1. Now more than ever: role of primary care for relevant health care for people and populations 6th AAFP Family Medicine Global Health Workshop Denver, 10 - 11September 2009 Professor Chris van Weel, president of Wonca

2. Going back to the future, for health care XXIst century Presentation Problems facing Health Care Ecology of Medical Care WHO Resolution The Case of Primary Care Data and Experience Two research examples Back to WHO and resolution Future, integrated primary care Professor Chris van Weel

3. Challenges in delivering health care Specialty model Disease specific, a doctor for every disease Technology, supplier driven Disease in isolation Disease-mechanism Biochemical determinants Episodes in isolation Disuptive care Body – mind anomaly

4. Global Perspective common denominator Health Systems differ Enhance, impede roles & functions Perverse incentives Mission health care generic ‘Ecology of medical care’ Morbidity in context Variation in care System consequence, no discipline characteristic Professor Chris van Weel

5. Challenges in delivering health care II Selective health care systems Lack of equity – supporting only some Lack of continuity – usually ignoring primary care Top-down where bottom-up is needed Specialists acting outside their specialty domain Primary care unrewarded as specialty and career Uneven distribution of needs and facilities Low morale in health care Brain drain within and between countries

6. The Ecology: Community/Population Perspective and Three Transitions Domain Health Problems Selfcare Primary care Secondary care Role Patients Health care structure Professor Chris van Weel

7. Health care policy move From hospital to primary care From specialist to community From professional to selfcare Societal perspective Professor Chris van Weel

8. WHO 62nd WORLD HEALTH ASSEMBLY Resolution WHA62.12: Primary health care, including health system strengthening People at the centre of health care To train and retain adequate numbers of health workers, … including primary health care nurses, midwives, allied health professionals and family physicians …. Vertical (disease-specific) programmes integrated, implemented in primary health care; Access to appropriate medicines, health products and technologies, required to support primary health care;

9. ‘Reach’ of Primary Care Primary care morbidity Unique domain illness, disease Population perspective Needs, intersectorial Patient perspective Personal doctor Empowerment, needs vs. demands System perspective Navigating resources Professor Chris van Weel

10. Domain of Primary Care unique clinical domain Top-10 Chronic Diseases Obesity Hypertension Chronic nervous complaints Deafness COPD Chr. Isch. Heart disease Varicose veins Hyperlipemia Depression Psoriasis Professor Chris van Weel

11. Effectivness Primary Care* (go to Starfield B. Is primary care essential? Lancet 1994)

12. The Family Physician (GP) (Norman Rockwell 1947)

13. Two emprirical examples: Does the epidemiological setting matter? A-priory chance Comparing hypertension treatment of physicians internal medicine and family physicians Does the integral approach matter? Disease orientation versus person-centred care The outcome of depression in family medicine

14. Professor Chris van Weel PERFORMANCE FPs - PHYSICIANS (hypertension) UNCOMPLICATEDCOMPLICATED FP PHYSICIAN Gerritsma en Smal, 1982

15. Professor Chris van Weel PERFORMANCE FPs - PHYSICIANS (hypertension) UNCOMPLICATEDCOMPLICATED FP Few interventions Limited time Purposeful PHYSICIAN Gerritsma en Smal, 1982

16. Professor Chris van Weel PERFORMANCE FPs - PHYSICIANS (hypertension) UNCOMPLICATEDCOMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN Gerritsma en Smal, 1982

17. Professor Chris van Weel PERFORMANCE FPs - PHYSICIANS (hypertension) UNCOMPLICATEDCOMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN Protocol driven Relative limited time Purposeful Gerritsma en Smal, 1982

18. Professor Chris van Weel PERFORMANCE FPs - PHYSICIANS (hypertension) UNCOMPLICATEDCOMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN More interventions More time Exploring Protocol driven Relative limited time Purposeful Gerritsma en Smal, 1982

19. Professor Chris van Weel LESSONS OF THE EXAMPLE Importance of clinical environment Frequent health problems (early diagnosis, follow-up) Practice primarily focussed on ‘norm’ Exceptions require additional interventions Generic but context dependent International position of family practice.

20. Two emprirical examples: Does the epidemiological setting matter? A-priory chance Comparing hypertension treatment of physicians internal medicine and family physicians Does the integral approach matter? Disease orientation versus person-centred care The outcome of depression in family medicine

21. DOES PERSON CENTRED CARE MATTER? Example: FPs’ treatment depression van Os TW, van den Brink RH, Tiemens BG, Jenner JA, van der MK, Ormel J. Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. J.Affect.Disord. 2005;84:43-51.

22. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: OUTCOME: van Os TW et al, J.Affect.Disord. 2005;84:43-51

23. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: OUTCOME: Follows guideline Does not follow guideline van Os TW et al, J.Affect.Disord. 2005;84:43-51

24. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: OUTCOME: Follows guidelineGood Does not follow guideline Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

25. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineGood Does not follow guideline Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

26. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineFP-Patient relation good Follows guidelineFP-Patient relation poor Does not follow guideline FP-Patient relation good Does not follow guideline FP-Patient relation poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

27. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineFP-Patient relation good Follows guidelineFP-Patient relation poor Does not follow guideline FP-Patient relation good Does not follow guideline FP-Patient relation poor Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

28. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineFP-Patient relation good Follows guidelineFP-Patient relation poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

29. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineFP-Patient relation good Follows guidelineFP-Patient relation poor Poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

30. OUTCOME FPs DEPRESSION CARE CLINICAL COMPETENCE: EMPATHYOUTCOME: Follows guidelineFP-Patient relation good Good Follows guidelineFP-Patient relation poor Poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor van Os TW et al, J.Affect.Disord. 2005;84:43-51

31. EFFECTIVENESS of FAMILY PRACTICE Knowledge what is effective Cost-effectiveness health care (Starfield) FP density ~ Life expectancy Early diagnosis of malignancies (melanoma) For subspecialist this relation inverse! Poor understanding of why it is effective Black box, counterintuitive

32. Role, function family physician Medical generalist All health problems All stages All Individuals Need driven Community oriented Family or household focus Social determinants Personal doctor Patient centred Integrated care Continuity of care Professor Chris van Weel

33. Understanding effectiveness of primary care: practice, ICPC, R&D Need of comprehensive data Dynamics primary care Information beyond diagnosis Reflecting context of primary care Build on primary care experience Primary care position in the medical home Professor Chris van Weel

34. International Classification of Primary Care ICPC Developed by Wonca 1987, WICC Maurice Wood Primary care focus Specificity of generalist Relation with WHO Relation ICD International Standard Europe, Australia WICC (chair Michael Klinkman) : ICPC-3 Professor Chris van Weel

35. WHO 62nd WORLD HEALTH ASSEMBLY Resolution WHA62.12: Primary health care, including health system strengthening People at the centre of health care To train and retain adequate numbers of health workers, … including primary health care nurses, midwives, allied health professionals and family physicians …. Vertical (disease-specific) programmes integrated, implemented in primary health care; Access to appropriate medicines, health products and technologies, required to support primary health care;

36. VERTICAL vs HORIZONTAL PROGRAMS OF CARE HIV AIDSHIV AIDS MALARIAMALARIA TBTB COPDCOPD INTEGRATED PRIMARY CARE

37. STRUCTURE ANOMALY Horizontal programming more effective, efficient Focus: responding to needs Target: unselected patients & communities Where the science is Vertical programs more sexy Focus: supply driven Target: pre-selected groups & episodes Where the money is

38. Fifteen by 2015 Organize special programs through primary care: make a smal part of special program money (15%) available for primary care development

39. Conclusions Now more than ever: Primary care matters It safes lives, and not only money Better population health and better functioning health care system Core concepts acknowledged Personal, continous, social/family context, trust Primary care can be, and must be, developed Academic outreach of teaching, training It is not ‘an art’ Better understanding of its effectiveness urgently needed Research and development No need to postpone action