyses of international trends and consequences in care for older people was undertaken in England. The Review found that, in England, older people (age 65+) account for nearly two-thirds of bed days whilst the rate of emergency admission growth was highest in older age groups. Significantly, the Review found a growing body of evidence internationally that hospital admissions and lengths of stay could be reduced by a range of social care interventions such as early transfers of people from hospital to the community, and the provision of ongoing home-based care. Good nutrition, hygiene, support with mobility, help with medications and reducing environmental hazards will all help limit some of the common causes of hospital admission among more dependent older people. Support with morale and confidence, and in combating depression are other examples.

5. Ageing Populations: Chronic Disease For example, in UK: 75% of >75s suffer from chronic illness 50% of those have more than one condition By 2030, the incidence of chronic disease in > 65s will more than double c.80% GP consultations associated with a chronic condition Chronically ill patients far more likely to be admitted as inpatients and use over 60% of hospital bed stays Patients with more than one chronic condition cost six times more than those with only one � higher use of care services Older people, and especially the very old, are high users of health (medical) care. (Age-related) chronic disease now represents the major disease burden on cost and use of medical care services globally and a chief driver is the growing numbers of older people living and coping with one, or more often multiple, long-term chronic conditions Trends in institutional (hospital) capacity and utilization across Europe since the early 1990s have consistently shown the more intensive use of facilities, the presence of fewer hospital beds, and shorter lengths of stay. Changes in the nature and pattern of care provided to older people. This includes a common policy of earlier discharge to nursing homes /own homes with help from community-based health and social care services. One of the most comprehensive analyses of international trends and consequences in care for older people was undertaken in England. The Review found that, in England, older people (age 65+) account for nearly two-thirds of bed days whilst the rate of emergency admission growth was highest in older age groups. Significantly, the Review found a growing body of evidence internationally that hospital admissions and lengths of stay could be reduced by a range of social care interventions such as early transfers of people from hospital to the community, and the provision of ongoing home-based care. Good nutrition, hygiene, support with mobility, help with medications and reducing environmental hazards will all help limit some of the common causes of hospital admission among more dependent older people. Support with morale and confidence, and in combating depression are other examples.Older people, and especially the very old, are high users of health (medical) care. (Age-related) chronic disease now represents the major disease burden on cost and use of medical care services globally and a chief driver is the growing numbers of older people living and coping with one, or more often multiple, long-term chronic conditions Trends in institutional (hospital) capacity and utilization across Europe since the early 1990s have consistently shown the more intensive use of facilities, the presence of fewer hospital beds, and shorter lengths of stay. Changes in the nature and pattern of care provided to older people. This includes a common policy of earlier discharge to nursing homes /own homes with help from community-based health and social care services. One of the most comprehensive analyses of international trends and consequences in care for older people was undertaken in England. The Review found that, in England, older people (age 65+) account for nearly two-thirds of bed days whilst the rate of emergency admission growth was highest in older age groups. Significantly, the Review found a growing body of evidence internationally that hospital admissions and lengths of stay could be reduced by a range of social care interventions such as early transfers of people from hospital to the community, and the provision of ongoing home-based care. Good nutrition, hygiene, support with mobility, help with medications and reducing environmental hazards will all help limit some of the common causes of hospital admission among more dependent older people. Support with morale and confidence, and in combating depression are other examples.

6. Ageing Populations: Chronic Disease Pro-active management and prevention of chronic illness is important to reduce expensive use of medical (hospital) care as well as have an effect of reducing dependency rates. Such interventions would at least partially offset expected demographic pressures from rising numbers of older people. There is a need to promote measures that are likely to promote healthy ageing and so reduce dependency in old age growing consensus is emerging in Europe on the need for radical service redesign in health and social care. This effects the understanding that the burden of disease in developed countries (especially for older people) has moved away from treating acute illnesses, such as cancers and heart attacks, to managing long-term care needs and treating chronic diseases. Policy futures have emphasised a future based on �integrated community-based care� so moving away from an overly acute (hospital) or institutional (nursing home) focus to one that embraces the management and co-ordination of both long term care needs and chronic illnesses of older people. growing consensus is emerging in Europe on the need for radical service redesign in health and social care. This effects the understanding that the burden of disease in developed countries (especially for older people) has moved away from treating acute illnesses, such as cancers and heart attacks, to managing long-term care needs and treating chronic diseases. Policy futures have emphasised a future based on �integrated community-based care� so moving away from an overly acute (hospital) or institutional (nursing home) focus to one that embraces the management and co-ordination of both long term care needs and chronic illnesses of older people.

7. �Unhealthy� Lifestyles Increase Health Risks A significant proportion of the disease burden faced is caused by lifestyle behaviours including smoking, poor diet and lack of exercise and alcohol. �750 million was spent just on prescriptions for drugs to combat obesity, diabetes, alcoholism and smoking in the English NHS last year

8. �Unhealthy� Lifestyles Increase Health Risks England � only way we currently get a handle on the growing prevalence and inequalities associated with LTCs is through health survey of individuals, from this can see associations between people�s lifestyle choices and risks of one or more LTCS � See � for example � those with two or more LTCs tend to have higher blood pressure; are obese; eat less fruit & veg; and smoke � statistically significant England � only way we currently get a handle on the growing prevalence and inequalities associated with LTCs is through health survey of individuals, from this can see associations between people�s lifestyle choices and risks of one or more LTCS � See � for example � those with two or more LTCs tend to have higher blood pressure; are obese; eat less fruit & veg; and smoke � statistically significant

9. �Unhealthy� Lifestyles Increase Health Risks Policy responses: Individuals should adopt healthier behaviours to avoid ill-health in later life; Better health will reduce future health costs if individuals change their behaviours Individuals should take greater responsibility for their health care Active lifestyle-management to at-risk patients and groups

10. �Unhealthy� Lifestyles: a complex solution When the Tackling Obesities: Future Choices project mapped the �causes� of obesity, they identified close to 100 factors creating an obesogenic environment (See Figure 1). There are numerous reasons, some individual others structural, as to why people smoke cigarettes, drink excessively, over-eat or do not exercise. Key point here is that healthcare plays a relatively small role in impacting on the social determinants of ill-health � income, education, housing quality, safety etc � so obviously cannot do everything � a multi-component response needed, cross-Government departments � When the Tackling Obesities: Future Choices project mapped the �causes� of obesity, they identified close to 100 factors creating an obesogenic environment (See Figure 1). There are numerous reasons, some individual others structural, as to why people smoke cigarettes, drink excessively, over-eat or do not exercise. Key point here is that healthcare plays a relatively small role in impacting on the social determinants of ill-health � income, education, housing quality, safety etc � so obviously cannot do everything � a multi-component response needed, cross-Government departments �

11. �Unhealthy� Lifestyles: Primary care�s �role� Integrate focus on health behaviour and well-being in health and social care Integrate means to healthier populations cross-Government Target groups through population-based risk assessments Target individuals by focusing and investing in health promotion activity to �at-risk� patients �Reward� providers for achieving �health� amongst their patients But primary care has a key role as it is the patients� shop window through to health �But primary care has a key role as it is the patients� shop window through to health �

12. Patient expectations Third key factor is patient expectations � Demands � access; reliable; quality We know relational continuity important � not just about choices; though informed choice of treatment or managing own conditions important Also � societal demands for good health � it�s a personal human rightThird key factor is patient expectations � Demands � access; reliable; quality We know relational continuity important � not just about choices; though informed choice of treatment or managing own conditions important Also � societal demands for good health � it�s a personal human right

13. Patient expectations Patients are different � never have been passive recipients of care, but information revolutions such as the internet mean that people have the opportunity more than ever before to understand their own symptoms and diseases, and so challenge physicians with self-diagnoses and knowledge � the informed patient � so the relationship between primary care professionals and patients is changing �Patients are different � never have been passive recipients of care, but information revolutions such as the internet mean that people have the opportunity more than ever before to understand their own symptoms and diseases, and so challenge physicians with self-diagnoses and knowledge � the informed patient � so the relationship between primary care professionals and patients is changing �

14. Patient expectations Regardless of system type or wealth or societal/cultural issues � about 80% of �care� is informal and unpaid Not all patients are engaging the other way � fully engaged in their health � Sir Derek Wanless� social care review in UK led by King�s Fund = fully engaged patients = costs will rise less severely, healthier populations will be achieved and older people will live more independent lives � [When patients] participate more actively in the process of care, we can create a new health care system with higher quality services, better outcomes, lower costs, fewer medical mistakes, and happier healthier patients. We must make this the new gold standard of healthcare quality and the ultimate goal of our improvement methods.Regardless of system type or wealth or societal/cultural issues � about 80% of �care� is informal and unpaid Not all patients are engaging the other way � fully engaged in their health � Sir Derek Wanless� social care review in UK led by King�s Fund = fully engaged patients = costs will rise less severely, healthier populations will be achieved and older people will live more independent lives � [When patients] participate more actively in the process of care, we can create a new health care system with higher quality services, better outcomes, lower costs, fewer medical mistakes, and happier healthier patients. We must make this the new gold standard of healthcare quality and the ultimate goal of our improvement methods.

15. The �Tipping Point� The prevalence and growth of people with long-term conditions and those �at risk� of chronic illness means a �tipping point� in European health policy has been reached � the costs (human and systemic) of doing nothing now outweigh the costs of embracing a radical redesign in care systems � it�s a move from a system based on episodic treatment of illness in acute settings; to the long-term management of health in communities and the home environment � To me, not seeing the need � given rising burden of disease; demographic changes; and costs of doing nothing = tipping point vs. costs of change, including the potential political one of tackling the all-powerful medical profession � The prevalence and growth of people with long-term conditions and those �at risk� of chronic illness means a �tipping point� in European health policy has been reached � the costs (human and systemic) of doing nothing now outweigh the costs of embracing a radical redesign in care systems � it�s a move from a system based on episodic treatment of illness in acute settings; to the long-term management of health in communities and the home environment � To me, not seeing the need � given rising burden of disease; demographic changes; and costs of doing nothing = tipping point vs. costs of change, including the potential political one of tackling the all-powerful medical profession �

16. The �Tipping Point� Hypothesis: Health care systems with a stronger orientation to health promotion, disease prevention, and the provision of accessible, universal and integrated primary care based-services will achieve better health outcomes and at lower cost More effective health care systems have a stronger orientation to health promotion, disease prevention and the provision of accessible and universal primary and community care-based services. The benefits of such a strong primary care-based component to a health system have been identified through influential analysts such as Barbara Starfield. By ranking the primary care orientation of twelve western industrialised nations, she concluded that countries with a strong primary care base to their health care system achieved better outcomes, and at lower cost, than countries in which the primary care base was weaker (Starfield, 1998). In Starfield�s analysis, features which were consistently associated with good or excellent primary care included the comprehensiveness and family-orientation of primary care practices, within a wider system in which governments regulated the distribution of health care resources via taxation or national insurance. Given that the burden of disease is shifting to the long-term chronically ill, national health systems must adapt to meet this challenge � a task requiring a move away from episodic care undertaken in specialist hospital institutions to long-term care management and co-ordination undertaken in the community. The importance of a primary care orientation to health system design with a strong public health component has never been more relevant.More effective health care systems have a stronger orientation to health promotion, disease prevention and the provision of accessible and universal primary and community care-based services. The benefits of such a strong primary care-based component to a health system have been identified through influential analysts such as Barbara Starfield. By ranking the primary care orientation of twelve western industrialised nations, she concluded that countries with a strong primary care base to their health care system achieved better outcomes, and at lower cost, than countries in which the primary care base was weaker (Starfield, 1998). In Starfield�s analysis, features which were consistently associated with good or excellent primary care included the comprehensiveness and family-orientation of primary care practices, within a wider system in which governments regulated the distribution of health care resources via taxation or national insurance. Given that the burden of disease is shifting to the long-term chronically ill, national health systems must adapt to meet this challenge � a task requiring a move away from episodic care undertaken in specialist hospital institutions to long-term care management and co-ordination undertaken in the community. The importance of a primary care orientation to health system design with a strong public health component has never been more relevant.

17. Bellagio Model  �Population-oriented & Integrated� Primary Care Final � wish to present the conclusions of an expert international working party that gathered earlier this year in Bellagio, Italy � specifically to examine how primary care in Europe and the USA should respond to the chronic care agenda � if we understand the importance of primary care, how do we energise the MOVEMENT � what will it take for primary care to truly become the hub around which health systems are run � we know, for example, that most health care systems in Europe are making some policy strides � but what ingredients are needed to change these from small baby-steps in the face of a health care mountain, to a fully-fledged and resourced expedition Final � wish to present the conclusions of an expert international working party that gathered earlier this year in Bellagio, Italy � specifically to examine how primary care in Europe and the USA should respond to the chronic care agenda � if we understand the importance of primary care, how do we energise the MOVEMENT � what will it take for primary care to truly become the hub around which health systems are run � we know, for example, that most health care systems in Europe are making some policy strides � but what ingredients are needed to change these from small baby-steps in the face of a health care mountain, to a fully-fledged and resourced expedition

18. Bellagio Primary Care Group 24 experts from 11 countries Focus on how to improve primary care in US & Europe Focus on strategies to improve care to chronically ill Evidence and policy This was the group � eagle-eyed may spy Barbara Starfield whose work has cemented the evidence to show the importance of primary care to health care systems; Ed Wagner � the maestro of chronic-care model; Chris Ham in the centre there, influential with policy-makers in England in its quest to reinvigorate integrated primary care � This was the group � eagle-eyed may spy Barbara Starfield whose work has cemented the evidence to show the importance of primary care to health care systems; Ed Wagner � the maestro of chronic-care model; Chris Ham in the centre there, influential with policy-makers in England in its quest to reinvigorate integrated primary care �

19. Bellagio Model  �Population-oriented & Integrated� Primary Care Health systems must become more pro-active, helping individuals to stay healthy and avoid the development of (additional) chronic conditions. Primary care as first contact care, accessible by all, guaranteeing a sustained and trustworthy partnership between providers and patients, comprehensive, coordinated care for a predetermined population, activated by patient choice plays an essential role in improving health care systems altogether This the conclusion of a work in progress � led by the Bertlesman Foundation in Germany � of what health systems in Europe should aspire to � collective �vision� of the 24 participants � stress � help people stay healthy; - first contact; - accessible and universal; - comprehensive; - trusted partnership patients and care providers; - co-ordinated (the hub around which the rest of the system operates); - population or community-focused; - enabling patient choices It�s a neat definition �This the conclusion of a work in progress � led by the Bertlesman Foundation in Germany � of what health systems in Europe should aspire to � collective �vision� of the 24 participants � stress � help people stay healthy; - first contact; - accessible and universal; - comprehensive; - trusted partnership patients and care providers; - co-ordinated (the hub around which the rest of the system operates); - population or community-focused; - enabling patient choices It�s a neat definition �

20. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership The system will not adapt naturally as a �complex adaptive system� Leadership at every level is required to strategically guide redesign of (primary) health care systems Joined-up governance and responsibility The group � if we are to fulfil the MOVEMENT, and so better address future demands of health care needs of people � NINE key principles, ingredients if you like, that must come together �The group � if we are to fulfil the MOVEMENT, and so better address future demands of health care needs of people � NINE key principles, ingredients if you like, that must come together �

21. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust The public (patients) must have trust in the reliability, accessibility and quality of care Trust can be developed by increasing accountability & transparency; by integrated people�s experiences; by establishing quality markers; by tapping in to underlying societal values Trust � people have a way of not using the systems if they are designed badly or do not fulfil their needs � people need trust in their ability to meet their demands � reliable, accessible, quality � Trust � people have a way of not using the systems if they are designed badly or do not fulfil their needs � people need trust in their ability to meet their demands � reliable, accessible, quality �

22. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Use public health and routine data to identify at-risk patients and communities; Develop pro-active systems that manage care in the community; To prevent disease onset to those at risk and to manage those already with disease. Population management � effective links to community and public health � e.g. PARR or combined model v. effective in using routine hospital statistics or insurance claims/bills to establish population and individual risk profiles � tremendous opportunity � Population management � effective links to community and public health � e.g. PARR or combined model v. effective in using routine hospital statistics or insurance claims/bills to establish population and individual risk profiles � tremendous opportunity �

23. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration �Horizontal� integration in primary & community care settings to promote �holistic� management of the person � effective treatment and care management �Vertical� integration from primary care settings � effective diagnosis & rapid access to specialist care Horizontal integration here means stronger cooperation between medical and social professionals in the local community (such as social workers, community nurses, physiotherapists, dieticians, etc.) (Olesen). Vertical integration is defined by better collaboration between primary care providers and the hospital system/specialists (Olesen). Leaders at the different levels communicate on important issues and share information in both directions. Horizontal integration here means stronger cooperation between medical and social professionals in the local community (such as social workers, community nurses, physiotherapists, dieticians, etc.) (Olesen). Vertical integration is defined by better collaboration between primary care providers and the hospital system/specialists (Olesen). Leaders at the different levels communicate on important issues and share information in both directions.

24. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Knowledge-sharing Trust-building Vision-making Culture-crossing Innovation-developing Partnership-inducing Policy-shaping Educational Collective core business Professional networks, education and leadership needed to engender collaborative ethos and influence d-makers � P4P unproven as a tool � mix of incentives required � mandated vs non-mandated networks for change � supporting community-based interdisciplinary networks for population-oriented care. One example of networking are the knowledge sharing meetings in Denmark. Health professionals from the hospital and from the health center, including nurses, physiotherapists, dieticians, physicians, and behavioral therapists that work directly with the patients, meet on a regular basis. The aim of the meetings is to ensure a common understanding of care between organizations and to get different organizational cultures come to a better understanding and thereby at some time approach a common health professional culture between organizations. The meetings are lead by the manager of the local health center and the specialist from the hospital. The meetings are informal, planned and follow an outline for the meeting (Fr�lich).Professional networks, education and leadership needed to engender collaborative ethos and influence d-makers � P4P unproven as a tool � mix of incentives required � mandated vs non-mandated networks for change � supporting community-based interdisciplinary networks for population-oriented care. One example of networking are the knowledge sharing meetings in Denmark. Health professionals from the hospital and from the health center, including nurses, physiotherapists, dieticians, physicians, and behavioral therapists that work directly with the patients, meet on a regular basis. The aim of the meetings is to ensure a common understanding of care between organizations and to get different organizational cultures come to a better understanding and thereby at some time approach a common health professional culture between organizations. The meetings are lead by the manager of the local health center and the specialist from the hospital. The meetings are informal, planned and follow an outline for the meeting (Fr�lich).

25. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Infrastructure Application of evidence-base; Shared IT across all settings; Multidisciplinary care teams and care management by medical professionals other than doctors; Integrated and coordinated care management; Individualised care plans; Self-management support Professional networks, education and leadership needed to engender collaborative ethos and influence d-makers � P4P unproven as a tool � mix of incentives required � mandated vs non-mandated networks for change � supporting community-based interdisciplinary networks for population-oriented care. One example of networking are the knowledge sharing meetings in Denmark. Health professionals from the hospital and from the health center, including nurses, physiotherapists, dieticians, physicians, and behavioral therapists that work directly with the patients, meet on a regular basis. The aim of the meetings is to ensure a common understanding of care between organizations and to get different organizational cultures come to a better understanding and thereby at some time approach a common health professional culture between organizations. The meetings are lead by the manager of the local health center and the specialist from the hospital. The meetings are informal, planned and follow an outline for the meeting (Fr�lich).Professional networks, education and leadership needed to engender collaborative ethos and influence d-makers � P4P unproven as a tool � mix of incentives required � mandated vs non-mandated networks for change � supporting community-based interdisciplinary networks for population-oriented care. One example of networking are the knowledge sharing meetings in Denmark. Health professionals from the hospital and from the health center, including nurses, physiotherapists, dieticians, physicians, and behavioral therapists that work directly with the patients, meet on a regular basis. The aim of the meetings is to ensure a common understanding of care between organizations and to get different organizational cultures come to a better understanding and thereby at some time approach a common health professional culture between organizations. The meetings are lead by the manager of the local health center and the specialist from the hospital. The meetings are informal, planned and follow an outline for the meeting (Fr�lich).

26. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Infrastructure Payment mix Incentives that �crowd-in� professional and organisational behaviours that are best for patients ? Mix of capitation payments and pay for performance ? ? Incentives linked to system or health outcomes vs activity ?

27. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Infrastructure Payment mix Measurement Evidence required to convince on efficacy of approaches Systemic generation of evidence and use of improvement methods Standardized measurement for benchmarking performance in primary care

28. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Infrastructure Payment mix Measurement Change management Active programme for practice change at many levels: Medical and inter-professional education; Professional development Use of improvement methodology to formulate goals, undertake action, measure and evaluate outcomes and seek continuous improvement

29. Bellagio Model  �Population-oriented & Integrated� Primary Care Shared leadership Public trust Population-oriented management Integration Professional networks Infrastructure Payment mix Measurement Change management For the Bellagio Model to work, it will be essential that all nine key features will need to be put in place Singling out selected features can only be a first step, as all of these features work together in a synergistic and reinforcing fashion Primary care is the �hub� around which all care should be co-ordinated

30. The �New� Principles for Primary Care:Patient-centred, Pro-active & Co-ordinated Manage and promote health and healthy behaviour Support self-care in the home environment Involve the patient as a partner in care delivery Facilitate informed patient choices Use case managers to co-ordinate care to enable individualised care plans that promote health Work in multi-disciplinary teams Integrate care across organisational boundaries, especially to social care � avoid disease-based silos Integrate access from generalists to specialists � early diagnosis of urgent care needs and rapid response Identify patients with or at-risk of chronic disease early Pro-actively manage at-risk cases by anticipating their needs

31. Concluding RemarksThe Future of Primary Care in Europe The key �ingredients� for the successful development of �new� primary care are emerging The evidence-based looks convincing to the converted, but requires sustained investigation for example, on the cost-effectiveness of primary care-led innovations seeking to promote self-care and healthy behaviours The future of primary care should never be viewed as some structural Nirvana to be imposed universally, but must be adapted to suit different systems, cultures and geographies.

32. If Primary Care was a cake � All different, BUT: You�d like the look of it You�d want to eat it It�s accessible, but you�d travel to the shop that sells the best It tastes great It has magical life enhancing as well as healing properties It�s mildly addictive It�s a product you can trust to fulfil you when you need it It comes with a recipe and instructions on how to make it � available on the �net In Germany � it would be a black forest cherry torte � shwarzwalder kirschtorte � elaborate in structure and many poor imitations In Italy � it might be Tiramisu � relatively simple and easy to make, if not to perfect In Poland � it might be the traditional Makowiec � a poppy-seed cake � time-consuming In the Netherlands � it could be SPIKU � a Dutch-Indonesian layered cake � baking it requires much patience In Germany � it would be a black forest cherry torte � shwarzwalder kirschtorte � elaborate in structure and many poor imitations In Italy � it might be Tiramisu � relatively simple and easy to make, if not to perfect In Poland � it might be the traditional Makowiec � a poppy-seed cake � time-consuming In the Netherlands � it could be SPIKU � a Dutch-Indonesian layered cake � baking it requires much patience

33. Concluding RemarksThe Future of Primary Care in Europe The evidence is clear the importance of a primary care orientation to health system design with a strong public health component has never been more relevant. Yet, integrated primary care remains the �Cinderella� health service in all countries when compared to investments in the larger medical institutions the �Bellagio Model� calls for a sustained and renewed political and professional commitment towards primary care-led health systems of benefit to all patients Maybe a primarily Western European view � though eastern Europe too � given the issues related to a growing dependent elderly populations; age and lifestyle related chronic illness and risk; and a new type of patient � � European Forum for Primary Care � one method in which the movement can flourish �Maybe a primarily Western European view � though eastern Europe too � given the issues related to a growing dependent elderly populations; age and lifestyle related chronic illness and risk; and a new type of patient � � European Forum for Primary Care � one method in which the movement can flourish �

34. Nick Goodwinngoodwin@kingsfund.org.uk