Strategy for PHC, strategy for patients

Strengthening the role of primary health care is one of the cornerstones of public health and the conditions for maintaining a stable, effective and safe health care system. Therefore, it is undoubtedly a positive phenomenon that works on development strategy for this sector are being continued. It is said that even a draft report has been prepared.

The information on the content of this report which has thus far been available in a fragmented manner does not allow conclusions to be made about the direction and definitely it will be necessary to wait until the Health Minister discloses the report to fully assess its contents.
It is worth reminding briefly how we arrived at this point of PHC organisation and why we are here. It was only twenty years ago that the physicians working ‘in the district’ (what a terrible phrase, isn’t? ...) carried out their duties within the organisational framework of health care institutions.

However, it was not exactly an integrated form of care due to ineffectiveness and futility of various incentive mechanisms in a purely budgetary system. Introducing and developing a contract-based system that replaced budgetary planning led to rapid disintegration of forms of organisation, whereas in the few places where such organisations managed to defend themselves, their efficiency seems to be far from perfect. The former public health care institutions (Polish ZOZ) quite quickly underwent privatisation, entirely new entities were established, and currently privately owned entities constitute about 90% of the total potential.

At present several trends can be observed to have impact on the organisational forms. Firstly, large networks of health care providers are being developed, although their growth rate seems to be much lower than the growth that can be observed with regard to the pharmacy sector. The process of privatisation of the public entities supervised by the local authorities, especially by the local self- government, has been considerably slowed down. One might risk stating the opposite - that public hospitals began, sometimes successfully, to create their own PHC centres. At the same time, some of the slightly larger private entities started to grow ‘vertically’ by offering services within other scopes of health care benefits, such as advisory clinics, rehabilitation or one-day clinics.

Soon after privatisation took place, exceptionally rapid emergence of organisations defending the interests of these newly established entities could be observed, which was actually a result of the reform attempted in the very beginning of the existence of the Polish National Health Fund (NFZ).
These organisations were effective in attaining their goals, despite changing government coalitions and a wide range of concepts for health care governance – and they did it either by negotiation or by exerting public pressure, or resorting to strike action. Public funding of primary health care increased, not only in terms of absolute but also relative amounts, although, it is honest to say so, as a general rule the scope of responsibility was broadened too.

The announced document, therefore, will be of importance not only for the PHC entities and their staff. Preparing myself to do some research on the subject, I decided to make a checklist:

1. How will the PHC team be defined and will it still be a team? The possible role of a nurse is not the only challenge but certainly the first to be encountered.
2. How will implementing the strategy impact other segments of the health care system? Peer review is an essential part of functioning of every organisation and assessment of specialist care, hospital care or long-term care cannot be avoided.
3. Will development of prevention be included and how will it be done?
4. Will the role of the local self-government be recognised and, if yes, in what ways will it be done? Difficulty in accessing a primary care physician is a strongly diversified problem in terms of geographical location and it would certainly be more effective to support the self- governments on one hand and get them involved in problem solving on the other hand.
5. Will the possible organisational changes, which are likely to quite rightly highlight the need for greater coordination, not cause the competitiveness potential of PHC (possibly being the reason for quite good results obtained in patient satisfaction surveys) to be lost?
6. And the final question, linked to the previous questions, and a fundamental one: how will the new strategy affect the patients? How to convince them that within PHC it is really possible to obtain a majority of needed everyday health care benefits?

As the twig is bent…

I will begin by making an introductory remark that although my BMI remains within normal limits, I still should say good-bye to a few kilograms. As it is already known, the value of the index itself is not a problem, however, it indicates a possible problem or health risks.
The problem is not so much widespread among children as it is among adults, nevertheless, if it occurs, then it has more serious consequences and sometimes it also has more serious reasons that should not be ignored.

This issue came up visibly several times last year during the so-called ‘sticky bun debate’. The debate which was in some part informed, in some part amusing and spiced with demagogic objections, and during which the participants did not refrain from using stereotypes. The debate which was positive before the regulation came into force and negative after 1st of September (beginning of the school year in Poland). The Health Minister issued a regulation based on his legislative authority specifying which products can be sold in the shops located within the premises of educational institutions and which meals can be served in school canteens, which has been binding since the beginning of this school year. It should be also noticed that advertising and promotion of the products which are not in the list has been banned, therefore, the regulation has an intermediate educational effect.

It is worth recalling that the regulation met with some objections on the part of the former Minister of Education and fundamental criticism coming from the Minister currently in power.
Nevertheless, in this case the Polish legislator has vested all the legislative power in the hands of the residents of Miodowa Street 15 (the seat of the Ministry of Health) and up till now no changes have emerged on the horizon. So, it seems, health wins?

And here we should stop. As it is expected that the regulation will last the whole school year, it would be a good idea to assess its effectiveness already in May. It is not about media reports in the ‘children continue to buy chips’ sensational style but actual, in-depth studies on the attitude change of teachers, children, parents and local authorities.
Without involving all these groups the regulation will be only halfway to success, and a ridiculed and dead letter in the worst case. To end on a positive note, I would like to draw your attention to the programme that is carried out in my former workplace - at the University Clinical Centre in Gdańsk. One can only regret that in few cities in Poland similar effort was made.

Further reading:
Which strategies to employ to tame childhood obesity epidemic are evidence based - as one of the topics for the future debate and decisions.

Czym skorupka za młodu

Od razu zastrzegę się, że chociaż mój BMI mieści się w granicach normy, to powinienem jeszcze z kilkoma kilogramami pożegnać się. Jak już wiadomo to nie sam wskaźnik jest problemem. Zgodnie z nazwą po prostu wskazuje na możliwość problemu czy ryzyka zdrowotnego i w pewnym zakresie to ryzyko mierzy.
Wśród dzieci problem nie jest tak rozpowszechniony jak wśród dorosłych, nie mniej jeśli już występuje ma poważniejsze konsekwencje a czasami także przyczyny, których nie powinno się ignorować.

Temat pojawił się dość mocno w ubiegłym roku w czasie tzw. „debaty drożdżówkowej”. Debaty miejscami merytorycznej, miejscami zabawnej, z domieszką demagogii, w której uczestnicy nie stronili od posługiwania się stereotypami.  Pozytywnej przed wejściem w życie, negatywnej po 1 września. Minister Zdrowia na podstawie delegacji ustawowej wydał rozporządzenie, określające co wolno sprzedawać w sklepikach na terenie placówek oświatowych i podawać w stołówkach szkolnych, które obowiązuje od początku bieżącego roku szkolnego.

Trzeba zwrócić uwagę, że zakaz obejmuje także reklamę i promocję produktów spoza listy, zatem regulacja ma także wymiar, w pośredni sposób, edukacyjny. Warto przypomnieć, że przy pewnym oporze ze strony byłej i totalnej krytyce ze strony obecnej minister edukacji.

Ustawodawca jednak dał w tym przypadku całą władzę w ręce Miodowej (siedziba MZ) i na razie zmian w tym zakresie na horyzoncie (czyli projektu przekazanego do konsultacji społecznych) nie widać. Czyli, wydawałoby się, zdrowie górą?
Tu należałoby chwilę poczekać. Skoro wygląda na to, że regulacja przetrwa cały rok szkolny, to warto w pierwszej kolejności, jeszcze w maju, sprawdzić jak ona działa. Nie chodzi tu oczywiście o doniesienia medialne w stylu „dzieci i tak kupują chipsy” ale realne, pogłębione sprawdzenie, na ile zmieniło się nastawienie nauczycieli, dzieci, rodziców i samorządów. Bez zaangażowania tych wszystkich grup regulacja administracyjna okaże się co najwyżej połowicznym sukcesem, w najgorszym zaś wyśmianym i martwym zapisem.

Dla pozytywnego zakończenie wpisu chciałbym polecić uwadze program, w który jest realizowany w moim byłym miejscu pracy, Uniwersyteckim Centrum Klinicznym. Szkoda, że w niewielu miastach w Polsce podjęto podobny wysiłek.

Dla ułatwienia przekazuję zainteresowanym linki do dwóch jeszcze dodatkowych materiałów

• Rozporządzenie "drożdżówkowe", czyli o czym była cała ta dyskusja...
• Jakie strategie walki z otyłością dzieci działają a jakie nie - jako podstawę do dalszej dyskusji i działań, w tym ważnym przecież obszarze.