Primary care in 34 countries: perspectives of general practitioners and their patients Primary care in 34 countries: perspectives of general practitioners and their patients Eerstelijnszorg in 34 landen: perspectieven van huisartsen en hun patiënten (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op woensdag 23 november 2016 des middags te 12.45 uur door Wilhelmina Louise Albertine Schäfer geboren op 29 augustus 1984 te Rotterdam Promotoren: Prof. dr. P.P. Groenewegen Prof. dr. F.G. Schellevis Copromotor: Dr. W.G.W. Boerma ISBN 978-94-6122-409-5 © 2016 NIVEL, P.O. Box 1568, 3500 BN Utrecht, The Netherlands http://www.nivel.nl [email protected] Telephone: +3130 2729 700 Fax: +3130 2729 729 Cover design: D. Schäfer Lay out: NIVEL Printing: GVO The research presented in this thesis was conducted at NIVEL, Netherlands Institute for Health Services Research, Utrecht, Netherlands. Financial support for studies in this thesis was provided by the European Commission under the Seventh Framework Programme (FP7/2007-2013) under grant agreement 242141 (for the QUALICOPC study). The research was co-funded by a grant from the Ministry of Education, Culture and Science (OCW). Contents Chapter 1 General introduction 7 Part I Evaluating primary care Chapter 2 Study protocol: QUALICOPC, a multi-country 37 study evaluating quality, costs and equity in primary care Chapter 3 Measures of quality, costs and equity in 61 primary care: instruments developed to analyse and compare primary care in 34 countries Part II The breadth of GP service profiles Chapter 4 Two decades of change in European general 111 practice service profiles instruments developed to analyse and compare primary care in 34 countries Chapter 5 Organisational characteristics facilitating 153 a broader range of general practitioner service profiles: an international study Part III Patient perceived quality of primary care Chapter 6 Assessing the potential for improvement of 203 primary care in 34 countries: a cross-sectional survey Chapter 7 GP practices as a one stop shop: how do 249 patients perceive the quality of care? A cross-sectional study in 34 countries 5 Chapter 8 General discussion 283 Summary 317 Samenvatting (summary in Dutch) 323 Acknowledgements 331 Curriculum Vitae 335 List of publications 337 6 1 General introduction General introduction This thesis aims to evaluate primary care service delivery in Europe and in other parts of the world. Strong primary care is expected to meet the current challenges of healthcare systems which are facing increasing numbers of people with chronic diseases and rising healthcare costs [1]. The thesis is written in the context of the international study ‘Quality and Costs of Primary Care in Europe’ (QUALICOPC). The countries studied include 26 EU member states as well as Australia, Canada, Iceland, FYR Macedonia, New Zealand, Norway, Switzerland and Turkey. As primary care is the point where many patients enter the professional healthcare system, easy access and a generalist approach to the health problems people present are important features. The generalist approach implies that health problems are clarified, diagnosed and treated as far as possible and that patients are referred or given guidance when other healthcare services need to be involved [2,3]. Primary care services can be delivered by a variety of providers such as nurses, general practitioners (GPs), pharmacists, physiotherapists, psychologists and social workers [3-6]. In the countries studied in this thesis, GPs are the core providers of primary care services [3]. In the large majority of these countries, GPs have completed a specialised training in family medicine1. In the countries studied, GPs practise almost exclusively in an outpatient setting [7]. As suggested by the title of this thesis, primary care is evaluated from the perspectives of both GPs and patients. This covers how GPs describe their work, e.g. how they organise their practices and what type of services they deliver. The evaluation from the patient perspective includes how they assess the care they receive. Patients’ assessments have become more important during recent decades in the evaluations of healthcare systems and services. Without taking account of these assessments, it is too easy for care delivery to stay provider-centred [8]. 1 In some of the countries, the doctors are called family physicians, family practitioners of family medicine specialists. In this thesis we refer to all these doctors as GPs. 8 General introduction The main question addressed by this thesis is: How can we explain differences within and between countries in the strength of primary care in terms of the breadth of GP service profiles, and how does this relate to assessments by patients? This introductory chapter provides information on the background, research questions, hypotheses and methodology used in this thesis. Background Challenges of health care systems Healthcare systems are currently facing a variety of challenges including increasing numbers of people with chronic diseases and rising healthcare costs. Driven by the available evidence, strong primary care is seen as part of the solution for these challenges [1]. Due to various changes, healthcare systems are being challenged to keep achieving their main objectives, which include improving the health of the population, being responsive to the needs and expectations of the population and providing protection against the costs of ill health for the population [9]. Demographic developments have led to a shift in the nature of health problems from acute and infectious diseases to non-communicable, lifestyle-related and long-term diseases [1,10]. In the coming years there will be further increases in the prevalence of diseases such as diabetes mellitus, chronic obstructive pulmonary disease (COPD) and depression, as well as a growing number of people with multimorbidity [11]. Moreover, the ageing population means that the availability of the future healthcare workforce is being threatened: the proportion of people of working age will decrease but they will have to deliver healthcare for a larger number of elderly [12,13]. Due to demographic and technological developments, the absolute and relative spending on healthcare are increasing in many countries [4]. As resources spent on healthcare cannot be used elsewhere in society, societies are constantly facing questions about the optimum size of healthcare budgets. Governments are trying to contain healthcare expenditures while tackling the challenge of keeping the population protected against healthcare costs in an equitable manner and also maintaining the quality of care [4]. A final General introduction 9 important change in healthcare systems relates to the changes in the position of patients. More often than before, today’s patients have the possibility of preparing for consultations by looking up medical information about their disease and its potential treatments on the Internet. This may reduce the information asymmetry between professionals and patients. Patients have the option of having a more active and well-informed role in the decisions to be taken about a treatment plan [14], even though this may not be equal for all groups of patients. Healthcare providers need to be able to adapt to these changes. As a response to these changes, decision makers in many countries have focused on strengthening the role of primary care within healthcare systems. This policy direction resulted from the growing evidence about the potential benefits of primary care and has been encouraged internationally by the World Health Organisation (WHO), starting with the 1978 Declaration of Alma Ata [15]. More recently, the WHO stressed the importance of good primary care in the document “Primary Health Care - Now More Than Ever” which was published in 2008 [1]. A recent report published by the European Commission also addressed positive expectations regarding the potential of strong primary care in coping with the current European health systems’ challenges [4]. Strong primary care and responsiveness to patients’ needs and expectations Previous studies found that, in countries with stronger primary care, the healthcare system performs better [16-31], which makes it a potential solution addressing various healthcare system challenges. The current evidence also has several gaps. There is for example only limited evidence on how specific elements of strong primary care relate to patients’ assessments. This thesis focuses on patients’ assessments of primary care as outcomes that are related to the responsiveness to patients’ needs and expectations. This section explains what ‘strong primary care’ is and what is known about the relationship with responsiveness to patients’ needs and expectations. Primary care in a country is characterised as strong when it contains a set of characteristics related to the service delivery process and to its supporting structure [5,14]. First, primary care needs to be accessible, i.e. 10 General introduction close to where patients live and without (for example) financial restrictions. Moreover, patients need to be able to visit their primary care doctors for a broad range of problems and health needs, i.e. the service delivery needs to be comprehensive. Thirdly, it is important that