Researcher, NIVEL – Netherlands Institute for Health Services Research
Peter P Groenewegen PhD
Director, NIVEL – Netherlands Institute for Health Services Research and Utrecht University, Dept of Sociology, Dept of Human Geography, European Forum for Primary Care
Johan Hansen PhD
Senior Researcher, NIVEL – Netherlands Institute for Health Services Research
Nick Black MD FFPHM FRCS
Professor of Health Service Research, London School of Hygiene and Tropical Medicine, London, UK
Received date: 27 February 2011; Accepted date: 10 March 2011
BackgroundAll European health systems face several common challenges related to increases in lifestyle and chronic diseases, a decreasing future workforce, inequalities in health and the consequences of societal changes. Primary care, which has the potential to help meet these challenges, would benefit from the contribution of health services research (HSR) on a wide range of topics. As funding for such research is limited, priorities need to be defined. AimWith the European Union (EU) funded project Health Services Research into European Policy and Practice (HSREPP) we identified several HSR priority areas for health care in general across Europe. This article focuses on our findings as they apply to primary care. MethodsGeneral findings of the HSREPP project were based on bibliometric analyses of past research and ongoing EU-funded projects, an online expert survey and conference discussion.We checked these general findings by presenting the preliminary results at the third biannual conference of the European Forum for Primary Care in 2010. During this conference a debate was held on whether the identified research topics were also applicable to primary care. ResultsSeveral research areas were identified. At the level of the healthcare system these areas included evaluation of primary care reforms, the influence of funding on cooperation between primary care providers plus workforce management and migration. At the organisational level the relationship between primary and secondary care, the internal organisation of primary care settings, patient involvement and community oriented care and aspects of professional–manager relations need to be studied. Finally, the role of primary care in increasing equity in access and health outcomes was found to be an important topic for future research. ConclusionsGiven funding constraints, it is imperative that research priorities are identified to ensure that resources are devoted to the most pressing and important issues facing primary care. Priority areas for future research are amongst others the evaluation of primary care reforms in Europe, and the relations between primary and secondary care.
health services research, primary care, priority setting
Health services research (HSR) is an increasingly important resource for the efficient and sustainable organisation of health service delivery. It is commonly defined as:
•.the multidisciplinary field of scientific investigation that studies how social factors, financial systems, organisa-tional structures and processes, health technologies and personal behaviours affect access to health care, the quality and cost of health care and, ultimately, the health and wellbeing of citizens.[1,2]
HSR is important in shaping and supporting health-care delivery and health system design in Europe. As Funding for HSR is scarce and competes with other priority areas of European Union (EU) Funding, it is important to identify research priorities. In this article we propose and discuss some priorities for HSR with regard to primary care in order to meet the future information needs of policy makers in Europe. The outcomes can offer support in shaping both research programmes for primary care and general research programmes at a national and a European level. The article is mainly based on the EU-funded project Health Services Research into European Policy and Practice (HSREPP), the aim of which was to identify HSR priorities for use in future European research programmes. We focus on research priorities for primary care for two reasons. First, primary care has a major impact on the whole healthcare system. A well-organised primary care system has the potential to prevent more specialised and often more expensive parts of healthcare systems from becoming over-loaded. Second, there is much variation in primary care organisation and strength of primary care within Europe. New member states of the EU are still transforming their healthcare systems from special-ist/polyclinic-based systems to primary care-based systems. This underscores the need for opportunities to learn from other countries.
Our line of reasoning is that European healthcare systems face a number of common challenges and that primary care can play an important role in coping with these challenges. However, we need to know more about how primary care can play that role and in this article we discuss the research priorities for generating this knowledge.
Challenges for European healthcare systems
European healthcare systems face a number of com-mon problems and HSR can contribute to their solution.[4,5] The first problem arises from two conse-quences of an ageing population (apart from the positive side that most people value a long life!). First is the changing nature of health problems from acute and infectious disease to non-communicable, lifestyle related and long-term disease. With increasing age multiple morbidity also increases. Health problems in older citizens are often intermingled with social prob-lems, such as loneliness as a result of the death of a spouse. Healthcare systems have to anticipate and adapt to these changes. Specialisation and a strong delineation between health care and social care have to be overcome. The second side of an ageing European population is that the proportion of young people diminishes. This poses a serious threat to the future healthcare work-force. Fewer young people over the coming decades can be expected to increase competition between sectors and countries to recruit the best students. HSR should address the problem of an increasing need for health care in a situation of decreasing availability of health workers.
The second common problem facing European healthcare systems relates to inequalities in health. The increasing life expectancy of Europeans is unequally distributed both geographically and socially, within and between countries. The consensus is that there is an increase rather than a decrease in health inequal-ities. Socioeconomic inequalities in health account for a substantial part of the economic cost of health care, social security benefits, reduced labour productivity and welfare losses. Health care can help to counteract the increasing trend in health inequalities in two ways; first by improving access to good quality care for all population groups and second by designing special programmes that address the health of specific groups in society.
The third problem relates to societal changes that permeate healthcare systems and for which healthcare systems have to find solutions. An important social cultural change is individualisation; the long-term process in Western societies of diminishing depen-dence of citizens on their social environment and increasing autonomy and freedom of choice. Indi-vidualisation is associated with the wish of people to stay in their own homes and live independently. At the same time the possibilities of realising this are ham-pered by another consequence of individualisation, namely a decrease in the cohesiveness of local social relations. The process of individualisation also influ-ences the mutual expectations and the relations be-tween citizens and healthcare professionals. Due to the availability of more information through, for example, the internet, citizens have developed their knowledge on health care and in line with this their demands for health care. Moreover, patients have become more involved in the decision-making process.
Another important societal change affecting health care is the increasing use of markets in health care. The shift towards more long-term diseases requires healthcare systems to integrate care and to counter fragmentation. Market-oriented health care has poss-ible repercussions on the way healthcare organisations are able to cooperate and provide integrated care. Healthcare providers who perceive more competition in their professional environment tend to express less trust in their colleagues. Information that used to be shared might be seen as commercially sensitive and no longer to be shared. Some forms of cooperation in health care are now being scrutinised and challenged by national competition authorities. Another important consequence of the use of markets in health care is that certain groups of people, e.g. older people and people with multiple morbidity, might be avoided by health-care providers as it is more difficult to achieve im-proved outcomes in these groups.
The core argument of the World Health Report 2008, Primary Care Now More Than Ever, is that well organised primary care systems are better able to solve these problems. Our core argument is that HSR in the area of primary care can make a useful contribution towards finding and supporting the solutions for these problems.
Primary care as a solution for these challenges
Primary care is assumed to be able to cope better with the changing pattern of disease than hospital-oriented health care. Strong primary care has a generalist approach, taking into account the social and family context of patients, and provides continuity, compre-hensiveness and coordination. Primary care can counteract the current fragmentation of health care by guiding patients through the system where necessary. Countries with a strong primary care system might be able to develop more comprehensive models to man-age and coordinate care for long-term conditions. However, the problem-solving ability of primary care would benefit from integration of primary care and social care, in order to better support people in self-management of their situation and to facilitate their living longer at home and in the community. Also, the integration of primary care and public health is important for tackling health inequalities, especially in areas with low social cohesion. Primary care favours access to care for the population in general and minority groups in particular. Primary care is also more responsive to patients’ needs and pReferences.
Priority areas for HSR into primary care
The project HSREPP aimed to identify priority areas for HSR. The general methodology of the project was based on the ‘listening model’ for priority setting, using a combination of a technical assessment and an interpretive assessment: an online survey among 295 researchers and policymakers in Europe, an analysis of the health services research literature of the past decade and an inventory of EU funded projects, the organisation of a working conference with about 350 participants as a platform for discussion on HSR priorities and finally a check of the results by pre-senting the preliminary results at several conferences. An exact description of the combination of methods used in this project and its results can be found in the final report of the project.
In addition to closed questions to rank topic areas, the survey in the HSREPP project incorporated an open question directed at HSR topic experts as to what they considered the top priority for the next two to five years and why. The respondents who answered that question suggested a wide variety of topics. These were graphically represented in a word frequency analysis, using the free software ‘Wordle’ (with font size being proportional to frequency of occurrence; see Figure 1). This manner of questioning provided unbiased answers as any topic could be cited. It was clear that primary care was seen as an important area for HSR. That particular key term was mentioned quite frequently (in 10% of instances in comparison to 6% for hospital care). In addition, many of the important themes that were listed had a clear implication for the organisation and role of primary care, referring among others to the importance of integrated care, performance, workforce and human resources, quality and effectiveness and patient management.
Figure 1: Word cloud of the priorities identified in the HSREPP stakeholder survey, using Wordle (www.wordle.net)
The priorities identified through the HSREPP pro-ject concerned HSR priorities in general; they covered both primary and secondary care. To check to what extent the identified priorities were applicable to primary care a debate was held at the third biannual conference of the European Forum for Primary Care in 2010. During the debate session, the word cloud was used to present results of the HSREPP project and participants were asked to reflect on these priorities. The HSREPP project identified three priority areas in the domain of health systems and four in the domain of healthcare organisations and service delivery. Their relevance for primary care was supported by the group discussion at the EFPC conference, although the areas sometimes needed further refinement to be applicable to primary care.
In the area of healthcare systems research we ident-ified the following priorities, which were then refined for the primary care field based on the EFPC confer-ence discussions.
• Evaluation of health care reform From the point of view of primary care this is important, especially for new member states of the EU in Central and Eastern Europe that have attempted to transform their healthcare systems over the past two decades.
• Public versus private Funding and privatisation or commercialisation For primary care the effects (both intended and unintended) on access, health outcomes, affordability and responsiveness are im-portant. Cooperation is more important than competition; so an important issue is how modes of Funding and incentives affect cooperation.
• Workforce management and migration Inless aﬄuent countries international mobility of health workers might reinforce labour supply problems in primary care as a consequence of demographic changes. Changing definitions of professional tasks (task delegation and substitution) are important issues in primary care.
In the area of healthcare organisations and service delivery the priority areas and their identified rele-vance for primary care are:
• Inter-organisational relations Central issues for primary care in this area are the relationships between primary and secondary care and the seamless organ-isation of care for people with (multiple) long-term conditions where integration of care between or-ganisations is very important.
• Intra-organisational control Research in this area focuses on how organisations arrange their work internally. It includes topics such as workforce/ skill-mix or changing service provision. Within primary care this relates to the transformation of primary care from a ‘cottage industry’ to a set of larger, more corporate organisations. The current phase of this transformation varies across Europe.
• Patient relations Because of its location close to people, primary care has the potential for greater patient involvement and participation. The gate-keeping and guidance role of primary care is im-portant in demand management. Further, there is a growing need for knowledge on community oriented care (which is broader than patient-oriented care).
• Governance and accountability Issues of quality and safety are as important in primary care as in hospital care. Improvement of patient safety might require approaches different from those in the hospital context. The changing organisational size of primary care raises issues of professional–man-ager relationships and regulation of provider or-ganisations.
It is clear that these topics cover many of the recog-nised research priorities for primary care. The recently published series of articles The research agenda for general practice/family medicine and primary health care in Europe show similar priorities. These articles identified patients’ and doctors’ perceptions, perspec-tives and pReferences as being important for future research. In addition, knowledge of community oriented care was found to be lacking. They also revealed that the implications of multiple morbidity should be addressed. Regarding governance, they emphasised clinical governance and stated that the impact on health and sustainability of the effects of therapy, communication strategies and educational interven-tions should be addressed. In the HSREPP project, governance referred to the organisational aspects of governance.
An important area that did not come up as a specific priority area within the general HSREPP priority setting exercise was equity. However, this subject was stressed during the debate about priorities for primary care. The role of primary care in reducing health inequal-ities – which is in itself plausible – is under-researched. The systematic review by Kringos et al, based on primary care literature between 2003 and 2008, showed that evidence for a positive relationship between stronger primary care and better equity in access to health care and, ultimately, health outcomes was weak. Few studies contributing to evidence in this area were found. HSR can monitor trends in access to care and help design and evaluate specific programmes. Equity should be a spearhead for future research in the field of primary health care. It is important to know how social, cultural and environmental circumstances in-fluence health inequalities between populations. At the EFPC conference this theme was emphasised by De Maeseneer and Willems.
The importance of an international perspective
The priority areas for HSR in primary care are not only important for separate countries, but especially when taking a European perspective. First with regard to health systems research; since the 1990s, policy makers in Central and Eastern Europe have supported reform leading towards primary care. Also in other coun-tries of Europe, such as Spain, Greece and Portugal, reforms of health systems have aimed to strengthen primary care. There is a strong need for evidence to monitor and support these developments in Europe.
The last big European study of primary care was the European Study of GP Task Profiles[11,26] in the early 1990s, just after the fall of communism. The need for new Europe-wide research to monitor the changes since that time is being filled by several studies. The first is PHAMEU (Primary Health care Activity Monitor Europe; www.phameu.eu), the aim of which is to
describe the structure of primary care at system level. The results will be available in mid 2011. The second study is partly a replication and partly an extension of the European Study of GP Task Profiles. This is the Quality and Costs of Primary Care Study (QUALICOPC; www.qualicopc.eu). The extension is both in data collected – especially in the use of patient surveys – and in topics studied: equity, avoidable hospitalis-ations, healthcare costs and identification of good practices.s
Second, for healthcare organisations and service delivery, an international perspective is important in European HSR in the area of primary care. There is a lot of variation in the organisation of primary care. This makes analysis of the relationships between organisation of primary care and outcomes possible. Much of the literature on the positive outcomes of strong primary care is based either on analyses within healthcare systems, such as the USA’s, or on inter-national comparisons that include only European OECD countries and OECD countries outside Europe. It is important to establish studies that include a broader range of European countries.
The variation in organisation of primary care in Europe means that we can learn from each other. How-ever, there are large differences in research capacity across Europe, both in HSR in general and in primary care in particular. Therefore there is a need for a European infrastructure to support training and the sharing of HSR findings.
HSR is important to help healthcare systems cope with the challenges that they face. Many European health-care policy makers can see the potential of HSR and support giving HSR a place in European research programmes. The study Health Services Research into European Policy and Practice (HSREPP) aimed to identify priorities for HSR in Europe. In this article we have discussed these priorities with a special emphasis on primary care. The main priorities that resulted from this project, as we applied them to primary care, were:
• evaluation of primary care reforms
• the influence of Funding and other incentives on cooperation
• workforce management, planning and migration
• the relationship between primary and secondary care
• the internal organisation of primary care providers
• patient involvement and community oriented care
• issues of professional–manager relationships.
Based on the discussions at the EFPC conference and the lack of evidence in this area, we have added to this priority list the role of primary care in improving equity in access and health outcomes. It has to be recognised that methodologies used in this study have some limitations, such as the use of a limited number of literature databases and a focus on EU-funded projects. Also the use of Wordle only gives an im-pression of frequency of occurrence of topic fields – it does not disclose how topics relate to each other, nor does it show if expert opinions differ, depending on their country of origin (see elsewhere for these findings). When reflecting on the methods used, it is clear that each has its pros and cons. Therefore we chose a combination and triangulation of sources of information to provide the most stable set of future priorities. Furthermore, the identified priorities focus on all EU countries as a collective, while the need for research at the national level may vary according to country and healthcare system. Some interesting pro-jects on primary care in Europe are already under way. However, there is still a broad range of issues that have to be more fully explored. An important condition for this to happen is that HSR capacity in general, and in primary care in particular, is developed in countries that lack this.
The research leading to these results has received Funding from the European Commission’s Seventh Framework Programme (FP7/2007-2013) under grant agreement 223248.
Policy research not requiring formal Ethical Approval.
Not commissioned; externally Peer Reviewed.