Primary care in a National Health Service: time for radical reform

Sustainability in Internal Medicine: A Year-Long Ward-Wide Observational Study

Population aging and multimorbidity challenge health system sustainability, but the role of assistance-related variables rather than individual pathophysiological factors in determining patient outcomes is unclear. To identify assistance-related determinants of sustainable hospital healthcare, all patients hospitalised in an Internal Medicine Unit (n = 1073) were enrolled in a prospective year-long observational study and split 2:1 into a training (n = 726) and a validation subset (n = 347). Demographics, comorbidities, provenance setting, estimates of complexity (cumulative illness rating scale, CIRS: total, comorbidity, CIRS-CI, and severity, CIRS-SI subscores) and intensity of care (nine equivalents of manpower score, NEMS) were analysed at individual and Unit levels along with variations in healthcare personnel as determinants of in-hospital mortality, length of stay and nosocomial infections. Advanced age, higher CIRS-SI, end-stage cancer, and the absence of immune-mediated diseases were correlated with higher mortality. Admission from nursing homes or intensive care units, dependency on activity of daily living, community- or hospital-acquired infections, oxygen support and the number of exits from the Unit along with patient/physician ratios were associated with prolonged hospitalisations. Upper gastrointestinal tract disorders, advanced age and higher CIRS-SI were associated with nosocomial infections. In addition to demographic variables and multimorbidity, physician number and assistance context affect hospitalisation outcomes and healthcare sustainability.

The role of general practitioners in the EU: time to draw lessons from a too wide range?

Although the role played by general practitioners (GPs) is historically consolidated, continuous changes have been recently introduced in Europe because of the increasing multimorbidity and complexity of patients. Here we try to compare the roles played by GPs in the four major countries of Europe. In France GPs are self-employed medical doctors, and their remuneration consists of a payment scheme for the services provided. The weekly opening hours of French GPs are on average approximately 48. In Germany primary care is mainly provided by GPs and outpatient internists, and patients are free to choose the facility and the professional. German GPs are self-employed professionals mainly remunerated for each consultation, who work for an average of 50 opening hours per week. In Italy GPs are self-employed professionals mainly paid on per capita basis, who have their own list of patients and must guarantee a minimum number of clinical opening hours per week, which has often become the average number in practice. Accordingly, the patients' weekly access to Italian GPs' clinics is very limited. In Spain GPs are civil servants who work in multifunctional facilities with multi-professional teams. The weekly hours worked by Spanish GPs are 38 hours, as for any other civil servant. Trying to draw positive lessons from the comparison, the Spanish facilities seem to be the most advanced examples of horizontal-integrated organizations able to fulfil the expectations of a growing population of ageing people. The range of generalist professionals could be enlarged beyond GPs, as the German example shows.