Health checks. Diagnosis. Treatment. These were the guiding principles behind the noble idea of coordinated care introduced in autumn 2022 in Poland’s PHC. Each element of the patient pathway would be described with three adjectives – effective, fast, and efficient. The aims of the care were, among other things, to expand the catalogue of diagnostic tests in PHC facilities, ensure faster access to specialists and, as the ministry put it, “activate the patient”, who would be able to “take action regarding their health”. People with cardiovascular, pulmonary, and endocrine conditions, as well as diabetics, must have been happy. And rightly so. However, after a year, it’s clear to see how long the road still lies ahead. Regrettably, years of negligence, ineffective communication with patients, and a failure to build public awareness have led us to the point where today we’re among the top countries in terms of medicine consumption. We also lead the infamous obesity rankings for the youngest part of our population.
Polish practice
How does coordinated care work today? Just take a look at the so-called pulmonology pathway, where spirometry is performed at the Primary Health Care (PHC) facilities. Having said that, the activity of GPs ends at this examination and the patient is referred to a specialist. Depending on which voivodeship you live in, the waiting time for an appointment varies from 2 months (Podkarpackie voivodeship) up to 7.5 months (Opolskie voivodeship)*. What happens to the patient after an outpatient clinic visit? You can guess that they end up in hospital, or more specifically in a hospital queue, and wait there for days – or weeks and months, more like it. What about the reason? The patient pathway from the specialist clinic to the ward is still unregulated.
Unfortunately, the assumption that the hospital is the only facility that can effectively treat the patient persists. This way of thinking stands in contrast to the experience of other European countries. In Scandinavia, the patient is consulted by medical assistants and nurses before being seen by a doctor and is only referred to a specialist if necessary. As a result, the availability of medical appointments increases and queues to specialists’ offices become shorter. In Poland, the opposite is true – the number of visits to PHC facilities and specialist clinics is increasing. It increased by 2.8 per cent in 2022 compared to 2021 in primary care and by 0.6 per cent in specialist medical care**. Waiting times for medical appointments are also increasing, having increased by 1.7 months between 2015 and 2022 and now standing at around 4.1 months***.
Why is it so? Because we’re unable or unwilling to rationalise therapy. It’s the provider who should be interested in treating the patient effectively as opposed to signing them up for follow-up appointments every month. Here it can be seen that change is needed and could include, for instance, financial benefits for providers in return for effective treatment, the absence of complications, or the fact that the patient will not end up in hospital.
Coordinated care facing an enormous challenge
Fully implementing coordinated care at a level similar to, say, the Scandinavian model is quite a challenge – both for healthcare providers and for those governing the country. Numerous problems with the introduction of coordinated care have been highlighted by people including general practitioners affiliated with the Zielona Góra Agreement and the College of General Practitioners.
These are, primarily:
- staff shortages among PHC and specialist doctors,
- under-pricing of medical consultations, coordinators’ work, and some diagnostic tests,
- no valuation of the costs of organising coordinated care and administrative costs****.
The implementation of coordinated care, which is in principle a correct thing to do, as its theory involves moving away from a hospital-centric vision of patient treatment, overlaps with problems in health care going on for years. To date, we haven’t produced a treatment pathway where diagnostic and treatment times are reasonable, and the patient is effectively treated already at the outpatient clinic level and not only in a hospital. The premise, which was intended to relieve the burden on medical staff in practice, is not quite working either.
Why is that? This is for several reasons (which I’ve already mentioned), but primarily, the system doesn’t provide the coordinated care units with attractive bonuses for entering this model. And there are examples in Polish healthcare where the implementation of such incentives has a positive impact on medical staff as well as, above all, on patients. In the pilot project oriented towards the comprehensive specialised care for surgically treated obesity (Polish acronym: KOS-BAR), special bonuses were offered to providers for achieving desired treatment outcomes such as lower mortality or complication rates, shorter hospitalisation times, faster return to work, as well as the abatement of diabetes, hyperlipidaemia, and obstructive sleep apnoea. Another example whose implementation could have a positive effect is the National Cancer Network pilot programme. This is where it’s absolutely clear that a standardised diagnostic procedure, coordination of the entire process and uniform monitoring of quality and patient satisfaction ensures comprehensive care and treatment.
Oncology is the best example of how standards and coordination of the whole process positively affect not only the health of the patient but also the whole system. The so-called DiLO card (oncological diagnosis and treatment card) is the best proof.
You have to pay first to have it cheaper later
Showing healthcare providers the tangible gains they can make from implementing the new care model would stimulate the whole system. A financial reward for providers for achieving certain treatment outcomes, as I mentioned earlier, could help here. It would also be recommendable to create an incentive system for patients. Here, regular examinations, whereby citizens could receive a reward from the state in the shape of one monthly health premium free of charge, should act as a motivating factor.
Introducing coordinated care without such a driver means that the system isn’t working as it should.
Those at the helm must also realise that to make it cheaper in the future, more has to be paid as soon as now. Patients should also be similarly aware. The achievement of 7 per cent of Polish GDP being funnelled into health means increased financial obligations of society in this area. An example would be the Danes, who – compared to other European societies – contribute the most to the state coffers through taxes. What are the results? One of the best-performing health systems in the world.
*Data on queues can be found on www.swiatprzychodni.pl.
*** https://dentonet.pl/kolejki-do-lekarzy-w-polsce-coraz-dluzsze/#gref
****https://www.termedia.pl/poz/Porozumienie-Zielonogorskie-Opieka-koordynowana-niemozliwa-do-wdrozenia-w-tym-ksztalcie,48673.html and a presentation by the College of Family Physicians.
