sh/8/1 project

: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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Project No. SH/8/1 – Midterm Review Swiss_Contribution_SH-8-1_Midterm_Review_final

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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Executive summary

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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Executive summary

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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Executive summary

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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Executive summary

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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Executive summary

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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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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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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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.


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





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


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




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


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





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

16



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.

17



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.

18



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

19



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

20



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.

21



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.

22



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

23



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.

24



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

25



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.

26



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.

27



F8. Number of participants and services - Dietitian

F9. Number of participants and services – Health psychologist

28



F10. Number of participants and services – Physiotherapist

F11. Number of participants at services in August, September and October of 2014

29



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.

30



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.

31



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

32



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.

33



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

34



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.

35



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.

36



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).

37



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

38



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

39



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.

40



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.

41



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

42



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

43



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.

44


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.

45


Recommendations

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.

46


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

47


Recommendations

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.

48


Recommendations

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.

49


Recommendations

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.

50


Recommendations

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)


month)

6 GPs / GP Cluster (HUF 100 000

HUF / month)


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

51


Recommendations

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.

52


Recommendations

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.

sh/8/1 project

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