Co-ordination and integration between primary, secondary and also social care are among the hottest topics in healthcare, not only in the UK but also internationally.
In October 2011, the European Hospital and Healthcare Federation (HOPE) published Better Health – a shared challenge for hospitals and primary healthcare, a report that is the culmination of the Hope Exchange Programme 2011: a four-week exploration of this topic by hundreds of healthcare managers with managerial responsibilities from countries across the European Union (EU).(1)
The report highlights experiences and innovations in integration and co-ordination between primary and secondary care across these EU countries, and draws interesting conclusions.
Back in 2008, the World Health Report Primary Health Care: now more than ever stressed the need for healthcare systems to “improve their response capacity and anticipate new challenges” through co-ordination and continuity of care.
Published in May 2010, the World Health Organization charter Key components of a well functioning healthcare system says one of the elements determining the effectiveness of health systems is the effectiveness of services provided; it argues that the level of effectiveness of these services depends, among other things, on an integrated range of clinical and public-health interventions.
Its other findings suggest that poor co-ordination, inconsistency between different levels of care and fragmented care may harm patients, resulting in duplications of analyses and medications and the provision of unnecessary treatments likely to increase patients’ uncertainty and fading their confidence in the system. Poor integration might overburden primary or secondary care, causing inappropriate admissions, high rates of readmissions or unnecessary lengths of stay.
In addition, weaknesses in primary care might lead to the overuse of emergency care and high rates of referral back from hospitals to primary care, likely to translate into inefficiencies and wasted resources for the overall system, as well as in disparities in health professionals’ workloads.
All European countries are implementing strategies to create or improve links between the different parts of their healthcare systems. The extreme variety of their system organisations offer many different examples, each targeted to a specific context. The bulk of experience available gives countries the possibility to examine each other’s arrangements and find ways to adapt such approaches and implement change in their own health systems.
In some countries, policymakers identified the need for radical or at least comprehensive changes within the system. These changes mainly look at the patient journey and aim at making his/her experience with the health system easier, shorter and more effective. Frequently, national, regional and local networks introduce innovative models for managing specific pathways of care or new patterns for treating specific cases, which are likely to be pilot projects that pave the way for a more extensive use of these integrated patterns.
In general, diseases are no longer considered as separate episodes of illness requiring acute treatment and hospital admissions, but complex conditions that require the co-existence of many factors, such as the co-operation of patients and their families, GPs and nurses covering all the new roles and tasks every system assigns to them – as well as the co-operation of all sectors, from prevention to palliative care.
This new paradigm forces countries to rethink all reciprocal relations within the health system, the role of professionals, and the role of e-health technologies and other IT solutions, which together enhance quality of care and improve performance of the health system.
Overarching changes in the health system
Countries, like Finland, France and, less recently, Austria have questioned the effectiveness of their health systems’ organisation and have started developing new solutions involving a deeper co-operation between different levels of care to ensure more effective treatment for patients and improved sustainability.
In Finland, the ‘New Healthcare Act 2011’ emphasises the rights of patients and the need for continuity of care. This is ensured by reinforcing integrated treatment paths between primary and secondary care. Clinical care plans and patterns are shared between primary care and hospitals – the information flows between them are supported by technology, and there is a continuing education and training exchange between specialists and GPs. Primary healthcare centres offer a full range of diagnostics and oral health; they are provided with inpatient wards and effectively hold the role of gatekeepers, with a share of 95% of successful resolutions.
Thanks to this high level of integration, primary and secondary care are also able to refer patients directly to social services.
In France, the government introduced legislative changes in 2009 to overcome general fragmentation in the system and poor integration between different levels of care. The ‘New Governance Initiative’ aims towards the reconciliation of the independent culture of French family doctors with the need for greater collaboration with other health professionals and organisations. The initiative sets out a plan for the development of multidisciplinary health centres with different health professionals to be gathered under the same roof (maisons de santé) and promotes networks of health professionals to manage defined health needs and the development of common prevention guidelines for generalists and specialists.
In 2005, the Austrian Federal Health Commission undertook one of its biggest reform projects. Called ‘Patient Oriented Integrated Care’, the project is a population-centred care approach to bridge the boundaries of the Austrian federal healthcare system. One of the project’s main features is that it oversees co-operation among a large number of stakeholders, as well as the pooling of resources of different healthcare financers and financing sources.
Targeted experiences and strategic projects
Many new patterns of care have been introduced across Europe with the aim of offering efficient and effective responses to the needs of patients with complex long-term conditions. Strategies oriented towards a better integration of services in general embrace the different roles of nurses and GPs and the distribution of different tasks among different levels of healthcare professionals. This includes the introduction of multidisciplinary teams and a move towards care closer to home, prominently based on e-health and IT solutions.
Germany is deploying ‘Medical Supply Centres’ – outpatient care facilities placed directly in hospitals where patients are transferred before discharge, being followed by multidisciplinary teams. These teams can use the hospital’s equipment, know the doctors who were in charge of the patient before and have full access to the patient records from the hospital stay. These centres have been introduced to save costs – by sharing physical resources, equipments and personnel – and to improve the patient’s experience, since it allows them to go through a unique pathway of care.
In Malta, a multidisciplinary shared-care diabetes programme represents a holistic approach to diabetes care. It establishes strict clinical management guidelines and minimum standards of care at the primary care level, ensures that patients are provided with timely and equitable access to secondary care specialists, and sets up routine visits to primary care and specialist diabetes services with the collaboration of key stakeholders in the area.
The programme ‘fast-tracks’ urgent cases to vascular surgeons while avoiding unnecessary hospital referrals of patients who can be effectively managed in primary care. Central to the success of this programme has been the implementation in all health centres of a single computerised register of all Maltese diabetic patients. This tool provides information on the actual costs of diabetes care and its burden on the national health budget, allowing health centres to keep track of each patient’s progress within the system and enhancing communication between members of the interdisciplinary teams.
The health system in Portugal is well integrated but is going through a series of initiatives aimed at increasing continuity of care. While a central role is played by GPs, one of the most important innovations are the ‘Mobile Support Units for Home Care’ co-ordinated with the social services. These units, managed by multiprofessional teams including specialised doctors, nurses, and social workers, offer support to patients at home in a state of chronic disease and dependence on technology. They guarantee continuity of care after hospitalisation, reduce hospital admissions and improve quality of life for patients.
In Sweden, one of the main strengths and the principal mean of integration is the communication and information exchange between primary care, secondary care and patients/citizens. All information from primary care is accessible to the hospital staff – even if (as is most often the case) primary health centres and hospitals have different IT systems, health professionals can always see a summary of information. Many Swedish county councils use ‘lean’ management principles – an approach designed to minimise waste and reduce costs while maximising effectiveness – and consequent implementation tools to ensure processes are efficient and to add value to the patient’s experience.
In most European member states, a significant improvement in the delivery of healthcare services has been achieved over the past 10-20 years. In general, changes have not arisen from thorough policies based on a comprehensive vision, but as the result of specific targets and strategies.
In particular, the fostered need to cut waiting lists, reduce emergency admissions, decrease acute care costs and, not least, provide more effective care, have prompted the redistribution of competences and the shift of boundaries between care levels. All over Europe, the trigger for change has been the need to increase technical and operational efficiency. Here, all reforms have tackled delicate issues, sometimes bringing demanding and overarching changes to their management organisation.
Due to a rising and ageing population, efforts have been addressed towards multiple and chronic diseases. Successful cases of co-ordination have relieved GPs from follow-up of cases, making their activity more effective and appropriate, and reducing hospital referrals of non-acute cases but also preventing acute cases.
The introduction of integration and structured multidisciplinary approaches to (complex) patients are often still geographically limited, but successful pilots are likely to be adapted and increasingly used for more extended applications. Many countries have also invested resources and efforts in implementing efficient IT systems. These have proven to be central to addressing integration and continuity of care, and their diffusion and interoperability is probably the key factor to reach further improvements and better care for tomorrow’s Europe.
Gloria Lombardi is Health Economist at HOPE, the European Hospital and Healthcare Federation. She has a background in management and economics for public and international institutions. She develops economic analysis and comparative studies on European hospitals and health systems, and has an expertise in health technology assessment and cross-border co-operation.
Pascal Garel is Chief Executive of HOPE. He has a professional background in healthcare management, with 10 years’ experience working at two French teaching and research hospital centres (Nantes and Rouen).
HOPE is a non-profit organisation, gathering national hospital organisations in the member states of the European Union and Switzerland. One of the objectives of HOPE is to support the exchange of knowledge and expertise across Europe.
1. European Hospital and Healthcare Federation. Better health – a shared challenge between hospital and primary care. HOPE; Brussels: 2011.