Primary health care is key to solving the diabetes challenge (Guest blog)
19.07.22
Sometimes slow burning crises are the most threatening, especially when the solutions require a real rethink of a complex system. We have read the forecasts ‒ we can see it happening already and know it will get worse ‒ but the difficult business of tackling it can seem less urgent that the more immediate disasters that make today’s headlines. It’s a flaw of human nature that takes real effort to overcome.
Still, there’s no escaping the scale of the problem posed by chronic diseases like diabetes that accompany population ageing. In 2020, 60 million people in Europe had diabetes; by 2030 it will be 66 million. This comes at a cost, first to the health of people living with diabetes, but also to society as we seek to care for growing numbers of people.
The economic cost can rise sharply if the number of people with unmanaged diabetes leads to more heart disease, more kidney failure, more visual impairment and more mobility issues. Such preventable complications account for 75% of diabetes-related health spending.
Responding to these challenges requires a reinvention of how and where we deliver care. It means working to prevent diseases from developing in the first place, as well as ensuring that once people have a chronic disease like diabetes, we strive to prevent the complications that come with it over time. This demands earlier screening, earlier diagnosis, and timely, effective treatment.
The good news is we know what to do. We are not starting from scratch: the answer lies in retooling and expanding a core component of our health systems which has been proven to be effective, efficient, and equitable. I’m talking, of course, about primary health care ‒ where 90% of people with diabetes are already managed.
Person-centred care
Primary health care professionals ‒ GPs, nurses, pharmacists and others ‒ are the first and most frequent point of contact for many people at risk of diabetes and for those with the disease. It is ideally suited to delivering the prevention-focused, person-centred care that reduces complications and improves patient outcomes.
Primary health care professionals ‒ GPs, nurses, pharmacists and others ‒ are the first and most frequent point of contact for many people at risk of diabetes and for those with the disease. It is ideally suited to delivering the prevention-focused, person-centred care that reduces complications and improves patient outcomes.
The problem is that while more chronic disease management is being pushed towards primary health care, investment has not followed the patients. There is also the question of how resources are used. On average, people diagnosed with diabetes have lived with it for between five and 10 years. Investing in earlier diagnosis, which is the key to preventing disease progression, is vital.
People diagnosed on time also require counselling and a more personal and proactive management of their therapeutic needs, based on regular reviews of their risk. Primary care physicians must be trained and empowered to prescribe the right medication for the right patient at the right time. Of course, the trouble is that health care professionals in primary care are busier than ever managing a tsunami of chronic diseases of which diabetes is just one.
Rising demand for shrinking services
The primary care workforce is shrinking, relative to the growing patient populations they are asked to manage, and many are in need of training in chronic disease management. They are also exhausted having been on the frontline of a global pandemic in which they juggled ongoing patient care with spikes in cases of COVID-19 and regular staff shortages.
The result is fewer of those living with chronic diseases have access to quality care. Primary health care is not always the most attractive of the many options open to healthcare graduates, exacerbating the workforce crisis just when we need it most.
The solution is to think hard about how we organise care. In particular, as laid out in the OECD’s report, Realising the Potential of Primary Health Care, efficient task distribution can unlock greater value without demanding more working hours from key staff. It’s about ensuring that skilled individuals are not doing tasks for which they are overqualified, nor are they expected to do things for which they are under-equipped.
For example, asking GPs to spend hours on administration is a waste of a finite resource; expecting a nurse without specialist training to manage patients who have complex combinations of chronic conditions is unlikely to deliver the best outcomes; ignoring the potential of community pharmacists to conduct health checks is a missed opportunity. It is important that everyone in the system makes sound decisions about which patients to refer for specialist care and which patients to manage in primary care.
Digital tools, as we saw during the COVID-19 crisis, also have a role to play but, once again, investment in training, technology and infrastructure are required. And there are efficiencies on the horizon if we can use patient data for the good of individuals and the wider health system.
To make all of this work, we need a quality outcomes framework that measures key targets, tracks progress and rewards it. The approach taken by Australia's Practice Incentives Programme Quality Improvement Measures can provide inspiration to European health systems keen on reforming chronic disease care but searching for concrete examples of how to make it happen.
From policy to practice
If you follow this topic closely, you’ll have ready countless reports on this topic, all of which say similar things: primary health care ‘can save lives and money while levelling the playing field to achieve more equal access to medical treatment’, to quote the OECD. The case has only strengthened since the WHO’s 1978 Alma-Ata Declaration which is often seen as a watershed moment in the evolution of primary care. EU reports on health system performance assessment and effective ways of investing in health build on the same theme.
The challenge has been to translate this into action quickly enough to cope with the chronic diseases crisis. However, with the pandemic focusing minds on the added risks faced by vulnerable patients and a renewed focus on system resilience, there are opportunities to make a breakthrough. Specifically, the EU4Health instrument provides a basis for identifying best practices and supporting pilot initiatives. The recently launched NCD roadmap, as well as the currently developing Joint Action on diabetes and cardiovascular disease, are important elements to ensure a focus and action on chronic diseases. The opportunity lies in translating these initiatives into systematic change to care for people living with chronic diseases like diabetes.
Primary health care is a key part of the solution to the challenges of today and of tomorrow. Now is the moment to make change happen. Inaction is not an option.
