Some recent changes and challenges in french primary care Isabelle Dupie, Hector Falcoff International Forum on Quality & Safety in Healthcare Paris, pril 2014

Conflicts of interest We have no conflict of interest related to this presentation.

A French paradox The French health care system : – « a weak primary care system » (Macinko & Starfield, 2003) – « the best health care system in the world » (WHO, 2000) Why ? Because we were rich ! – Universal health insurance – Primary care : unorganized but abundant – Big secondary and hospital care sector

Positive changes in the last 10 years General practice becomes an academic discipline (2004) : titular professors, lecturers, PhD students… Patient lists + gatekeeping role for GPs (2004). Role of GPs defined by the law (2009). A unique National College gathering the Unions, the academic and scientific societies, the CME/DP associations (2010). Introduction (2011) of new types of payments : capitation, P4P (± 10% of the total earnings of the GPs). Development of team work in PC : multi professional group practices called « Maisons de santé pluriprofessionnelles » ; 5- 10% of GPs in 2014, 25% anticipated in 2020).

Two major challenges (Touraine, Lancet 2014) How to keep our good health indicators and : Contain health care cost (12 % GDP in 2013 !). Reduce health inequalities which are « substantial » (European Commission, 2013).

Life expectancy at 35 years old in France Woman, executive Woman, manual worker Man, executive Man, manual worker

Equity Définition : equal care for people with equal health needs. Inverse care law : the availability of good medical care tends to vary inversely with the need for it in the population served (Hart 1971). Can we change this ?

Why and how to register social information for an adult patient in general practice ?

Equity of primary care : next steps Testing the feasability/acceptability of social data collection. Dissemination of the guideline. Implementation in medical records softwares Development of equity indicators Incentivisation PDSA cycles… A LONG WAY TO GO !

Patient safety National Plan for patient safety Most knowledge on patient safety come from hospitals : 4,5% hospitalizations due to serious adverse events occurred in the ambulatory sector Michel P et al.Enquête Nationale sur les évenements indésirables graves liés aux soins (ENEIS2) Root Causes analysis Immediate failures were mainly: – therapeutic errors, – monitoring failures – And therapeutic delays. Most cases were adverse drug events, mainly related to anticoagulant drugs, neuroleptics and diuretics. Michel P et al. Les évenements indésirables graves liés aux soins extra hospitaliers:fréquence et analyse approfondie des causes,2009

What do we know? (1/2) ESPRIT 2013 : an innovative research program – A professional consensus on definition of Adverse Events (AEs) in Primary Care : "An adverse event is an event or circumstance associated to health care, that could cause or has caused harm to a patient and which, we hope not to happen again. » – The national incidence survey in Primary Care : 22 AEs /1000 contacts (visit - home visit - phone contact) Quite frequent : 1 AE / 2days / GP No harm for 3/4 AEs 2% serious AEs

What do we know? (2/2) – Main types of risk situations identified by ESPRIT 2013 Organization problems in medical practice Prescription writing Communication with patient Lack of proper knowledge and skills mobilizing

What are we doing ? Some local innovative experiences… – patient safety improvement activities Mortality morbidity review Adverse event analysis meeting – in multi professional staff or in peer groups or quality circles We need to organise data collection Some ongoing studies - mainly on adverse drug events

A lot still to do… Develop a safety culture among health care providers : – How to promote the definition of AE among professionals ? – How to detect Aes ? Provide a reporting system – Why and How to report ? Build a capacity to share and disseminate knowledge – How to learn from errors ? Needs for research : better identify AEs’ contributing and recovering factors – How to reduce harm risk ?

Thank you for your attention !