The strength of primary care in Europe

At the October 2012 EGPRN conference in Antwerp on ‘Patient-centred Interprofessional Collaboration in Primary Care,’ Peter Groenewegen gave a keynote lecture in which he tried to answer two questions: ‘What determines how strong primary care is?’ and ‘Do strong primary care systems indeed perform better?’

During the Christmas Holidays, I have read the book Groenewegen based his answers on: the landmark PhD-thesis of Dionne Sofia Kringos (1). The book reports on the EC funded PHAMEU project (Primary Health Care Activity Monitor for Europe), which was carried out in 31 European countries (http://www.phameu.eu). In this project, an instrument was developed, the ‘European Primary Care Monitor.’ This translates the structure of primary care (governance, economic conditions, and workforce development), the process of health care delivery (access, comprehensiveness, coordination, and continuity) and the outcome of primary care (quality, efficiency, and equity) into a set of indicators that describe its complex reality. It enables the identification of relative strong and relative weak elements of a country's primary care system (2). Every European general practitioner/family physician who is involved in the (innovation of the) organization of primary health care should read this book (or the articles) in which the concepts of the core dimensions of primary care are described (2,3).

The second half of the book contains the studies that have been carried out using the European PC Monitor: comparisons of primary care strength and efficiency in European countries, analyses of factors that contribute to a strong primary care system and finally, an analysis of the impact of primary care. Since these studies have been submitted for publication (December 2012), I cannot provide a detailed summary. To be honest: there was a lot of complex mathematics and economics in the study designs and analyses!

Nevertheless, what does the author herself conclude at the end of her journey through European primary care? A few highlights. ‘In almost all countries high quality primary care information on comprehensive aspects of the system is lacking.’ Using the European PC Monitor, ‘a distinction can be made between countries with strong, medium and weak primary care (structure and process).’ Only few countries with a relatively strong primary care also have the most efficient health care systems. Overall, the PHAMEU results suggest that, ‘to improve primary care efficiency it is particularly important to focus on strengthening access and coordination of care,’ and making ‘economic resources available for primary care.’ ‘Perhaps the highest gains in access can be made by reducing the level of primary care co-payments to increase the affordability for patients. Countries should make a clear choice between demand regulation via well-accessible (gate keeping) general practitioners or via co-payments.’

The primary care orientation of a country is determined by various contextual factors. Modifiable factors are: having a national health service based system—with gate keeping as a crucial factor—and having predominantly left-wing governments. The author warns: ‘The fact that an increasing number of countries in Europe are governed by liberal governments forms a potential threat to the development of strong primary care.’

The PHAMEU study could confirm the positive effects of a strong primary care. A strong primary care is ‘conducive to reaching important health care system goals.’ It diminishes socioeconomic inequalities in self assessed health. An important message for family physicians is that strong primary care reduces unnecessary hospitalizations. In addition, it is associated with better population health for conditions like ischaemic heart disease, cerebrovascular disease, asthma and COPD: there is less loss of life years of total life expectancy. However, the results of the PHAMEU project could not prove that strong primary care actually results in reduced health care expenditures.

Kringos concludes that the results of this internationally comparative study in 31 European countries, ‘strengthen the evidence base for policymakers to prioritize primary care strengthening on the health policy agenda and invest in improving the quality and completeness of primary care information infrastructures, for funding agencies to invest in primary care research, for researchers to improve further our understanding of the functioning of primary care at both macro, meso and micro level, and for primary care professionals for the importance of their work for improving population health, reducing socio-economic inequality in self- assessed health and reducing (expensive) avoidable hospitalizations.’

I would like to add that this truly pan-European collaboration of northern, eastern, southern and western European investigators has provided a solid foundation for further research into efficient and equitable primary care of high quality. Moreover, they have given general practitioners/family physicians a conceptual framework of primary care that can inspire us in performing our roles in medical education, vocational training and health care innovation (2). Finally, this framework will help in making political choices.