Common challenges, common solutions: lessons from primary care in Europe

The Nuffield Trust’s 2013 European Summit on primary health care brought together primary care leaders from 16 countries to discuss the common challenges facing primary care organisations across Europe.

The key findings, published today, should make GPs in England feel encouraged. They are not alone in the pressure they experience and the need to develop new ways of working, and Europe is full of ideas and examples about how to develop and change to meet the challenges of an uncertain future.

A cluster of themes emerged from the Summit, which were common to most countries. Primary care services have a vital role to play in all health systems, and all countries know they must strengthen skills and capacity of primary care to fulfil this broad role, from prevention through to palliative care at the end of life.

All countries know they must adapt services in response to patients with a complex blend of health and social care problems and those from very deprived communities. All countries know that is difficult for small practices to deliver high quality primary care, because of low numbers of staff, limited technology and management support, and variability in access to diagnostics and to specialists.

Discussions about whether and how to scale up general practice are taking place all over England, and it may be reassuring to GPs who are struggling with this question to know that the issues are international

The challenges are common, but there are also many potential solutions. The Summit featured an array of case studies which illustrated imaginative ways to tackle them. Three themes in particular are relevant to current debate on primary care in the NHS.

The first theme is scale, and the benefits that can be obtained from working in larger practices or groups of practices. The Swedish case study practice had merged with its neighbour and become privately owned (competing with other organisations including chains of multiple practices) offering a wider range of services.

The Dutch case study organisation – Zorg In Ontwikkeling (ZIO) – a network of approximately 80 GPs, had a central office which supported practices in many ways. These included: negotiating with payers, workforce development, premises management and advising on best practice for common conditions.

In Croatia, the co-location of GP practices within larger poly-clinics built links between GPs and specialists, increasing the likelihood of integrated working in the future.

Discussions about whether and how to scale up general practice are taking place all over England, and it may be reassuring to GPs who are struggling with this question to know that the issues are international.

A second theme is the need for a response to deprivation and complexity that tailors services around the needs of the person. A case study from a Belgian inner city, a multi-ethnic practice described how longer consultations, motivational support and preventive interventions were used to address the needs of this complex patient group.

These solutions are similar to those described by the Deep End GPs in Glasgow, and also to the techniques advocated for GPs to care for frail older people with multiple co-morbidities.

The new NHS GP contract promotes continuity and tailored care for older people, but the Belgian case study indicates how GPs working with younger people with multiple social and health problems can think creatively about how to create extra time and bring in different services to address their complex needs.

The third theme is how to link GP practices with the numerous other services which can help patients. These were well illustrated by the two English case studies presented at the meeting. Both had developed a range of practice-based specialist and diagnostic services, working in collaboration with local hospital consultants to diversify their services beyond traditional general practice.

Links between primary care, social care, therapists, specialists, diagnostic service, psychological support services and others were also evident in the case studies from Finland, Holland, Croatia and elsewhere.

In each case, GPs had developed associations with other professionals; working in multi-disciplinary teams; sharing the management of complex patients and developing integrated care pathways.

So what might drive a typical English GP practice with 6-7000 patients to take on these new ways of working? The pressures on GPs from growing patient demand, financial constraints, workforce shortages and other factors are unlikely to reduce in the near future. GPs are looking for innovative ways to respond.

The potential benefits of scaling up general practice through mergers and networks are described in a recent Nuffield Trust report, but these require major changes in current organisational arrangements.

This Summit showed that there are other, less challenging places to start. GPs can begin by developing effective working relationships with professionals and services outside the practice, safe in the knowledge that demand for general practice seems unlikely to fall.

The message from the Summit is about courage and ambition. GPs are uniquely well placed to forge collaborations with other practices, other primary care professionals, social services and specialists. Diversifying the range of services on offer in general practice and working collaboratively across practices will improve access for patients and, if managed carefully, could help small practices to become more resilient for the future.