Introduction
Purpose and Values
The biannual conference of the European Primary Care Forum in 2008 has an essentially exploratory purpose. Its aim is to enable participants to identify, define and then appreciate the significance of those critical questions which will determine the future of primary care in Europe. The Forum is looking to support contributions which address, in particular, issues of equitable access, cost effectiveness, clinical quality and the maintenance of continuity of care. Both urban and rural settings are relevant, with their differing but equally important modern pressures.
Context
The context is that of a recent rapid increase in the number of member countries in both the European Union and the WHO European Region, and the growing need to understand more clearly the overall impact on health and public service systems of both the emergent new clinical approaches and service models in contemporary primary health care. While as organisations these range internationally from the small general medical practice to multi-specialist polyclinics, all national health systems share similar pressures for change and development. Collaboration in understanding these pressures and the responses they require is essential in the modern Europe to take forward its economic and social development, and to enhance the overall health status of its divergent but increasingly interdependent communities.
Themes
In this context six common pressures for change and development have been identified from a review of individual states' current policies and relevant international research. These may be regarded as the formative influences on the future organisation of primary health care in Europe. Together they represent the imperative for shared learning.
Theme 1. Urgent health care
The need to contain costs is leading to major structural and staffing changes in primary health care. Urgent health care is becoming a single strategic subject in its own right, as previously separate services for night time cover, accidents, patient transport, minor casualty referrals and emergencies are brought together at both policy and practice levels. There is a new emphasis on Prevention. The changes are having significant implications for the role and location of general medical practitioners, community nurses and others, with new information and clinical technologies paving the way for radical innovations in first contact services and their organisation. The changes require equally important adjustments in patient expectations and public attitudes, and in professional responses to these. Urgent health care is a critical theme for cooperation and integration across Europe.
Theme 2. Migration and Mobility
The growth of international labour markets in health care personnel, allied to greater freedom of movement across national borders within Europe, poses a great challenge to primary health care today. Its values of continuity and confidentiality are under strain, as are its historic service models of comprehensive personal care. With these pressures, however, come opportunities to draw on a larger, multi-ethnic and multi-disciplinary workforce; and on different traditions that make possible alternative service models. These may be more responsive in the future to the particular needs of disadvantaged patient groups and local communities, and the EU Bratislava Declaration provides the potential for more diverse and patient-led services as part of tomorrow's multi-cultural societies. There is a sensitive political balance to be struck between the potential benefits and drawbacks of greater migration and mobility, and this is a topic where the knowledge and wise application of sound European experience is essential.
Theme 3. Specialisms
Since 2000 global development targets have helped to ensure that both multi and inter-professional approaches to primary health care have received renewed attention: in pursuit of broader public health and sector-wide social capital goals. Substitution has been a basic principle, particularly of community care policies, with support for new forms of practitioner also coming from modern universities and the growth of private and voluntary health care agencies. There is both a future threat and opportunity in this trend for the traditional primary health care professional, who must now respond to the requirements of older populations, altered morbidity patterns and increased political performance management. The concept of Specialism increasingly applies now to a service, and to complex as well as single morbidities, rather than a single clinical role or profession. New criteria of what constitutes quality are a decisive factor in this development and awareness of successful innovations in primary health care specialisms across Europe is, therefore, important both to encourage necessary new forms of practice and the appropriate adaptation of existing ones.
Theme 4. Changing hospital interfaces
Across Europe the extension of social market values, and the widespread adoption of 'Autonomy' principles and practices by hospitals, has led to generally greater tensions with primary health care services and professionals. These tensions can extend into competition and even conflict, as hospitals assume wider outreach responsibilities, deploying evidence based clinical protocols and commercial business techniques to promote vertical disease management in their institutional interests. The achievement of cooperative relationships with hospitals as they change their roles, and the need for more integrated and cost effective service delivery models across primary and secondary health care is pivotal to the future viability of international health systems. An understanding of the new clinical and professional relationships required is essential at the interface of primary and secondary care. Leading local practice developments in hospital outreach and domiciliary services, particularly in Eastern Europe may, accordingly, have far reaching impacts and implications.
Theme 5. Workforce
Partly as a result of recent European legislation governing terms of employment and procurement there is now a new fluidity and flexibility in the staffing of primary health care. New roles and changing workforce patterns, in particular, have created a propensity to experiment with novel forms of recruitment and regulation that affect equally local practice and national policies. There is a pressing need to ensure that different workforce developments, and the wider range of contractual options attached to them, are coherent and sustainable. In particular, it is important to be aware of changes in the role of General Medical Practitioners and the emergence of alternatives to the traditional family doctor, especially through popular support for the growth of nurse practitioners. Cooperation between different stakeholders and the systems wide integration of primary health care resources are two important perspectives to apply in workforce analyses; without which many parts of Europe are in danger now of both fragmented and overlapping frontline health care service provision.
Theme 6. Chronic conditions
The trend towards self care and maintenance in the community is common across Europe, as the payers and purchasers of primary health care target their budgetary resources on the growing numbers of patients with long term conditions and extended years of disabled life. Accordingly, new forms of patient empowerment and partnership are developing, often underpinned by USA style consumerism and the shared use of Evidence-based Medicine material with primary health care professionals and practitioners. These relationships require novel forms of governance and coincide with a rapid expansion in relevant clinical research and interventions. Robust evaluations are now required urgently. This is an area where personal continuity of care may be threatened by Americanised disease management protocols, and a new unified knowledge framework and transferable learning for primary care is an important priority.