EFPC Conference Istanbul 9-10 September 2013

Balancing The Primary And Secondary Care Provision For More Integration and Better Health Outcomes


Istanbul 9/10 September 2013; Galatasaray University



Health systems will not automatically gravitate towards greater fairness and efficiency. This world will not become a fair place for health all by itself. Deliberate policy decisions are needed. It requires appropriate conditions at the health care system level and in actual practice to make primary care providers able and willing to take responsibility for the health of the population under their care.

A key element is effective collaboration with well-organized secondary care. Therefore EFPC and TAHEV supported by the International Hospital Federation (IHF) and the WHO regional office for Europe, seizes the momentum where austerity measures are still ongoing, to emphasize the need to further explore how a fine balance between primary and secondary care can lead to more integration and better health outcomes.

There are many competing definitions of integration and integrated care. A review by Kodner and Spreeuwenberg (2002, p 3) led these authors to suggest that:

Integration is a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex, long term problems cutting across multiple services, providers and settings. The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called ‘integrated care’.

Many advocates of integration see it as a potential solution to fragmentation, defined as the breakdown in communication and collaboration in providing services to an individual which results in ‘deficiencies in timeliness, quality, safety, efficiency and patient-centredness’ (Wagner 2009). MacAdam (2008), for example, writes about integration as ‘frameworks of care’ that reduce fragmentation and duplication of health care, which can lead to poor patient outcomes, inefficient services and wasted resources.

There is a need for a policy shift from separation to integration of services in order to tackle the complex social problems experienced by vulnerable populations. In order to enable these people to maintain stability and encourage independency and employment, access to stable services that suit their complex needs must be ensured. Consequently, governments can save on social expenditures, as fewer people will have to rely on government services.

Fragmentation is often the result of organisations, professionals and services operating independently of each other, with adverse consequences for service users. A comprehensive set of changes in the health care delivery system is needed to firstly improve coordination of care with a special focus on addressing the rising burden of NCDs, the ageing population and the high prevalence of co morbidity. Secondly, in acknowledging the specific needs of the individual, people centeredness and patient empowerment are key in this approach.

Much of the focus on integration has tended to be on structures and governance. This is, however, only one aspect; process and cultural changes are likely to be at least as important.


In this broader context the purpose of this conference is to identify, explore and further develop primary care as a hub for person-centered health systems with ensured continuity. The conference organizers emphasize that the key players in primary and secondary care encompass a wide range of disciplines such as medical doctors, nurses (general and more specialized), pharmacists, dieticians, physiotherapist that play an equivalent role in efficiently and effectively delivering health care.

This might include primary care interventions which are leading to better interactions with hospitals. But also redesign of payment systems with multiple payments to better support different functions. The organizers reiterates that regional differences have to be taken in to account. Some countries have further developed primary care systems where e.g. minor surgery, treatment of NCDs and prevention, policy of insurers in trying to shorten the average length of stay in hospitals etc, form an integral part of the health system as opposed to countries in the region where hospitals are dominant.

The limited empirical evidence-base for, and the absence of tools for, measurement and comparison of integrated services remain a significant barrier for the evaluation and implementation of these policies. The conference organizers recognize the need for policy discussion and comparative analysis on integrated services at an international level to assist stakeholders and policymakers to prepare for future challenges.

The added-value of service integration, in terms of cost savings and improved outcomes, remain uncertain despite the logical expectation of a win-win scenario, especially in the long-run. As evidence from available literature underlines, implementing an integrated service system requires significant financial input and the undertaking of organizational and structural changes in financing, management and practice. Given that available evidence shows that the returns on integration tend to be long-term, there might be reluctance amongst policymakers to make such commitments.

The conference will provide an opportunity for the health service delivery system to interact and exchange useful information and lessons learnt. The conference will therefore build upon the individual capacities and knowledge of patients/citizens, GPs, hospitals, nurses and health insurers, to increase their understanding on integration of care including a robust primary care setting.

In this conference participants will try to provide answers to the following burning questions:

*What are the reasons for integration?

*How to overcome cultural differences between sectors (esp. Primary and Secondary Care)?

*What are the consequences of integration from the perspective of patients, primary care units and secondary care hospitals?

*Integration cannot be achieved just by bringing organizations together. What else is needed?

*How can we define proper incentives providing a better integration?

*Where to start integration? From primary care upwards into hospital care or vice versa?

*What are the further implications of reduced hospital care due to integration?

The conference aims to significantly increase the participant's capacity to understand the need of a strong primary care within the health care delivery system and the developments that already have taken place to modernize integration of Primary Care and Secondary Care in the recent past.