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Posts Tagged ‘primary care’

Rehabilitation is mostly understood as a side order of a full-blown treatment of an illness. Should it be so? The first casualty of that point of view is rehabilitation itself. Rehabilitation is “a set of interventions needed when a person is experiencing limitations in everyday physical, mental, and social functioning due to ageing or a health condition, including chronic diseases or disorders, injuries, or trauma”[i] The definition does not imply that rehabilitation should be linked to the treatment of an illness. My point is that rehabilitation should be linked to maintaining one’s physical or mental health: a prevention tool more than a cure.

If we take that approach, rehabilitation would become part of primary care as against being a by-product of specialist care. Primary care is the point to which a person will turn when feeling something is wrong with his/her health. That does not mean necessarily that the person is ill; that the person is a “patient”. I resent very much that word. The label “patient” is diminishing any way you look at it. Does it mean you must be tolerant with the health professional who is treating you? Or is it that you must endure your suffering? The use of the word “patient” limits also the scope that rehabilitation should have since it links rehabilitation to illness.

Rehabilitation should take a bigger role in humans’ wellbeing. A recent paper[ii] points out that almost one in three people on the planet needs some kind of rehabilitation. If we narrow the focus, 1.71 billion people have musculoskeletal conditions that could benefit from rehabilitation. Narrowing even more, around 30% of the population in the European Region has musculoskeletal problems.

With an ageing society, that percentage is only going to increase and the health system, or primary care for that matter, is not and will not be able to cope with the problem. A different approach must be taken to devise a system that relies more on prevention and less on after- the fact- cure. The situation represents a unique opportunity for developing easy to use ICT tools that help primary care professionals address the growing demand for preventive and curative rehabilitation therapies.


[i] Cieza A. Rehabilitation the health strategy of the 21st century, really? Arch Phys Med Rehabil 2019; 100: 2212–14. Cited by Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020

[ii] Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2932340-0 Accessed 08.12.20

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Due to the current situation, Primary Care has been brought to the limits of its endurance. This cannot come as a surprise. Most systems are tailored to the current needs that the system has to attend to, not to emergency situations. The job of Primary Care is to attend the day-to-day business of the population, acting as the front door to the health system, and to monitor the evolution of chronic patients.

Covid-19 has added a new dimension to this job description: doing the triage of the population in view of identifying those infected with the virus. It would not be a big problem if that were a normal procedure: anamnesis, decision, and derivation to the appropriate health resource or, as is the case of the flu, a recurrent winter event that can be pre-programmed. But this is not the case. To start with, SARs-CoV-2 is a very infectious virus that occurs throughout the entire year. The fact that it is highly infectious has changed the way the healthcare professional has to confront his/her prospective patient. The professional has to be equipped with Personal Protective Equipment (PPE), the premises have to be disinfected regularly, incoming people have to be pre-checked to avoid unnecessary contagion of personnel and contamination of the premises. All of these procedures necessarily slow the flow of patients precisely when the flow increases due to the pandemic. The result is a bottleneck in the system, and in an attempt to solve it, monitoring of chronic patients is sent to the back of the Primary Care priorities. The system assumes that a chronic patient will not evolve so quickly as to need urgent intervention: just take your medication and hope for the best.

But there is a solution. There are plenty of simple ICT applications to monitor vital signs and other signs like glucose. Unfortunately, we must admit that the biggest barrier to its introduction has come from healthcare professionals. While it is assumed that if the patient needs a medication, the healthcare professional will administer/prescribe it, it is still exceedingly rare that the same professional will prescribe an app. There is no explanation for this dichotomy. How can you explain that a professional will not recommend/prescribe something that is good for the patient and for himself/herself? It saves work for the professional and empowers the patient, allowing the latter more control of the management of his/her condition. There is for sure a long way to go, but the first step in the journey is to convince health professionals of the usefulness of ICT apps, probably using the same procedure that pharmaceutical companies use to introduce their products.

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Remedial care, meaning actions taken after an ailment has been detected, has been the traditional focus of healthcare. Probably that is the reason why, when politicians decide to invest in healthcare, they put the emphasis on hospitals and fancy machinery. Let us not be cynical and think that it is because a picture taken in front of a multimillion-euro hospital looks better than one taken in front of a non-descript primary care building. Most probably, policy makers are the slaves of some defunct theory (to paraphrase Keynes).

They, or probably all of us, do not follow the advice – Keynes again- that “When my information changes, I alter my conclusions.” We see it on the current so-called second Covid-19 wave. There is a lot of talk about building more wards dedicated to Covid-19 – remedial – and little emphasis on reinforcing primary care – prevention – where the pressure for tests and tracing is mounting.

Contrary to reacting to a situation, preventing it is a lot more efficient and effective. Unfortunately, the Covid-19 pandemic has demonstrated how few preventive measures have been taken by all of us. We cannot say the problem lies solely with policy makers; it has been all of us who have decided not to take the most basic measures to fight the spread of the virus. We are all to blame.

Apart from the tracing app, there has been very little development of ICT based instruments to fight Covid-19. The fact is that we, as a society, tend to focus on the immediate, and not to look at the big picture: too many tactics and very little strategy. Confronting the problem as a Covid-19 problem will not solve the imbalance in favor of remedial care against prevention care.  We need to divert our investments, human and material, to primary care, where healthcare becomes much more than treating illnesses, where healthcare is preventing people from becoming ill. Thinking that way, I can see lots of ICT applications that could help primary care do its job: simple, user-friendly applications to be used by normal people, designed to help practitioners do their job and the population to remain fit and healthy.

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And it looks like we are losing the battle. According to “Healthcare expenditure statistics” from Eurostat, “[The] highest share [of total healthcare expenditure] of current healthcare expenditure [related to preventive care] in 2014 was recorded in Italy and the United Kingdom (both 4.1 %), while at the other end of the range, shares of less than 1.0 % were recorded in Romania (0.8 %) and Cyprus (0.6 %).” At the other end “curative care and rehabilitative care services incurred more than 50.0 % of current healthcare expenditure in the vast majority of EU Member States”

It may be that this is the right balance, but allow me to doubt it. And my doubts grow as I focus on the demographic change taking place in Europe. The baby-boomers are getting older and we are not doing anything about it, despite the fact that it is probably a generation ready to embrace a healthier and more active life than previous older generations.

I have been wondering, since I started working for the healthcare and social sectors, why it is that prevention does not get the attention of our policy makers.

Many explanations come to mind. Of course, simply saying “they are stupid” is the easy one but I refuse to fall for it. I strongly feel that anybody who has attained a position of responsibility may have many faults, but being stupid cannot be one of them; they would never have reached that position of responsibility.

The urgency of solving the immediate problem may be one of the reasons; after all, if somebody has an acute illness something urgent has to be done. It is a plausible explanation but, if that were the case, policy makers would never plan for the future building new roads or housing developments since they would be too busy repairing the existing road network or the old houses in inner cities.

I am afraid that highways are built because they make the news. I am afraid that most of the things that our policy makers do are geared towards a 30 second appearance in prime time national TV news. If that assumption is right, then it is clear that the opening of a new hospital (curative and rehabilitative care) is a better news item than the establishment of a prevention scheme that does not require any new buildings, or any new expensive and photogenic equipment. It requires only brains and hands, probably the least photogenic tools of the healthcare process and, probably too, the most ignored by policy makers.

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This is a real story of a real person in a real country that, I am afraid, can be replicated across many other countries in Europe. It is a story about cuts in healthcare services and its real influences in overall expending for the Government and for the people.

Mr. XXX is a manual worker whose job implies using his arms to move thing around. After several months of feeling that his right arm was hurting, he went to visit the primary care doctor. The diagnosis was clear: a strong tendinitis that prevents him from performing  his duties until he is properly treated. So the primary care physician sent him to the traumatologist for consultation and further treatment.

And here the nightmare starts. Due to cuts in healthcare personnel, the waiting list for traumatology is such that Mr. XXX receives an appointment for 90 days from now. What are the implications? First, Mr XXX cannot work and he will be on sick leave for at least the next three months. He will be paid  by the social security a percentage of his salary, with a complement by his employer to make up for the basic 100% of his salary. Secondly, his employer will have to employ another person to fulfil Mr. XXX duties.

So the outcome is that, by cutting back on personnel disregarding the actual demand, the health service has prompted an increase on the social security budget and at the employer’sexpense, while Mr. XXX lies in bed weighing to be taken care of!

Are these the savings that we are aiming for? I certainly doubt it.

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Efficacy in the provision of care coupled with efficient use of scarce resources is the goal of any social and health care system. Or is it?

Governments feel hijacked by their constituencies. They feel the need to provide quick answers to problems that, in most cases, their constituencies are not even aware of. Politicians feel the need to do something, and that something has to be readily visible. If you were an average  politician, what would you prefer? A front page picture in the paper of the inauguration of a hospital, or a long interview in the middle pages explaining how you have bet on primary care? You can fill in the blank ________________.

And yet, we all use a lot more primary care services than those of an acute hospital, no matter if we are young or old. We rely for our well-being on proximity services: social and health primary care. Only on extreme occasions do we use an acute setting.

Furthermore, primary care is focused on prevention, as opposed to remedial actions provided by acute hospitals. To top it off, prevention is recognized as the basic pillar of efficacy in care and efficiency in the use of resources.

And then, why is it that prevention is the black swan of care? I can only think of one answer and it is not a pretty one: our politicians need quick fixes and they have neither the knowledge nor the willingness to confront complicated problems.

Can we do something about this? I would like to think that we can. The constituents, or in other words the professionals and users of the socio-health system, should make their voices heard loud and clear: we would like a system that helps us to prevent ailments, not a system that only takes care of us when it is too late.

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