One of the weak points of our current primary care system—that is primary health care and community care together—is the lack of an integrated approach. This applies especially to the prevention, treatment and long term care of elderly persons and the chronically ill. Primary care appears like a group of islands with little connection; each island with its own practices, professional characteristics and standards. We perceive family doctors, physiotherapists, pharmacists, dentists, mother and child carers, all kinds of nurses (district nurses, practice nurses, nurse specialists, home nurses, auxiliary community nurses), home care workers, psychologists, social workers, welfare workers, etc.; all doing their best from their own point of view to help the patient. However, most of them are working next to each other instead of working with each other.
But care does not stop at the threshold of your own practice and your own profession. An integrated and multidisciplinary approach is necessary to achieve a health care supply chain connecting with the needs and demands of the patient. A supply chain that turns around the patient instead of the patient trying to find his way between the islands. A supply chain that takes into account a patient who more and more wishes to stay in his own surrounding, neighbourhood and home, even when the need for more complex care arises. Home is also the service flat, the old people's home and the nursing home. In the future, primary care and care at home will be the standard and multidisciplinary cooperation will be the key to a more patient oriented approach.
An integrated and more organised approach to primary care is needed. An approach with working agreements on who supplies which treatment or gives which care when and where, as well as who communicates with whom and who is responsible for the coordination. The continuity of care asks for a redesign within and between primary care and community care in order to achieve one coordinated approach in the neighbourhood of the patient. As to how large a neighbourhood / community / region is, we should always keep in mind that health care delivery—although the organisational level can be larger—should be on a relatively small scale, so that the human dimension is not lost.
Where does this take us? What does the future of an integrated and coordinated primary care look like?
At the base are the collaborating health service professionals and community care workers in and from a Community Health Centre (CHC) that is centrally located in the neighbourhood and directly accessible. The CHC operates as one window for all questions and needs concerning health and care.
Experience has taught us that a scale of approximately 10,000 inhabitants offers the best possibilities for an effective multidisciplinary cooperation, task differentiation, quality improvement and business economics, while at the same time the patient will be recognised by the staff as a person and not as an anonymous number.
In the ideal situation, the CHC contains: family practice, nursing care, home care, pharmaceutical care, paramedical care, psychological care, child clinic, social care, mental health care, diagnostic facilities. There should be a possibility for social encounter and eating facilities especially for the elderly and disabled. A few GP beds for observation and short stay would diminish an unnecessary stay in hospital. A combination of CHC and Housing facilities for the elderly would lead to an integrated housing, care and social facility in the neighbourhood. There could be an integrated website where tenants and residents in the neighbourhood / community / region could ask online questions and would find online answers and information about their health and welfare questions.
Integrated and client orientated care is provided by applying clinical guidelines, multidisciplinary working agreements and health care supply agreements for common diseases and complex afflictions like: diabetes, chronic respiratory diseases, stroke, heart failure, depression, stress, dementia, hypertension, and sicknesses to the movement apparatus. Furthermore, there will be a policy towards: drug prescription, referral behaviour (gate keeping) and early recognition of problems (somatic, mental, educational).
Quality development takes place by the care workers themselves, supported and facilitated to this end. Effective leadership and management is necessary to ensure teamwork, output and budget agreements. Electronically connected patient files prepare the way to a more population based care in which a better transfer between care workers, prevention, determination of risk groups, and early alert of health and social problems, will make the care more patient oriented and to the point.
The CHC gives an answer to the change in demands, social change and to the rationalisation of care. In the end, the CHC functions as one window to all questions on health, care, social problems and well being. The CHC could be, so to speak, the heart of the neighbourhood. A better organised and modernised provision of care close to the patient, also offers the opportunity to give primary care a central role in the management of chronic diseases. To that end organised primary care could make arrangements with the health insurance system to take responsibility for health care supply chains (for example, diabetes) and purchase, if necessary, the missing care and treatment from others (hospitals). In doing so the CHC, as part of a better organised and integrated primary care system, focuses on patient empowerment, high quality of care and cost effectiveness.
One warning remains: organisation, integration and cooperation are never the goals in themselves. If they become so, there lures the danger of an organisation-centred or staff-centred approach that is not in the interest of the patients. There is no such thing as the one and only solution. If there was, the proposed CHCs would be not be possible, for instance, in small communities of less than 10,000 inhabitants. The solution prescribed here has to be seen as a way of thinking in which the patient is in the centre and ultimately in the drivers seat.
During the congress on the Future of Primary Health Care on October 11–13, 2006 the optimal content, processes and structure of the community health centre will be discussed. Please surf to http://www.futureofprimarycare.com.
Han van Oosterbos
Former Chief Executive of the Care Group Almere, The Netherlands Chairman of the Congress Committee The Future of Primary Care in Europe October 11–13, 2006 in Utrecht, the Netherlands