Health care close to home has been a political goal for a long time. It is time to put the patient at the centre of the geography of care rather than the place of residence. Digital services are becoming more and more available and, after the Covid-19 health crisis, people will live more individually again.

Medicine is a mass and routine business: sophisticated operations and therapies are only of high quality where they are practised frequently. If almost everything is offered almost everywhere, this inevitably results in poor provision in the area of cutting-edge medicine. Nevertheless, the local lack of care services causes anxiety and resentment among large parts of the population, especially since it contradicts the logic of the subsidiary state to centralise tasks. This is why there are so many regional hospitals, which also perform difficult operations and therapies in order to get off the ground economically.

Faced with the choice between high objective quality of care and institutions of cutting-edge medicine in their own jurisdiction, governments and voters often opt for their own. The denial of services to patients and the postponement of important surgeries during the Covid 19 crisis seems to confirm the preference for hospitals away from the centres, but the evidence is unclear. Digitalisation offers the opportunity to put aside the old conflict between quality-oriented health policy and regional policy and align it with the complementary goals of patient proximity and top quality. Although these goals are partly in conflict with each other, they are both essential if patients are placed at the centre of health care. From an impact perspective, health care must be close to people geographically and, above all, humanly, while at the same time offering high quality in demanding therapies and operations. This was also confirmed by the Praevenire Health Days 2021, which dedicated a separate block of events to care close to home. In the following, those aspects of the event that relate to the outlined paradigm shift will be discussed in order to derive a new perspective on the geography of care.

Patients at the centre

In order to deal with the paradox that high objective quality is not considered the ultimate goal of health care in politics when it collides with local interests, different strategies have been developed in recent years. Firstly, the benefit for the patient is now declared the highest maxim of action, both in concrete individual cases and in the design of structures, processes and practices. This makes economic sense because it reduces costs beyond borderline cases, gives patients more healthy or almost healthy years of life and thus also creates economic benefits. Unfortunately, it is easy to point out the ambiguities associated with this principle. Often patients themselves do not know what they really want, or they do not dare to formulate their wishes. Tactically skilful opponents of patient-centred care can use this fact to derail many initiatives. And there are many opponents. Because even if everyone is “theoretically” in favour of patient-centredness, many are “practically” against it if an aspect that is important to them is negatively affected.

PVEs and Remote Intelligence

Secondly, in order to provide patients with all the expertise they need close by, some countries are increasingly relying on primary care units (PVEs), in which several GPs work together with representatives of as many health care professions as possible. This not only saves patients long distances, but also improves communication among the experts – both to the benefit of the patients. PVEs also create good conditions for the integration of “remote intelligence”. External expertise can thus be consulted for diagnosis and therapy decisions. At the hospital level, “distributed tumour boards” are now an established example of remote intelligence. The establishment of close cooperation between general practitioners, specialists in private practice, regional hospitals and highly specialised university hospitals would go one step further here by attempting to involve all of them with their particular expertise in the treatment. The biggest challenge here – apart from the need to convince those to be involved of the benefits of cooperation – would be that it requires knowledge, know-how and experience in the cooperation constellations, i.e. training and time. This in turn makes it easy for opponents to stir up opposition.

Digital before outpatient before inpatient

Thirdly, in view of the slow progress in optimising healthcare according to objective criteria, patient organisations have coined the motto “digital before outpatient before inpatient” in recent years[1]. It is intended to help optimise care close to home for the benefit of patients and to open up the discourse for unconventional digital approaches to solutions. There is no doubt that for many patients, online access would be the closest to home, because it is possible from their own homes. Nevertheless, many follow-up consultations still take place on site, even in completely uncritical cases – with travel expenses and unusable waiting time for the patients, including risks of infection. The reason is that there is also great resistance to online services outside of declared telemedicine. These are primarily justified by unresolved quality and safety issues, without there being any evidence for the existence of these problems.

Change of perspective

In view of the difficulties that any structural changes must reckon with, it is advisable, on the one hand, to concentrate on processes (and practices) rather than structures[2] and, on the other hand, to contrast the concept of “care close to home” with the concept of “health care optimised for patients”. This requires a change in thinking and forces us to take into account the heterogeneity of people. There is a growing group of patients for whom care close to work is much more important than care close to home, or more precisely: “care close to work”. For those who work alternately in different cities, in remote places and on the journeys in between, it does not help to be well cared for only in the vicinity of the main residence and the official office. For him or her, the question of the expense of visiting the doctor is completely different from those who work from home as pastors, farmers or in a home office. She or he will be grateful for an online follow-up and may not be able to use a consultation close to home. While lonely older patients prefer to make time for the doctor’s appointment and waiting in the waiting room because this is part of their social life. It is important to respect both lifestyles and to take them into account in the design of the health system. There are also other groups of the population that have special needs: for example, mothers or fathers who chauffeur their children from one appointment to the next in the afternoon and then finish their work after 10 pm. Or people with serious illnesses, for whom the exchange with similarly affected people is important, which is almost never possible locally on site. Or people who need different special treatments that are not available in one place and have to be guided through the system by a permanent reference person (usually a GP). Or. Or. Or. Our world is becoming more and more individualised, care is becoming more and more specialised and proximity to home is becoming less important. Therefore, health care should adapt to the people, not the people to the health care.

Seven demands

The discussions around care close to home, among others but not only at the Praevenire Health Days 2021, suggest the following conclusions:

1. Firstly, we need electronic patient dossiers (health records), which actually contain all the data about us, which must be coded according to transnational standards.
2. Secondly, we need an expansion of digital care services (telemedicine, apps, measuring devices networked via IoT).
3. Thirdly, we should expand the health centres both close to home and in the companies and also integrate specialist doctors into them.
4. Fourthly, we need to expand cooperation between the actors, which goes beyond “cooperation with patients”, is institutionally established and strengthened through exchange at eye level.
5. Fifthly, it is necessary to guide people through the complex health system better than before, both automatically digitally and personally and on the basis of professional training of the “pilots”.
6. Sixth, we need to take into account the reality of patients’ lives when measuring the quality of the health system.
7. And seventhly, all of this also requires explicit training of all health professionals, including further training of those who have had different experiences in the system for a long time.

Consequences for regional development

Patient-centred health care is not the end of local care. Dormant communities without their own social life are a sad undesirable development that does not make their inhabitants happy. But social life also includes integrated health care. Digitalisation does not change this. But here, too, small centres, such as PVEs, are a better solution than the most even distribution of care services in the countryside.

References

1] See press release on the topic by Gerald Bachinger, among others the spokesperson of ARGE Patientenanwälte Österreichs (Patients’ Advocates Working Group of Austria) 2] Lecture by Thomas Czypionka “Chronisch schlecht versorgt? Need for action in the field of chronic diseases?” Praevenire Health Days 2021