sh/8/1 project
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:SH/8/1 Project
Public Health Focused Model Programme for Organising Primary Care Services
Backed by a Virtual Care Service Centre (SH/8/1 Project)
Midterm Review Summary
November 2014
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Executive summary
TABLE OF CONTENTS
A. EXECUTIVE SUMMARY ........................................................................................................................ 5
A.1. THE FOCUS OF IMPLEMENTATION OF THE PILOT IN THE FIRST TWO YEARS ............................................................... 5
A.2. ACHIEVEMENTS SO FAR ............................................................................................................................... 6
A.3. THE FOCUS OF IMPLEMENTATION FOR THE REST OF THE PROJECT PERIOD ............................................................... 7
A.4. RECOMMENDATIONS .................................................................................................................................. 7
B. OBJECTIVES AND METHODOLOGY OF THE MIDTERM REVIEW .......................................................... 10
B.1. OBJECTIVES ......................................................................................................................................... 10
B.2. METHODOLOGY .................................................................................................................................. 10
B.2.1. Quantitative Analysis: Internal Project Reports, and Health Care Data ........................................ 10
B.2.2. Qualitative Analysis: Site visits, Semi-structured Interviews, and Staff Reports ............................ 11
C. STEPS TAKEN IN PROGRESS TOWARDS THE ACHIEVEMENT OF OBJECTIVES....................................... 13
C.1. INTRODUCTION TO THE GPS’ CLUSTERS, OVERVIEW OF HUMAN RESOURCES AND THE
COMPETENCIES .................................................................................................................................. 13
C.1.1. Jászapáti GPs’ Cluster .................................................................................................................... 13
C.1.2. Berettyóújfalu GPs’ Cluster ............................................................................................................ 14
C.1.3. Borsodnádasd GPs’ Cluster ............................................................................................................ 14
C.1.4. Heves GPs’ Cluster ......................................................................................................................... 15
C.2. EVALUATION OF THE MAIN ACTIVITIES ............................................................................................... 17
C.2.1. Health Status Assessment.............................................................................................................. 18 C.2.1.1. Overview .................................................................................................................................................. 18 C.2.1.2. Planning and recruitment ......................................................................................................................... 18 C.2.1.3. Scheduling the Health Status Assessment and its Location ...................................................................... 19 C.2.1.4. Participation ............................................................................................................................................. 19 C.2.1.5. Documentation of the Health Status Assessment .................................................................................... 20 C.2.1.6. Results ...................................................................................................................................................... 21
C.2.2. Lifestyle Counselling ...................................................................................................................... 25 C.2.2.1. Overview .................................................................................................................................................. 25 C.2.2.2. Methodology of the Evaluation ................................................................................................................ 25 C.2.2.3. General Features of Lifestyle Counselling ................................................................................................. 25 C.2.2.4. Evaluation of Dietary Counselling Service................................................................................................. 29 C.2.2.5. Evaluation of Health Psychological Counselling ........................................................................................ 30 C.2.2.6. Evaluation of Physiotherapeutic Counselling ............................................................................................ 31
C.2.3. Community Health Promotion Activities ....................................................................................... 31 C.2.3.1. Programs and Activities Organized by the GPs’ Clusters ........................................................................... 32 C.2.3.2. GPs’ Clusters’ Activities, Events and Number of Participants ................................................................... 32 C.2.3.3. Programs and Activities Organized by Other Organizations to Which the GPs’ Clusters Joined ............... 33 C.2.3.4. Involvement of Stakeholders and Roma People of the Target Regions in the Activities ........................... 34
C.2.4. GPs’ Cluster Management ............................................................................................................. 36 C.2.4.1. Overview .................................................................................................................................................. 36 C.2.4.2. Internal Communication and Managerial Roles ....................................................................................... 37 C.2.4.3. Financial Management ............................................................................................................................. 38
C.2.5. IT Support of GPs’ Clusters ............................................................................................................. 38 C.2.5.1. Overview .................................................................................................................................................. 38 C.2.5.2. Problems in IT Support Delivery ............................................................................................................... 39 C.2.5.3. Summary of Support Delivery................................................................................................................... 40
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C.2.5.4. Functions of Phase-2 and Phase-3 ............................................................................................................ 41
D. RECOMMENDATIONS ........................................................................................................................ 44
D.1. RECOMMENDATIONS REGARDING THE DAY-TO-DAY OPERATION OF THE PILOT....................................................... 44
D.1.1. Recommendations on the Health Status Assessment .................................................................... 44
D.1.2. Recommendations on new competencies and additional services ................................................ 45
D.1.3. Recommendations regarding the financial, legal, organizational and ICT framework of the Pilot45
D.2. RECOMMENDATIONS ON THE MAIN DEVELOPMENT DIRECTIONS OF THE PILOT ...................................................... 46
D.3. PRELIMINARY HEALTH POLICY RECOMMENDATIONS........................................................................................ 46
D.3.1. Recommendations regarding the content of the Pilot ................................................................... 47
D.3.2. Recommendations regarding financial sustainability and national adoption of the Model Programme .................................................................................................................................... 49
D.3.3. Recommendations regarding political feasibility .......................................................................... 51
LIST OF FIGURES
F1. Competencies of GPs’ clusters members (self-assessment on 5-1 scale, mean values) ................................ 16
F2. Competencies of GPs’ clusters members (rated by the other members on 5-1 scale, mean values) ............ 17
F3. Participation in Health Status Assessments ................................................................................................... 20
F4. Activity data regarding Health Status Assessment ........................................................................................ 22
F5. GP-client visit numbers .................................................................................................................................. 23
F6. Ratio of definitive care provided by GPs ........................................................................................................ 24
F7. Laboratory utilisation rates ............................................................................................................................ 24
F8. Number of participants and services - Dietitian ............................................................................................ 27
F9. Number of participants and services – Health psychologist .......................................................................... 27
F10. Number of participants and services – Physiotherapist ................................................................................ 28
F11. Number of participants at services in August, September and October of 2014 .......................................... 28
F12. Perceived influence in the GPs’ clusters, rated by cluster members on a 1-5 scale (mean values) ............... 37
LIST OF TABLES
T1. Composition of semi-structured interviews .................................................................................................. 12
T2. Head count of Jászapáti GPC between July 2013 and November 2014. ........................................................ 13
T3. Head count of Berettyóújfalu GPC between July 2013 and November 2014. ............................................... 14
T4. Head count of Borsodnádasd GPC between July 2013 and November 2014. ............................................... 15
T5. Head count of Heves GPC between July 2013 and November 2014. ............................................................ 15
T6. Community health promotion activities organized by GPs’ clusters ............................................................. 32
T7. GPs’ Clusters’ Activities, Events and Number of Participants ........................................................................ 33
T8. Community health promotion activities organized by local stakeholders to which GPs’ clusters joined ...... 33
T9. Locally organized activities and events in which GPs’ clusters are involved .................................................. 34
T10. Information technology items supplied for participating practices ............................................................... 38
T11. Information technology items supplied for clusters and their workers ......................................................... 40
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T12. The comparison of the various cost models .................................................................................................. 50
T13. The total additional expenditures of the K, T and R model per year (in billion HUF) .................................... 51
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A. EXECUTIVE SUMMARY
Since the introduction of the family physician system in the first half of the 1990s, the foundations
of primary health care in Hungary have been left virtually untouched. The organising principle of
independent general practitioners working as private entrepreneurs with a right to practice
(“praxisjog”) has not only become outdated, but to a certain extent an obstacle to a better
performing health care system. The decision of the Swiss Government to finance a model
programme aiming at the reorganization of primary health care in Hungary rather than to invest in
the current system of primary care, was critically important, as the Programme provided vision and
strategic direction for the reorganization of primary health care in the past governmental period.1
The newly elected government has a continuing interest in primary care as the focus of health
policy so the model programme of the Swiss Contribution could become the cornerstone of health
care reform, provided that the developments of the past two years will be consolidated and this
pilot programme will be aligned with other developments, mainly with the project on the
establishment of a community-based care coordination model in the outpatient sector of the
Hungarian health care system.
The most important findings and conclusions of the Midterm Review of the Public Health Focused
Model Programme are highlighted along four topics: (1) the focus of implementation of the Pilot in
the first two years, (2) achievements so far, (3) the focus of implementation in the second half of
the Pilot, and (4) the most important recommendations for implementation and further
development.
A.1. THE FOCUS OF IMPLEMENTATION OF THE PILOT IN THE FIRST TWO YEARS
1. Establishment of four GPs’ clusters (GPC) from 6 independent practices per cluster;
2. Provision of prevention-oriented additional services for the local population, based on the
employment of highly qualified and committed health professionals thereby expanding the
competencies of primary healthcare, and reaching out to socially disadvantaged population
groups to improve their access to care and their social inclusion;
3. Establishment of protocols for the provision of additional services and for the supervision of
new services;
4. Education and training of members of the GPs’ cluster to enhance motivation and
competencies, and to facilitate team building in order to increase efficiency;
1 Another project aiming at the establishment of a community care coordination model(TÁMOP 6.2.5/B) is similar to this
flagship programme but it has only become operational in the second half of 2014.
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5. Information and Communication Technology (ICT) development to support the operation of
GPs’ clusters as new organizational entities and innovative sites for the provision of new
services, previously unknown in the primary care sector;
6. Infrastructure development to support the provision of new services;
7. Establishment of a monitoring and evaluation system including indicator development in the
frame of the Pilot to measure impact;
8. Increasing the motivation of the local population for accessing the new services
9. Establishment of the theoretical and practical details of a comprehensive health status
assessment in order to describe specificities of local health needs, provide a baseline for
comparison, identify those with increased health risks and/or unrecognised diseases;
10. Increasing awareness in the local population of the importance of health promotion, healthy
lifestyle and healthy behaviour; sensitising the stakeholders for the value of health.
A.2. ACHIEVEMENTS SO FAR
The planned 4GPs’ clusters have been established and in operation, providing new services for the
local people, including local Roma groups. The protocols for the provision of new services have
been developed, and new patient pathways are available. As a result of the health status
assessment survey, previously unrecognized diseases have been screened en masse, the number of
patient-doctor encounters increased and stable demand emerged for the services of the Pilot
among the local population.
1. Despite the general shortage of human resources in health care, all four new GPs’ clusters have
been established. New health professionals were employed, including public health
coordinators, public health specialists, health psychologists, physiotherapists and dietitians.
Health mediators recruited from the local communities were also employed part-time to
facilitate outreach to disadvantaged population groups. All employees of the GPs’ clusters were
trained. The clusters have been providing a set of new services according to plan.
2. The local population has become acquainted with the clusters. Awareness of the Programme
and motivation to access the new services is rising.
3. Team building within the GPs’ clusters has been under way. Consolidation of the teams will be
used as the basis of future organizational development, and further development of services.
4. Measurable health gain has already been realised due to the early identification of risk or
diseases status during health status assessment.
5. Extensive development on methodological issues has been completed and put in place,
including various protocols, indicators, monitoring and evaluation, supervision and organisation
of the Programme.
6. The first phase of the ICT development has been implemented along with the necessary
infrastructure development.
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A.3. THE FOCUS OF IMPLEMENTATION FOR THE REST OF THE PROJECT PERIOD
For the remaining two years, the Pilot should focus on:
1. the improvement of already implemented services and protocols,
2. the fine-tuning of the service portfolio, including an even better fit to local health needs,
3. the expansion of the service portfolio in outpatient specialist care and the management of
chronic care patients,
4. the organisational development of the GPs’ cluster, including its links with the community care
coordination project and with primary social care,
5. the second phase of ICT development,
6. the piloting of new incentive mechanisms for the GPs’ clusters,
7. the further increase of participation from the local community in the Programme,
8. improving the attitudes of local population regarding health promotion, healthy lifestyle and
behaviour, and to make the local population more aware of their responsibility regarding their
own health, supporting the local population in taking this responsibility,
9. the monitoring and evaluation of the Programme, the measurement of its impact on population
health, and on health policy scenarios to support national decision-making regarding the roll out
of the Programme.
A.4. RECOMMENDATIONS
Recommendations regarding the day-to-day operation of the Pilot
1. The timing of the Health Status Assessment (HSA) should be adjusted so that more time slots in
non-working hours are available to increase participation of the working population.
2. Opportunities for personal discussion of the findings of the health status assessment with the
GPs after its completion should be further expanded.
3. The timing and sequencing of additional services should be re-examined and better adjusted to
local needs.
4. Workshops for involved health professionals should be organized to increase the effectiveness
of the HSA.
5. Additional services provided by the newly employed health professionals show some
heterogeneity. Measures should be taken to standardize services while allowing adjustment to
local needs.
6. Professional supervision and coaching of health professionals should be further developed.
7. Additional services for chronic care patients should be expanded with the inclusion of new
activities.
8. In the second half of the Programme the legal and organizational form of the GPs’ cluster needs
to be refined and sustainable financing should be ensured.
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Executive summary
9. It is recommended to implement an organizational development project for GPs’ clusters in the
first half year after the Midterm Review.
10. Regarding the financial management of GPs’ clusters, functional (and not organizational)
integration and larger financial autonomy is recommended.
11. Regarding software development we suggest to drop Phase-3 and integrate its most important
elements into Phase-2.
12. The involvement of a legal expert from the National Center for Patients’ Rights and
Documentation (in Hungarian: Országos Betegjogi, Ellátottjogi, és Gyermekjogi Dokumentációs
Központ) is recommended to establish processes regarding the protection of personal data
handled by the GPs’ clusters.
13. Stronger involvement of the local media in the provision of health-related information is
recommended along with greater efforts for the social marketing of health behaviour in the
local population.
Recommendations on the main development directions of the Pilot
14. The developments of the first half of the Pilot should be consolidated.
15. The expansion of additional services with the provision of certain outpatient specialist services
should be considered.
16. The organizational development of the Pilot should be extended to improve coordination with
primary social care providers.
17. Development activities should focus on additional services for chronic care patients.
18. The mechanisms of case management should be elaborated.
Preliminary health policy recommendations
19. On the basis of the preliminary findings of the monitoring and evaluation of the Pilot, the impact
of the Pilot can already be detected at this early stage of implementation, providing support for
the continuation of the implementation of the Pilot.
20. In national health policy, the cooperation of health care professionals in primary health care
should be promoted as opposed to the currently dominant independent practices.
21. Any changes planned in primary care should not detrimentally affect the financial situation of
primary care doctors, but any financing increases should be preceded by the reform of the right
to practice, otherwise it will further aggravate the problem of exchanging of practices, and of
the entry of young doctors in the primary care sector.
22. Improved competencies in primary care should be honoured with increased financing. Improved
competencies should be paid for separately. Quality should be measured by indicators at the
level of GPs’ clusters to incentivise group work and practice cooperation.
23. The present set of national quality indicators in primary care have several methodological
limitations and therefore need to be revised.
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Executive summary
24. Participation of the GPs in the implementation of the reorganization of primary care should be
voluntary.
25. The legal and financial framework for primary health care should be clarified, and local
governments should be involved in the financing of the sector.
26. The Programme fits well in the international trends regarding the development and challenges
of health care systems, in previous Hungarian reforms and the current development projects
under implementation. The GPs’ cluster model is a special, innovative form of “group practice”.
27. In order to ensure the harmonisation and coordination of development projects in the entire
health care system, the Programme should consider the implementation of relevant
methodologies being developed in the frame of the project on community care coordination
(TÁMOP 6.2.5/B), and should elaborate on linking with pilots to be implemented in the
geographical areas of the Programme.
28. If nation-wide e-Health development projects are implemented, the technologies should be
adopted by the Programme.
29. The sustainability of the Programme is dependent on proper financial incentives. In the second
phase of the Pilot, these should be devised to fit to the current payment system.
30. There are several realistic scenarios for the national roll out of the Programme all being
contingent on the actual state of the government budget.
31. The impact on health expenditures and the cost-effectiveness of the Programme should be
carefully followed the second half the implementation of the Programme.
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Objectives and Methodology of the midterm review
B. OBJECTIVES AND METHODOLOGY OF THE MIDTERM REVIEW
B.1. OBJECTIVES
The GPs’ cluster pilot programme serves a dual purpose: (1) to add further public health and health
promotion capabilities to the local primary health care system, and (2) to change how individual
primary care providers operate (service provision processes, patient data flow, coordination with
other health care providers, innovative tools and new ways of thinking). The evaluation carried out
by the midterm review reflects this dual purpose, thus its main objectives are:
To evaluate the operation of GPs’ clusters from all the relevant aspects: organisation and
management of the GPs’ clusters, coordination, communication and relations to local
players, internal communication and IT services, new services and changes in the work of
GPs, and financial sustainability.
To evaluate the public health and health promotion projects;
Building on the findings of the evaluation, guidance is provided for the second half of the
implementation period. The potential impact on the development of the Hungarian primary health
care sector is also reviewed. Thus, the further objectives of the midterm review are as follows:
To provide guidance for the second half of the Pilot implementation period;
To formulate an intermediate policy proposal for the development of primary health care
system in Hungary.
In this manner, the midterm review fulfils the following project milestones, hence it:
Summarizes assessments and evaluations (on operation/management of GP districts and
health promotion activities) that are available (tasks 8.2, 8.3);
Serves as a first intermediate policy proposal for the development of primary health care
based on the intermediate results that have been developed (task 8.4).
B.2. METHODOLOGY
Due to the innovative nature of the pilot project, inherent to the new organisational model of the
GPs’ clusters, the application of both quantitative and qualitative and methods were needed.
B.2.1. Quantitative Analysis: Internal Project Reports, and Health Care Data
The evaluation used internal data as well as data from the national reporting system of the National
Health Insurance Fund Administration (NHIFA, OEP). The internal reports provided statistical data
about the volume of activities carried out by the GPs’ cluster members inter alia the number of
clients that were invited to and participated in the health status assessment, the number of
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Objectives and Methodology of the midterm review
consultations or sessions provided by the physiotherapist, the dietitian, or the health psychologist,
and the number of clients served.
Activity and performance data routinely collected from GPs, outpatient and inpatient care
providers, and pharmacies by the NHIFA were also used:
Activity, utilisation, financial and quality assessment indicators were identified and defined
together with the National Health Insurance Fund Administration. The majority of these
indicators are routinely used by the health insurance fund either as part of the quality
indicator system of GPs, or for internal and external reporting purposes. (Definitions and
methodological details of indicators are given in the text when the results are discussed.)
Data were obtained from GPs, but were summarised by clusters in this report. No individual
patient data were handled. While indicator values are separately provided for each cluster,
this report should not be considered as a comparison of performance of the four GPs’
clusters.
Data were also provided for a control group of 158 individual GPs. The control group was
originally created for the baseline health status assessment by WP7; detailed analysis of the
results is available in a separate report.
The monthly or quarterly data were generally accessible from the beginning of 2013 until
Sept 30, 2014. In the case of monthly availability, data was transformed and further analysed
as quarterly data for the purposes of this report. Log frame indicators have also been
overviewed in a summary table.
A self-administered, web-based questionnaire, using Google Forms, was created and distributed
among all GPs’ cluster members. The questions covered several aspects of the operations of the
GPs’ clusters (for example, job satisfaction, change in workload, perception of client needs). The
questionnaire was open from 12 to 20 November 2014, the response rate was 100 %.
B.2.2. Qualitative Analysis: Site visits, Semi-structured Interviews, and Staff Reports
Between February and April, 2014, all four GPs’ clusters were visited on site by five members of the
evaluation team, and semi-structured interviews were carried out with altogether 64 members of
the GPs’ clusters. The following persons were interviewed in all clusters: head GP, public health
coordinator, public health specialist, community nurse, physiotherapist, dietitian, and health
psychologist. A sample was interviewed from the pool of general practitioners, their practice
nurses, district or school health visitors, and assistant health mediators. See the table below for
details.
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Objectives and Methodology of the midterm review
T1. Composition of semi-structured interviews
* The post was not filled at the time of site visits.
The semi-structured interviews covered the following areas:
Work activities carried out by each member (“what they actually do”)
Mapping internal communication and coordination in the GPs’ clusters (e.g. “communication
network”, the role of internal meetings)
How the new staff members change/complement the operation of primary care
Perceptions about managing and coordinating roles in the model
What the cluster members think about the role of GP in the Hungarian health care system
Perceptions about the patient-provider relation (patients’ inclusion into therapy choice,
factors influencing patients’ compliance)
Use of IT solutions (currently available GP systems as well as GPs’ cluster IT developments)
Evaluation of trainings in the framework of the Programme
Personal motivation to participate in the model
What GPs’ cluster members perceive as key success factors of the Model Programme
During the 60 to 90 minute-long interviews, the evaluators took notes, and these notes were later
transcribed to a commonly accessible document (interviews were not recorded). Summary
statements were made at the level of the GPs’ clusters (anonymity of sources was taken into
account where needed), and these statements were verified by all five evaluators. The summary
document of the site visits and semi-structured interviews were circulated among the project’s
other WPs.
The second qualitative source was the monthly reports, prepared by each member of the GPs’
clusters. Summary reports compiled from the individual reports by the National Institute on Primary
Care were also used during the preparation of the midterm review.
GPsCluster Head GP
Public
health
coordinator
General
practi-tioner
Practice
nurseDietician
Physio-
therapist
Health
psycholo-
gist
Public
health
expert
Community
nurse
Assistant
health
mediator
District/
school
health
visitor
Heves 1 1 4 2 1 1 1 1 1 4 4
Jászapáti 1 1 2 2 -* 1 1 1 1 6 0
Borsodnádasd 1 1 1 2 1 1 1 1 1 2 1
Berettyóújfalu 1 1 2 2 -* 1 1 1 1 2 2
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STEPS TAKEN IN PROGRESS TOWARDS THE ACHIEVEMENT OF OBJECTIVES
C. STEPS TAKEN IN PROGRESS TOWARDS THE ACHIEVEMENT OF
OBJECTIVES
C.1. INTRODUCTION TO THE GPS’ CLUSTERS, OVERVIEW OF HUMAN
RESOURCES AND THE COMPETENCIES
A brief introduction of the four GPs’ clusters participating in the Programme is provided in this
section. Moreover, this section includes an overview of the human resources of the GPs’ clusters
(head count tables). Workers of the GPs’ clusters were asked to evaluate their own and their
colleagues’ competency in the on-line survey described above in detail. The results of this
evaluation are depicted in Figure F1 (see later).
C.1.1. Jászapáti GPs’ Cluster
The Jászapáti GPs’ cluster is composed of general practices of three settlements, namely Jászapáti,
Jászkísér and Jászivány. In Jászapáti, one general practice for children and three general practices
for adults are members of the cluster, one of the latter also covering the adult population of
Jászivány. In Jászkísér, two out of three mixed general practices are participants in the Programme.
In Jászapáti, the Head GP is Dr. István Völgyi. All posts with the exception of the GP resident
posthave been successfully filled since 1st October 2013.
T2. Head count of Jászapáti GPC between July 2013 and November 2014.
The dietitian service in the GPC was provided via temporary replacement (denoted with an r in
Table T2. where applicable) between February and August 2014. This service is not provided since
then, but the Program Management published recruitment notice in order to fill the vacant position
that is expected to be filled from 1st December 2014.
The general composition of Jászapáti GPC according to head count is shown in Table T2.
July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014
Head GP 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
GP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Praxis nurse 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
GP cluster nurse 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health coordinator 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health specialist 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Health psychologist 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Physiotherapist 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Dietetitian 1 1 1 1 1 1 1 1r 1r 1r 1r 1r 1r 1r 0 0 0
Health visitor 0 0 0 4 4 4 4 4 4 4 4 4 4 4 4 4 4
Health mediator 3 4 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12
Jászapáti GPC
Head count
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STEPS TAKEN IN PROGRESS TOWARDS THE ACHIEVEMENT OF OBJECTIVES
C.1.2. Berettyóújfalu GPs’ Cluster
The Berettyóújfalu GPC is composed of six general practices of three settlements (Berettyóújfalu,
Hencida, and Komádi). Out of the ten general practices in Berettyóújfalu, there are three general
practices for adults and one mixed (including Mezőpeterd settlement), which are part of the GPC.
One general practice for adults in Hencida, and one mixed general practice in Komádi (including
Homorog settlement) arealso members of the GPC.
In Berettyóújfalu, the Head GP is Dr. János Cséki. All positions have been successfully filled since 1st
October 2013 (with the exception of the GP resident and dietitian). The dietetician services have
been provided since September 2014 with the employment of two part-time professionals.
The general composition of Berettyóújfalu GPC according to head count is demonstrated by Table
T3. below.
T3. Head count of Berettyóújfalu GPC between July 2013 and November 2014.
C.1.3. Borsodnádasd GPs’ Cluster
The Borsodnádasd GPs’ cluster is composed of six general practices of four settlements
(Borsodnádasd, Arló, Járdánháza, and Borsodszentgyörgy). A mixed general practice from each of
the latter three settlements above, and two mixed general practices in Borsodnádasd are involved
in the cluster. Except for one general practice for adults in Arló, every general practice in the four
settlements above are involved in the GPC.
In Borsodnádasd, GPC the Head GP is Dr. Gábor Benkő. All posts have been successfully filled since
1st October 2013 with the exception of the GP resident position.
Due to prolonged illness, physiotherapy services were provided by temporary replacement
(denoted with an r in Table T4. where applicable) between July and October 2014, however, as of
November 2014, the service is not available. Recruitment has been under way, and the position is
expected to be filled from the 1stof December, 2014.
July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014
Head GP 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
GP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Praxis nurse 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
GP cluster nurse 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health coordinator 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health specialist 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Health psychologist 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Physiotherapist 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Dietetitian 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2
Health visitor 0 0 0 7 7 7 7 7 7 7 7 7 7 7 7 7 7
Health mediator 2 9 12 11 11 11 12 12 12 12 12 12 12 12 12 12 12
Berettyóújfalu GPC
Head count
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The general composition of Borsodnádasd GPC according to head count is demonstrated by Table 4.
below.
T4. Head count of Borsodnádasd GPC between July 2013 and November 2014.
C.1.4. Heves GPs’ Cluster
The Heves GPs’ cluster is composed of six general practices of four settlements (Heves, Átány,
Kömlő, and Tiszanána). Out of the seven general practices in Heves, one general practice for adults
and one general practice for children, whilst both two mixed general practices in Tiszanána are
involved in the cluster. Furthermore, one mixed general practice in Kömlő, and one mixed general
practice in Átány are involved, and in the latter settlement the general practice service has been
provided via temporary replacement.
In Heves GPC, the title of Head GP is held by Dr. János Szabó. A special situation arose from the fact
that one of the GPC’s practice nurses is a civil servant, so there was a need for an additional
contract to be included. All posts have been successfully filled since 1st October 2013 with the
exception of the GP resident.
T5. Head count of Heves GPC between July 2013 and November 2014.
The dietitian service of the GPC has not been available since 1st September 2014, whilst the
physiotherapeutic service has been in recess since 1st October 2014. Recruitment of a dietitian is
July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014
Head GP 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
GP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Praxis nurse 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
GP cluster nurse 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health coordinator 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health specialist 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Health psychologist 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Physiotherapist 1 1 1 1 1 1 1 1 1 1 1 1 1r 1r 1r 1r 0
Dietetitian 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Health visitor 0 0 0 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Health mediator 8 12 12 12 11 11 11 11 12 12 12 12 12 12 12 12 12
Head count
Borsodnádasd GPC
July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014
Head GP 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
GP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Praxis nurse 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
GP cluster nurse 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health coordinator 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Public health specialist 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Health psychologist 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Physiotherapist 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0
Dietetitian 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
Health visitor 0 0 0 8 8 8 8 8 8 8 8 8 8 8 8 9 9
Health mediator 3 9 12 11 12 12 12 12 12 12 12 12 12 12 12 12 12
Heves GPC
Head count
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under way and the position is expected to be filled from 1st December 2014. Recruitment of a
physiotherapist is ongoing.
The general composition of Heves GPC by head count is demonstrated by Table T5.
Figure F1. provides a summary of the results of the workers self-assessments in each GPCs
regarding their own competencies (mean values). GPC workers were asked to answer on a scale
ranging from 5 to 1 (5: in possession of all relevant competencies, 1: lack of all relevant
competencies).
F1. Competencies of GPs’ clusters members (self-assessment on 5-1 scale, mean values)
Figure F1. shows that according to the self-assessment, the Dietitians, Physiotherapists and GPs’
cluster nurses rated their own competencies with the highest score (5) whereas Health
psychologists gave their competencies the second largest score (4.75), followed by Health visitors
(4.71), and Health mediators (4.65). Whilst the Head GPs rated their own competencies at 4.5, their
scores were closely followed by that of the GPs (4.4), Public health coordinators (4.5), and Praxis
nurses (4.26). Since in the self-assessment even the lowest mean score was 4 which was self-
assigned by the Public health specialists, it can be seen that GP workers have evaluated their own
competencies overall as good.
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F2. Competencies of GPs’ clusters members (rated by the other members on 5-1 scale, mean values)
Figure F2. shows that when members of the GPs’ clusters was asked to evaluate the competencies
of each other, both the Head GPs and Physiotherapists were ranked with the highest mean score of
4.69. Along with the former, the Public health coordinators (4.59), Praxis nurses (4.5), GPs (4.4), and
Public health specialist (4.35) have received higher scores than as they evaluated their own
competencies at self-assessment as shown in Figure F1. On the other hand, it can be observed that
the Physiotherapists, GPs’ cluster nurse (4.57), Dietitians (4.54), Health physiologists (4.41), Health
visitors (4.34), and Health mediators (4.08) overrated their own competencies compared to the
scores they received from other GP workers. Again, since even the lowest mean score was as high
as 4.08, from the results above it can be seen that GPC members have evaluated each other
competencies overall as good.
C.2. EVALUATION OF THE MAIN ACTIVITIES
This section provides detailed evaluation of the Health Status Assessment, Lifestyle Counselling and
Community Health Promotion Activities. Furthermore, GPs’ Cluster management and IT support
dedicated to GPCs will also be evaluated. Prevention Care Services and Chronic Care Services in the
GPs’ Clusters cannot be evaluated, because these types of activities have not been in the focus of
the development so far.
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C.2.1. Health Status Assessment
C.2.1.1. Overview
HSA provides comprehensive evaluation of the health status of all adults belonging to the GPs’
cluster. As a result, clients are redirected to appropriate prevention services or treatment if needed.
The organisation of the assessment represents a novelty in terms of screening in primary care that
is made possible by the extra capacity of the GPs’ clusters, particularly by the employment of a
community nurse and a public health specialist in each cluster. Roma assistant health mediators
participate in recruitment, and personally invite clients to the assessment.
The assessment is composed of a health interview survey and a short examination, performed by
the public health specialist and the community nurse. All adults belonging to the GPs’ clusters are
planned to receive invitation for the assessment according to a pre-defined schedule. Since health
status assessment was the very first new activity of the GPs’ cluster, GPs’ cluster members are very
much focused on it. When workers were asked about whether they considered the GPs’ cluster
successfully implemented, several respondents referred to the high participation rate of the health
status assessment.
The process of HSA is guided by a protocol about organisation (planning and scheduling), survey and
examination methodology as well as monitoring and reporting. A more detailed description about
the protocol is given in the operations manual.
C.2.1.2. Planning and recruitment
Organisation of and recruitment for the health status assessment seems to be one of the central
topics of GPs’ cluster meetings. Monthly targets (the number of clients to be assessed) is
determined by the program management office at the National Institute of Primary Care, while
“meeting those targets” is the responsibility of the GPs’ clusters. Several respondents claimed that
one of the main topics of their regular meetings is about deciding how to deliver the expected
monthly participation rates.
During the first months (before the spring of 2014) only those clients were invited to health status
assessments who had had lab test results from the previous 6-12 months. In one of the GPs’
clusters, those patients were invited to the assessment who had just visited the GP office. This
selection strategy was a consequence of the lack of bilateral agreements with local laboratories in
the beginning, but subsequent agreements made it possible to utilise a more randomised selection
process later. The monthly list of selected clients is typically prepared by the practice nurses.
Personal invitation letters are signed by the general practitioner, whom the client is registered with,
and personally delivered by the assistant health mediators. When the client cannot be reached, a
second (or third) delivery attempt is made later on. At the time of the interviews, documentation of
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the delivery process was not standardised (e.g. unsuccessful attempts are reordered or not) A
detailed protocol along with monitoring the activities of the assistant health mediators is under
preparation.
Based on the experiences so far, an active supporting role of the GP seems important: GPs must
emphasise the importance of the assessment. The personal signature of the GP is an important
element, so is the support of the practice nurse. In a few places, we also met with the practice of
the client having to consent to participation by his or her GP before compiling the list. Naturally,
participation rate would be extremely high in this case; however, organisation of assessments might
become more difficult after meeting all the “known” patients. In Heves and Borsodnádasd, other
programs are also aimed at health assessments for parts of the population (Charity Service of the
Order of Malta, micro regional health development offices, supported from EU funds). Better
coordination and/or sharing the assessment results would be needed in the future.
Practically all staff members were a bit worried about the recruitment process becoming more and
more difficult as they have to successfully reach more and more “new” clients (those who generally
do not visit the GP office). Process evaluation and sharing best practices as well as actively using all
the possible local communication channels are needed in the future.
C.2.1.3. Scheduling the Health Status Assessment and its Location
HSA is typically carried out during weekday working hours. One GPs’ cluster began offering the
service in prolonged hours once in a month (until 6pm) during this spring, but participation rate
remained low in the beginning. Evaluation of accessibility by the active-age (and working)
population is needed in the future. Scheduling is typically prepared before the invitation letters are
delivered, however, flexibility is offered for clients (new times and dates can be arranged over the
phone).
Infrastructure for the health status assessment was set up in all of the settlements of all GPs’
clusters. Assessments were typically carried out in GPs’ or other physicians’ offices in the beginning.
This still happens in smaller villages in most of the cases. GPs’ clusters’ own offices were provided
and renovated by the local governments in most cases which serve as places for health assessments
in the central micro regional settlement. Accessibility is a key factor: for example, health status
assessments takes place in a central location in Heves with easy access for the population, but far
from the GPs own districts.
C.2.1.4. Participation
HSAs are primarily carried out by the public health specialist and the community nurse. Survey
questionnaire is typically filled by the public health specialist, and physical examination is provided
by the community nurse. In Heves or Borsodnádasd, public health coordinators also participate in
the assessment when they have free time. The mental health questionnaire is typically filled by the
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clients themselves, but the health psychologist (in Heves) or the assistant health mediators (in
Jászapáti) were on hand as local variations of implementation. The health psychologist and the
physiotherapist participated in assessments in Berettyóújfalu several times before March 2014.
The new members of the GPs’ clusters represent a significant increase in capacity. Utilization of this
capacity for health status assessment was summarised using the GPs’ cluster reports about
participation in the HSA carried out until the end of October 2014. The number of completed
assessments varies between 1590 and 2621. Because the capacity used for health status
assessments in each GPs’ cluster is similar to each other, the absolute values are comparable.
Participation rates are also shown by comparing participants to the number of clients registered
with each clusters’ GPs (Figure F3). The number of registered clients was provided by the NHIFA,
and applies to June 30, 2014.
F3. Participation in Health Status Assessments
C.2.1.5. Documentation of the Health Status Assessment
Documentation of the assessment is the responsibility of the person who carried it out. When
results are received later from an outpatient care facility (laboratory), the data must be recorded by
the practice nurse in each practice. A separate list about these results is compiled by the practice
nurse, and sent to the public health coordinator each month. Results of the health status
assessments, including recommended lifestyle counselling or chronic care management, are
available for the GPs and the practice nurses.
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One GPs’ cluster (in Jászapáti) used specialised software (EPI-INFO), others were using Excel tables
or paper-based records for data collection. As a result of the Phase-1 of the GPs’ cluster software
development, a standardised software solution was introduced in all clusters this October.
Migration of data from earlier assessments is ongoing.
C.2.1.6. Results
The HSA can result in one of the four categories: “healthy”, “lifestyle risk factor, without suspected
illness”, “suspected illness”, or “acute treatment needed”. The GP has to review and reconfirm the
status assessment. Patient path is organised according to the needs identified: referral to lifestyle
counselling and/or to further examinations by the GP. At the moment, there is no perfectly standard
reporting about the patient pathways of those who have been participating in the assessment. This
problem is solved by the recent introduction of the Phase-1 GPs’ cluster software.
Based on the monthly reports, prepared by each GPs’ cluster and sent to the National Institute of
Primary Care in October, 2014, a summary flow chart was compiled which illustrates the
participation rate, the effectiveness of the health status assessments in terms of identifying people
with further service needs, as well as the referral ratios. Since the indicators used in Figure F4. do
not have commonly agreed definitions, opportunities for benchmarking are also limited. There are
clearly differences in the recruitment strategies, resulting in different participation rates (from 43%
to 81%), and further referrals to the GPs or lifestyle counselling also show various practices followed
in each GP cluster. When the migration of the earlier health status assessment data to the Phase-1
software is completed, it will be possible to create a similar flowchart about the whole program
period.
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F4. Activity data regarding Health Status Assessment
The number of GP-client visits was analysed by using data from the NHIFA. Comparison of the first
six months of 2013 and 2014 was carried out by using the B300 reports sent by GPs to NHIFA,
describing their monthly activity list. The GP-client visit rates represent the first six months of the
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given years. An increase can be observed in all clusters though to a different degree compared to
the control group (Figure F5).
F5. GP-client visit numbers
The ratio of definitive care was also measured by comparing those GP-patient visits when no
referral was made to other health care providers (except for laboratory or radiology referrals) to all
visits. By comparing the first half of 2013 and 2014 it was found that positive change occurred in all
the GPs’ clusters (between 2.83 and 7.09 percentage points), exceeding the average change of
1.08% of the control group (Figure F6).
Laboratory utilisation rate in the first three quarters of 2013 to 2014 increased in all GPs’ clusters:
both in comparison to historical data and to the control group (Figure F7). The values represent the
total number of cases during three quarters per 100 patients registered with the GPs. It must be
noted that only those cases are included in the analysis when the referring physician was the GP,
and the laboratory recorded the fact of this referral in its financial report for the health insurance
fund. The rate of change is also calculated and shown in the figure. Note, that all changes are higher
than the +7% change measured in the control group. It can be concluded that the laboratory
utilisation rate increased in all the GPs’ clusters but is still lower than the mean value of the control
practices.
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F6. Ratio of definitive care provided by GPs
F7. Laboratory utilisation rates
A question in the self-administered web-based survey asked about the change in workload of GPs
and practice nurses. Perceptions about an increased workload were apparent: GPs and practice
nurses reported about 40% higher workload on average. Change in workload should be evaluated in
more detail in the future.
GPC1 GPC2 GPC3 GPC4 Control
2013Q1Q2 53,71% 46,38% 46,44% 56,78% 49,07%
2014Q1Q2 56,53% 51,34% 53,53% 60,24% 50,15%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
Change in definitive care
2013Q1Q2 2014Q1Q2
40,5
31,8
18,8
34,6
49,4 44,9
40,4 39,2
44,9
53,1
3%
19%
101%
22%
0%
20%
40%
60%
80%
100%
120%
0,0
10,0
20,0
30,0
40,0
50,0
60,0
GPC1 GPC2 GPC3 GPC4 Control
Laboratory utilisation rate
2013Q1-3 2014Q1-3 % comparison
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C.2.2. Lifestyle Counselling
C.2.2.1. Overview
Lifestyle Counselling is aimed at providing specific counselling for assessed clients by targeting the
identified risks and medical conditions after Health Status Assessment or Preventive Services and
for chronic care patients. The objective of lifestyle counselling is to improve the clients' health
awareness and promote lifestyle change by reducing the detected risk status, improving the existing
chronic disease, and halting the development of complications.
The dietitian, physiotherapist and health psychologist as new members of the clusters are
responsible for Lifestyle Counselling.
Referral to Lifestyle Counselling is a possible outcome of the Health Status Assessment, and the GPs
may also send clients to participate. Lifestyle Counselling is mainly available in a group session, and
where appropriate on an individual basis. The first step in the use of additional services is the
participation at a motivational interview, which is aimed at assessing the client's willingness to
cooperate and strengthening motivation that is a condition for the use of additional services.
C.2.2.2. Methodology of the Evaluation
Additional services were evaluated considering the 1) procedures specified in the Operations
Manual, 2) summary of the findings in daily routine on the basis of the monitoring interviews
carried out in the GPCs, and 3) data from an on-line questionnaire.
C.2.2.3. General Features of Lifestyle Counselling
Organization
The use of new services is accessible from several directions in practice, somewhat overwriting the
provisions of the GPs’ cluster procedure, hence they have been:
offered as a result of screenings
"referred" followed by GP care
used within the framework of organized services that were installed on the basis of target
group level principles (adapted physical education, physiotherapy in elderly home, baby-
mother club, etc.)
used voluntarily by clients .
The activity of GPs was evaluated differently in the clusters. Whilst GP referrals were indicated as
primary concern in Borsodnádasd, the number of referred patients was reported as insufficient in
Berettyóújfalu calling for greater activity.
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Lifestyle Counselling provided by the dietitian, physiotherapist and health psychologist is organised
so that each service is available at least once per week in each settlement in all four GPs’ clusters.
Documentation
The method of appointment to the services became uniform by the end of the first half of 2014. The
staff indicated that prior patient care data, such as laboratory findings, medication taken, and the
results of specialised examinations would be required for their more efficient work.
Uniform requirements for documentation of Lifestyle Counselling were accepted during the
summer of 2014. Up to that time, only some aspects of the provided services had been recorded,
and the social insurance identification numbers of the clients had not been registered.
Retrospectively, this will be possible in the near future by the method of additional data entry for all
those who participated at Lifestyle Counselling before.
The introduction of the E-Doki IT system created the platform for recording appropriate care data in
a unified format (data protection, standardization, and patient surveillance). Moreover, the option
of making prescheduled appointments is also provided in the E-Doki IT system. The system’s
operationwill be evaluated at a later stage.
Participation
Summary statistics from the services provided by new members in accordance with the renewed
GPs’ cluster reporting system are available since the summer of 2014 in the National Institute on
Primary Care. The use of services that are provided by various professionals is demonstrated based
on September 2014 data sets in the case of health psychologists and physiotherapists. Since dietary
counselling was only provided in one GPs’ cluster in September, data sets from July 2014 are used
as a basis of demonstration.
Calculating the number of participants in Lifestyle Counselling, supplied statistical data of GPs’
clusters was corrected excluding data on community health development activities (e.g. Health day,
and village festival) and including only individual or small group sessions.
Figures F8-F10 show separately for dietitians (F8), health psychologists (F9), and physiotherapists
(F10) the number of participants served, and the number of services provided. The average number
of participants per service was also calculated, and is shown in the figure. Figure F11 shows the
participation at services as a whole between August and October 2014.
The graphs illustrate that newly employed health professionals operate very differently within the
GPCs. There is a ground for considerable differences in the way they focus more on individual or
group sessions, but large differences are found in their capacity utilization, and operational
efficiency. In any case, it should be noted that the different practices require better organization
of counselling and more detailed analysis in the second half of the Programme. Comparisons
should be done by type of service comparing the same professionals.
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F8. Number of participants and services - Dietitian
F9. Number of participants and services – Health psychologist
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F10. Number of participants and services – Physiotherapist
F11. Number of participants at services in August, September and October of 2014
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C.2.2.4. Evaluation of Dietary Counselling Service
Both individual and small group consultations have been provided. These services have been
provided on a regular basis by a full-time dietitian during standard working hours, followed by a
dietitian in part-time employment from late in the afternoon to early evening hours.
Dietitians had to face certain difficulties at the beginning, since their work and the competences of
the dietitian was less known in the wider population. Further complications arose when counselling
underprivileged residents from the fact that current theoretical knowledge regarding optimal diet is
not easily applied by low-income population groups, whose nutritional choices are primarily driven
by availability and pricing of food items. In such cases, participants at the consultations repeatedly
voiced their opposition impetuously against the given advice and it is unlikely that they followed
those recommendations. In order to solve the problems above, good practices have been identified
in the GPCs. The need for the adaptation of current dietary advice to low-income population
groups, and the sharing of practical experience between clusters’ workers is a key for more
effective counselling.
During the monitoring interviews between February and April 2014, the evaluating team received
feedback from GPC members that more intensive professional support would be necessary in terms
of health-related, technical, methodological, and communication skills. Followed by this request,
the establishment of a dietitian service supervisory system has begun.
Whilst one out of three dietitians responding to the on-line survey indicated adequate level of
satisfaction with some unused professional capacity regarding the supervisory system, two
dietitians said that this system, however, is not yet well known for them, and currently the support
towards the identification and coordination of intervention opportunities is inadequate.
Furthermore, the dietitians in each GPC indicated the need for communication training, and the
development of special dietary recommendations for low-income persons and families taking into
account clients’ possibilities. Other improvements for the future were deemed as necessary
including the establishment of cooperation with mass caterers. In line with this, participation at
community programs is expected to effectively influence the region's dietary habits. The
collaboration and participation of experts from different backgrounds (psychologists, marketing
managers) in counselling activities, and the involvement of local opinion formers (local Roma
women) is expected to facilitate the effectiveness of everyday work. Moreover, based on numerous
opinion of GPC workers, the development of practical skills (cooking together, tasting), and setting
up a kitchen for educational purposes would be required. Both at the monitoring interviews and in
the on-line survey in November 2014, the dietitians expressed their needs for nutritional diary,
sample diet, and compilation of publications that could be handed over to clients. Furthermore,
supporting software would be helpful in order to serve the above requests in an adequate manner,
and allow for traceability.
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Based on data from the Borsodnádasd GPC, 30% of clients attended dietary counselling of those
referred to see the dietitian.
C.2.2.5. Evaluation of Health Psychological Counselling
Results of the monitoring interviews revealed the greatest disagreement about the activities of
health psychologists. Even experts disagreed regarding the professional competencies of health
psychologists.
Each position of health psychologist was filled at the time of the monitoring interviews in the GPCs,
with one health psychologist being employed for 30 hours per week. Health psychologists
significantly differed with respect to prior qualifications and experience. Fortunately, the majority of
the professionals have clinical / psychotherapeutic experience.
Nevertheless, good practices were also identified when evaluating the health psychological
counselling especially in cases of classic health psychological services such as support for cessation
of tobacco use, stress management, skills development, and career orientation group sessions.
Besides those activities noted above, good practices included individual and group health
psychological counselling and therapy, as well as the mental health support of GPC workers, case
discussions on a weekly basis, and conflict management sessions.
GPC members indicated the need for methodological support for their role incorporating local
conditions tailored professional concept development and more intensive supervision during the
monitoring interviews. Following this request, the expansion of the supervisory system has started.
According to the on-line questionnaire in November 2014, health psychologists have overall been
satisfied with the agreed system of supervision, whilst one member of staff expressed need for
more professional content development.
Regarding the operation of group counselling, health psychologists voiced their experience that
making contact and establishing personal relations (and confidence-building even in the form of
individual counselling!) with underprivileged patients tends to be highly challenging. Group sessions
are not suitable at entry level for these clients due to their condition or ability or skills. This shall be
taken into account when formulating the professional expectations towards health psychologists.
In addition to the above, group sessions can be facilitated in already existing communities, and
there is a great need for therapeutic competencies in the GPCs. Moreover, all four GPCs indicated
the prejudices and stigmatizing nature of psychological counselling in small settlements, leading to
resistance against the uptake of psychological counselling that further aggravates the problem of
involving clients, and hinders more efficient use of existing professional capacity.
Based on data from the Borsodnádasd GPs’ cluster, 18.4% of the clients have attended
psychological counselling amongst those referred to see the health psychologist.
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C.2.2.6. Evaluation of Physiotherapeutic Counselling
Individual and group services are held by the physiotherapists, with typical predominance of either
the former or latter in the given cluster. The preference for individual or group services has been
developed according to local features and availability of appliances. Such solutions have been
evolved in order to seek the form of care, availability of facilities, or where particular development
of appliances is not required.
Delays in the procurement of appliances turned out to be problematic with regards to the activities
of physiotherapists, and even currently the transportation of appliances creates difficulties for the
professionals.
Physiotherapists did not express the need for additional professional support or supervision.
Nevertheless, the supervisory system of this profession has also been created in order to ensure
consistency. The two physiotherapists who filled the on-line questionnaires were overall satisfied
with the supervisory system.
Based on data from the on-line survey, this has been the most popular form of additional service,
both at community settings, and in clients’ homes. It should be highlighted that the preventive
group sessions organised in educational institutions are large-scale, involving many pupils. On the
other hand, there is also significant need for individual sessions of physiotherapy. The availability of
appliances is a highly limiting factor on the agreed form of counselling, settings, and target groups.
C.2.3. Community Health Promotion Activities
Community health development (health promotion) activities are aimed at the improvement of the
individual and community determinants of health and equity in the microregions of the GPs’
clusters. The planning and implementation of activities is guided by the settings-based approach.
Public health coordinators are responsible for planning and organizing community programs
involving all other members of the GPs’ clusters. Their primary helpers in carrying out activities
related to the programs are the health mediators.
One main point of consideration was to pay as much attention to organizing regular activities (clubs,
series of events and programs, etc.) targeting specific segments of the population as to planning ad-
hoc events (eg. health-related days) (Table T6) because the former ones are more appropriate for
behaviour change, while the latter events are meant for raising awareness and providing
information.
Each community project has output indicators that are specified in the plan, e.g. promotional
materials prepared for the project, list of participants, documentation of the event. Process and
output indicators will be compared among the 4 GPs’ clusters. The contribution of the community
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health projects to the outcome indicators will be calculated in comparison between the 4 GPs’
clusters.
C.2.3.1. Programs and Activities Organized by the GPs’ Clusters
The GPs’ clusters have organized and provided the services and events for the population at the
intervention area, presented in Table T6.
T6. Community health promotion activities organized by GPs’ clusters
Community health promotion activities organized by GPs’ clusters
provided on a regular schedule (weekly or monthly) organized occasionally (ad-hoc)
Group sessions for disadvantaged (Roma) mothers
Club for mothers and children
Health day for the Roma
Mental health
Psychofitness , Skills development, Stress management
club
Health day for the entire community (village)
Physical activity for children
Gymnastics for children in nursery school in elementary
school
Therapeutic exercises at schools
School health day for children
Physical activity for adults
Nordic walking, Spinal exercises, Walking clubs,
Stretching, Body control training
Gymnastics for pensioners
Clubs of exercises for special joint and muscle disorders
Zumba club for girls, for Roma mothers
Events related to world health days
World Health Day
World AIDS Day
International Day of Older Persons
World No Tobacco Day
Health and lifestyle clubs
Club for dieters
Club for diabetics
Anti-smoking club
Lectures on various health topics
C.2.3.2. GPs’ Clusters’ Activities, Events and Number of Participants
In case of clubs and smaller-scale events, the number of participants is registered and reported by
the public health coordinator. Participation at activities organized solely by the GPs’ clusters is
shown in Table T7.
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T7. GPs’ Clusters’ Activities, Events and Number of Participants
GPs’ cluster Types of activities*
Number of events
Start of activities
Number of participants
Estimated proportion of Roma participants
Borsodnádasd 29 256 11.2013 4360 40%
Heves 26 222 02.2013 2258 61%
Berettyóújfalu 15 120 09.2013 4396 41%
Jászapáti 23 236 03.2014 1308 7 %
*An activity is a particular kind of event/project/club, etc. An event is an activity organized at a specific location at a given time. A given type of activity may be organized several times and/or at different locations, making it into multiple events.
C.2.3.3. Programs and Activities Organized by Other Organizations to Which the GPs’
Clusters Joined
A number of activities are initiated and implemented by civil organizations and stakeholders in the
target region. Discussions between the WP6 leader and GPs’ cluster workers suggested taking these
activities into account and cooperating in the organization of or joining these activities whenever
possible rather than organizing parallel, competing events. Financial considerations also supported
this solution.
Ongoing services organized jointly with local stakeholders on a regular (weekly/monthly) basis are
presented in Table T8.
T8. Community health promotion activities organized by local stakeholders to which GPs’ clusters
joined
Community health promotion activities organized by local stakeholders to which GPs’ clusters joined
on a regular basis (by week or month) occasionally (ad-hoc)
Club for retired persons
Parental club
Physical education for pensioners
Thematic events for local residents
Family forum, family day, Roma day
Children’s day
Village festivals
Sport days
Vitamin day
Health day
Forum on hygiene
Physical activity for children
School group workout
Health days in local schools
Health and lifestyle clubs
Lifestyle Club - "your food is your life"
Slimming diet club
Activities for the elderly
Pensioners’ cultural meeting
International day for the elderly
Lectures on health-related topics
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Community health promotion activities organized by local stakeholders to which GPs’ clusters joined
on a regular basis (by week or month) occasionally (ad-hoc)
Mental health
Skills development sessions
Self-awareness group sessions for pupils
Interactive group sessions for students
Stress reduction group
Table T9. presents data on participation in the locally organized activities and events in which GPs’
clusters are involved.
T9. Locally organized activities and events in which GPs’ clusters are involved
GPs’ clusters Number of cooperated civil and stakeholder
Types of activities*
Number of events
Start of activities
Number of participants
Estimated proportion of Roma participants
Borsodnádasd 11 18 35 03.2014 1417 51%
Heves 13 15 36 09.2013 1588 40%
Berettyóújfalu 11 13 95 09.2013 2458 50%
Jászapáti 8 13 25 03.2014 957 20%
*An activity is a particular kind of event/project/club, etc. An event is an activity organized at a specific location at a given time. A given type of activity may be organized several times and/or at different locations, making it into multiple events.
C.2.3.4. Involvement of Stakeholders and Roma People of the Target Regions in the
Activities
In order to secure local cooperation, 4 meetings with stakeholders were held in the spring of 2014
at which 77 stakeholder organizations participated. They were informed of the Model Programme
in order to forward its aim and particulars to municipalities, NGOs and local Roma governments.
Stakeholders were invited to sign cooperation agreements (letters of intent titled “Coalition for
Health”) in which the aims and setup of the Programme were summarized, and the framework of
future cooperation and joint actions were elaborated. Cooperation agreements were signed by 54
stakeholders. More agreements are expected to be signed as public health coordinators have been
negotiating with 61 additional stakeholders.
A fundamentally important element of the Programme ensuring local involvement is the part-time
employment of Roma persons from the local Roma communities as health mediators in the GPs’
clusters. They facilitate the access of other Roma to health care services, mediate between health
care professionals and the disadvantaged local population, and are considered of great importance
in the organization of community health programs.
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Health mediators started to work in the summer of 2013. Each 48 of them participated in 30-hour
training on health mediation. However, many health mediators had only primary school education
which limited the range of work they were capable of performing, and also restricted their future
employability once the Programme will have terminated. Therefore, in agreement with the
Programme Management and representatives of the National Roma Self-Government, vocational
training in social work and assistant health nursing was organized and offered to those who had
neither vocational nor higher education. Both trainings offered nationally recognized certification
for those who completed all requirements.
Altogether 23 persons applied (2 for social work and 21 for assistant health nursing) of whom 22
successfully completed the theoretical and practical training and examination as well between July
2013 and May 2014. 1 person dropped out due to health reasons. Those who received their
certifications became eligible to perform simple health care tasks and can also serve as peer
educators having considerably widened their health-related knowledge and skills. These
qualifications provide an opportunity for career development, enabling more Roma to gain
employment in mainstream health roles. Their status also improved in their families and
neighbourhood as well according to anecdotal evidence.
The present recognition and effectiveness of the health mediators (most of them Roma women)
varies reflecting their trailblazing status. There have been instances when they were not well
received by non-Roma inhabitants; in other cases even Roma persons were mistrustful of them so
there was a request to equip them with personal identification badges which was accepted by the
Management. Some GPs’ clusters invite health mediators to work meetings, others do not.
Nevertheless, the majority of them contribute importantly, mostly to the recruitment of clients to
the health status assessment and to the organization and implementation of group and community
activities;working closely with other team members and social workers, facilitate recruitment of
Roma clients and encourage uptake of culturally appropriate preventive services, such as health
promotion activities at different settings, health status assessment, life style counselling, screening
programmes, maternal and child health services.
The quantification of the participation of Roma at community events and services is problematic
both legally and technically. Ethnic identity can be legally recorded only by the written approval of
the person whose ethnicity is to be asked. This would require the distribution of a targeted
questionnaire and consent form to each participant at every single community health promotion
event which is unfeasible; therefore, Roma participation is estimated at these events. Mother-child
clubs that are organized by health visitors every month at their target areas since the end of 2012
are specifically targeted to disadvantaged families. Participants of these clubs were personally
invited to join the clubs by health visitors who know every single family with expecting and/or
nursing mothers and mothers caring for children in their respective districts.
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C.2.4. GPs’ Cluster Management
C.2.4.1. Overview
The local management of the GPs’ clusters consists of the head GP (in Hungarian translation: GPs’
cluster coordinator) and the public health coordinator. When cluster-level management and
governance processes are evaluated, it must be taken into consideration that a pilot project must
have a stricter and more centralised governance approach than independently managed clusters
would have. While project guidelines and protocols play a significant role in the management of the
GPs’ clusters (e.g. meetings, planning, and reporting procedures are set up), there is also some
variation in how implementation is carried out at each cluster. It should be noted that local
variations, reflecting local innovations and adaptation to local needs are considered as valuable
elements of a pilot project.
Respondents of the on-line survey generally think that their personal influence over the local
management of the GPC, as well as the influence of the GPs’ cluster over the whole Programme is
moderate (average values are scattered around 3 on the 1 to 5 scale where “5” represented high
influence). Both coordinators (the head GP and the public health coordinator) evaluated their
influence over the Programme higher, and especially high as regards to local management (Figure
F12).
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F12. Perceived influence in the GPs’ clusters, rated by cluster members on a 1-5 scale (mean values)
A future expansion of the model must build on local governance to a greater extent so that better
inclusion of local network members would be needed. While a pilot programme has obviously
limited options for testing local governance processes, it still may be an issue for further analysis
during the second half of the pilot implementation period.
C.2.4.2. Internal Communication and Managerial Roles
The internal communication of the GPs’ clusters was generally perceived as good by the participants
interviewed. By mapping the communication links, it was revealedthat there is regular
communication between the head GP and the public health coordinator as well as between the
public health coordinator and the non-physician staff (both with “new” and “old” personnel,
including practice nurses and district health visitors). Communication between the head GP and
other GPs is mainly restricted to weekly communication.
The managerial structure of the GPs’ clusters is unique in the sense of having “dual leadership”.
Based on the experience of the interviews, it was concluded that the public health coordinator plays
a significant role in internal coordination and communication, while the head GP is rather perceived
as the external communication link of the GPs’ cluster towards Management. The importance of
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coordination between the head GP and the public health coordinator is also seen as a key issue by
most of the members. Managerial roles must be further analysed because it may influence model
expansion to a great extent.
C.2.4.3. Financial Management
The financial management of the GPs’ clusters has been extremely centralised. Salaries and wages
are standardised all over the clusters. Materials, small appliances, or services required for the
operation of the clusters is purchased centrally in Budapest, and governed by strict public
purchasing rules. Application of public purchasing processes basically for all purchases, including
low-value procurements, caused significant delays in implementation and led to high levels of
frustration of the GPs’ cluster members. Central purchasing comes with high administrative burden,
e.g. forms have to be filled several times, and delays of cost reimbursements, e.g. personally
prepaid telecommunication invoices, travel cost reimbursements. A more decentralised mode of
operation should be defined for the second half of the project, at least to cover small-value
expenditures, suggested to be defined as up to one or two thousand euros per month per cluster.
C.2.5. IT Support of GPs’ Clusters
C.2.5.1. Overview
IT support goals were specified as new software development and operation, and better IT
hardware infrastructure: some personal devices and tools (assets) to be delivered to the GPs’
cluster staff. Table T10 contains the IT items that were provided for staff support, not including
server side central or network related equipment.
T10. Information technology items supplied for participating practices
Item Quantity (pcs)
PC for GP offices with monitor, keyboard 24
Office software package 20
Notebook with docking station 10
Android based smartphone 34
Headless PC 10
Monitor 20
Notebooks for pooled use 6
Operating system licenses for PC/notebook 20
Projector and screen 8
Office printer 2
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Item Quantity (pcs)
Department A3 colour multifunction printer 2
Office wifi/router 24
C.2.5.2. Problems in IT Support Delivery
As it is well known from the periodic progress reports, IT development had a significant backlog in
asset delivery, new software development and service introduction. The main reasons of this delay
were the following:
Public procurement rules and processes proved to be much more rigid and slower than
originally expected.
It took time to clarify the vision about the “new GP software”. The related part of the
Feasibility Study contained general expectations about a central database only to support
research and statistical reporting, to enable a sector-based integration and patient case
management.
It took a longer than expected time to develop a common understanding about what a new
GP and cluster supporting software should be on the part of consortium partners. Majority
of stakeholders wanted to build a completely new GP program and make it available for the
GP software market. Other stakeholders thought that the new GP system should be only a
minor enhancement in relation to the current, 3rd party delivered GP software, and they put
the focus on the Virtual Care Service Centre (VCSC), implementing medical decision support
subsystems and self-managed, Internet based healthcare solutions. Finally the SH/8/1
project consortium has been delivering an integrated solution of VCSC, where both the ICT
and administrative background of the GP cluster system are established.
The OM specifies the organization structure, roles and responsibilities, but not the workflow.
The IT specification and the missing workflow had to be prepared later by the WP-03.
The original plan underestimated the time and labour demand of the software development,
and assumed an almost immediate delivery of the new GP software and IT environment. Not
only professional issues, but public procurement processes as well involve a multi-level,
multi-actor decision making and approval protocol demanding multiple negotiations that
take time.
At the beginning of the execution, WP-03 had to face the challenge that due to changes in
national regulations, GYEMSZI (National Institute of Quality and Organizational Development
in Healthcare and Medicines) had to discard plans for an internal IT developer team, and also
had to place its IT hosting to NISZ (National Infocommunications Services, an official national
IT service provider). Therefore, the bulk of software specification work had to be done
internally, while the development work had to be procured publicly. The steering committee
of the project accepted the WP-03 proposal to rent the hosting facilities instead of buying
hardware, and restructure the financial sources to the software development procurement.
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C.2.5.3. Summary of Support Delivery
To satisfy the longer term development plans and the immediate support needs, WP-03 decided to
implement a 3-phase plan:
Phase-1 is the “immediate solution”. It delivers all the basic group collaboration tools and
services what is sufficient to support the daily GPs’ clusters activities as defined in the GPs’
Cluster Operations Manual.
Phase-2 is new GP software with the additional GPs’ cluster functionality. The new GP
software is completely network oriented, it stores all medical data in a central – regional –
standard Electronic Health Records database, and it supports asynchronous messaging
between internal and external actors of the care organization.
Phase-3 is a Web based VCSC solution including some care community and trial self-
management functionality, plus experimental remote diagnostic or monitoring devices.
Phase-1 specification was ready in June 2013. The delivery of Phase-1 was expected no later than
the end of 2013. Unfortunately, the supplier was able to deliver the prototype system only in April
2014. According to the feedback to WP03, GPs and other project participants started to use Phase-1
solution slowly. In addition to the general problems related to learn and use a new IT system, one of
the major causes of this slow user acceptance was the lack of personal IT equipment.WP-03
delivered the necessary IT devices only in late March, 2014 as shown in Table T11.
T11. Information technology items supplied for clusters and their workers
Item Quantity (pcs)
Windows notebook (Dell) 49
Apple MacBook Air 13'' i5 Notebook 2
Samsung S5830 Galaxy Ace Smartphone 32
EPSON Projector EH-TW550 6
Konica Minolta Bizhub C284e colour multifunction network printer 5
Wall projector screen 180x180 cm 13
Microsoft Windows 7 Home Premium Edition 64bit 51
Samsung Galaxy TAB 3 7.0 3G 40
Apple iPad mini Cellular 32GB Black 2
All GPs’ cluster co-workers had access to the Phase -1 system by October 2014. Phase-1 is just a
simple collaboration tool for cluster members without any “wired” process flow, and this may be
the main reason of its limited popularity. Further investigations via personal, anonymous interviews
must be carried out by WP-08 to judge the situation fully about Phase-1.
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WP-03 delivered the first draft of the Phase-2 business specification by the end of 2014 January.
The Business Requirements Specification of Phase-2 (including Phase-3) was passed to VATI
(Hungarian Nonprofit Limited Liability Company for Regional Development and Town Planning) –
currently SZPI (Széchenyi Programoffice Consulting and Service) –, the Intermediate Body related to
the SH/8/1 in April 2014. SZPI answered on 13th of May with some modification requests and some
quality assurance questions, mostly on targeting legal personal data protection issues. WP-03
answered all issues in writing on May 19th. After a long silence, SZPI presented a second letter
regarding newly found quality issues on 22nd of July. Finally WP-03 and the Quality Manager
assigned by SZPI held a meeting discussed the Pilot as a whole, the main objectives and goals, and
the legal environment. WP-03 implemented some minor text changes, and SZPI approved the BRS
on 28th of August.
WP-03 passed the procurement documents (translated into English) and the BRS (in Hungarian) to
the Swiss Contribution Office (SCO) via the Intermediate Body for further approval in October, 2014.
WP-03 is now waiting for the SCO approval.
During this process WO-03 prepared the procurement specifications to the GP and GPs’ Cluster
workflow definition procurement, and the software quality assurance procurement as well. There is
a third data migration task in the pipe, this is planned to be procured by the Semmelweis University
Consortium Member.
All of these sub-project procurements are waiting for management approval.
C.2.5.4. Functions of Phase-2 and Phase-3
The following paragraphs give a concise overview of the Phase-2 functions.
Baseline GP practice software function
Practice general management functions
Practice controlling
Practice legal/contract management
Institutional supervisory control
Institutional PR/communications
Institutional project management
Institutional quality management
Institutional regulation execution
Practice daily operative functions
Practice originated campaign
Local knowledge management
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External medical communications (clinical evidence request and storage, external
service related communications, professional consultation requests, etc.)
Patient administration (registration, dismissal, sick leave)
Medical attendance / primary care professional services (case management and
treatment history track, incident management, date booking, etc.)
Practice “back office” functions (book keeping, assets administration, HR, etc) – to be
specified later.
Supplementary Cluster functions added to the GP baseline
Introducing new actors at GPs’ cluster level and supporting cluster wide operations with a
process driven workflow. Special cluster activities for:
patient status surveys (adult and child), risk assessment
cluster organized campaigns
prevention services
lifestyle consultancy
chronic treatment (care and rehabilitation)
community health services (smoking, alcohol, overweight, sedentary lifestyle, diabetes,
cardiovascular risks, dental hygiene, stress control)
general cluster-wide project activities support
aggregated cluster reporting
Management portal for cluster management an d research support
Integrated resource allocation and patient booking system
Chronic treatment support services
Personalized care and care plan
Professional knowledge base center for GPs’ cluster staff
In addition to the central EHR database an option to build up a patient controlled Patient
Health Record (PHR) database and web based medical consulting
Customer oriented medical knowledge base for public use:
Information inquiry
public consulting
moderated patient forum
medical financial records for registered users (eFIN)
medical and health related service directory and search tool
public services and GP encounter booking on the web
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Phase-3 specification will be prepared during the Phase-2 development period, and if necessary,
proper integrating interfaces will be added using an agile development method like SCRUM for
example.
Planned Phase-3 features will focus on telemetry and smart-phone devices. Currently the following
service types are under consideration:
Blood pressure measurements. Automated and timed measurements according to the
personal care plan. Measurements are carried out at home and reported to the GPs’ Cluster
and/or to the PHR system automatically. Semi-automatic processes will be developed to
filter incoming data, generate suggestions to patient and alarm triggers to the GP.
Blood glucose level measurements. Semi-automated per-incident or timed measurements
according to the personal care plan. Measurements are carried out at home or at the
workplace and reported to the GPs’ Cluster and/or to the PHR system automatically. Semi-
automatic processes will be developed to filter incoming data, generate drug related
suggestions to patients and alarm triggers to the GP.
Electrocardiogram telemetry. Remote ECG can be used as a monitoring tool and in case of
any unexpected fainting-fit as well to check hearth status. Normal ECG monitoring
algorithms shall be applied either locally (smart phone application) or centrally (GPs’ cluster
server level) to discover emergency and trigger alarms. ECG measurements shall be time-
stamped, compressed and stored as special PHR or EHR state evidence.
Most of the functions described above already exist in the form of commercial services or products.
WP-03 will focus in Phase-3 on the selection of the most sophisticated ones and their integration to
the GPs’ cluster platform developed in Phase-2.
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Recommendations
D. RECOMMENDATIONS
During the Midterm Review, illuminating findings emerged from the data analysed in the frame of
the monitoring and evaluation system, from which several conclusions can be drawn with multiple
implications. First, regarding the day-to-day operation of the Programme, second, on the main
directions of the further development in the second part of the Programme period; and third, for
the Hungarian health care system as a whole. Consequently, this chapter is divided into three main
parts: (1) the recommendations regarding the more effective and efficient operation of the Model
Programme, (2) the recommendations on its strategic development, and finally (3) preliminary
health policy recommendations on how the Model Programme fits to international development
trends, to previous and ongoing health care reforms and developments in Hungary, as well as on
the potential future scenarios of a nationwide adoption of the Programme. During the review
process, implementation has been ongoing, so some of the problems identified earlier have already
been solved. These are indicated parallel to the recommendation concerned.
D.1. RECOMMENDATIONS REGARDING THE DAY-TO-DAY OPERATION OF THE PILOT
D.1.1. Recommendations on the Health Status Assessment
RcO.1. The timing of the HSA should be reconsidered in order to open the possibility for more time
slots in non-working hours to increase participation by those in employment.
RcO.2. The opportunity for clients to discuss the findings of the HSA with the GP after the HSA
should be further expanded in order to increase trust and reassure the client.
RcO.3. Additional public health services are not fully utilized by clients after the HSA. This
disconnection increases the risk of non-participation and ineffective follow-up. In general,
the protocols, timing and sequencing of additional services should be re-examined.
RcO.4. The documentation of HSA should be standardised.
The standardized documentation of the HSA has already been implemented with Phase-1 of
the ICT development. The electronic processing of previous HSA questionnaires is
continuous and will be completed by the end of January 2015.
RcO.5. To increase the effectiveness of the HSA, workshops should be organized to discuss
experiences, share good practices and consolidate the standardised implementation of the
survey.
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D.1.2. Recommendations on new competencies and additional services
RcO.6. Additional services provided by newly employed health professionals show some
heterogeneity. The reasons for this should be explored and measures should be taken to
increase standardization, but also leave room for addressing the differences in local needs.
RcO.7. Additional services for chronic care patients are not sufficiently developed. These should
include new activities, including, for instance, patient education, case management plans,
and ICT support for the provision of virtual health services.
RcO.8. New health professionals require more guidance and professional support for their work. A
system for professional supervision and coaching should be established for at least the
dietitian and the health psychologist whose services have shown the largest divergence.
The system of professional supervision has already been implemented.
RcO.9. Given the novelty of the position, health mediators expressed their wish to possess a valid
identification card with photo to identify them and increase acceptance among the local
Roma communities.
Health mediators have already been equipped with photo ID cards.
D.1.3. Recommendations regarding the financial, legal, organizational and ICT framework
of the Pilot
RcO.10. In the second half of the Programme, the legal and organizational form of the GPs’ cluster
should be established, and a sustainable financing model should be developed.
RcO.11. Regarding the financial management of GPs’ clusters, functional integration and larger
financial autonomy are recommended.
RcO.12. It is recommended to implement an organizational development project for GPs’ clusters in
the first half year after the Midterm Review.
RcO.13. The current plan and implementation of software development should be revised. Instead
of the originally planned 3 phases, Phase-3 should be dropped and its most important
elements should be integrated into Phase-2. This would free some resources, which could
be reallocated toWP-9 in need. The GPs are in need for nationally available ergonomic and
economical IT solution.
RcO.14. The involvement of a legal expert from the National Center for Patients’ Rights and
Documentation (OBDK) to establish processes which comply with the regulations on the
protection of personal data is recommended.
RcO.15. A stronger involvement of the local media in the provision of health related information
and in shaping the attitudes of the local population, reflecting to RcO.13 is essential.
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Recommendations
RcO.16. Regarding the Swiss-Hungarian Partnership, the new care-cure therapies, methodologies
and functions require new technological solutions and devices that must be developed and
innovated on the existing technological inventions available for the industries concerned.
The staffs of the GPC shall be involved in defining innovations demand, testing and trial of
the innovated products and monitoring the efficacy and effectiveness of the new products
used in everyday operation. Considering that cooperation and partnerships are strongly
encouraged, especially in focus areas in which Switzerland may contribute particular
experience, know-how and technologies, and having in mind that both the integrated
chronic health and social care services and the prevention oriented home care services
provided by the GPs’ clusters require devices, equipment and medicine directly innovated
for them and their activities, Swiss-Hungarian multisectoral (industrial and health)
partnerships in innovation cooperation are recommended. Cooperation in organizing
multilateral partnership for preparing and submitting proposals to the EU calls such as
Horizon 2020 (including Innovative Medicines Initiative 2) Health Programme III, etc. are
especially important to assist replication of the GPs’ cluster system developed by SH/8/1
project.
D.2. RECOMMENDATIONS ON THE MAIN DEVELOPMENT DIRECTIONS OF THE PILOT
For the second half of the Programme focusing on three main areas of development is suggested.
These include the extension of the current model by considering the potential horizontal, vertical
and intersectorial functional integration possibilities within the national primary health care, and
into the directions of outpatient specialist care and social care systems; the further development
and renewal of outpatient chronic care, as well as the establishment of the case management
function. In this respect the directions of ongoing reform initiatives and the international initiatives
should also be taken into account.
RcS.1. The developments of the first half of the Pilot should be consolidated.
RcS.2. The provision of certain outpatient specialist services should be considered.
RcS.3. The operational development of the Programme should consider mechanisms to improve
collaboration with primary social care providers.
RcS.4. Development activities should focus on additional services for chronic care patients.
RcS.5. The mechanisms of case management should be elaborated.
D.3. PRELIMINARY HEALTH POLICY RECOMMENDATIONS
In this section we formulate recommendations for the harmonization of the Programme with the
national and international trends and initiatives for health care development. On the basis of the
actual cost data of GPs’ clusters, a model was created to assess the cost implication of the national
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adoption of the Programme’ developments. Finally the political feasibility of a large scale roll out is
considered.
D.3.1. Recommendations regarding the content of the Pilot
The preliminary health policy recommendations are based on the framework of problem-based
policy-making. Problem-based health policies are led by objectives, based on scientific evidence and
are feasible. Therefore the impact of the Programme is considered on the main health policy
principles of effectiveness, efficiency and equity.
RcP.1. On the basis of the preliminary findings of the monitoring and evaluation of the
Programme, its impact can already be detected at this early stage of implementation. There
are three indicators, where the performance of the GPs’ clusters has been improved. These
findings support the continuation of the implementation of the Pilot.
RcP.2. The analysis of performance on the basis of the national quality indicators in primary care
could not be carried out properly; it has become clear that the indicators used presently
have several methodological limitations and therefore need to be revised.
RcP.3. The available data do not allow us to analyse the impact of the Programme on total health
expenditures. Therefore, a framework for modelling this impact was elaborated, which
should be implemented after thorough discussion in the second half of the Programme.
Together with the measurement of health gain it will be possible to evaluate the cost-
effectiveness of the Programme, which in turn will provide additional input for the decision
making on the national adoption of the project through the elaboration of various health
policy scenarios. The health policy relevance, consequences and implications of the
Programme cannot be considered in isolation. Therefore, the international trends, as well as
good practices and other national developments targeting the renewal of the Hungarian
health care system should also be evaluated. The performance problems of the primary care
in Hungary, the development potentials in primary care, the previous reform measures
aimed at the increase of the competencies of primary care, as well as the ongoing relevant
healthcare reform initiatives, which are formulated in various development projects (e-
Health, health visitors, community care coordination) should also be considered. Building on
the theoretical, methodological, practical and IT basis delivered by the Programme and
several EU co-funded projects in the framework of the Social Renewal Operational
Programme – SROP), a call similar to the Programme is being prepared in the frame of the
new Human Resource Development Operational Programme for 2014-2020 (HRDOP) in order
to extend the model. Therefore one of the measures in HDROP (draft) intends to replicate
the complex renewal of primary care system by extending the main results and experiences
delivered by SH/8/1 project concerning prevention and care oriented patient-focused
cooperation of local service providers.
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RcP.4. The Programme fits well in the international trends regarding the development of health
care systems, as well as in previous Hungarian reform initiatives and the current
development projects under implementation. These facts reinforce the recommendation
that in the second phase of the implementation, the Programme should focus on the
possibilities of further functional integration, especially the expansion of the competencies
of GPs’ clusters to better support outpatient specialist services (primary care led vertical
functional integration).
RcP.5. The further development of the Programme should consider the experiences with previous
reforms, especially the innovative Hungarian Care Coordination Pilot. According to the
established terminology the GPs’ cluster in the Swiss Contribution Project, can rather be
defined as a “practice cluster” (“practice community”) extended with health professionals,
which is a special form of “group practice”.
RcP.6. In order to ensure the harmonisation and coordination of development projects at the level
of the whole healthcare system, the Programme should consider the implementation of the
relevant methodologies, being developed in the frame of the project on community care
coordination (TÁMOP 6.2.5/B implemented in SROP), and should elaborate the interface with
pilots planned to be implemented in the geographical area of the Programme. It is important
to mention that the participants of the Programme are involved in the TÁMOP 6.2.5/B’s
developments, so the utilisation of the results and developments of the Programme is
possible also in the framework of the community care coordination project. The
establishment of patient pathways is supported strongly by this project. Within this
framework health management guidelines are made upon which regional healthcare centres
will rely in order to harmonise the activity of service providers and to perform the
coordination of patient care. The topic covers many areas, including information flow among
service providers, support of access to patient data, development and operation of patient
pathways, support of appropriateness of patient transfers, tracking of patient satisfaction.
RcP.7. Concerning the fact that the major goal of the Programme is to improve the health status of
the serviced population not only by providing care for the sick but also by providing services
aimed at preventing diseases and improving the health status of the entire target population
the developments of the Programme should be severely considered at planning the public
health actions and interventions in Hungary. A definitive link between primary health care
and public health services has to be formed in line with the Health 2020, the new WHO
European health policy framework and strategy which indicates as one of its four priority
areas the strengthening of people-centred health systems along with public health capacity.
RcP.8. In the case of successful implementation of nation-wide e-Health development projects, the
technologies should be adopted by the Programme.
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RcP.9. The long term sustainability of the Programme is dependent on the implementation of
proper financial incentives. In the second phase of the Programme, these should be devised
to fit to the current payment system.
The third principle of Problem-based Policy Making is feasibility, which requires our efforts to
improve the performance of the health care system correspond to the economic and political
realities of the balance of the government budget, and the representation of the interests of
relevant actors. The shortage and aging of health care personnel, the level of fiscal deficit and the
risks associated with fragile economic growth, are just a few examples of constraining factors, which
need to be taken into account if the national roll out of the Pilot is considered.
D.3.2. Recommendations regarding financial sustainability and national adoption of the
Model Programme
In the frame of the assessment of feasibility and long term sustainability we have developed a basic
cost assessment framework, on the basis of which we provide preliminary cost projections for the
roll out of the Pilot. The objective of the model was to determine the approximate financing needs
of the continuation of the Pilot at a larger scale after its 2016 closure. We have used a simple
methodology.
The basis of the calculation was the real cost data of the functioning GPs’ clusters (including
the costs already incurred and planned costs), averaged for the 4 GPs’ clusters (PK model) in
addition to the costs already covered by the social health insurance system (additional costs
model). This had been further developed into three main models, based on the modification
of the original functionality (and cost structure) of the PK model.
In the K model, the costs of the PK model have been complemented with a few additional
cost items, including e.g. one motor-vehicle per GPs’ cluster, and few pieces of equipment.
The T model involves substantial deviations from the original PK model: 3 GPs’ clusters share
1health psychologist, physiotherapist and dietitian, certain activities are also planned
together, and material expenditures are reduced by 40-50%.This model introduces a new
position, a cluster manager responsible for the administration of 3 GPs’ clusters.
The R model represents an even more significant cost reduction: additional services are
provided by already working health professionals (practice nurse, health visitor)
compensated with a somewhat increased remuneration. The management and professional
supervision of the GPs’ clusters are carried out by the same GP (1 per 3 clusters). The
monthly and yearly costs were calculated for each model first per GPs’ cluster, and that in
turn was multiplied by the number of clusters to estimate the total costs of gradual roll out,
both on a linear basis.
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Tables T12 and T13 provide a detailed description and comparison of the various cost models, and
the estimated yearly additional expenditures of the gradual extension of these models from 200
GPs’ clusters to 1100 GPs’ clusters (national adoption of the Programme).
T12. The comparison of the various cost models
RcP.10. The national adoption of the most expensive K model would cost an additional 92 billion
HUF, which does not seem to be a realistic scenario. The realistic scenarios lie between this
scenario and the least costly, R model (a roll out to 200 GPs’ clusters, roughly 7 billion HUF
per year), and will ultimately depend on the actual state of the government budget.
Model PK Model K Model T Model R
Brief description GP Cluster of the PilotModel PK complemented with
additional cost items
Model PK with cost savings
elements
Extensive cost saving based on
additional services provided by
current primary care staff
FunctionalityComplex professional programme with
the full staff based on the ongoing project
Complex professional programme with
the full staff of the PK model
Reduced staff and services: part
time workers and less intensive
extra activities
Mainly the current staff provides the
additional services in exchange for a
compensation
Leadership &
management model
One part time professional leader from
the participating GPs for each GP Cluster
No separate administrative manager
One part time professional leader from
the participating GPs for each GP
Cluster No separate administrative
manager
One part time professional leader
among the GPs for each GP Cluster
One full time operational manager
for every 3 GP Clusters
One full time operational manager for
3 GP Clusters, who acts as professional
leader at the same time
Involvement and extra
payment of GPs
6 GPs / GP Cluster (HUF 300 000 HUF /
month)
6 GPs / GP Cluster (HUF 300 000 HUF /
month)
6 GPs / GP Cluster (HUF 100 000
HUF / month)
6 GPs / GP Cluster (HUF 100 000 HUF /
month)
Health professionals
Both the public health workers (e.g.
preventive nurse) and the newly involved
health care specialists (dietitian,
psychologist, physiotherapist) are full
time workers
Both the public health workers (e.g.
preventive nurse) and the newly
involved health care specialists
(dietitian, psychologist, physio-
therapist) are full time workers
One prevention nurse is full time
for each GP Cluster. The rest of the
new health care specialists are part
time workers
The current practice nurses of GP
practices and the district nurses would
receive wider role for extra payment in
the preventive activities (e.g.
organization of screening program)
Other personnel2 assistant health mediators for each GP
(12 for each GP Cluster)
2 part time assistant health mediators
for each GP
1 part time assistant health
mediators for each GP (6 for each
assistant health mediators are financed
from the communal work programme
Personnel costs 66.3 million HUF/year 73.2 million HUF/year 32.7 million HUF/year 21.8 million HUF/year
Share of personnel costs
per category49%/ 18%/ 17% /16% 50%/ 17%/ 17%/ 16% 42%/ 23%/ 17%/ 17% n/a
8.6 million HUF/year 7.7 million HUF/year 6.0 million HUF/year 10.8 million HUF/year
Calculation is based on real spending in
the project (GP clusters)
Calculation is based on real spending
and planned costs in details (extended
activities)
Calculation is based on Model T
lowered by 40-50 % (less activities)
150 thousand HUF / GP / month (900
thousand HUF / GP Cluster / month)
2.3 million HUF/year 2.9 million HUF/year 1.6 million HUF/year -
Renovation of existing building, ICT costs
and purchasing of medical equipment
partly based on actual spending (no
motor-vehicle is included)
Yearly depreciation costs of
equipment, ICT, large motor-vehicle
and building renovation
Yearly depreciation costs of
equipment, ICT, middle-sized motor-
vehicle and building renovation
Capital costs are not included in this
model (should be funded from other
sources, EU SF, or central government
budget)
Proportion of main costs
items (personnel /
material / investment)
85,9%/11,1%/3,0% 87,4%/ 9,2%/ 3,4% 81,3%/ 14,8%/ 3,9% 66,9%/ 33,1 %/ 0%
GP Cluster models for cost analysis
Investment costs (yearly
depreciation)
Material costs
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T13. The total additional expenditures of the K, T and R model per year (in billion HUF)
No. of GPs’ clusters (No. of
GPs)
Population covered (million)
K model (billion HUF / year)
T model (billion HUF / year)
R model (billion HUF/year)
A 200 (1200) 1.86 16.75 8.05 6.51
B 400 (2400) 3.72 33.51 16.10 13.02
C 600 (3600) 5.58 50.26 24.16 19.54
D 1100 (6600) 9.90 92.15 44.88 35.83
RcP.11. The impact of the Programme on health expenditures cannot be studied simply by the
estimation of the additional costs of the operation of the GPs’ clusters. Further
expenditures are generated by the provision of services for the new patients identified by
the screening, and the renewal of services of chronic care patients, while cost reductions
can be expected on the middle run. Together with the estimation of health gain, the cost-
effectiveness of the Model Programme can be evaluated in the second half of its
implementation by a team consisting of experts in health economics and leading staff
members of the Programme.
D.3.3. Recommendations regarding political feasibility
There is a clear mandate for the health government to strengthen and reorganize the primary care
sector. However, the current structure of primary care is rigid and the involved actors are very
sensitive to any changes. Therefore, successful reform interventions should be planned carefully in
terms of timing, process and communication in the political, professional and lay arena, and should
be based on the professional and financial motivation of health personnel. In order to minimize
substantial resistance:
RcP.12. The extension of tasks and competencies should be coupled with increased financing.
RcP.13. The planned changes should not detrimentally affect the financial situation of primary care
doctors, including the monetary value of the right to practice. On the other hand, the right
to practice is one of the most important obstacles of entry and exit therefore, it is crucial to
find a way to preserve the advantages of practice right as well as to eliminate its inherent
weaknesses. Any financing increases should be preceded by reforming the right to
practice; otherwise it will further aggravate the problem of exchange of practices and limit
the entry of young doctors into the primary care sector.
RcP.14. Participation in extension process should be voluntary.
RcP.15. The legal and financial framework for primary health care should be clarified, and local
governments should take greater financial responsibility for the operation of the sector.
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RcP.16. The cooperation of health care professionals in primary health care should be promoted as
opposed to the currently dominant independent practices. The increased competencies
should be paid for separately. Quality should be measured by indicators at the level of GPs’
clusters to incentivise group work and practice cooperation.
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