Together we change: An ambitious blueprint for primary healthcare in Flanders

With the publication of the document ‘Together we change: primary care now more than ever’ four leading professors of family medicine in Flanders send a strong message to health policy makers about their vision for the future of primary healthcare in Flanders (1). Obviously, the subtitle refers to the 2008 World Health Report, which not only emphasizes the firm basis of the document but also its relevance beyond Flanders. Likewise, the 28 contributors to the vision document, who all are well-known experts in family medicine and primary healthcare, underline the broad support for the presented vision within Flanders.

In its vision of the future of primary healthcare, ‘Together we change’ includes many up-to-date concepts for primary care: integrated care models for the management of patients with chronic diseases, multidisciplinary primary care networks to meet the heterogeneous healthcare needs of patients, the gatekeeper’s role of family doctors for specialized care, the collaborative organization of out-of-hours care, regional budgets, pay-for-performance, monitoring of performance, quality systems, and the position of primary healthcare in innovation, research and education. The vision document considers experiences abroad, e.g. with the gatekeeping role of family doctors, with the UK Quality and Outcome Framework, and with regional budgets (2–4). And last but not least, the document provides many concretely formulated recommendations about how to move forward from the current situation to the envisaged future.

In the view of ‘Together we change,’ the basis of future primary healthcare is an obligatory registration of each citizen with a family practice that is part of a primary healthcare organization. Family practices provide first-contact care for all listed patients and provide access to more specialized care through referral. For patients with chronic diseases who receive specialized care, models of primary and secondary care integration are in place. Primary healthcare is organized in regions with an average of 100 000 inhabitants. Within these regions, professional networks of multiple disciplines are responsible for providing primary healthcare. These networks include family doctors, nurses, psychologists, pharmacists, physiotherapists, social carers, midwives, occupational therapists, health educators, home carers, personal caregivers, and volunteers. Out-of-hours care, the collaboration with hospital care and palliative care are organized on the regional level. A (fictive) macro budget is allocated to each region. This budget is tailored to regional healthcare needs, and can be used as ‘benchmark’ for cost-effectiveness of primary healthcare. Financing of family doctors gradually evolves to 60% through capitation, 30% through fee-for-service, and 10% through pay-for-performance. Quality and performance indicators are defined at the regional level and evaluated via data from electronic health records. Future primary healthcare facilitates graduate and postgraduate education of professionals, quality improvement, innovations and research.

This ambitious blueprint for primary healthcare in Flanders is not solely a vision document. The authors provide suggestions for a roadmap for the next two years with changes on different levels in the proposed direction. If realized, this would mean a huge reform of primary care, bringing Flanders at the forefront of strong primary care systems. The point of departure is quite good in the sense that Belgium, and Flanders in particular, belongs to the one-third of European countries with a relatively strong primary care system (5). Another strong point is the tuning of this future vision with a recently published framework for the reform of hospital care (6).

We would like to make a few comments. First, the document has been prepared by a long list of respected experts, but patients and their organizations are absent. In one of the last chapters, the authors claim that primary care starts with the needs of patients. These needs are mainly formulated from the perspective of healthcare professionals (e.g. how to improve freedom of choice, shared decision making, and health literacy). More attention for the patients’ voice, e.g., by an analysis of actual healthcare needs of patients or by including patient organizations in the preparation of this document will strengthen the claim of patient-centeredness.

Second, apart from patients medical specialists are also an important stakeholder; perhaps not in supporting this vision but because of the possibility to prevent or slow down changes. Changes in the organization of primary care will have consequences for other sectors, notably specialist and hospital care. Collaboration with medical specialists is warranted when integrating primary and secondary care for patients with chronic diseases. The organization of primary out-of-hours care needs to be tuned to emergency care in hospitals.

A final remark concerns the ‘cultural change’ that will be necessary to adopt this new design of primary healthcare. The authors provide a two-year roadmap to initiate the necessary steps towards a new primary care system. However, attention should be paid to the timing and the feasibility and acceptance of primary care reforms, both by professionals and patients. For example, the introduction of a gatekeeping system—currently not existing in Flanders—needs to be accompanied by an intensive information campaign to convince people that family doctors are sufficiently competent to take their role as gatekeeper. Family doctors may have to increase their knowledge and skills to perform adequately.

The authors of the vision document and the Flanders community should be congratulated with this future vision of primary healthcare. If implemented, primary healthcare in Flanders will represent the most up-to-date primary healthcare system globally, taking the current state of knowledge into account. We look forward to the next steps, and—in the longer term—to the evaluations that will undoubtedly provide lessons for other countries.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.