PHC Models in Europe

1. PHC Models in Europe Teppo Heikkilä, MD Budapest June 2011 PHC Models in Europe / Teppo Heikkilä

2. Five Models of PHC • PHC Model 1: Direct access to any GP or specialist • PHC Model 2: Referral required from GP, mainly solo-practices in PHC • PHC Model 3: Referral required from GP, mainly group-practices in PHC • PHC Model 4: GPs working mainly in health care centres • PHC Model 5: Polyclinics (Shemasko). Not necessarily GPs at all PHC Models in Europe / Teppo Heikkilä

3. ”Solo practice” basic model based mainly on specialists’ services Various primary care doctors, that can be accessed directly Local health services; preventive services, elderly care, some public health functions, etc. PHC Models in Europe / Teppo Heikkilä

4. ”Solo practice” basic model based mainly on generalists’ services Through referral to other services Direct access to the chosen generalist Local health services; preventive services, elderly care, some public health functions, etc. PHC Models in Europe / Teppo Heikkilä

5. ”Group practice type of arrangement” Through referral to other services Direct access to the chosen group service/own GP/FD Local health services; preventive services, elderly care, some public health functions, etc. PHC Models in Europe / Teppo Heikkilä

6. ”Health centre type of arrangement” Through referral to other services Direct access to the health centre usually determined by residency (or choice) Usually no separate local health services, apart from possibly local public health services PHC Models in Europe / Teppo Heikkilä

7. ”Policlinic-based arrangement” Through referral to other services Direct access to the policlinic usually determined by residency (or choice) Usually no separate local health services, apart from possibly local public health services PHC Models in Europe / Teppo Heikkilä

8. Five Models of PHC • Simple and relatively easy to observe • Do not offer complete answers to the European PHC structure • Do not define if the system is financially based on health insurance funds or taxation PHC Models in Europe / Teppo Heikkilä

9. European PHC Models • We went through the European PHC systems and compared them to the five PHC Models created beforehand • We used WHO’s Health in Transition (HiT) reports • HiT reports contain information about health care systems structured in the same format • For countries in EU Primecare we also used the answers to the questionnaire PHC Models in Europe / Teppo Heikkilä

10. HiT Reports of European Countries • HiT report released 2006 – 2010 26 countries • HiT report released 2000 – 2005 16 countires • HiT report released 1999 2 countires • No HiT report 9 countries • In total 53 countries PHC Models in Europe / Teppo Heikkilä

11. Challenges • There are different kinds of local solutions and partial solutions in different countries with their own models e.g. in referral systems and health care service coverage in PHC • Different systems can coexist in one country • Different systems in different regions • Public and private systems working side by side • Each health insurance fund providing own system PHC Models in Europe / Teppo Heikkilä

12. Challenges • Difficulty to classify each country to one PHC Model exactly • The PHC Model system can be described as a continuum where each country settles somewhere between the PHC Models • E.g. kind of partial referral system (Austria) or a mix of solo- and group-practices (e.g. Denmark, Estonia, Italy) PHC Model 1 PHC Model 2 PHC Model 3 PHC model 4 PHC Model 5 PHC Models in Europe / Teppo Heikkilä

13. Challenges • Some basic elements of the PHC Models could have been understood differently in different countries • E.g. gate-keeping • Can a patient go to the specialist • Only with referral • If paying a formal or informal fee for the specialist • In some defined cases without a referral • To some defined specialists without a referral? • E.g. group-practice • Is it a practice owned by a group of practitioners, or a facility in where a group of independent practitioners are working side by side? PHC Models in Europe / Teppo Heikkilä

14. Challenges • In some countries (e.g. former Soviet Countries) there is going on a progress in developing health care systems • During the process the health care system can represent different PHC Models • In these cases some of the HiT reports could have been too old to describe the present PHC Model PHC Models in Europe / Teppo Heikkilä

15. Challenges • There can also be some human errors when reading the HiT reports and trying to understand and assess the elements of the PHC Models PHC Models in Europe / Teppo Heikkilä

16. PHC Model 1Direct access to any specialist • Andorra (HiT 2004) • No mention about referral systems in HiT report • Austria (HiT 2006) • Partial referral system, where the patient in theory needs a referral to go to a specialist, but • Patient can choose a specialist to be the first contact in health care system • Patient can change the first contact in every three months • Czech Republic (HiT 2009) • In practice PHC Model 1. Patients can go directly to the specialist if they want to PHC Models in Europe / Teppo Heikkilä

17. PHC Model 1Direct access to any specialist • France (HiT 2004) • Germany (HiT 2004) • Turkey (HiT 2002) • Many actors in PHC. Public system is close to the PHC Model 4, but undeveloped. Most patients go directly to the private specialist PHC Models in Europe / Teppo Heikkilä

18. PHC Model 2Referral required, mainly solo-practices in PHC • Croatia (HiT 2006) • There are some health centres (PHC Model 4), but most of the GPs work in solo-practices • Cyprus (HiT 2004) • Implementing new model, where there are solo-practices and heath care centres. Most of the GPs in solo-practices • Hungary (No HiT Report) • Assessed based on questionnaire in EU Primecare • Ireland (HiT 2009) • At present PHC Model 2, implementing PHC Model 4 PHC Models in Europe / Teppo Heikkilä

19. PHC Model 2Referral required, mainly solo-practices in PHC • Italy (HiT 2009) • Both solo- and group-practices, mainly solo-practices • Latvia (HiT 2008) • Trying to create PHC Model 4. In practice more close to the PHC Model 2 • Malta (HiT 1999) • Old HiT Report. Public (PHC Model 4) and private (PHC Model 2) system side by side. Private system dominant PHC Models in Europe / Teppo Heikkilä

20. PHC Model 2Referral required, mainly solo-practices in PHC • Norway • Health centres, but GPs working in private solo-practices • Romania (HiT 2008) • Slovakia (HiT 2004) • PHC Model 2, although PHC doctors are working mainly in shared facilities PHC Models in Europe / Teppo Heikkilä

21. PHC Model 3Referral required, mainly group-practices in PHC • Belguim (HiT 2007) • Bulgaria (HiT 2007) • Denmark (HiT 2007) • Both solo- and group-practices, but group-practices more common and growing • Estonia (HiT 2008) • Both solo- and group-practises, but group-practices more common (and growing?) PHC Models in Europe / Teppo Heikkilä

22. PHC Model 3Referral required, mainly group-practices in PHC • Israel (HiT 2009) • Four health insurance funds, which all run their own health care system. The biggest one is close to PHC Model 3 with features of PHC Model 4. The second biggest one is close to PHC Model 1. • Lithuania (HiT 2000) • Old HiT Report. PHC Model 3 based on the answers to the EU Primecare questionnaire. • Netherlands (HiT 2010) • United Kingdom (HiT 1999) • Old HiT Report. The UK has gone through a health care reform after that. Does that affect their PHC Model? PHC Models in Europe / Teppo Heikkilä

23. PHC Model 4Health care centres in PHC • Albania (HiT 2002) • Old HiT Report. Planning to develope PHC Model 4. Has that been put into effect? • Bosnia and Herzegovina (HiT 2002) • Finland (HiT 2008) • Iceland (HiT 2003) • Moldova (HiT 2008) • Portugal (HiT 2007) • The role of the private sector seems to be small but is not clear in the HiT report PHC Models in Europe / Teppo Heikkilä

24. PHC Model 4Health care centres in PHC • Slovenia (HiT 2009) • At present PHC Model 4 but going towards PHC Model 2 as health care is getting privatized • Spain (HiT 2006) • Sweden (HiT 2005) • Quite old HiT Report. Some changes happened after that. Do they affect the PHC Model? • Macedonia (HiT 2006) PHC Models in Europe / Teppo Heikkilä

25. PHC Model 5Polyclinics (Shemasko) • Many former Soviet Countries are developing their health care systems. Many countries seem to go more or less towards PHC Model 4, but some also towards other PHC Models. • They have started to train general practitioners / family doctors almost in all former Soviet Countries • Difficult to define the PHC Model at present because of ongoing plans and progress • In practice, based on HiT reports the PHC Model in most countries is still very close to the Shemasko model PHC Models in Europe / Teppo Heikkilä

26. PHC Model 5Polyclinics (Shemasko) • Armenia (HiT 2006) • Azerbaijan (HiT 2010) • Belarus (HiT 2008) • Kazakhstan (HiT 2007) • Kyrgyzstan (HiT 2005) • Trying to go towards PHC system based on family doctors (PHC Model 4) PHC Models in Europe / Teppo Heikkilä

27. PHC Model 5Polyclinics (Shemasko) • Russian Federation (HiT 2003) • Taijikistan (HiT 2010) • Turkmenistan (HiT 2000) • Ukraine (HiT 2004) • Uzbekistan (HiT 2007) PHC Models in Europe / Teppo Heikkilä

28. Hard to Define the PHC Model • Poland (HiT 2005) • Some basic elements of PHC Model could not be found in HiT report, such as • Is there a referral system? • Do family doctors work mainly in solo- or group-practises or is there any kind of health care centre based system? PHC Models in Europe / Teppo Heikkilä

29. No HiT Report • Georgia • Greece • (Hungary) • Luxenbourg • Monaco • Montenegro • San Marino • Serbia • Switzerland PHC Models in Europe / Teppo Heikkilä

30. PHC Models in Europe / Teppo Heikkilä

31. Countries in EU Primecare • PHC Model 1 • Germany • PHC Model 2 • Hungary • Italy • PHC Model 3 • Estonia • Lithuania • PHC Model 4 • Finland • Spain PHC Models in Europe / Teppo Heikkilä