We Went to Oxford and Got Schooled in Primary Care
As other countries continue to spend far less on health care but perform better on measurable health outcomes, there's opportunity to learn what works abroad and apply those lessons stateside.
It’s a hard notion for many Americans to accept—although we spend more money on health care than any other country in the world, we are far from having the best health outcomes. When you look at measures that include life expectancy, infant mortality rates and preventable illness, other countries that spend far less than the U.S. perform better. But in many of these countries people of all ages and socio-economic status are able to easily access primary care that is comprehensive, patient-centered and rooted in local communities.
One of our goals as program officers at RWJF is to look beyond our borders to identify promising practices that might be incorporated into America’s health care system. Last fall we traveled to Oxford, England, to learn first-hand about promising primary care practices in Chile, England, the Netherlands and Canada—all high and middle income countries that spend less on health care yet have better outcomes than the U.S. We attended a conference organized by the Training and Research Support Centre (TARSC), an organization supported by Charities Aid Foundation of America through a grant from the RWJF Donor-Advised Fund. TARSC provides support and training to government and civic health organizations, and the conference was the next step after its report, “Strengthening primary care in the USA to improve health: Learning from high and middle income countries.” We came away with a lot of insights from both, but were struck by several themes that were constant throughout.
The first, and possibly most important, is that primary care is most effective when it is well integrated into community and population health. In the Netherlands, for example, primary care is local, highly coordinated, and accessible 24/7. Everyone in the country must register with a general practice and select a personal doctor who oversees continuity of care. Primary care providers can only accept patients who live within 15 minutes of their practice. Being local means that, besides knowing their medical history, doctors and their staff have a more robust understanding of their patients’ living, working, and social environment. Most doctors (some 78%) are also part of larger care groups—multidisciplinary teams that combine family practice with nursing and home care, social and mental healthcare, dental and diagnostic facilities—that integrate population-focused preventive services as well as long-term care for people with chronic conditions into the primary care model.
Chile has its own version of this public health-oriented model. The primary care system is built on a network of family health centers in cities, villages and rural settings that serve nearly 75% of the population. Each primary care center is run by municipal health administrators and takes a “biopsychosocial” approach to care—addressing medical, psychosocial and socioeconomic issues. To receive annual financing, center administrators must develop a health plan that includes taking into account local demographics, epidemiological profiles and social determinants of health. For example, one new program targets people in communities who are at risk of diabetes and hypertension. Some 237 primary care centers in Chile serving upwards of 130,000 people provide free medications and offer workshops led by teams of nurses, nutritionists and kinesiologists to teach people how to prevent or control diabetes and hypertension. Another program involves regular workshops at the health centers that are designed to help seniors maintain self-sufficiency and mobility while also addressing mental health concerns like depression and social isolation. This particular program currently reaches 50% of Chile’s senior citizens—over 1.1 million people in total.
Another key lesson we learned from these four countries is that for primary care to really impact quality and cost, it must be highly accessible and simple to navigate. In England, for example, nearly 99% of people are enrolled or registered with a general practitioner in the area they live. Once registered, the National Health Service arranges for all medical records—from hospitals, specialists, previous providers, etc.—to be electronically transferred to the local GP. Patients are contacted within six months of registering to schedule a check-up, while home visits to new mothers and infants, frail elderly, and people with chronic illness are standard services in England. Because primary care physicians are gatekeepers for referrals to specialists, GPs provide 90% of the care for patients. This reduces unnecessary visits to specialists and cuts down on excess or duplicate testing; top drivers of higher cost and poorer outcomes in the U.S.
A law requiring primary care to be available 24 hours a day, seven days a week bolsters accessibility in the Netherlands. To meet demand, physicians formed primary care cooperatives of 40 to 250 individual providers that provide after-hours coverage for 100,000 to 500,000 people within a 30 km radius. On evenings and weekends, a dedicated phone line connects patients with a triage nurse who might recommend self-care, schedule a visit to the doctor the next morning or in emergencies, call an ambulance. In some cases, a doctor will be dispatched to the patient’s home, arriving within 15 minutes in a specially marked car carrying medicine, oxygen and other emergency medical supplies. Even better, the doctor has the patient’s electronic health records in hand. The primary care cooperative system has reduced visits to hospital emergency departments by 89% in the Netherlands and hospital admissions by 34% while winning high scores for patient and provider satisfaction.
The report and the meeting reinforced our belief that we can learn much about primary care from the experiences of other nations. It is worth mentioning that all four countries have universal health insurance—something we haven’t yet achieved here in the U.S. Still, increased support for primary care mandated by the Affordable Care Act is driving momentum toward finding new ways of delivering and paying for care that promotes better coordination, accessibility, and value. It is conceivable that many of the practices we learned about at the conference could be adopted in the United States—and in fact, may already be implemented in some pilot projects.
One U.S. attendee, Lisa Letourneau MD, MPH, Executive Director of Maine Quality Counts, said she finds herself talking about the lessons learned from the Oxford meeting to everyone who will listen. “The meeting really re-lit the fire in me to push for more meaningful, wider, and more sustainable payment reform for primary care in Maine and more broadly,” she said. In April, her team brought together leaders from all of the primary care and medical associations in Maine to gain their support for payment reform. “I’ve been giving a lot of thought to the specific role that regional improvement organizations like ours can give to these efforts,” said Letourneau. “We have a unique role to play regarding connecting healthcare and broader efforts to improve community/population health, and particularly positioning, and supporting, primary care as the intersection of those two worlds."
Over the past three years, another RWJF project, The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), has identified and visited over 30 primary care practices in 20 states in the U.S. to learn how these practices—like those in the four countries we studied—make primary care more accessible by creatively using their clinician and staff workforce. The LEAP team, led by Ed Wagner MD, Director Emeritus at MacColl Center for Healthcare Innovations and Margaret Flinter PhD, RN, FAAN, Senior Vice President and Clinical Director at Community Health Centers Inc, has developed a great resource for primary care practices, organizations and leaders. Find a description of the project, the findings, a guide to developing effective primary care teams, and other resources at improvingprimarycare.org.
To keep the exchange of ideas flowing we encourage you to share in the comment section below your experience with promising primary care practices and innovations that are driving greater community engagement and accessibility here at home. Whether the ideas come from a rural village in Cuba, the local councils of Manchester, England or from an American city like Camden, NJ, we will work to leverage the U.S. primary care system to help achieve RWJF’s larger vision—to build communities where all of us have the opportunity to live the healthiest lives we can.
To learn more about RWJF’s efforts to learn from countries around the world, please read Looking Beyond Our Borders for Better Results by RWJF Assistant Vice President Brian Quinn, in Stanford Social Innovation Review.