Richard Smith: Being creative in developing primary care

richard_smith_2014Primary care covers the whole population, but it’s underfunded and has increasing difficulty recruiting doctors; and there are worries about equity and the quality of care. This could be the NHS in Britain, but it’s the health system in Florianópolis, Brazil. The NHS can learn from the Brazilian experience, and Jorge Zepeda, a family physician and former director of primary care in Florianópolis, shared how the services have responded creatively to the pressures at a C3 breakfast seminar last week.

The development of primary care in Brazil

Brazil committed itself to universal health coverage soon after democracy was restored in 1988 after years of military rule. Recognising the importance of primary care, the country introduced the much admired Family Health Strategy in the 1990s. Interdisciplinary teams of GPs, nurses, and community health workers are responsible for defined populations of 3000 to 4000 people. Universal coverage remains an aspiration in most parts of Brazil, but 2000 teams covering 4% of the population in 1998 has grown to 40 000 teams covering 65% of the population in 2016.

The teams’ clinics are situated within the area they serve, and provide not only primary care but also public health interventions such as vaccination, contact tracing, and school health services. Community health workers are supposed to provide a bridge with populations like drug addicts, sex workers, and the homeless who are hard to reach but, said Zepeda, had retreated to routine visiting of homes. In Florianópolis they are revitalising the work of community health workers, and a British GP in the audience who had worked in the north of Brazil said that community health workers had played a much more important part in services there.

In recent years dentists, psychiatrists, and allied health professionals like physiotherapists have been added to the teams.

The results have been impressive. Child mortality has fallen, and among adults there have been falls in deaths from cardiovascular disease and in hospitalisation. Satisfaction rates are high—higher than traditional health centres and even higher than in some private sector health facilities. Brazil has high vaccination rates and has done well with containing HIV, but there has been less success with managing dengue fever and now infection with Zika virus. Deaths from noncommunicable disease fell by 20% between 1996 and 2007, but, as in the rest of the world, obesity, diabetes, hypertension, and neuropsychiatric conditions are all increasing.

Challenges in primary care

Since its inception the public health system has been underfunded. It is funded out of taxation, which is progressive, but a quarter of Brazilians have private insurance, which is tax deductible and so regressive as it means a transfer of funds to the wealthy. Brazil spends 8-9% of its GDP on healthcare, but only 45% goes to the public sector. Another problem is the Medical Laws Act, which resulted from lobbying by doctors’ organisations and stops any other health workers from being able to prescribe drugs. It also stops midwives from being able to deliver babies, no doubt contributing to Brazil having the world’s highest caesarean rate.

This protectionism is seen across the globe, and seems to me to be a major blot on the medical profession in that it stops the billions of people who have no access to doctors from getting effective care.

Primary care has human resource problems beyond the shortage of doctors, including bureaucracy meaning it takes six months to make appointments, absurdly high overheads on salaries, the impossibility of getting rid of poor performers, and the lack of a career structure.

But primary care has advantages in that it’s run by municipalities, giving managers like Zepeda considerable autonomy. Florianópolis, which is an island of 470 000 people in the south of Brazil, also has the advantage that it’s one of the wealthiest parts of Brazil—and it was the first to achieve 100% coverage in primary care. Almost half (45%) of the population has private insurance, but three quarters of the population uses the primary care services. Other advantages include an electronic record system, undergraduate and residency training programmes, and continuity of management.

Three initiatives to develop primary care

Zepeda and his team have introduced three initiatives to counter the financial constraints, shortage of doctors, and problems of coordination. A common strategy has been used to introduce all three initiatives. Firstly, the team has used participatory meetings and working groups. Staff have been involved in the initiatives from the beginning. Secondly, the team has used opinion leaders, clinicians who are open to change, professionally respected, and liked. They serve as role models and show how ordinary clinicians can make improvements.

The first initiative is called Advanced Access and aims to reverse the inverse care law, reduce bureaucracy, and increase the role of nurses. Guidelines produced by working groups proposed getting rid of special clinics (for example, for diabetics) and seeing any patients in clinics. The guidelines say the team should aim to see half of patients on the day they first make an appointment, which means a bigger role for nurses, and see all patients within seven days of them making an appointment. As a result, the number of consultations and the proportion of the population seen both increased.

The second initiative was to introduce nursing protocols, increasing the amount that nurses can do. Nurses in Brazil are underused, mostly doing programmed tasks, and are bogged down in paperwork. The team in Florianópolis wanted them to do more complex tasks, including seeing all patients as they presented and providing case management for complex cases. There were barriers in that the nursing professional rules were restrictive and some of the nurses themselves were reluctant to extend their role. Nevertheless, the team went ahead, used a legal loophole to allow nurses to prescribe, developed local protocols to extend the scope of what nurses could do, and introduced a training programme for nurses.

The best path to achieving these ambitious aims is not, emphasised Zepeda, straightforward. The team avoided talk of nurses making diagnoses, spoke of task sharing not task shifting, and never suggested that the role of nurses was being enhanced because of a shortage of doctors; and the protocols began with activities that were the most acceptable.

The third innovation is the introduction of PACK (Practical Approach to Care Kit), a package of simple evidence and policy based guidelines and onsite, team based training developed over 15 years and widely used in South Africa. PACK was developed as a response to the need to provide primary care when few doctors are available for a wide range of problems, including noncommunicable disease, mental health, and end of life care, in addition to infectious disease and maternal and child health. This is a need that is common in low and middle income countries and in remote and underserved areas in high income countries.

The teams from Brazil and Cape Town recognised that the guidelines developed in South Africa could not be simply adopted in Brazil, where disease patterns and policies are different, and a year was spent adapting the guidelines. One adaption has been to colour code what doctors can do and what nurses can do. Similarly, the training has been adapted. The programme is now being tested in a pragmatic trial.

In South Africa PACK is used primarily by nurses, and so the initiatives of developing nursing protocols and adapting PACK have been integrated. The introduction of PACK made the television news in Brazil and was described by one of the local health leaders as “the only great news in a terrible year.” (The leader was presumably thinking of Zika, the impeachment of the president, strikes, and problems in the economy, but was probably speaking before the highly successful Olympics and Paralympics.)

These three initiatives have combined to sustain and enhance primary care in Florianópolis. Advanced Access has already spread to other parts of Brazil, and there is interest across the country in the other initiatives.

The message for other countries, including Britain, is that faced with funding problems and shortages of staff it’s necessary to think of new ways of organising and delivering care.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: RS was involved in the development of PACK and the bringing together of the team from South Africa and the BMJ, but he has no involvement now. He was also an unpaid trustee of C3.