The five building blocks of a value-driven primary care organization

American professor Barbara Starfield was the first to demonstrate conclusively that well-organized primary care contributes to better health outcomes, increased life expectancy and lower costs. Her research forms the basis of many government policies on the future of healthcare with a prominent role for primary care. In a well-organized primary care system, general practitioners, pharmacists, district nurses and paramedics work closely together. From this collaboration, the care is coordinated to municipalities, GGDs and hospitals.

This sounds simple, were it not for the fact that primary care in the Netherlands is characterised by a lack of organisational power. Primary care providers operate on islands and there is a lack of cooperation within and especially outside the organisation’s own walls. The big question is: how do you change this? Fortunately, science also offers a solution here with five building blocks that, when applied correctly, form important pillars for a future-proof primary care organisation.

Building block 1: Leadership and governance

Practice in the US and Australia, for example, shows that primary care organizations are especially successful when clinical and managerial leadership are combined. Often in these organizations we see that a general practitioner, physiotherapist or nurse has become proficient in governing. This works well, because they understand how things work in healthcare. Clinicians with managerial qualities are generally better able to lead improvement projects and set concrete and measurable goals. They are also more likely to gain the trust of colleagues. However, an open and safe organisational culture is essential for success. A culture where learning is encouraged and mistakes are not swept under the carpet. Incidentally, it is not necessary for clinical and managerial leadership to be represented in one person. It can also be done in a duo function. We see this in many hospitals and larger healthcare groups.

Building Block 2: Data-driven performance management

In order to bring about changes and improvements, there must be (more) data driven. This is increasingly happening in hospitals, but primary care lags behind. GPs don’t realise that they are sitting on a pot of gold with the clinical data in their GP information systems (his). By linking his’en, a large amount of clinical data becomes accessible. This makes it possible to detect practice variations, observe trends and, with the right algorithms, even make predictions about people’s expected demand for care. This makes it possible to use and direct clinical and business processes in an efficient manner, and thus to organise the consultation process more efficiently.

Building block 3: Cooperation and shared responsibility

The third basic condition for a well-functioning primary care organization is multidisciplinary collaboration. A number of scientific studies show that the better the teamwork and the greater the safety within the team, the lower the mortality, the number of unwanted readmissions and the costs. Multidisciplinary cooperation is achieved by making solid agreements, drawing up rules of conduct, using means of communication effectively and taking joint responsibility. This involves the four B’s: Determining Strategy, Deciding and Governing, Discussing Interests and Creating Meaning. Easier said than done, research shows.

Building block 4: Coordination of care

The same significant relationship was shown with the coordination and continuity of care from primary care. Good coordination is characterised by active case management, the drawing up of care plans that are accessible to everyone, and structural multidisciplinary consultation. The better this is arranged, the lower the mortality rates, unwanted hospital admissions and healthcare costs, and the higher the patient satisfaction. Continuity and coordination of care is especially important for complex patients, such as people with multimorbidity and frail elderly; groups that we increasingly see in our society. Primary care is ideally suited to coordinate care for these patient groups and to fulfil a gatekeeper function, because it has an overview. General practitioners can play a leading role in this, but in other countries we also see district nurses playing this role.

Building block 5: Accessibility

This last building block is certainly not the least. In today’s day and age, direct offline and online access to a primary care organization is extremely important for patients, but also for the organizations themselves to better manage their capacity. As a healthcare organisation, this means that you need to make smart use of e-Health applications, such as making appointments online, digital access to medical records and e-consults. It is important, however, to link a control mechanism to this to prevent a proliferation of digital applications. This is difficult for individual practices to organize, but by working together you increase your possibilities.

Building on the legacy of Starfield

Applying the five building blocks requires a different approach and patience, and sometimes means a major cultural shift. But examples abroad show that it is possible. Starfield has researched and proven the positive effects of this (see figures below for actual results of its research).

Added value primary care_Costs of care

Until her death in 2011, she continued to fight tirelessly for a generalist and people-centred approach to patients and to advocate for a strong primary care system that guides people through the jungle of facilities and gets them to the right place. Her research, publications and lectures have made a huge contribution to the role of primary care.

Added value primary care_Health

But since her death, research into the added value of primary care has virtually ground to a halt. This has to change, because we cannot continue to build on pre-2011 evidence, or continue as before with only disease-specific programs. The world is changing at a rapid pace. E-Health applications are mushrooming, new insights are emerging and the demand for care is also changing.

Added value of primary care_Less life years

The marketing machine is eager to get in on this. New management philosophies are constantly appearing, all of which lack a scientific foundation, barely grasp the concepts of health and healthcare and often fail to excel in implementation. We must not allow ourselves to be distracted by this, but must organise primary care in accordance with the five building blocks and continue to assess it. And daring to take the next steps by increasingly letting go of the traditional echelons of zero, first, second and third line and looking at the characteristics of the system as a whole. Want to know more about the next steps? Then download the free e-Book.

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Pim Valentijn

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