Atencion Primaria Practica最新文献

El proceso de reforma de la atención primaria y comunitaria en España, iniciado en la década de los años 80, se planteó con unos objetivos teóricos ambiciosos que a lo largo de su desarrollo no se han visto cumplidos, al menos en un porcentaje significativo, lo que no es contradictorio con el hecho de que la reforma ha tenido importantes repercusiones positivas sobre muchos aspectos asistenciales, docentes y de investigación de esta parte nuclear de nuestro sistema sanitario.

A los problemas y errores cometidos en el inicio se han ido añadiendo otros en distintos ámbitos como por ejemplo, en el ámbito presupuestario y de dotaciones de recursos, el organizativo y el profesional, lo que, junto a una evidente falta de voluntad política para acometerlos bajo una perspectiva innovadora, han llevado a la situación crítica en la que hoy se encuentra nuestra atención primaria y comunitaria.

The process of reform of primary and community care in Spain, initiated in the decade of the 80s, was raised with ambitious theoretical objectives that throughout its development have not been fulfilled, at least in a significant percentage, which is not contradictory to the fact that the reform has had important positive repercussions on many aspects of care, teachers and research of this core part of our health system.

To the problems and mistakes made at the beginning have been added others in different areas such as budgetary and resources, organizational and professional, which, together with an evident lack of political will to undertake them from an innovative perspective, have led to the critical situation in which our primary and community care finds itself today.

La atención primaria española tiene problemas urgentes y problemas importantes. Los problemas urgentes precisan de una inversión multimillonaria. Los importantes requieren un rediseño del modelo que refuerce la longitudinalidad y otorgue mayor autonomía profesional. No sabemos si su mejor futuro vendrá tras una transición por reforma o tras una ruptura por desplome del actual modelo. La mejor opción la representa el «radicalismo selectivo»: poner en práctica en algunos centros algunas medidas escogidas de gran alcance que mejoren el modelo, incluidos los cambios normativos, especialmente aquellos relacionados con la autonomía de la gestión y el empoderamiento de la atención primaria, y que se extiendan luego a los demás en un proceso de innovación-difusión. Desde lo macro, las instituciones políticas, académicas y sanitarias deben tomar medidas que hagan atractiva la atención primaria –para los ciudadanos y los profesionales– y acaben con su descremado sociológico, pues la atención primaria ha de ser para todos o nunca será.

Spanish primary care has urgent problems and important problems. Urgent problems require a multi-million investment. The important ones require a redesign of the model that reinforces longitudinality and grants greater professional autonomy. We do not know if its best future will come after a transition by reform or after a rupture due to the collapse of the current model. The best option is «selective radicalism»: implementing in some centers some far-reaching selected measures that improve the model, including regulatory changes, especially those related to management autonomy and the empowerment of primary care, and then extended to others centers in a process of innovation-dissemination. From the macro perspective, political, academic and health institutions must take measures that make primary care attractive – for citizens and professionals – and put an end to its sociological skimming, since primary care must be for everyone or it never will be.

Primary care must face the new challenges of the XXI century that have already started with the Covid-19 pandemic. These challenges have to do with a new sociosanitary reality characterized by a rise of the prevalence of the comorbidity and fragility linked to the eldering and the impact of the determinants of the health. Changes in the population, one with more informed patients who demand participating in the decisions that affect their health in a society that is increasingly digitalized. In this context the primary care must solve its challenges such as changing its way of functioning in more cohesive teams that can incorporate new profiles that are really needed and that bring value and where a compromise with teaching and investigation exists. The management of these challenges requires that the professionals working in primary care in the XXI century deepen in their competences looking further than the limits of their health centres. Competences such as the selection and use of the best knowledge, the critical thought, the use of communication to approach to the values and preferences of their patients, the shared decision making and social conscience. In order to these changes to pursue, an institutional impulse is necessary, one with the, many times insistently claimed by the professionals, measures. Among which is, firstly, a bigger inversion in personnel and equipment as well as the commitment with evidently proved models intended to obtain a more coordinated and integrated attention between the primary care, the hospital, the mental health, the public health and the social services, the judicious use of the e-health solutions or the incorporation of a knowledge area of primary care in the University.

Los sistemas de atención primaria europeos están en crisis, las causas van a persistir e incrementarse. Para entenderlo, hay que asumir que estamos en una crisis multisistémica globalizada que afecta al resto de instituciones y servicios públicos. Dicha crisis va a ir a más allá. Dentro de los posibles cursos de acción, tanto extremos como intermedios, habrá que plantear un decrecimiento general sanitario. Ampliar el paradigma biopsicosocial para incluir la dimensión existencial, será necesario tanto para los profesionales como para los pacientes. La irreversibilidad del deterioro parece evidente, dado que ni va a haber refuerzo del sistema ni recursos suficientes para mantenerlo al nivel actual. La merma de profesionales será el factor clave que, unido al aumento de presión asistencial, funda la capacidad del sistema. Para que los profesionales mantengamos la posición en estas circunstancias, tendremos que asumir tanto las luces como las sombras, autocuidarnos, apoyarnos mutuamente y plantear un diálogo con nuestras comunidades.

European Primary Care systems are in crisis, the causes are set to persist and increase. To understand this, it must be assumed that we are in a globalised multi-systemic crisis that affects the rest of public institutions and services. This crisis is set to grow. Within the possible courses of action, both extreme and intermediate, we will have to consider a general decrease in health care. Broadening the biopsychosocial paradigm to include the existential dimension will be necessary for both professionals and patients. The irreversibility of the deterioration seems evident given that there will be neither reinforcement of the system nor sufficient resources to maintain it at the current level. The decline in the number of professionals will be the key factor which, together with the increase in the number of patients cited, will undermine the capacity of the system. If we professionals are to maintain our position in these circumstances, we will have to take on board both the lights and the shadows, take care of ourselves, support each other and establish a dialogue with our communities.

La diversidad organizativa y financiera que caracteriza la atención primaria europea ha permitido responder extraordinariamente a la pandemia de COVID-19 con soluciones innovadoras: reorganización de la oferta de servicios, digitalización, nuevos roles profesionales e inclusión de nuevas profesiones en atención primaria, y pagos añadidos por la realización de actividades. La telemedicina ha transformado la atención al paciente. Las crisis humanitarias (inmigración y refugiados) requieren todavía nuevas soluciones en Europa. Los cuidados paliativos en atención primaria se han transformado. La novedosa educación médica virtual debe ser evaluada. La disminución de la burocracia es una clara necesidad, al igual que la coordinación con los servicios de medicina preventiva y de salud pública. La práctica en solitario versus los equipos de atención primaria, el acceso a la prescripción de ciertos fármacos, la hiperprescripción, las actividades preventivas, y las migraciones de médicos constituyen los retos del futuro para la atención primaria europea.

The organisational and financial diversity that characterizes European primary care has made it possible to respond extraordinarily to the COVID-19 pandemic with innovative solutions: reorganisation of the scope of services, digitization, new professional roles and inclusion of new professions in primary care, and the use of additional fees for service. Telemedicine has transformed patient care. Humanitarian crises (immigration and refugees) still require new solutions in Europe. Palliative care in primary care has been transformed. The new virtual medical education must be evaluated. The reduction of bureaucracy is a clear need, as is coordination with preventive medicine and public health services. Solo practice versus primary care teams, access to the prescription of certain drugs, over-prescription, preventive activities, and migration of physicians constitute future challenges for European primary care.