Primary Care in Portugal

By Patricia Barbosa Researcher at National School of Public Health Portugal and Dr. Vitor Manuel Borges Ramos. Specialised in Family Medicin National School of Public Health Portugal

Primary health care is the central pillar of the Portuguese health system. It is based on a community health center network covering the entire country. The primary health care reform initiated in 2005 is probably the most important reform taking place in the public social sector in Portugal.

It is also, possibly, one innovative reform in the current European primary healthcare context, supported by consistent health policies. It's guided by health governance principles (inclusion, transparency, accountability); has a strong focus in improving healthcare access and quality; the organizational philosophy is based on the idea that public health and community care services are part of an "umbrella" primary care concept rooted in multi professional teamwork.

The organizational changes implemented since 2006 promotes new practice conditions and motivation for more professional satisfaction and better performance. It also develops the articulation with other levels of care and promotes contracting and negotiation of primary care performance and chronic disease management and stimulates effective use of information, medicines and medical tests.

The most original feature of this reform is the fact that it combines a bottom-up with a top-down approach, to manage change in order to attain effective managerial decentralization. The bottom-up approach was designed to attract primary care professionals to a "team practice model" with considerable organizational autonomy, on a voluntary basis.

The top-down component is constituted by the definition of national development strategies and establishment of 74 "primary care/ health center groups", as organizations capable of absorbing managerial responsibilities from the "regional health administrations", in order to provide effective support to "team practices", community care and public health initiatives.

To achieve the main goal five different types of small multi professional teams were created, called functional units of the health center groups (ACES). Management and clinical governance structures were also newly created, as well as formal bodies for community participation and involvement (Figure 1). Source: Ramos, V, 2011 The new organization of primary care is based on five main lines: Decentralized team's network Permanent small multidisciplinary teams, with specific tasks: - Providing individual and family care (USF and UCSP) - Providing care to groups with special needs and community interventions (UCC) - Public health interventions in physical and social settings and actions with population scope (USP) Resource concentration and services sharing - Multidisciplinary team (URAP) that provides and enhances specific support and advice to the functional units and health projects Management decentralization to the local level Creation of health center groups (ACES) with CEOs and boards and development of local skills to achieve scale economies for resource management (UAG) Clinical and health governance Involvement of all the professionals, under the supervision of clinical councils in each ACES Community participation Emphasis and strengthening of community participation through bodies as citizen offices (Gabinete do Cidadao) and community councils (Conselho da Comunidade) Source: The health family units (USF) are the main focus of this transformation. They are small multi professional teams with an average of 5-8 Family Doctors (FD), 6- 10 family health nurses and other professionals which results in a real team work. These units are characterized by: professionals join on a voluntary basis organizational, functional and technical autonomy contract with the NHS based on a detailed chart of services (common to all USF in Portugal) a 3 year annual plan with pre-determined objectives and targets (commissioning process between the USF and the health administration entity) de-centralized access to contracted Rx, lab tests and physiotherapy (private and/or public) mixed payment system - linked to age-sex and size of patient list, performance on identified completed episodes of care, certain highly selected "fee for service" items; and dependent on the achievement of the commissioned targets (accessibility, quality, outcomes and cost-effectiveness). We estimate that in the previous situation (before USF implementation in 2006), there were about 1.500.000 citizens (15% of the population) without a FD (they had access to PHC but not to a FD). With this new PHC organization, with already 311 USF, Portugal established a gain of 473.637 citizens covered by a FD (4,7% of the population). If we calculate an average of 1750 new citizens covered by each functioning USF, we expect in 2018 to have a coverage gain of 800.000 to 1.000.000 citizens (about 8 to 10% of the population). In order to make this possible, Portugal needs at least 750 USF (and of course more Family Doctors). At that stage only 5% of the population will be without a FD. This is a complex reform, pursuing and achieving "real" community changes, with unusual challenges for public sector innovation, which provides an extraordinary learning experience.