Assessing primary care performance in Luxembourg

(Note that the PI you will be leading this is Valerie Moran, who will be joining LISER in January) Strong primary care underpins an effective, efficient and responsive health system (European Commission, 2018). Strong primary care enables health systems to control costs and produce better health outcomes (Kringos et al., 2015a, Starfield et al., 2005). Primary care can contribute to the prevention of morbidity and mortality and compared to specialist care, is associated with a more equitable distribution of population health (Starfield et al., 2005). Key domains for assessing primary care performance include accessibility, integration, person-centeredness, comprehensiveness, care coordination, continuity, organisation, human resources as well as the ability to address personal health needs and sustain partnerships with patients and informal caregivers (European Commission, 2018). Several reports have characterised Luxembourg as having a weak primary care system (Berthet et al., 2015, European Commission, 2016a, Kringos et al., 2015b, OECD/European Observatory on Health Systems and Policies, 2017) and identified some reasons for this. GPs do not have a gatekeeping role and patients are free to visit medical specialists directly (European Commission, 2016a, Kringos et al., 2015b, OECD/European Observatory on Health Systems and Policies, 2017). Gatekeeping and comprehensive primary care could help to control costs by reducing unnecessary specialist visits (Berthet et al., 2015). A lack of GP gatekeeping can also contribute to poor continuity of care (Kringos et al., 2015a). Continuity of primary care is facilitated by GPs having responsibility for the medical care of a registered list of patients, but a patient list is not mandatory in Luxembourg and patients have a free choice of GP (Kringos et al., 2015a). Another issue is the underdevelopment of the primary care workforce (OECD/European Observatory on Health Systems and Policies, 2017, Kringos et al., 2015a). While Luxembourg has a relatively high proportion of nurses (Berthet et al., 2015, OECD, 2016), there is a lack of non-physician roles (OECD, 2016) or task substitution such as nurse-led clinics within primary care (Kringos et al., 2015b). In respect of access to primary care, there is a lack of information on variation in supply of GPs between cantons and a lack of national norms on GP distribution (Kringos et al., 2015b). A related issue is the need for workforce planning, particularly given an ageing GP workforce (Kringos et al., 2015b). Luxembourg also has weak primary care governance with a lack of state inspection and primary care policies (OECD/European Observatory on Health Systems and Policies, 2017, Kringos et al., 2015a). A key challenge relating to the wider health system is the relatively long inpatient length of stay (Berthet et al., 2015, OECD/European Observatory on Health Systems and Policies, 2017) and low outpatient contacts per person (OECD). There is a need to move excessive activity from acute inpatient care towards ambulatory and outpatient care (European Commission, 2016a). A strong primary care system can facilitate and support a more optimal balance of care between community and inpatient settings. Chronic diseases such as asthma, hypertension and depression are key contributors to poor health (OECD/European Observatory on Health Systems and Policies, 2017) but these illnesses can be managed in a primary care setting. The weaknesses of the primary care system may be contributing to poor quality of care evidenced by process and outcome measures. There is potential to improve preventative care that can be delivered in primary care, such as rates of influenza vaccinations among older people, and breast and cervical cancer screening (Kringos et al., 2015b). Luxembourg has a relatively high number of avoidable hospital admissions for people with diabetes compared to other EU countries. Moreover, there was a considerable increase in mortality from diabetes between 2000 and 2014, in contrast to a declining trend in neighbouring countries (OECD/European Observatory on Health Systems and Policies, 2017). Poor quality primary care may also be contributing to higher costs. For example, expenditure associated with diabetes in 2015 was €7,500 per person in Luxembourg compared to an EU average of around €3,000 per person (European Commission, 2016b). There are indications that the need to strengthen primary has been recognised. The Health Reform Law of 2010 introduced a pilot programme to support care coordination for people with chronic illnesses and multimorbidity. Under the programme, GPs would act as care coordinators to organise patients' care pathways and support integrated medical records. A national electronic health record (Dossier de Soins Partagé ? DSP) was introduced in 2015, in a pilot on a subset of patients with chronic illnesses and multimorbidities before being extended to the entire population covered by health insurance (Berthet et al., 2015, OECD/European Observatory on Health Systems and Policies, 2017). The DSP contains information pertinent to promoting continuity and coordination of care and the efficient use of health care services (Berthet et al., 2015, European Commission, 2016a). However, no evaluation of this pilot programme has been undertaken (OECD/European Observatory on Health Systems and Policies, 2017). Strategies and programmes targeting diabetes patients are also under development (OECD/European Observatory on Health Systems and Policies, 2017). There is a clear need to conduct research on the primary care system in Luxembourg. This would inform policies that would strengthen primary care, which would help to control costs and improve outcomes. Luxembourg has the most expensive health care system in Europe and there is scope to improve efficiency to address expenditure growth (OECD/European Observatory on Health Systems and Policies, 2017). Moreover, there is room to improve quality, particularly in relation to primary care indicators. A strong primary care system will help to address the challenges of population ageing, particularly those arising from chronic diseases and multimorbidity. While there is a move towards addressing these issues, for example, with the introduction of GP care coordinators for people with chronic illnesses, there is a need to monitor and evaluate new policies to ensure they are achieving their set objectives. References BERTHET, F., CALTEUX, A., WOLTER, M., WEBER, L., VAN GINNEKEN, E. & SPRANGER, A. 2015. Luxembourg: HiT in brief. Brussels: European Observatory on Health Systems and Policies. EUROPEAN COMMISSION 2016a. Luxembourg Health Care & Long-Term Care Systems. An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Luxembourg Publications Office of the European Union. EUROPEAN COMMISSION 2016b. So What? Strategies across Europe to assess quality of care. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union. EUROPEAN COMMISSION 2018. A NEW DRIVE FOR PRIMARY CARE IN EUROPE: RETHINKING THE ASSESSMENT TOOLS AND METHODOLOGIES. Report of the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union. KRINGOS, D. S., BOERMA, W. G. W., HUTCHINSON, A. & SALTMAN, R. S. 2015a. Building primary care in a changing Europe, Brussels, The European Observatory on Health Systems and Policies. KRINGOS, D. S., BOERMA, W. G. W., HUTCHINSON, A. & SALTMAN, R. S. 2015b. Building primary care in a changing Europe. Case studies, Brussels, European Observatory on Health Systems and Policies. OECD 2016. Health Workforce Policies in OECD Countries Right Jobs, Right Skills, Right Places. Paris: OECD Publishing. OECD/EUROPEAN OBSERVATORY ON HEALTH SYSTEMS AND POLICIES 2017. Luxembourg: Country Health Profile 2017, State of Health in the EU,. OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. STARFIELD, B., SHI, L. & MACINKO, J. 2005. Contribution of primary care to health systems and health. Milbank Q, 83, 457-502.