Sound and timely scientific advice is an essential requirement for the European Commission to elaborate its own policy making and to assist member states in their efforts to pursue modern, responsive and sustainable health systems. To this end, the Commission set up in 2012 a multi-disciplinary and independent Expert Panel on Effective Ways of Investing in Health (EXPH) that began its activities on 11 July 2013. The core element of the Expert Panel mission is to provide the Commission with informal advice in response to questions submitted by the Commission on matters related to health care modernization, responsiveness and sustainability. The Expert Panel consists of 12 international experts from a variety of disciplines and countries.
On 10 July 2014, the Expert Panel launched the report on definition of a frame of reference in relation to primary care with a special emphasis on financing systems and referral systems (EXPH, 2014a). The Panel formulated a ‘core definition’ considering that:
‘… primary care is the provision of universally accessible, integrated person-centered, comprehensive health and community services provided by a team of professionals accountable for addressing a large majority of personal health needs. The services are delivered in a sustained partnership with patients and informal care givers, in the context of family and community, and play a central role in the overall coordination and continuity of people’s care. The professionals active in primary care teams include, among others, dentists, dieticians, general practitioners/family physicians, midwives, nurses, occupational therapists, optometrists, pharmacists, psychologists and social workers’.
(EXPH, 2014a: 4)
Starting from this definition the Panel reflects on the balance between continuity and access. The report states clearly that the role of primary care as the lynchpin of the wider team is becoming more significant with inter-professional cooperation being key in primary care settings.
A strong primary care system can be the starting point for effective referral and discharge systems, ensuring integration between different levels of care. An effective referral system benefits patients and health professionals. Referral is often thought of as a linear process in which a patient is transferred from one provider to another. This model is most appropriate for people with new (non-life-threatening) health problems, the reasons for which may be unclear for patient and provider and therefore are best presented at the primary care level. Usually, all year round 10% of these problems will require referral to other providers. For people with chronic conditions, and especially for those with multiple conditions, a ‘spiral’ model of referral may be more appropriate. Patients are referred within primary care and between different levels of the system on an ongoing basis. This requires a high degree of coordination, explicit definitions of the responsibilities of the providers involved and good information for patients. The report concludes that gate-keeping can offer advantages to patients, providers and the health system so long as important organizational and patient management factors are taken into account.
The Expert Panel emphasizes the importance of ensuring that primary care services are accessed by the population without people facing financial hardship and notes that there is little evidence that user charges lead to more appropriate use and cost control. When user charges are present, there should be mechanisms to protect people with low incomes and those who regularly use health care. European Union health systems show a trend towards blended provider payment systems in primary care, combining risk-adjusted capitation with some fee-for-service reimbursement. The Opinion describes factors that may contribute to the effectiveness of pay-for-performance programmes and implementation features that may weaken the effectiveness of financial incentives.
Finally, the Opinion formulates general research questions in relation to the development of primary care in Europe and specific research question in relation to referral and financing and strategic directions at different levels.
An interesting aspect is that a public consultation on the Opinion took place via the website from 20 March to 19 May 2014. In total, 59 organizations and one individual participated in the public consultation, providing a lot of input to the Opinion. In total, 286 contributions were received. This indicates that primary care is a relevant topic nowadays for all stakeholders (EXPH, 2014b).
Up to now there have been very positive reactions on the Opinion: The Lancet was one of the first to react in an editorial: ‘Making primary care people-centered: a twenty first century blueprint’ on 26 July 2014 (The Lancet, 2014).
The Expert Panel recently published another opinion ‘Future EU agenda on quality of health care with a special emphasis on patient safety’ and is working on two new opinions: one on ‘access’ and the other on ‘disruptive innovation’, which will be available at http://ec.europa.eu/health/expert_panel/opinions/. By publishing these opinions the Panel aims to contribute to the debate on the future development of health systems in Europe.
