Karl Krajic  |  Petra Plunger  |  Ursula Reichenpfader  |  Jürgen M Pelikan
2. Status quo of Patient-/ User oriented health promotion in general practice and community pharmacy in Europe.
A Cross analysis of Country Reports on the status quo of health promotion in general practice and community pharmacy in Member States of the European Union participating in the project

A. Introduction
B. Country Reports: Cross-Analysis relating to General Practice
Background
1. Material and Methods
1.1. Country Reports
1.2. Literature Search
1.3. Personal Communication
Results
1. Health Promotion in Professional Role and Practice
1.1. Professional Organisations: Policy and Position
1.2. Role Concepts and Professional Practice
2. Health Promotion in Education and Training: Extent and Character
2.1. Undergraduate Level: Basic Medical Education (BME)
2.2. Postgraduate level: Vocational Training:
2.3. Continuing Professional Development
3. Health Promotion in General Practice Research
3.1. Research in General Practice/ Primary Health Care: Character and Infrastructure
3.2. Research on Health Promotion in General Practice/Primary Health Care: Issues in Literature
4. Health Promotion and General Practice Infrastructure
4.1. Reimbursement and Incentive Policies
4.2. Organisational Factors and Practice Pattern
References

C. Country Reports: Cross-Analysis relating to Community Pharmacy
1. Background
1.1 Methods and Sources:
1.1.1 information from national CR:
1.1.2 Literature search and other published material
1.1.3 Personal communication (project meetings, other conferences)
2. Results
2.1 How strong is the interest of community pharmacy in health promotion and to what extend is health promotion an element of everyday practice?
2.2 What are supporting factors and barriers for health promotion in community pharmacy?
2.3 Role definition (and self-understanding) and perception of professional role of community pharmacists by relevant actors with respect to health promotion
2.3.1 What is the position of professional bodies regarding health promotion in community pharmacy?
2.3.2 What is the professional understanding of health promotion in community pharmacy and how does it relate to the professional role?
2.3.3 What is the perspective of health policy regarding health promotion in community pharmacy?
2.3.4 What do patients expect regarding health promotion in community pharmacy?
2.3.5 What are future perspectives on the development of the professional role in health promotion
2.4 Community pharmacy infrastructure
2.4.1 Factors related to organisation of work in community pharmacy
2.4.2 Remuneration systems/ adequate resources
2.4.3 Co-operation
2.5 Education and training
2.5.1 What is the status quo on education and training related to health promotion?
2.5.2 What are future scenarios for education and training related to health promotion?
2.6 Research
2.6.1 What is the status quo of research related to health promotion in community pharmacy?
2.6.2 What are future perspectives for research in this area?
References
Appendix


3. Health Promotion in General Practice Research

Only a very rough assessment of the developmental situation in a limited number of the Member States can be provided. As already noted above (see section 1.2. "Role Concepts and Professional Practice"), health promotion activities in general practice are still not well documented and evaluated. From material in the Country Reports, and supplemented by literature, the following can be summarised:

3.1. Research in General Practice/ Primary Health Care: Character and Infrastructure
As indicators of research infrastructure in general practice information systems, research networks, the status of general practice as an academic discipline, availability of journals and conferences are relevant. With respect to health promotion, the following information was provided:

Research Infrastructure and national examples of relevant research activities from available Country Reports - In Spain, academic departments of Family and Community Medicine are established and a primary care journal (Atención Primaria) publishes a special issue covering health promotion and prevention once a year. In it, recommendations are reviewed and updated, and results of the evaluation of the "PAPPS" programme are presented. Health centres enrolled in the national "PAPPS" programme receive back-up from a specific documentation and evaluation centre. Local regular meetings allow adaptation of national protocols and health centres receive feedback on their prevention and health promotion activities. Those mainly involved in research are networks of the regional autonomous scientific societies, with research activities performed in teaching health centres. - In 1984, the foundation of the Irish College of General Practitioners (ICGP) provided a co-ordinated approach to the development of general practice as a unique discipline in medicine in Ireland. Through its Postgraduate Resource Centre, regional research networks and national programmes are organised in areas such as smoking cessation, women's health, and methadone treatment. A continuous and systematic documentation on health promotion and prevention as routinely provided in general practice is not available. - In Germany, general practice academic development and specific research will be increasingly encouraged in the future. However, at present only three departments of general practice (out of 36 medical schools) have been established with full tenure. As can be inferred from the national model projects provided, implementation research and evaluation are carried out with support of a specific University department or other research institution (e.g. projects "PAGT", "School and Health", "Promotio"). The previous involvement in international programmes (see participation in CINDI programme of project "Community-Based Behavioural Medicine Östringen") can be influential for setting up sustainable local networks. - In Belgium, the scientific general practice organisation (SSMG) is represented at the Superior Committee for Health Promotion in the French community and is involved in conducting action research in the context of European and regional projects in areas such as methadone treatment (project "ALTO") or alcohol-related education, and is currently developing a research project on colorectal cancer screening. Several quality circles, also in collaboration with community pharmacists, are running. - In Austria no departments of general practice have been established yet. At this point, there is no national strategy for enhancing infrastructure for research and development in primary care and no specific R&D funding arrangements within current general practice schemes are in place. Thus, established research networks in general practice do not exist. Local initiatives occur in quality circles encouraged by professional organisations. A few research activities relevant to prevention and health promotion have been initiated and are conducted in the context of pre-existing European initiatives and networks with a focus on communication and patients' preferences. The Austrian Society of General Practice and Family Medicine (ÖGAM) is currently participating in the "IMPROVE" project network, a multi-centre European follow-up project initiative(16). Prior research activities have built on the European study project EUROPEP" and have been published in Austrian medical periodicals. A further research initiative is currently operating within the pre-existing European network "Teaching Cancer Care in General Practice". A national delegate has recently been involved in the international network EUROPREV (European Review Group on Prevention and Health Promotion in General Practice and Family Medicine). - In Greece, general practitioners carrying out local projects and initiatives are not directly involved in research activities. Accompanying research is directed by University departments of Preventive Medicine or Hygiene and Epidemiology in the area of nutrition, child health, prescribing, mental health and accident prevention. Also, there is collaboration with NGOs (non-government organisations) and public and private foundations.

3.2. Research on Health Promotion in General Practice/Primary Health Care: Issues in Literature

Issues relevant for research on health promotion: some examples from literature - Methodological issues have been addressed as well: Complex health promotion interventions in general practice research publications are not consistently referenced under the heading of "health promotion". Rather, they appear within related conceptual frameworks of communication and consultation techniques. Interventions referenced as "health promotion" mostly refer to individual disease prevention activities. Often published work does not include descriptions of implementation. Furthermore, as has been cited in an article by Woolf and colleagues, (Woolf, Johnson 2000): "The soft science of behavioural medicine, which figures prominently in primary prevention and lifestyle change, is difficult to evaluate with randomized, controlled designs or to measure with standardized endpoints that reviewers expect." - Also, with respect to the appropriate research settings, it has been noted recently by van Weel (van Weel 1999) that "[…] the impact of scientific evidence is reflected by non-scientific considerations like the cultural values of non-intervention. In particular in family medicine research with its contextual complexity, this is an important but poorly understood factor that underlines the need for a research setting that takes into account socio-cultural values."

In conclusion, health promotion activities in general practice are not well documented to date and information from Country Reports and literature has pointed to needs and difficulties of (general) practice-based research. Some research activities, increasingly with involvement in national and multi-national research initiatives is developing and small local research activities are piloted. Still in many countries, research infrastructure and measures supporting general practitioners in getting involved in research in general are still in an early developmental stage. A coherent framework for research and evaluation is needed. A coherent framework for research and evaluation is needed.

4. Health Promotion and General Practice Infrastructure

This section covers aspects in general practice infrastructure relevant for professional practice in general and for health promotion practice particularly. Infrastructure in this context refers to the material and organisational features against which current practice is provided and include the following
- Financial resources such as remuneration and incentives
- as well as organisational factors

- such as forms of practice patterns - availability of patient information systems - specific quality assurance structures

In literature there is little systematically known about the effects of certain components of infrastructure and organisation on actual medical practice patterns, let alone on their quality or impact on health outcomes. While it has been studied how certain payment/remuneration methods might affect physician income, provision of specific procedures, referral rates, or use of health services, less is known about these relationships and performance of health promoting and complex, communication-intensive health services in general practice/ family medicine.

As a general remark, it has to be recognised that general practice, despite the common core content, still is operated in different health systems across Europe(17). Features such as models of health care, for instance, primary-care orientation, system of personal doctor with patient list, and the role of general practitioner as prime provider or gatekeeper, will definitely influence practice and its specific relationship with health promotion. This, however, was not explored in detail in this project. Authors often refer to the need for specific support measures to enable general practitioners to engage in health promoting practices. However, these needs are to be seen in their specific national and local contexts. Frequently in literature(18), general practitioners interested and involved in health promotion activities name "lack of time" and "lack of adequate payment" as the main obstacles for practising health promotion or as reasons for being reluctant to change established practices.

This applies to many of the model projects and initiatives described in available Country Reports in some form or another and is dealt with more thoroughly in the below sections. Thus, "lack of time" can be understood as an indicator of perceived lack of resource(s) in relation to specific given circumstances, and potentially amenable to specific measures(19). The following section summarises findings as described in the Country Reports available.

4.1. Reimbursement and Incentive Policies
Generally, available Country Reports indicate, that specific reimbursement schemes exist predominantly in health insurance systems (with general practitioner payment on a fee-for-service or mixed base). Remunerated services in this context are established by law, entitlement and scope, specified in contracts and mostly concern prevention activities such as cancer screening, health checks and well child clinics, as well as specific counselling in disease-oriented clinics. Notably, no specific remuneration or incentive schemes explicitly reward communication or relationship aspects in the consultation. Thus, current arrangements seem to focus on procedural interventions instead.

Reimbursement policies and financial incentives for health promotion and prevention services as from Country Reports available: - Relating to the issue of adequate payment, no extra remuneration fees for prevention and health promotion are currently provided in Greece. - In Ireland, with the exception of childhood immunisation (fee-per-item only, no bonus system or target payments), no specific remuneration system is in place at present. Changes in the nearer future are expected, though proposals for fees for a specific cardiovascular prevention package and cervical smears are currently under negotiation . - Established remuneration schemes with fees for specific individual preventive services are reported by authors in Luxembourg, Austria and Germany. General practitioners receive fees for packages which are available for health checks, certain cancer screening and risk factor counselling activities. Common to these arrangements -all operated in systems of independent general practitioners with fee-for-service payment - is their clearly defined legal status with (almost universal) eligibility within the social security system. Interestingly though, this measure alone does not necessarily determine level of service provision beyond a certain level of uptake. In Luxembourg, it was not sufficient to raise general practitioners' participation in the national breast cancer screening programme and the author from the German Country Report noted that despite the strong financial incentives for preventive services, service provision and uptake are only moderate. Particularly in the former case, perceived low patient demand and competing workload for curative care has been expressed by the general practitioners as major relevant factors for t not getting more involved in the mammography programme(20). Also, as examples from Austria show, current reimbursement schemes do not allow for group health or patient education. - Similarly, "negative incentives" resulting from a change to a bonus system which was linked to service packages of antenatal care by the general practitioner previously in place, affected levels of general practitioners involvement in this area(21). As a consequence, this also led to a reduced involvement of general practitioners in childhood surveillance and immunisations. - Communication tasks are generally not specifically rewarded, which has been explicitly addressed by the author in Luxembourg(22) and is also described in the German Country Report(23)

4.2. Organisational Factors and Practice Pattern
When payment issues are not directly involved, e.g. in systems without fee-for-service payment, general practitioners may perceive (questions of) "lack of time" and/or "heavy workload" as major obstacles. This may be related to specific practice patterns, both as local or as national characteristics of general practice.

Country Report authors have addressed the factors underlying and shaping their professional role and the relationship with other health professionals and clients/patients (particularly factors that can affect - both negatively and positively - co-operation(24), collaboration and partnership and thus relevant for health promotion practice. The nature of solo practice in particular can hinder effective prevention work and health promotion. Also, multi-professional teamwork and the necessary legal and regulatory conditions are relevant for co-ordinated and collaborative health promotion.

Issues of collaboration and co-operation in general practice: Examples from Country Reports - In Luxembourg(25), the Deontological Code prohibits forms of multidisciplinary teams which has been described as a "weakness" in the current situation of health promotion - Similarly, it has been noted that communication and co-operation between general practitioners and specialists, as well as community orientation, was poor in Germany. Nevertheless, the author has identified some successful local collaborative initiatives: A regional pilot project to implement a network of co-operating office-based general practitioners and specialists using a "salutogenetic" approach are in the negotiation stage with the regional sickness fund (initiative "Verbund gesundheisorientierter Praxen"- Cooperation of health oriented surgeries), also co-operative initiatives for exercise -supported preventive projects in the community ("Arbeitsgemeinschaft Gesundheitsförderung Östringen"- project Community-based Behavioural Medicine). A local model initiative to overcome deficits of fragmented health and social services, has been piloted to engage local general practitioners in inter-professionally managed care of elderly patients with a holistic approach to health ("Projekt Ambulantes Gerontologisches Team"- Gerontological Out-Patient Team Project). - In Austria, regulations at present effectively preclude group practices(26) and multi-professional teams in general practice are uncommon. Showing the way ahead, regional initiatives have been set up, liasing general practitioners with nutritionists at their premises, in order to offer dietary counselling (project "Diabetikerschulung"- diabetes education; project "Diätassistentin in der Arztpraxis"- Dietician in general practitioner's Office). - Operating in a more primary care oriented system, the author of the Spanish country report, details findings from the evaluation of the national health promotion and prevention programme ("PAPPS"), showing that those health centres with shared general practitioner and nurse staffing were more likely to provide specific preventive services. - Similarly, in Ireland, where many general practitioners still work in solo practice (yet with some indication of a move towards group practice, encouraged by strategy documents of the Irish Department of Health and Children, and supported by the Irish College of General Practitioners) (single-handed) general practitioners working alone were significantly more likely to identify the lack of facilities as the reason for not providing family planning and women's health services than those working in group practices(27).

Overall, health systems that are characterised by a primary care orientation enable general practitioners better to work with a collaborative and co-operative approach, team- and community-oriented approach. In health systems with general practitioners predominantly in solo practice, it was felt that this form of practice general was not supportive in practitioners' health promotion and prevention work. Nevertheless, individual project initiatives to overcome this barrier have been initiated and were well accepted.

Also, literature (for example see Lawrence 1990) has pointed to other factors in practice environment, such as information systems, availability of lists, patient or disease registers and guidance material with such factors facilitating effective prevention and health promotion practice. (for more detail see for example (van Drenth, Hulscher et al. 1998)) Where available, examples from the Country Reports provide some information:

Patient lists and information systems - In Germany and Austria where no patient lists are in place, Country Report authors have mentioned that systematic recall systems and specific surveillance are thus potentially hindered. - Belgium and Luxembourg also do not have a patient list system. The former has recently introduced structures that encourage patients' listing with a specific general practitioner and provides for specific reimbursement incentives for registered patients ("Dossier Medical General"- general medical file); the latter will be phasing in such structures in the near future. The current deontological code in Luxembourg however, still prohibits active outreach by physicians.

Another organisational factor relevant for professional practice are clinical guidelines or specific protocols. Literature has explored issues of development, adherence and utilisation by practitioners, and effect on outcome (for example see Grol, Dalhuijsen et al. 1998). Our inquiry in the Country Reports has yielded the following information:

Specific instruments supporting general practitioners in health promotion and prevention: guidelines and protocols - Specific support has been described in the context of the Spanish prevention and health promotion programme ("PAPPS") where use of preventive charts was associated with higher provision of preventive services. - Specific prevention guidelines and protocols relating to lifestyle counselling and their use in general practitioner training and practice have been described by Country Reports authors from Spain. These protocols have been developed with the involvement of the Spanish Scientific Society of Family and Community Medicine and give guidance to general practitioners of how to intervene in counselling for smoking cessation and problem drinking. Protocols may also be adopted locally. - In Ireland the Irish College of General Practitioners has commissioned a number of guidelines and clinical protocols on topics such as asthma, general counselling, management of back pain, breast cancer and smoking cessation. These documents have been developed with the intention to improve quality and no obligation for use exist. - In Germany, the production of guidelines for a variety of conditions has recently been initiated on a larger scale, yet is vary much debated within the professionn(28), Quality criteria for development have been established and multi-specialty approaches are applied.

In contrast, in the Netherlands guideline development and implementation programmes have been implemented on a larger scale and evaluation processes in terms of the quality, applicability or utilisation of these instruments have been initiated. For example, The Dutch College of General Practitioners has issued cardiovascular prevention guidelines and has evaluated organisational characters in implementation (see Hulscher, van Drenth et al. 1997b). Strategies to improve utilisation and adherence such as outreach visits by trained facilitators have been used and evaluated (see B. Frijling "Smoking Cessation: Implementation of a Brief Intervention Strategy in General Practice", project conference proceedings). Also, a series of patient education letters have been introduced (see T. Drenthon "Development and Evaluation of Patient Information Letters in General Practice ", project conference proceedings, surveying general practitioners on implementation).

Generally, as information from Country Reports indicates, only a few guidance instruments (both guidelines and protocols) have been implemented. Areas covered are lifestyle counselling and specific patient education, yet no evaluation process in terms of the quality, applicability or utilisation of these instruments has been initiated yet.

Ultimately, commented as a prerequisite for health promotion development by the Greek Country Report author, is the status of the general practitioner where "General practitioners have only been in the field of practice for a short period of time, therefore the public hasn't got enough confidence in them and in the services they can offer. As a result, it is difficult for general practitioners to play an integral part in any aspect of health services in Greece for the time being."

Findings from literature: some examples Surveys of general practitioners on preventive medicine and their perceived need for support have identified both facilitating and hindering factors. Findings from an international WHO Study concerning early intervention with regard to alcohol, show that general practitioners perceive organisational factors such as financial issues and time/workload as the main inhibiting factors for "not doing more preventive medicine". - Particularly with respect to alcohol intervention, general practitioners ranked reimbursement schemes highest, followed by "government health policies not supporting general practitioners" and lack of time as most relevant hindering factors. Ref. Mc Avoy, B/ Donovan RJ, Kaner,E: Drugs: in press Mc Avoy, B/ Kaner,E; WHO Collaborative Study "The attitudes and practices of general practitioners concerning preventive medicine and early alcohol intervention", Strand I Report,1997; see also {13336 /id McAvoy, Kaner, et al. 1999}). - Recommendations from general practice organisations have addressed strategies for integrating health promotion, particularly with respect to reimbursement schemes(29) (including financial incentives for extra time needed), practice organisation (more specific in Hulscher, van Drenth et al. 1997a; human and technical resources, availability of supporting educational/ counselling material, geographical locality, availability of lists/registers).

In conclusion, considerable variety exists with respect to the underlying infrastructural conditions for health promotion in general practice and related measures to support general practitioners in these activities. Factors both at the level of reimbursement (including financial support) and at the level of organisational framework of general practice patterns are relevant for encouraging (hindering, respectively) general practitioners to realise their potential for involvement in health promotion activities.


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