Een geïntegreerde zorgverlening in de eerste lijn
16/02/2017
Table of contents
1Introduction
1.1Adopting one line for strong primary care
1.2Bending lines into circles
2Chapter 1: Why change?
2.1Who or what is Primary Care?
2.2Why reform?
2.3Paradigm shift
2.4Public authorities in one line
2.5Policy phase already undertaken
3Chapter 2: What do we change?
3.1The person with a care and support need at the centre
3.1.1Control in their own hands
3.1.1.1Integrated approach
3.1.1.2Self-management
3.1.1.3Health skills and empowerment
3.1.2Informal care
3.1.3Framing care and support aims
3.1.4The informal caregiver is a fully-fledged partner in care
3.1.5Primary care players also have a role in prevention
3.1.6Signposts in care
3.1.7More care in the neighbourhood
3.1.8Local social policy
3.1.9The care providers in primary care
3.1.10The residential care players are structurally part of primary care
3.1.11Family care
3.1.12Residential care centre
3.1.13Social work services
3.1.14More mental health care in primary care
3.1.15Complex care
3.1.15.1Complex Care: good digital registration and collaboration
3.1.15.2Complex care: the multidisciplinary care team and care coordination
3.1.15.3Complex care: case management in action
3.1.15.4Primary care opts for digital care coordination
3.1.15.5Primary care is the requesting party for good coordination with the hospitals
3.2Support of the care providers
3.2.1Primary care area
3.2.2The regional care area (at regional-urban care region level)
3.2.3The Flemish level: From Partnership Platform to a Flemish Institute for Primary Care
3.3Preconditions
3.3.1Initial training and on-going training
3.3.2Care capacity in primary care
3.3.3Support of primary care practice forms
3.3.4Funding of primary care
3.3.4.1Funding from the federal government
3.3.4.2Funding from the Government of Flanders
3.3.4.3Communicating budgets in closed barrels
3.3.5A digital primary care
3.3.6Innovation and entrepreneurship
3.3.7Quality policy
4CHAPTER 3. Transition
4.1Preparing regulations
4.2Reallocation of staff and resources
4.3Sharing ownership of the reorganisation
5Summary
6Appendices
6.1Lexicon
6.2Division of power Flemish - federal government
1Introduction
1.1Adopting one line for strong primary care
In this country, a lot of work has been done by many generations to create a well-founded, accessible, high-quality and affordable care system.
The Flemish care landscape is still characterised by well-trained, well-intended and hard-working partners who want to alleviate, with their head, heart and hands, the suffering and needs of our fellow countrymen and women and, where possible, to prevent it inflicting them. But that takes place in a fragmented way and from too many different structures. The citizen no longer sees the wood for the trees and has insufficient grasp of the organisation of hiscare[1] and support. The care providers and care workers, too, see too much of their time consumed by administration and meetings. It must become simpler, more effective and more transparent, whereby the care seeker has the maximum control over the organisation of his care.
The Flemish Coalition Agreement 2014-2019 includes a simplification of the primary care structures and the strengthening of primary care. Over the years, a broad consensus has grown concerning the necessity for fundamental reforms in primary care in order both to increase the satisfaction of persons with a care need and their informal caregivers, and to improve the performance of the care as a whole. Furthermore, a unique historic momentum presents itself in which a reform of the hospital sector in this country coincides with the implementation of the sixth state reform and, in particular, with the acquisition of new levers at the level of the Government of Flanders which will facilitate a better alignment between the healthcare sector and the welfare sector.
The Flemish Coalition Agreement also concurs with the principle that this also implies that the individual patient/customer must be more involved in decisions concerning his/her own care, that we recognise him/her as expert in his/her own medical condition or support need.
Together, people with a care need, the healthcare providers and the healthcare practitioners, the institutes that offer care, the healthcare insurers and the government, must now grasp the opportunity to implement a broadly supported reform. In mutual respect and in a participatory and transport process, but in full realisation that we may perhaps never regain such momentum in the future. This text therefore outlines the evolutions and policy direction for primary care in Flanders between now and 2025. This will demand a process that must be evaluated at regular intervals and, if necessary, be adjusted.
In this text we use the term ‘healthcare provider’[2] as a collective term for healthcare providers, healthcare practitioners and services offering care, in compliance with the terminology of the primary care decree[3]. The GP will, in the future organisation of primary care, (continue) to play a crucial role, although collaboration with other disciplines will be encouraged. Integrated care implies an integrated approach regarding the person with a care and support need[4]. A keen sense of enterprise is reflected in a large variety of independent healthcare providers, services and organisations with an extensive range of care services. The citizen has complete freedom of choice in this wide spectrum. That varied care landscape calls for a clear horizon. A clear horizon where the aim is well-defined as a collective quest by care and support users, healthcare providers, healthcare insurers and the government. That aim is the best possible quality of life for and autonomy of our citizen. The citizen must be able to dictate as far a possible that best possible quality of life. Those who are young and strong doe not lie awake at night thinking of that quality of life because it seems so self-evident to them, but they must realise that unrelenting risk behaviour can undermine that quality of life in the future.
Those who are old or in need of care run the risk of a life with limitations, but nevertheless want to keep control over their care in their own hands. That is why the person with a care or support need is central in the thinking and actions of everybody who is professionally or in some other way involved in healthcare and welfare.
1.2Bending lines into circles
The Flemish care landscape with its wealth of players and organisations has thus become confusing and fragmented. And consequently, the person with a care need may not always know how to keep control of his care need in his own hands. The healthcare and welfare sectors have for too long assumed their own compartmentalised organisational system, which allows everything to be neatly allocated to primary, secondary and tertiary healthcare, or placed in the compartment of healthcare, or of welfare, each with its own models and procedures. Everybody realises that the boundaries are blurring and that the position of the person with a care need has irreversibly taken a central position in the care and support model.
Let us bend the lines into circles in a concentric model. In the plans for future care and welfare provision, the objectifiable needs of our population must also take a central place in our thinking and acting. The WHO model positions the informal caregiver, the volunteers and the neighbourhood as the first protective and supporting skin around the person with a care need, who takes central place. When care needs become more complex, primary care must be activated. Considering the increasing care needs of an ageing population, it is of vital important to be able to rely on strong, well developed primary care. This can relieve the more expensive specialised care and contribute to a considerable extent to an accessible, effective and high-quality care system for everybody. Well-organised primary care can also reduce social inequalities in the area of healthcare by optimising the accessibility of care and assuming a signal function.
It is now time to recognise this model consistently in the policy, and to align our structures with it. In this way we will be working on simplification, integration and greater efficiency of organisations and structures.
There is no international travel guide for this collective journey to that new horizon. Those journeys can vary from country to country and are of course dependent on the nature and structures of the care and welfare system already in place, and the care culture that has grown there.
The World Health Organisation does, however, give us a number of tips:
Make sure the journey is participatory and is developed with the stakeholders;
Impose a mandatory public accountability on the players and organisations concerning the resources deployed and the quality of care and services provided;
Confidence cannot grow without transparency in the operation of the organisations and services;
Watch over integrity and good governance;
Provide supporting arguments for policy choices and ensure capacity to take decisions based on sound data, experience and intelligence.
Nobody has ever claimed that planning and undertaking this journey would be easy. Nobody will applaud spontaneously when we leave familiar things behind. Nevertheless, we have a duty to the ever-growing group of largely elderly people with a care and support need to undertake this quest for a new system of collaboration.
In Flemish primary care, we have a tradition of socially inspired enterprise, both individually and collectively. We want to acknowledge, stimulate and appreciate the dynamism this generates. We want to support the innovation that the practical training seeks to achieve during our quest. It is certainly not our intention to impose collaborative models from above. We do, however, want to find the right balance between the very important responsibilities of the players in the field and the role of the government which wants to act in a supportive and effective way, but which can also lay down the main lines, using the WHO recommendations as a compass.
We should also realise that primary care is a shared area of competence of federal, Flemish and local authorities. Without mutual collaboration and agreements, it will never work.
Primary care and hospital care are also linked in terms of budget. A shift of activities and volumes from in-patient care to the home situation also implies a shift of budget from the hospitals to primary care and vice versa. For example, a shortened stay in the maternity ward will imply higher budget requirements for maternity care at home, or less in-patient psychiatric care will result in more home-care psychiatric teams.
It will not be easy, but if we all roll up our sleeves and put our backs into this reorganisation, it will succeed. Thus we will turn fragmented primary care into strong primary care.
You are invited to join us on our journey to convert a number of visions in the near future into change and achievements that will eventually benefit all the stakeholders, and not least the persons with care and support needs.
Thank you for your contribution and interest, which is greatly appreciated.
Jo Vandeurzen
Flemish Minister for Welfare, Public Health and Family
2Chapter 1: Why change?
A primary care conference calls for a number of agreements on the terminology used in order to avoid confusion and unnecessary discussion. For this reason, we first present the terminology of ‘primary care’. The motives for embarking on a change process must be clear from the very start for every participant.
2.1Who or what is Primary Care?
Primary care can be defined as follows[5]:
Refers to directly accessible, ambulatory, general care for non-specified healthcare or welfare (related) problems, whether physical, psychological or social in nature;
Generally represents the first contact with professional care;
Can offer diagnostic, curative, revalidation and palliative care provision for the large majority of problems;
Offers prevention for individuals and risk groups in the indigent population;
Takes into account the personal and social context of people;
Ensures continuity of care over time and between care providers;
Supports the informal care available to the patient/client.
Internationally, much is changing in primary care[6]. The European office of the World Health Organisation published, as a sequel to the World Health Rapport ‘Primary Health Care: now more than ever!’[7] , the report ‘Health 2020: European Policy Framework and Strategy for the 21st century’[8], in which primary care is presented as the corner-stone of a modern healthcare policy:
"The primary care must be a cornerstone in every care system in the 21st century. That remains the focus for Health 2020.How can primary care anticipate the current needs? By creating a favourable climate for partnerships and by encouraging people to participate in new ways in their care and to take better care of their own health. Better and more cost-effective care is possible by making the best possible use of 21st-century instruments and innovations, such as communication technology - digital documents, telemedicine / ehealth - and social media. Viewing the patients as a partner and a source for input and being able to give accountability for what it means to the patient: those too are important principles.”
The academic chamber of reflection also states that primary care today must contribute to achieving the “Quadruple Aim”[9]. This concept formulates 4 aims for care:
- improvement of care as it is experienced by the individual;
- improvement of health at population level with special attention to accessibility and social justice;
- achieving added ‘value’ for the patient in the area of health with the resources deployed;
- ensuring that professionals in healthcare are able to do their work in a good and sustainable manner.
The care providers that are active in primary care in the healthcare sector include: pharmacists, dieticians, general practitioners, physiotherapists, psychologists, dentists, speech therapists, (home care) nurses, midwives, care specialists, occupational therapists, podologists, carers, social workers (list not exhaustive)[10].
We consider the following players in primary care in the welfare sector to be indispensable: the residential care players (services for family care and additional residential care, services for logistic help, services for minders, services for home care [recognition], social welfare services of the health insurance fund, local service centres, services for foster care, day care centres, convalescent centres, centres for short stay, groups of assisted dwellings, residential centres and associations for users and informal caregivers), centres for general welfare (CAW) and public centres for social welfare (OCMW), community work and associations where the poor have their say. Naturally, the youth services and the persons with a disability (VAPH) sector, as well as the Child and Family Agency (K&G), play an important role in primary care. They are part of the policy council that meets monthly with the Flemish Minister for Welfare, Health and Family, where coordination and policy orientation are discussed.
2.2Why reform?
The challenges that make a change process necessary are described below and are based on the abstract[11] from the academic chamber of reflection, which has assisted in the preparation process for this conference:
Demographic and epidemiological developments: we are getting older (in 2016, the average life expectancy for men was 84.6 years and for women 89.1 years). The prevalence of cancer is increasing, as a consequence of this ageing. Partly thanks to improved therapy, cancer is becoming a chronic disease. There is an increase in chronic conditions, with a particular rise of ‘multi-morbidity’ (having several chronic conditions): recent research shows[12] that half of those older than 75 have two or more chronic conditions, while two in every five people older than 75 have four or more chronic conditions. Care processes that focus on one condition are not sufficient here. In order to care properly for the patient, there is a need for a paradigm shift from illness-oriented care to care that takes the aims and preferences of the patient as its starting point[13]. This means an important role for primary care in avoiding the fragmentation of healthcare. Primary care must, with the citizen and patient, adopt the role as ‘integrator’ of the care. The increase in numbers of vulnerable people sets new demands for quality and inter-professional collaboration.
A second challenge is formed by scientific and technological developments and their implications for the affordability of healthcare. Scientific progress offers the perspective of new preventive and curative possibilities in the area of genetics, cardiovascular disease, neuroscience, cancer care and mental health care. It is no longer possible to imagine daily practice in healthcare without IT and communications technology. The stay in hospital is becoming ever shorter, and hospitals are seeing an increase in out-patient admissions. More technology is finding its way into home care. A clear vision must be developed concerning this and adequate strategies for dealing with it. Primary care has a role in translating new insights into the approach to health problems, and this with attention for the ‘relevance’ of the care and avoidance of medicalisation of daily life. Many of these new technologies and pharmaceuticals have an important impact on the healthcare budget, which implies responsible scientific and social choices.
Globalisation and social-cultural developments imply that diversity in society is increasing and that people now look internationally for solutions to their health problems. This means that care providers must have a broader spectrum of forms of interaction if they are to approach every person with a care demand appropriately. With higher education and increasing accessibility of medical information via the internet, some ‘patients’ are evolving more and more into ‘critical consumers’. They are well-informed and expect to enter into a dialogue with the care providers, to assess options together and to reach decisions that best suit their lives. People who belong to ethnic-cultural minorities bring considerable diversity to care situations, and we must deal appropriately with this. The changing social context (more people are working longer and seeking a new work/life balance) has an important impact on informal care (decline in the availability of volunteers, informal care, etc.). There is also a clear change in opinions on quality care at the end of life.