Pisa Conference 2010


The future primary health care in Europe III

30 - 31 August, 2010, Pisa, Italy

“From Innovation to Organisational Change in Primary Care which values for patients”

Purpose and Values

The biannual conference of the European Primary Care Forum in 2010 will explore a number of critical themes for primary care. Its aim is to enable participants to identify, define and appreciate the significance of questions - ranging from policy to organization, management and clinical care - which are likely to determine the future of primary care in Europe. The Forum is looking to support contributions which address, in particular, issues of equitable access, cost-effectiveness, service delivery, clinical quality and the maintenance of continuity of care. Both urban and rural settings are relevant, with their differing but equally important modern pressures.


The context is that of a recent rapid increase in the number of member countries in both the European Union and the WHO European Region, and the growing need to understand more clearly the overall impact on health and public service systems of both the emergent new clinical approaches and service delivery models in contemporary primary health care. While as organisations these range internationally from the small general medical practice to multi-specialist polyclinics, all national health systems share similar pressures for change and development. Collaboration in understanding these pressures and the responses they require is essential in the modern Europe to take forward its economic and social development, and to enhance the overall health status of its divergent but increasingly interdependent communities.


In this context six common pressures for change and development have been identified from a review of individual states’ current policies and relevant international research. These may be regarded as the formative influences on the future organisation of primary health care in Europe. Together they represent the imperative for shared learning.
The regional healthcare system of Tuscany is in itself interested in most of the themes as it is currently experimenting chronic care management, interdisciplinary collaboration within primary care teams, performance evaluation systems, alternative prevention programs. For such reasons, the conference program will also include visits to local primary care centres and innovative service delivery facilities.

Theme 1. Chronic Disease Management

This conference brings together the approaches adopted by European countries to address the policy issues necessary to provide high-quality and affordable health and
social care for people suffering from chronic disease.
Chronic diseases are increasing rapidly in most of the European countries. The majority of the European health care systems respond to this "epidemic", through the development of disease management programs. This approach is enhanced by the availability of an increasing number of guidelines. A lot of disease management programs utilise a quite "mechanistic" approach: definition of a patient group with chronic conditions, definition of targets (very often process-related, and when outcome-oriented focussing on intermediate outcome indicators,…), distribution of guidelines, creation of (financial and/or organisational) incentives.
This strategy has led to an increasing number of vertical disease-oriented programs, not always comprehensively integrated in the primary and secondary health care system, and requiring an increasing amount of resources.
The objectives of the conference theme are a) to create an overview of the actual state-of-the-art of Chronic Disease Management in European countries with special attention to the involvement of primary health care and the integration of Chronic Disease Management in primary health care-practice; b) to describe essential features of Chronic Disease Management and financing mechanisms in different European countries; and c) to describe quality assurance processes in relation to Chronic Disease Management;

Theme 2. Interdisciplinary collaboration & leadership development

Most of health care systems in Europe struggle with inadequate coordination of care, whether it is for emergencies or for people with chronic conditions, often leading to a lack of responsiveness to health needs. Strengthening primary care by extending roles and skills within health systems is more and more regarded as a solution, although it requires investments to improve local capabilities and performance. Some systems also need to respond to skill shortages, others to resistance to change among primary care professionals.
Research on the subject is showing interesting initial evidence, but is still controversial on lasting results, although some observers are convinced that interdisciplinary collaboration and professional leadership in primary care could represent a real “healthcare breakthrough”. But what those two features can really stand for within primary care settings? Why they will probably be more and more crucial within European healthcare systems? What are their key components, how they work and could be supported?
This conference theme therefore wishes to: a) to enable an overview of interdisciplinary collaboration forms within primary care in European countries, with special attention to the development of leadership capabilities; b) to describe essential features of both features, starting from educational systems to professional practice; and c) to describe benefits and barriers related to interdisciplinary collaboration and leadership enhancement in primary care;
The dissemination of experiences about interdisciplinary collaboration and leadership features, is probably key for a modern development of primary care capabilities throughout Europe and the ultimate delivery of effective and high-quality services.

Theme 3. Managing properly the medicalization of health problems

Recent discoveries in the medical field have reached important results in the history of our society.
On the one hand, this allows us to live longer and better, but, on the other hand, medicalization permeates every aspect of life and everyone believes that medicine may solve every problem. Death is also felt as an avoidable event that happens because “not everything was done that was possible”.
This approach asks medicine to be present everywhere and economical interests transform health in industry. The risk of an industrial pattern is the conflict of interest that is present not only in the pharmaceutical factories, but also in doctors or groups of doctors, in groups of patients and in devices (like the diagnostic) factories.
Disease mongering is one of the results of the conflict of interest that is giving healthy people new reasons to feel sick. The theme highlights the need for exploration of unwanted side-effects of medicine in general and the role of Primary Care in particular.

Theme 4. Monitoring of Primary Care performance

The investment in PC reforms to improve the overall performance of health care systems has been substantial. There is however a lack of up to date comparable information to evaluate the development of primary care (PC) systems. For example the EU-funded PHAMEU (Primary Healthcare Activity Monitor for Europe) project aims to fill this gap by developing a PC Monitor for implementation in 31 European countries. This project collects information on the features of primary care systems that reflect its stage of development. Focus is on PC governance; economic conditions; workforce development; the accessibility for patients to primary care services; the continuity of patient care; the coordinative capacity of primary care to streamline care processes; the scope of services delivered in primary care.; quality of care and efficiency of care. The Pisa conference wishes to highlight primary care data in various European countries by reviewing (inter)national literature and statistical databases, and consulting panels of national experts. This will increase the knowledge for comparison of countries in primary care development, and know-how of strategies conducive to strengthen primary care in terms of for example accessibility, integration and responsiveness.

Theme 5. Health indicators including patient related health outcomes and experiences

Health quality indicators are increasingly being developed locally, regionally and nationally for performance assessment, service regulation and quality improvement. Indicators are being seen as a lever for improvement underpinned by sanctions or incentives including pay-for-performance. Indicators have previously been developed for organisational structures and healthcare processes but more recently measures of patient outcome or experience, so called Patient Related Outcome Measures (PROMs) and Patient Related Experience Measures (PREMs) have been the focus of interest. The evidence on how, whether and to what extent health indicators can lead to improvements in quality of care is equivocal. This theme will explore how health indicators in primary or pre-hospital care have been developed, how they are being used and what impact they are having in terms of healthcare quality.

Theme 6. Research, funding and developments, in primary care

Primary care should not only apply the results produced by specialists, but also produce its own knowledge.
Primary care research should become an instrument of a “patient based medicine" tailored for the need of the specific part of the population.
Inclusion criteria should be as large as possible in order to match the real people’s need, particularly regarding women and elderly people with co-morbidity.
A multidisciplinary approach that includes all the health determinants should become the base of multi-centric European research projects in the near future to fill the gap between a disease-oriented knowledge and daily problems in primary care practices. This conference theme explores the need to re-address the European research agenda regarding Primary Care.

1st Round of Workshops

1 Chronic Disease Management

- Improving coordination in Primary Health Care across Europe (Irwin, UK)
- The Italian experience of chronic disease management (Valerio, Italy)
- Comprehensive community and home-based health care model for chronic diseases. Describing an experience of implementation (Fantini, Italy)
- Evaluation of the introduction of clinical guidelines for the management of patients affected by chronic diseases. The governance proposal of an Italian GPs co-operative. (Quadrelli, Italy)
- A new method of intervention group: the expert patient in heart failure (Peris, Spain)

2 Interdisciplinary Collaboration

- Health centre in a shopping mall: Empoli (Florence), the first year of activity (Salvadori, Italy)
- Opportunities for physical activity promotion in primary health care for children as perceived by the Finnish public health nurses (Javainen-Levonen, Finland)
- Is multidisciplinary group practice in "Maisons de Santé" the future of primary care in France? (Bourgueil, France)

Introductory Video: Archipel, centre for housing, care and welfare

3 Patient Expectations and Involvement

- The significance of matcheted patient-doctor expectations for a successful back pain consultation in primary care (Georgy, UK)
- Sense of coherence and carotid artery intima media thickness measurements: presenting four case reports from the Spili cohort in rural Crete, Greece (Anyfantakis, Greece)
- Resolutive role of customer care unit in a primary care team (Gascon, Spain)
- User's satisfaction with the resolution of the acute health's problems by the nursery (Mateo, Spain)

4 Monitoring of Primary Care Performance

Due to contract obligations with the EC the PHAMEU presentations are not yet publicly available!

- Monitoring the structure of primary care systems in Europe: results from the PHAMEU project, part I (Dedeu, Spain)
- Monitoring the provision of primary care services in Europe: results from the PHAMEU project, part II (Rotar Pavlic, Slovenia)
- What factors explain variations between primary care teams in patient visits? (Sarria-Santamera, Spain)
- EUPRIMECARE: quality and costs of primary care in Europe (Sarria-Santamera, Spain)
- International comparison of the implications of primary care systems in pandemic influenza A(H1N1)v (Cartier, France)

Introductory Video: Catalonia: Primary Care on the crossroads

5 Health Indicators and Patient Related Health Outcomes

- The quality and outcomes framework-transforming the face of Primary Care in the UK (Gillam, UK)
- Markets of professionalism: Is there a dichotomy in the performance monitoring of different models of primary care. Lessons from two devolved health care systems in the UK (O'Donnel, UK)
- The extent to which contextual effects explain patient satisfaction with GP assistance in four Italian regions (Murante, Italy)

Introductory Video: The Bromley by Bow Centre, East London - using innovation and creativity to address health in a community setting

6 Research, Funding and Developments, in Primary Care

- A training needs analysis of health professionals in Malta's Primary Health Department: a boon or a bane? (Bombagi, Malta)
- The roadmap for trombolysis in outpatients with acute stroke (Puccetti, Italy)
- Research agenda (Visentin, Italy)


2nd Round of Workshops

1 Chronic Disease Management

- Implementation of a screening program for the early detection of diabetic retinopathy using a non-mydriatic camera in Primary Care (Peris, Spain)
- Prevalence comparison of three chronic diseases from three sources; general practice medical records, interview survey and record/linkage of exemptions, drug dispensing and hospital discharge data (Gini, Italy)
- Cervical screening by public nurses - a humane approach of improving outcome of screening (Simek, Hungary)
- Are serious challenges in cancer survival partly rooted in the gatekeeper principle? (Olesen, Denmark)

2 Interdisciplinary Collaboration & Leadership 1

- Malta's specialist training programme in family medicine-an evaluation of the first year of training (Sammut, Malta)
- Current use of the Electronic Medical Record (EMR) among informatized GPs in Belgium (Avonts, Belgium)
- Organizational structure of general practitioners and quality of care for chronic diseases (Fantini, Italy)

Introductory Video: CASAP: a new model of Primary Care Services

3 Interdisciplinary Collaboration & Leadership 2

- Interdisciplinary collaboration in General Medicine. Analysis and perspectives of GPs gathering models in Italy according to the latest Italian National GPs contracts (Mazzeo, Italy)
- Survey on the role of Primary Care providers in sexual and reproductive health (Guarenti, Italy)
- Multidisciplinary assessment (Drewes, The Netherlands)
- The cooperation in thrombosis care: status, needs and their barriers and facilitators to improve the cooperation (Brage, Sweden)
- Castelldefels Salut: a city-wide health management strategy base on a proactive primary care development (Peris, Spain)

4 Primary Care and the Care for Older Persons

- Primary care and care for elderly persons: workshop on EFPC position paper (Boeckxstaens, Belgium)
- Priority setting with older patients in general practice (Junius-Walker, Germany)
- Quality care for quality aging: European indicators for home health care (Zanon, Italy)
- Position of the primary care for the elderly care in Slovakia (Liptak, Slovakia)

5 Monitoring of Primary Care Performance

Due to contract obligations with the EC the PHAMEU presentations are not yet publicly available!

- Quality Monitoring System; A Model from Sultanat of Oman (Sulaiman Al-Salmani, Oman)
- Primary health care in developing part of Europe (Rurik, Hungary)
- Monitoring the outcome of primary care systems in Europe: results from the PHAMEU project, part III (Cartier, France)
- The overall state of primary care in Europe: results from the PHAMEU project, part IV (Kringos, The Netherlands)
- Assessing clinical governance in Primary Care. Results of a diagnostic review in an Italian Local Health Trust (de Belvis, Italy)

6 Health Inequalities

- The accessibility of healthcare for poor people: a qualitative research in Slovenia (Rotar Pavlic, Slovenia)
- Specialist referral rates and nationality in Spain (Sarria-Santamera, Spain)
- Delivery anticipatory care in primary care: Lessons from a national programme in Scotland (O'Donnel, UK)
- Patients' rights through their eyes in public health institutions in Serbia (Zivkovic-Sulovic, Serbia)

Poster Debate Sessions

1 Chronic Disease Management

(2 Corners for debate)

- Maximizing screening attendance: a reference guide
- Chronic disease management in Belgium: care pathaways
- The current organization of care for depression within pregnant women caused by domestic violence and how to work for the better
- Maintaining function in persons with chronic diseases (CDs) by adapted physical activity (APA) programs

- How to inspire confidence among GP's to stimulate exchange of electronic patient information?
- What recommendations for the future of Primary Care in facing chronic conditions?
- New approaches to chronic care and their evaluation in Germany

2.1 Interdisciplinary Collaboration

- Integrating sexual and reproductive health in Primary Care in Europe
- New GPs gathering models provided by the 2009 Italian National GPs Contract
- Primary Health Care Education: Suez Canal University experience
- Implementation of knowledge and inter professional education for primary health care professionals and leaders, to facilitate inter professional and multidisciplinary collaboration in Primary Care (van Amsterdam, The Netherlands)
- Early Childhood Development: Community-based interdisciplinary service for children with special needs from rural areas

2.2 Leadership

- Reforming Primary Health Care: a nursing perspective
- Bridging the gap between policy makers and practitioners
- Advancing federal leadership in primary health care reform/policy in Canada
- Re-inventing community nursing in the Netherlands. How to bring this about? (Eyck, The Netherlands)

5 Health Inequalities

- Hard-to-reach: What does it mean for anticipatory, preventive care?
- Health strategy of Aquitaine region and their innovative policies
- Implementing a health equity approach to primary health care

3 & 6 Research, Funding and Developments, in Primary Care & Managing Medicalization

- Effectiveness of interventions for an appropriate use of resources in Milan: independent Medical Education for GPs and Health Education fro patients (Sgedhoni, Italy)
- New challenges require new types of health services research (De Maeseneer, Belgium)
- Future priorities for research on organizations and service delivery in Primary Care (Schäfer, The Netherlands)
- Innovation programmes: how to learn from innovation in practice (Pietersen, The Netherlands)

PC Site Visits in Toscane region

Local Health Authority 2 of Lucca:

1) Auditorium of the Healthcare Centre of Capannori: a global overview of the Primary Care Services delivered within the Local Health Authority;

2) The New Healthcare Centre:

o general description of the organization of the centre;

o detailed overview of care pathways and delivered healthcare services;

3) The Polo di Maggiano: visit to the Hospice, the Residenza per Anziani (Elderly Nursing Home) and the Nucleo Comi, long-term care facilities as alternatives to hospital admission.

Local Health Authority 12 of Viareggio:

1) Auditorium of the Hospital of Versilia:

o description of the current projects on continuity of care between hospital and primary care;

o short guided visit to the Hospital;

2) The Healthcare District of Tabarracci: overview of social and healthcare activities carried out within the District;

3) Primary Care Centre of CESER: presentation of projects related to work placement and social activities for mental patients. A video will be shown.

Local Health Authority 11 of Empoli:

1) Casa della Salute, a primary healthcare centre made up of a multidisciplinary team: detailed report of continuity of care projects and voluntary services carried out in the centre (such as drug addiction recovery services, diabetes association and other social services);

2) Hospital of Empoli: a guided visit to this two-year-old hospital, designed considering the different levels of intensity of care.

Local Health Authority 6 of Livorno:

1) Hospital of Livorno: a global overview of the Local Health Authority 6 of Livorno and description of projects related to the design and reorganization of Primary Health Care Services;

2) Hospice for Palliative Care of Livorno: presentation of the continuity of care model for palliative care;

2) The Social Healthcare District of Livorno Est

o guided visit to the Centre;

o description of social and healthcare activities carried out within the centre.

Local Health Authority 5 of Pisa:

1) Casa della Salute: an integrated healthcare centre, which is currently experimenting the Chronic Care Model (24-hour primary care services, paediatric services; emergency department, outpatient services, continuity of care, in-home care);

2) Centro Polifunzionale: a multidisciplinary healthcare centre which provides specialist care, rehabilitation services for children and adults, in-home care.

Organizing Committee

St Anna School

Paolo Tedesh
Laboratorio MeS staff

European Forum for Primary Care

Diederik Aarendonk
Anouk Faassen
Alice Riva

Scientific Committee

Giorgio Visentin,
Val Lattimer

Gavino Maciocco,
Niro Siriwardena,

Mona-Lisa Hagvide,
Diederik Aarendonk,

Paolo Tedeschi,