PRIMARY HEALTH CARE IN A EUROPEAN PERSPECTIVE
Jan De Maeseneer1
Editorial
Epidemiological studies during the last five decades have documented the constant ecology of medical care (1, 2): the majority of the health complaints of the people are dealt with trough self care and primary care, delivered in the local community. Only between five to ten percent of health problems are cared for in specialist care, hospitals and university hospitals. In contrast to this finding, only little attention has been paid to the development of primary care by politicians in the European Union. Moreover there is confusion about the concept: to be pragmatic, we would define primary care as »>continuous ambulatory care for undifferentiated problems with a generalist approach, delivered in the community by physicians and other health care providers, to whom the population has direct access«.
The key-features of primary care are a patient-centered responsiveness to all kinds of health problems in all kind of population groups, with special attention to the most vulnerable groups in society (elderly people, people living in poverty, ethnic minorities, chronic patients, ^).This responsiveness requires a patient-centered comprehensive approach and an unrestricted access of patients to primary care providers. More than half of the EU-member-states therefore do not require patients to contribute for general practitioners' care. The underlying rationale for this policy is that one should not discourage people from access to a very cost-effective level of care. A second key-feature of primary health care is the »navigation«-function: this function is on the one hand related to the undifferentiated scala of complaints that are presented at the primary care level, which asks for orientation and to the fact that specialist care becomes more and more fragmented so there is a need for a »general practitioner« that helps the patient to navigate in the most adequate way in the health care system. In a lot of countries general practitioners have a »gate-keeping role«. This means that they are responsible for adequate referral and guidance of patients to the secondary level of care, which may be cost-effective, provided that general practitioners have a financial incentive for efficient prescription and referral behaviour.
The third key-feature of primary care is its orientation towards the needs of individuals, in the context of their families and communities. Therefore family physicians operate in the framework of the local primary health care team utilising an interdisciplinary approach.
These key-features of primary care in the European Union are embedded in the three global policy objectives for health care as they are established by the European Council of 2002 in Barcelona: guaranteeing high quality care; guaranteeing equal access to services and guaranteeing financing mechanisms based on solidarity.
These three principles that distinguish health care in Europe from e.g. health care in the United States of America, are the results of centuries of historical developments in different parts of Europe, each with their own characteristics.The European countries can be clustered in three »subregions« as far as health care development is concerned: the North-West region with high emphasis on transparency, social accountability, implementation of EBM-guidelines;the South with orientation on flexibility and patient-cente-redness with emphasis on the individual doctor-patient relationship (the »colloque singulier«) and the Eastern-European countries with their historical focus on the population-oriented approach and systematic prevention.
These differentiated developments create an historical opportunity towards the building of a European primary health care environment integrating the strong assets of transparency, a practice based on scientific guidelines, flexibility and patient-centered-ness with a community-oriented approach looking at prevention and health promotion.The development of this European primary health care environment is however threatened by the promotion and implementation of market principles and profit-driven »USAtype« approach of health insurance.
1University Hospital - 1K3, Department of Family Medicine and Primary Health Care, De Pintelaan 185, B-9000 Gent, Belgium Correspondence to: e-mail: jan.demaeseneer@UGent.be
The question remains which model Europe has to go for?
Probably the »community oriented primary care«-approach could be a worthwhile concept, as it integrates the strong points of the different historical developments and places the primary care in the perspective of social accountability (3). In the community oriented primary care approach, the problems of individuals are taken as a starting point for a wider analysis of health problems in the community (4). Epidemiological data inform the primary care team about the most important problems in the local community, and are supplemented by both qualitative and quantitative appraisal of health problems. All the relevant information may than be integrated in a »community diagnosis«, where the different problems are listed and priorities are set with involvement of the local population. Based on a strategic plan, interventions to improve the health situation are planned and put into practice, involving the local stakeholders and community. Interventions are permanently monitored and evaluated. Such a cyclic approach may give a new perspective to the individual patient-oriented primary care practice.
There are three main reasons why primary care in the local community deserves more attention. The first is an economical reason: there is evidence that primary care is cost-effective: countries with a strong primary care component in their health care system perform well on relevant outcome indicators (5). Secondly, primary care puts the person of the patient with his complaints, concerns, emotions, uncertainties, in the middle of the care process, integrates all the relevant health information (e.g. in the electronic patient record) and prevents fragmentation of the care process. Finally there is also a political reason why investment in primary care is worthwhile: primary care contributes to social cohesion. The primary health care provider is one of the few persons that show the people that policy makers are taking care for them and take their (health) problems seriously. This may contribute to a better social climate, and may prevent people from becoming disappointed and look for non-democratic right-wing »political options«. In April 2005, the European Forum for Primary Care has been created, aiming at the exchange of experiences, the distribution of practices and the development of primary health care in Europe (www.euprima-rycare.org).The Forum wants to connect three groups of stakeholders in the field of Primary Care:
-	the health care field; this includes practitioners from the different professions: physicians, nurses, social workers, physiotherapists, dentists and several others;
-	health policy makers;
-	the producers and evaluators of (health) care information.
These parties work at three levels: the local or district level, the national level and the supra-national level. By linking policy, practice and research the Forum intends to stimulate policy making based on vision and evidence as much as it intends to support primary care practice oriented towards quality and equity. The Forum monitors policies in the European Union as far as they bear relevance to Primary Care, it informs its members and offers its reflections and opinions. However, the Forum is not limited to member states of the European Union but encompasses all European countries.
A comprehensive primary health care service, oriented towards the needs of individuals, their families and communities, embedded in an accessible high quality health care system, based on solidarity, could be one of Europe's best export products.
References
1.	White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961; 885-92.
2.	Green LA, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001; 344: 2021-5.
3.	De Maeseneer J, Derese A. Community oriented primary care. European Journal of General Practice 1998; 4: 49-50.
4.	Rhyne R, Bogue R, Kukulka et al. Community-oriented primary care: health care for the 21s'century. American Public Health Association, Washington, 2001.
5.	Starfield B, Shi L. Policy relevant determinants of health. Health Policy 2002;60:201-218.
PRIMARNO ZDRAVSTVENO VARSTVO IZ EVROPSKE
PERSPEKTIVE
Jan De Maeseneer1
Uvodnik
Epidemiolo{ke {tudije zadnjih petdesetih let podarjajo pomen ekologije zdravstva (1, 2). Ljudje poi{čejo pomoč za večino svojih zdravstvenih težav v primarnem zdravstvenem varstvu v svoji lokalni skupnosti ali pa se zdravijo sami. Le pet do deset odstotkov bolezni zdravijo specialistične službe, bolni{nice in klinični centri. Politiki v Evropski uniji pa kljub temu posvečajo le malo pozornosti razvoju primarnega zdravstvenega varstva. Še več, precej nejasnosti je tudi pri opredelitvi tega koncepta. Pragmatično bi primarno zdravstvo lahko opredelili kot »splošnozdrav-niško ambulantno obravnavo nediferenciranih bolezni, ki jo nudijo zdravniki ali drugi zdravstveni delavci v lokalni skupnosti, do katerih imajo prebivalci neposreden dostop.«
Bistvena značilnost primarnega zdravstvenega varstva je odzivnost na vse vrste zdravstvenih težav v vseh skupinah prebivalcev; usmerjena je k posameznemu bolniku, posebno pozornost pa posveča skrbi za ogrožene družbene skupine, kot so to ostareli, revni, etnične manjšine in kronični bolniki. Ta odzivnost temelji na celostni obravnavi bolnika in neomejenem dostopu bolnikov do zdravnika splošne prakse. V več kot polovici držav članic Evropske unije zato bolnikom primarnega zdravstvenega varstva ni treba plačevati. Vodilo te politike je, da ljudi ne smemo odvračati od uporabe te strokovno učinkovite ravni zdravstvenega varstva.
Druga bistvena značilnost primarnega zdravstva je njegova t.i. navigacijska funkcija. Ta je bistvenega pomena zaradi široke palete nediferenciranih bolezni, s katerimi se srečuje primarno zdravstveno varstvo. Zato je nujno usmerjanje, zaradi vedno večje razdrobljenosti specialističnega zdravstva pa so večje tudi potrebe po »splošnem zdravniku«, ki naj pomaga bolnikom čim učinkoviteje »krmariti« po zdravstvene sistemu. Zdravniki splošne prakse v mnogih državah imajo vlogo »nogometnega vratarja«, kar pomeni, da so odgovorni za ustrezne napotitve in usmerjanje bolnikov na sekundarno raven zdravstvene službe. Stroškovna učinkovitost te službe je odvisna od tega, v kolikšni meri so zdravniki finančno motivirani za ustrezno predpisovanje zdravil in napotitve bolnikov k specialistom.
Tretja ključna značilnost primarnega zdravstva je usmerjenost k potrebam posameznika v okviru družine in skupnosti. Družinski zdravniki zato delajo v lokalnem timu primarnega zdravstvenega varstva, ki temelji na načelu interdisciplinarnosti. Naštete ključne značilnosti primarnega zdravstvenega varstva v Evropski uniji so vgrajene v cilje globalne zdravstvene politike, ki jih je oblikoval Evropski svet v Barceloni leta 2002. To pa so: zagotavljanje visoke kakovostne ravni zdravstvenega varstva, zagotavljanje enakopravnega dostopa do zdravstvene oskrbe in zagotavljanje mehanizmov, temelječih na solidarnosti.
Ta tri načela, po katerih se zdravstveno varstvo Evropske unije razlikuje od zdravstvenega varstva npr. v Združenih državah Amerike, so se oblikovala v stoletjih zgodovinskega razvoja v različnih delih Evrope, od katerih ima vsak svoje značilnosti. Glede na razvoj zdravstvenega varstva v njih, lahko evropske države razdelimo v tri podobmočja. Prvo je severozahodno območje, za katerega je značilna preglednost, socialna naravnanost, izvajanje smernic EBM. Sledi južna regija, kjer poudarjajo prožnost in usmerjenost zdravstvenega varstva k posameznemu bolniku ter pomen odnosa med zdravnikom in bolnikom (»collo-que singulier«). Tretje področje tvorijo države vzhodne Evrope, za katere je značilna zgodovinska usmerjenost k populacijskim metodam in sistematični preventivni dejavnosti.
Te različne poti razvoja zdravstva ponujajo zgodovinsko priložnost za oblikovanje skupnega evropskega okolja za razvoj primarnega zdravstvenega varstva, ki bi povezovalo prednosti, kot so transparentnost, prožnost in usmerjenost naposredno k bolniku, s populacijskimi preventivnimi dejavnostmi in krepitvijo zdravja.
Razvoj takšnega okolja primarnega zdravstvenega varstva v Evropi pa je ogrožen zaradi uvajanja načel tržnega gospodarstva in »ameriškega tipa« zdravstvenega zavarovanja, usmerjenega le k dobičku. Odprto ostaja vprašanje, za kateri model naj se odloči Evropa.
Primarno zdravstveno varstvo, usmerjeno k skupnosti, morda ponuja pravo pot, saj združuje prednosti,
1University Hospital - 1K3, Department of Family Medicine and Primary Health Care, De Pintelaan 185, B-9000 Gent, Belgium Kontaktni naslov: e-pošta: jan.demaeseneer@UGent.be
ki so se oblikovale v zgodovinskem razvoju z družbeno odgovornostjo (3). Načelo primarnega zdravstvenega varstva, usmerjenega neposredno k skupnosti, je v tem, da pri preučevanju zdravstvenih problemov skupnosti izhaja iz zdravstvenih težav posameznika (4). Na osnovi pridobljenih epidemioloških podatkov, se tim delavcev v primarnem zdravstvu seznani z najpomembnejšimi zdravstvenimi problemi lokalne skupnosti in to nadgradi s kvalitativno in kvantitativno analizo teh bolezni.Vsi relevantni podatki so lahko vključeni v »diagnozo skupnosti«, kjer so našteti različni problemi in opredeljene prednostne naloge, ob vključevanju lokalnega prebivalstva. Ukrepi za izboljšanje zdravstvenega stanja so načrtovani in izpeljani na osnovi strateških usmeritev in vključujejo sodelovanje lokalnih prebivalcev in interesnih skupin, ukrepe pa je treba stalno spremljati in ocenjevati. Takšen ciklični način dela prinaša nove obete primarnemu zdravstvenemu varstvu, ki je usmerjeno predvsem k bolniku. Primarnemu zdravstvenemu varstvu na ravni lokalne skupnosti je treba posvečati več pozornosti zaradi treh razlogov. Prvi razlog je ekonomski. Dokazano je, da je primarno zdravstvo stroškovno učinkovito. Države, v katerih igra primarno zdravstveno varstvo pomembno vlogo v zdravstvenem sistemu, se lahko pohvalijo z dobrimi rezultati na področju zdravja (5). Drugič, primarno zdravstveno varstvo umešča bolnika kot osebnost z vsemi težavami, strahovi, občutenji in negotovostmi v središče procesa zdravljenja, združuje vse pomembne zdravstvene podatke (npr. elektronska zdravstvena kartoteka) in preprečuje razdrobljenost zdravstvenega procesa. In nazadnje, za smiselnost vlaganja v primarno zdravstveno varstvo obstajajo tudi politični razlogi, saj primarno zdravstvo prispeva k večji družbeni povezanosti. Zaposleni v primarnem zdravstvu so eni redkih, ki lahko ljudem pokažejo, da politika resno obravnava njih in njihove (zdravstvene) probleme. To dejstvo lahko prispeva k ugodnejšemu družbenemu ozračju in preprečuje, da bi se ljudje zaradi razočaranja zatekali k nedemokratičnim desničarsko usmerjenim političnim opcijam. Aprila 2005 je bil ustanovljen Evropski forum za pri-
marno zdravstveno varstvo. Njegov cilj je izmenjava izkušenj, obveščanje o delu in razvijanje primarnega zdravstva v Evropi (www.euprimarycare.org). Forum želi povezati tri interesne skupine na področju primarnega zdravstvenega varstva, in sicer:
-	področje zdravstvenega varstva, kjer delajo strokovnjaki raznih profilov, kot so zdravniki, medicinske sestre, socialni delavci, fizioterapevti, zobozdravniki in drugi;
-	zdravstveno politiko;
-	strokovnjake na področju zbiranja in evalvacije zdravstvenih podatkov.
Te skupine delajo na treh ravneh in sicer na lokalni, državni in naddržavni. S povezovanjem politike, prakse in raziskovalnega dela želi Forum spodbuditi politične pobude, ki bi temeljile tako na viziji kot na dokazih, obenem pa želi podpreti primarno zdravstveno varstvo, usmerjeno h kakovosti in enakosti. Forum spremlja politiko Evropske unije, pomembno za primarno zdravstveno varstvo, redno obvešča svoje članice in druge in jim sporoča svoje mnenje in ugotovitve. Forum zajema vse Evropske države in ni omejen le na članice Evropske unije. Celovito primarno zdravstveno varstvo, ki upošteva potrebe posameznikov, njihovih družin in skupnosti in je sestavni del dostopnega in kakovostnega zdravstvenega sistema, temelječega na solidarnosti, lahko postane eden najboljših izvoznih »artiklov« Evrope.
Literatura
1.	White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961; 885-92.
2.	Green LA, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001; 344: 2021-5.
3.	De Maeseneer J, Derese A. Community oriented primary care. European Journal of General Practice 1998; 4: 49-50.
4.	Rhyne R, Bogue R, Kukulka et al. Community-oriented primary care: health care for the 21s'century. American Public Health Association, Washington, 2001.
5.	Starfield B, Shi L. Policy relevant determinants of health. Health Policy 2002;60:201-218.