11.2.1. Personal services

Primary care is the first point of contact for patients in the health system. This contact may be a general practitioner, a nurse or a multidisciplinary team of providers. In recent years, there has been a trend in many countries to transfer care outside of hospitals because of the perceived high cost of hospital care, the challenges of providing care to dispersed populations, and to make health services more accessible to the public (Ettelt et al, 2006). This trend is visible in the declining number of hospitals and hospital beds in many countries (see below). Care outside hospitals is organized in different ways across Europe. Some countries employ extensive gatekeeping that controls access to specialist and diagnostic services, while others offer direct access and typically a greater choice of providers. In the latter case, the shortfall tends to be less continuity of care with more duplication of services and lower levels of equity and efficiency (Ettelt et al, 2006).

Studies have shown a significant association between primary healthcare and improved health outcomes (Macinko et al, 2003). Using OECD data, strong primary care systems are negatively associated with aggregate and gender-specific mortality rates, overall levels of premature deaths, and premature deaths from asthma, heart disease, cerebrovascular disease and pneumonia, even when other determinants of health (e.g. GDP and behavioural factors) were controlled. Strength of the system was measured using a 10-component scale of health system characteristics such as financing, resource allocation and accessibility, and specific features of primary care such as the level of gatekeeping, comprehensiveness of primary care and the degree of service coordination. While lower mortality rates are associated to a greater supply of primary care physicians, this does not seem to be the case with specialist physicians (Starfield et al, 2005).

Variations can be seen in both the availability of primary care facilities (HFA 2007), and in the intensity of utilization, as measured by the number of doctor consultations per capita. (Note that outpatients include all kind of physicians, i.e. both general practitioners and specialists). Countries in central and Eastern Europe, notably the Czech Republic, Hungary, Slovakia and Slovenia, appear to have significantly higher users of outpatient care than in the rest of Europe. On average, the difference between the EU Member States prior to 2004 and those after is minimal (11.4. versus 7.9), partly owing to the extremely low service intensity seen in Cyprus and Malta. Among the Western European countries, those with systems of social health insurance tend to have higher levels of utilization than those with tax-funded systems. Similar patterns can be seen for hospital utilization, as discussed elsewhere (Figueras et al, 2004), and below.

Table 11.4. Number of outpatient contacts per person, 1990-2005

The number of hospitals has seen a decreasing trend since 1990 in the original EU Member States, but not as much among the new Member States. On aggregate for the whole EU, the number of hospitals declined from 3.82 per 100,000 population in 1990 to 3.1 in 2004 (thus, a reduction of 0.72 hospitals), compared to a reduction in 0.89 hospitals in the EU15 and an increase of 0.8. hospitals in the new Member States (HFA 2007). In addition to a decreasing trend in hospital bed numbers, the average length of stay in hospitals has also decreased substantially in recent decades (McKee and Healy 2002); even from 1996 to 2004 the EU average length of stay declined from almost 10.9 days to 9.2 days (HFA 2007). These declines can be seen alongside an increase in the proportion of day-surgery procedures performed with an aim to increase activity, efficiency and reduce waiting times; although some variation can be seen across countries. A survey of 19 countries reveals very high rates of day surgery for some procedures, such as hernia repairs and cataract removals in Denmark, Sweden and Norway (along with the US and Canada) with much lower rates in Portugal, France, Scotland and Germany (Castoro et al, 2007).

It is also important to consider the number of hospital beds available to the population, since hospital sizes vary across the European region (Figure 11.2). When examining the number of hospital beds per capita, countries with the highest supply are Germany (829), the Czech Republic (810) and Lithuania (814), while countries with the lowest supply are Turkey (285), Spain (337) and Portugal (345). Most hospital beds are allocated to medical and surgical specialties (i.e. curing illness and providing treatment of injury). There seems to be a greater supply among countries with social health insurance systems in Western Europe compared to those funded largely by taxation.

Figure 11.2.Number of hospital beds per 100,000 population, 2007 or latest available year

Austria, Finland, Hungary and Romania apparently have relatively high rates of hospital utilization, with over 25 admissions per 100 population. Moreover, there has been no clear increasing or decreasing trend in the past decade in the number of inpatient admissions per capita. In some countries such as Austria, Denmark, Hungary, Norway, Poland and Turkey there has been an increase in admission, while in Belgium, France, Iceland, Ireland, Italy and Sweden reported a slight decrease.

The number of psychiatric beds as a proportion of total beds varies significantly across the region. Some countries have relatively low proportion of total beds used for psychiatric patients, Italy (3%), Turkey (4%), Austria and Cyprus (7.5%). Despite the general trend of deinstitutionalization of psychiatric patients seen in Western Europe over the last 30 years, and more recently also in some central and Eastern European countries (McDaid and Thornicroft, 2005), high levels of psychiatric beds as a proportion of total hospital beds can be seen in Malta (34%), the Netherlands (33%), Belgium (28%), Ireland (26%) and Croatia (17%) (HFA 2007). When examining the number of psychiatric beds per capita since 1996, there continues to be a decline in most countries (Table 11.5). The exceptions are Germany, Greece and the Netherlands, where a slight increase was seen.

Figure 11.3. Inpatient admissions per 100 population, 1990-2005

Table 11.5. Number of psychiatric beds per 100,000 population, 1996-2005 (and percentage decline)

Disease management programmes - originally created in the US to improve chronic care and contain costs - have increasingly been introduced in Europe as a response to the rising prevalence and complexity of chronic diseases. DMPs emphasise prevention and management of patient risk factors in addition to diagnosis and treatment. Similarly, the Chronic Care Model - which is a more specific guide of chronic disease management for provider organizations and an offshoot of DMPs (Bodenheimer 2006) - has guided the development of programmes for specific disease categories, most commonly diabetes, cardiovascular disease and cancer. A review of DMPs found they improve the quality of care and disease control and in some cases reduce hospital admission rates (Mattke et al 2007). As the experience with DMPs in Europe increases, and programmes extend beyond single diseases to more integrated approaches, the provision of health care and approaches taken to ensure high-quality care will look very different in the coming years.