equipocesca

Rethinking the health service production function: What role for primary health care in modern health service provision?

Seminar of Innovation in Primary Care. Oxford (UK), 29nd September 2012

Organized by Juan Gérvas MD, PhD (general practitioner, Equipo CESCA, Madrid, Spain; visiting professor, International Health, National School of Public Health, Madrid) and José M. Valderas MD, PhD (Professor, Department of Primary Care, Oxford, United Kingdom).

Health policy-making is by definition concerned with selecting health interventions between different alternatives. Evidence exist that some of those interventions have to be inter-sectoral actions, prompting other sectors to “do something good for health”, such as increasing tobacco taxes in order to reduce smoking. However, the bulk of the actions promoted by most health policies are (hopefully cost-effective) health services in response to well assessed health needs. There are very many types of services, defined in many different ways (e.g. laboratory services, nursing services, emergency services).

When defining those services we prescribe the use of well defined inputs in the expectation to produce some precise outputs and outcomes. For example, without narcotic analgesics and skilled primary care professionals it will extremely difficult to take care of terminal patients at home. Having both, however, is not sufficient guarantee that the above mentioned outputs and outcomes will be optimum. A number of important issues emerge therefore: what is the best mix of skills?, for example; or how to offer continuity of care for these patients (and relatives) during out-of-working schedule?; or, what is the role of palliative teams, and in general that of the hospital?; etc.

The answers to those questions have been the body of intense debate for decades, and they have remained reasonably stable. We now need to think about health systems, however, as organizations which offer services in a changing world, with changing technologies and therefore changing boundaries regarding the “best location” for the services, with private and public stakeholders wanting to participate in what has become a phenomenally important economic activity, strong resistance to change by many who fear that change may mean the end on long-cherished privileges, and so on and so forth.

In other words, there is a need to answer (again!) a number of critical questions that will determine the way health care will be delivered in the coming decades, such as:

1. who, where and when should take care of whom, suffering from which diseases-problems and under which circumstances?
2. what is the “right” location for each type of care?
3. who is expected to do what in each particular moment in order to improve the situation in the most efficient way?
4. how to set up in each period the (unavoidably fluid) “boundaries” to be articulated in the process of care?

and indeed many others.

I would like to suggest the document about “What role for primary  health care in modern health service provision?” for launching the debate that should lead us to the seminar proposed for the Autumn of 2012. The paper is the product of a number of reflections by me, Juan Gervas, with open discussions for a number of months with Antonio Durán and Barbara Starfield, unfortunately interrupted by Barbara’s death. It is not certainly not presented as any kind of dogma but rather as a sincere review of what used to be solid certainties and now are openly challengeable convictions, open to criticism. An ongoing on-line debate is also expected to take place along the tradition of our seminars, ending with a paper to be published in a peer-review journal after the face-to-face meeting.

Inscription for the seminar will be free but request is needed to Juan Gérvas (jgervasc@meditex.es as well as mpf1945@gmail.com) and to Raimundo Pastor (rpastors@meditex.es).

Thanks to you all.

• What role for primary health care in modern health service provision?. Gérvas, J. Septiembre, 2011. Descargar texto completo aquí. Download English version here.

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The Lancet published in May a few papers about the Brazilian health system, none of them on primary care, or with a focus on health policy. Therefore, important questions were kept out of the debate. This letter highlights some of the critical questions as maldistribution of doctors.

• Brazilian health service organization: problems at a glance. Gusso G, Pérez Fernández M, Gérvas J. Lancet. 2011; 378: 316-7. Download English version here.

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Brazil, with almost 200 millions inhabitants, has a public primary health system that covers 60% of the population. Health centers are public, with professionals working as public employees, and organized in health teams (one per 4.000 inhabitans, with a family physician, a nurse, an auxiliar and six agents of communiyt health). The Strategy of Family Medicine is supporting the work in the health centers. In this text, the authors present a summary of their recommendations to improve primary care in Brazil, after a field trial (visiting 19 States, 32 towns and 70 health centers).

• ¿Cómo construir una Atención Primaria fuerte en Brasil?. Gérvas, J., Pérez Fernández, M. Agosto 2011. Download English version here.

See comentary published in the Canadian Journal Medical Association: Brazilian health care faces harsh choices. Download pdf version of the article here.

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Barbara Starfield died 10th June 2011. She was a giant of primary health care. Her publications have being critical for building up a framework for health services researh, and for health policy. This obituary remember her work and life.

• Quando um gigante cai, os añoes ficam sem sombra. Gérvas, J., Peréz Fernández, M. Rev Soc Bras Med Fam Comunit. 2011; 6 (9). Download English version here.

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Seminars of Innovation in Primary Care started in 2005 and they are still on in 2011. This text explains how the Seminars are organized, the methodology and how they finish with formal publications. Key points are the on-line debate before and after the face-to-face workshop, the themes selected, the difussion of practical and theoretical questions and a mix of participants with very different backgrounds.

• Primary Care Innovation Seminars: An experience in dissemination of knowledge on network. Minué, S., Gérvas, J., Violán, C. Madrid. 2009. Download complete text here.

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Iodine supplements during pregnancy could be a dangerous practice in places with normal and medium level de iodine food content. Spanish data show that iodine supplements are associate with problems of the thyroid gland (in the female) and problems in the psychological-motor development of the offspring (girls).

• Iodine supplements to pregnant women. Gérvas J. Marzo de 2011. Note for Tiago Villanueva’s blog. Download text here and longer text in Villanueva’s blog at the BMJ.

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Flu H2N2 is presented as a terrible epidemic in the XX century, with one and half million deads from 1957 to 1968. But this data only give an impression of severity as we can expect around five millions with a “normal” seasonal flu in this period of time.

• Flu H2N2, mortality and vaccination. Gérvas J. March 2011. Download English version here.

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