Innovatori, indecisi, bisognosi o autonomi. I medici di medicina generale tra integrazione e accountability

Journal title MECOSAN
Author/s Sara Barsanti, Manila Bonciani, Federico Vola, Luca Pirisi
Publishing Year 2016 Issue 2016/98
Language Italian Pages 31 P. 9-39 File size 23950 KB
DOI 10.3280/MESA2016-098002
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Italian primary care is currently undergoing radical reform. Territorial Functional Aggregations (AFT), compulsory networks of general practices comparable to primary care groups (PCGs), have recently appeared in Italian legislation. In particular, Tuscany Region has become the national pioneer, experimenting AFT implementation since 2014. This paper contains a review of new initial perceptions of those general practitioners (GPs’) who are in charge of coordinate the new mono-professional groups. 115 coordinators have been asked to fill in a questionnaire about the impact of these reforms in terms of integration and accountability, with a focus on their new managerial responsibilities. Then the authors have run a cluster analysis to identify homogenous groups with similar perceptions and to understand how GPs are facing the reform.

Keywords: Primary care, general practitioner, health management, accountability, integration, cluster analysis

  1. Ashcroft R. (2014). Inadequate performance measures affecting practices, organizations, and outcomes of Ontario’s Family Health Teams. Healthcare Policy, 10(1): 86-96. DOI: 10.12927/hcpol.2014.23929
  2. Auerbach D.I., Chen P.G., Friedberg M.W., Reid R.,
  3. Lau C., Buerhaus P.I., Mehrotra A. (2013). Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage. Health Affair, 32 (11): 1933-1941.
  4. Barsanti S., Bonciani M., Salvadori P. (2013). Gli accordi attuativi aziendali per i medici convenzionati. Il caso della Regione Toscana. Politiche sanitarie, 14 (4): 211-220. DOI: 10.1706/1410.15654.
  5. Barsanti S., Nuti S. (2015). Il sistema di valutazione della performance delle AFT toscane. Anno 2014. Pisa: Edizioni ETS.
  6. Barsanti S., Nuti S. (a cura di) (2012). La valutazione della performance delle Società della Salute/zonedistretto del sistema sociosanitario toscano. Report 2011. Pisa: Edizioni ETS.
  7. Barsanti S., Piris L. (2015). Indagine di soddisfazione ed esperienza della medicina generale sulla organizzazione delle cure primarie e AFT in Regione Toscana. Anno 2014. Pisa: Tipografia Editrice Pisana. Ebook ISBN 978-88-8250-162-4 2015.
  8. Bevan G., Fasolo B. (2013). Models of governance of public services: empirical and behavioural analysis of “econs” and “humans” In: Oliver A. (a cura di). Behavioural Public Policy, Cambridge, UK: Cambridge University Press: 38-62.
  9. Bindman A.B., Weiner J.P., Majeed A. (2001). Primary Care Groups in the United Kingdom: quality and accountability. Health Affairs, 20 (3): 132-145. DOI: 10.1377/hlthaff.20.3.132
  10. Blount A., Bayona J. (1994). Toward a system of integrated primary care. Family Systems Medicine, 12 (2): 171-182. DOI: 10.1037/h0089151
  11. Bodenheimer T., Lo B., Casalino L. (1999). Primary Care Physicians Should Be Coordinators, Not Gatekeepers. JAMA, 281 (21): 2045-2049. DOI: 10.1001/jama.281.21.2045
  12. Bodenheimer T., Lorig K., Holman H., Grumbach K. (2002). Patient Self-management of Chronic Disease in Primary Care. JAMA, 288 (19): 2469-2475. DOI: 10.1001/jama.288.19.2469
  13. Boerma W.G.W., Rico A. (2006). Changing conditions for structural reform in primary care. In: Saltman R.B., Rico A., Boerma W.G.W. (a cura di). Primary care in driver’s seat? Berkshire: Open University Press.
  14. Bonciani M., Barsanti S. (2015). Esperienze di integrazione nell’assistenza primaria basate sulla co-location dei servizi: quali prospettive per il modello della Casa della Salute?. Mecosan, 96: 81-122.
  15. Borgonovi E., Lecci F., Ricci A., Salvatore D. (2011). Strumenti di governo per la gestione delle patologie croniche in medicina generale. In: Fondazione Farmafactoring (a cura di). Il Sistema sanitario in controluce. Rapporto 2011. Milano: Franco-Angeli.
  16. Bower P., Campbell S., Bojke C., Sibbald B. (2003). Team structure, team climate and the quality of care in primary care: an observational study. Quality and Safety in Health Care, 12 (4): 273-279. DOI: 10.1136/qhc.12.4.273
  17. Branson R., Armstrong D. (2004). General practitioners’ perceptions of sharing workload in group practices: qualitative study. BMJ.
  18. Bravo Vergel Y., Ferguson B. (2006). Difficult commissioning choices: lessons from English primary care trusts. Journal of Health Services Research and Policy, 11 (3): 150-154. DOI: 10.1258/135581906777641749
  19. Breton M., Pineault R., Levesque J.F., Roberge D., Da Silva R.B., Prud’homme A. (2013). Reforming healthcare systems on a locally integrated basis: is there a potential for increasing collaborations in primary healthcare?. BMC Health Services Research, 13: 262. DOI: 10.1186/1472-6963-13-262
  20. Breton M., Lévesque J.F., Pineault R., Hogg W. (2011). Primary Care Reform: Can Quebec’s Family Medicine Group Model Benefit from the Experience of Ontario’s Family Health Teams?. Healthcare Policy, 7(2): e122-e135.
  21. Broadbent J. (1992). Change in Organisations: A Case Study of the Use of Accounting Information in the NHS. British Accounting Review, 24 (4): 343-367. DOI: 10.1016/S0890-8389(05)80044-7
  22. Calinski T., Harabasz J. (1974). A dendrite method for cluster analysis. Communications in Statistics, (3): 1-27.
  23. Casalino L.P., Nicholson S., Gans D.N., Hammons T., Morra D., Karrison T. (2009). What does it cost physician practices to interact with health insurance plans?. Health Affairs, 28 (4): 533-543. DOI: 10.1377/hlthaff.28.4.w533
  24. Contandriopoulos D., Brousselle A., Breton M., Sangster-Gormley E., Kilpatrick K., Dubois C.A., Brault I., Perroux M. (2016). Nurse practitioners, canaries in the mine of primary care reform. Health Policy, 120 (6): 682-689.
  25. Corsalini E., Fattore G. (2012). L’assistenza sanitaria primaria in Europa: modelli, tendenze scenario per l’Italia. Mecosan, 82: 61-75.
  26. Corsalini E., Vendramini E. (2010) (a cura di). Integrare la rete dei servizi territoriali. Contenuti, forme e risultati delle best practice in Italia. Milano: Egea.
  27. Coulter A. (1995). Shifting the balance from secondary to primary care. British Medical Journal, 311: 1447. DOI: 10.1136/bmj.311.7018.1447
  28. D’Amour D., Ferrada-Videla M., San Martin Rodriguez L., Beaulieu M.D. (2005). The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. Journal of Interprofessional care, 19 (1): 116-131. DOI: 10.1080/13561820500082529
  29. Damiani G., Silvestrini G., Federico B., Cosentino M., Marvulli M., Tirabassi F., Ricciardi G. (2013). A systematic review on the effectiveness of group versus single-handed practice. Health Policy, 113 (1-2): 180-187. DOI: 10.1016/j.healthpol.2013.07.008.Epub2013Jul31
  30. Damiani G. (2015) “Lettura su Governance di sistema e di produzione. --Testo scaricabile al link: https://www.ars.toscana.it/files/eventi/eventi_2015/assistenza_anziani_nonautosufficienti/Damiani_21_aprile_2015.pdf.
  31. Davis K., Schoenbaum S.C., Audet A.M. (2005). A 2020 Vision of Patient-Centered Primary Care. Journal of General Internal Medicine, 20(10): 953-957. DOI: 10.1111/j.1525-1497.2005.0178.x
  32. OECD (2015). OECD Review of healthcare quality. Italy 2014: Raising standards. In: OECD Reviews of Health Care Quality. Paris: OECD Publishing. DOI: 10.1787/9789264225428-en
  33. Di Maggio P.J., Powell W.W. (1983). The Iron cage revisited: institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48 (2): 147-60. DOI: 10.1016/S0742-3322(00)17011-1
  34. Di Vincenzo F., Mascia D., Numerato D., Salvatore D. (2014). Le reti sociali e i professionisti in sanità: una review della letteratura. Mecosan, 89: 71-83.
  35. Dowell A.C., Hamilton S., McLeod D.K. (2000). Job satisfaction, psychological morbidity and job stress among New Zealand general practitioners. The New Zealand Medical Journal, 113 (1113): 269-272.
  36. Dowswell G., Harrison S., Wright J. (2002). The early days of primary care groups: general practitioners’ perceptions. Health and Social Care in the Community, 10 (1): 46-54. DOI: 10.1046/j.0966-0410.2001.00332.x
  37. Exworthy M., Wilkinson E.K., McColl A., Moore M., Roderick P., Smith H., Gabbay J. (2003). The role of performance indicators in changing the autonomy of the general practice profession in the UK. Social Science Medicine, 56(7): 1493-1504. DOI: 10.1016/s0277-9536(02)00151-x
  38. Fabbris L. (1997). Statistica multivariata. Analisi esplorativa dei dati. Milano: McGraw-Hill.
  39. Fantini M.P., Compagni A., Rucci P., Mimmi S., Longo F. (2012). General practitioners’ adherence to evidence-based guidelines: A multilevel analysis. Health Care Manage Review, 37 (1): 67-76. DOI: 10.1097/hmr.0b013e31822241cf
  40. Fattore G., Frosini F., Salvatore D., Tozzi V. (2009). Social network analysis in primary care: the impact of interactions on prescribing behaviour. Health Policy, 92 (2): 141-148. DOI: 10.1016/j.healthpol.2009.03.005
  41. Fattore G., Salvatore D. (2010). Network organizations of general practitioners: Antecedents of formation and consequences of participation. BMC Health Services Research, 10 (1): 18. DOI: 10.1186/1472-6963-10-118
  42. Friedberg M.W., Hussey P.S., Schneider E.C. (2010). Primary Care: A Critical Review Of The Evidence On Quality And Costs Of Health Care. Health Affairs, 29 (5): 766-772. DOI: 10.1377/hlthaff.2010.0025
  43. Fries T.E., Machta R., Meyers S.D., Genevro S., Peikes D.N. (2013). Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers. Annals of Family Medicine, 11 (1): 80-83.
  44. Gerrish Bnurs K. (1999). Teamwork in primary care: an evaluation of the contribution of integrated nursing teams. Health & Social Care in the Community, 7 (5): 367-375. DOI: 10.1046/j.1365-2524.1999.00199.x
  45. Gray J. (1982). The effect of the doctor’s sex on the doctor-patient relationship. The Journal of the Royal College of General Practitioners, vol. 32 (236): 167-169.
  46. Greß S., Delnoij D.M.J., Groenewegen P.P. (2006). Managing primary care behavior through payment system and financial incentives. In: R.B. Saltman, A. Rico, G.W Boerma (a cura di). Primary care in
  47. driver’s seat? McGraw Hill: Open University Press. Harrison S., Dowswell G. (2002). Autonomy and bureaucratic accountability in primary care: what English general practitioners say. Sociology of Health & Illness, 24 (2): 208-226. DOI: 10.1111/1467-9566.00291
  48. Harrison S., Lim J. (2000). Clinical governance and primary care in the English National Health Service: some issues of organisation and rules. Critical Public Health, 10 (3): 321-329. DOI: 10.1080/713658256
  49. Heller L. (2004). Change management nelle cure primarie: l’influenza delle leve aziendali sull’evoluzione degli strumenti manageriali per la medicina generale. In: E. Anessi Pessina, E. Cantù (a cura di) L’aziendalizzazione della sanità in Italia. Rapporto OASI 2004. Milano: Egea.
  50. Heller L., Tedeschi P. (2004). Scelte regionali per la medicina generale. In: E. Anessi Pessina, E. Cantù (a cura di). L’aziendalizzazione della sanità in Italia. Rapporto OASI 2004. Milano: Egea.
  51. Kerr E.A., Hofer T.P., Hayward R.A., Adams J., Hogan M., McGlynn E., Asch S. (2007). Quality by Any Other Name? A Comparison of Three Profiling Systems for Assessing Health Care Quality. Health Service Research (42), 5: 2070-2087, October.
  52. Kringos D., Boerma W.G.W., Hutchinson A., Saltman R.B. (2015). Building primary care in a changing Europe. WHO Regional Office for Europe.-- Testo disponibile al sito: http://www.euro.who.int/__data/assets/pdf_file/0018/271170/BuildingPrimaryCareChangingEurope.pdf
  53. Lamarche P.A. (2008). Is it really the tail that wags the dog?. Healthc Pap, 8 (2): 26-32; discussion 64-7.
  54. Leese B., Mahon A. (1999). Management and Relationships in total purchasing pilots: relevance for primary care groups. Journal of Management in Medicine, 13(3): 154-163. DOI: 10.1108/02689239910292053
  55. Lega F. (2006). Vincere la resilienza al cambiamento: come le aziende sanitarie stanno affrontando le sfide dell’innovazione strategica e del cambiamento organizzativo. In: E. Anessi Pessina, E. Cantù (a cura di). L’aziendalizzazione della sanità in Italia. Rapporto OASI 2006. Milano: Egea.
  56. Lester H., Campbell S. (2010). Developing Quality and Outcomes Framework (QOF) indicators and the concept of ? QOFability?. Qual Prim Care, 18(2): 103-9.
  57. Longo F. (2007). Implementing managerial innovations in primary care: can we rank change drivers in complex adaptive organizations?. Health Care Management Review, 32 (3): 213-225. DOI: 10.1097/01.hmr.0000281620.13116.ce
  58. Maciocco G. (2012). Remunerazione dei medici di famiglia e qualità dell’assistenza.-- Pubblicato online su Saluteinternazionale disponibile al link http://www. saluteinternazionale.info/2012/01/remunerazionedei-medici-di-famiglia-e-qualita-dellassistenza/.
  59. Malcolm L., Mays N. (1999). New Zealand’s independent practitioner associations: a working model of clinical governance in primary care?. British Medical Journal, 319 (7221): 1340-1342. DOI: 10.1136/bmj.319.7221.1340
  60. Marchildona G., Hutchisonb B. (2016). Primary care in Ontario, Canada: New proposals after 15
  61. years of reform. Health Policy, 120 (7): 732-738. Marshall M., Sheaff R., Rogers A., Campbell S., Halliwell S., Pickard S., Sibbald B., Roland M. (2002). A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance. British Journal of General Practice, 52(481): 641-645.
  62. Mascia D. (2009). L’organizzazione delle reti in sanità. Teoria, metodi e strumenti di social network analysis. Milano: FrancoAngeli.
  63. Milillo G. (2009). La crisi della medicina generale: la situazione italiana secondo l’analisi Fimmg. In: Guzzanti E. (a cura di). L’assistenza primaria in Italia. Roma: Iniziative Sanitarie.
  64. Ministero della Salute (2014). Patto per la Salute 2014-2016. --Testo disponibile al sito: http://www.statoregioni.it/Documenti/DOC_044351_82%20CSR%20PUNTO%20%2016%20ODG.pdf.
  65. Numerato D., Salvatore D., Fattore G. (2012). The impact of management on medical professionalism: a review. Sociology of health and illness, 34(4): 626-644. DOI: 10.1111/j.1467-9566.2011.01393.x
  66. Nuti S. (a cura di) (2008). La valutazione della performance in Sanità. Milano: il Mulino.
  67. Nuti S., Vainieri M. (2015). Il sistema di valutazione della performance delle AFT toscane. Anno 2014. Pisa: Edizioni ETS.
  68. Provan K., Milward H. (1995). A Preliminary Theory of Interorganizational Network Effectiveness: A Comparative Study of Four Community Mental Health Systems. Administrative Science Quarterly, 40(1), 1-33. DOI: 10.2307/2393698
  69. Ortun V. (2013). Primary care at the crossroads. Gaceta Sanitaria, 27 (3): 193-195.
  70. Rico A., Saltman R.B., Boerma W.G.W. (2004). Organizational restructuring in European health system: The role of primary care. Social Policy and Administration, 37 (6): 592-608. DOI: 10.1111/1467-9515.00360
  71. Rodríguez C., Pozzebon M. (2010). The implemen-tation evaluation of primary care groups of practice: a focus on organizational identity. BMC Fam Pract., Feb., 22, 11:15. DOI: 10.1186/1471-2296-11-15
  72. Saltman D.C., O’Dea N.A., Farmer J., Veitch C., Rosen G., Kidd M.R. (2007). Groups or teams in
  73. health care: finding the best fit. Journal of Evaluation in Clinical Practice, 13(1): 55-60. DOI: 10.1111/j.1365-2753.2006.00649.x
  74. Saltman R.B., Rico A., Boerma W.G.W. (a cura di) (2006). Primary Care in the Driver’s Seat? Organizational Reform in European Primary Care. McGraw-Hill: Open University Press.
  75. Scally G., Donaldson L. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. BMJ, 317 (7159): 61-65. DOI: 10.1136/bmj.317.7150.61
  76. Sheaff R., Smith K., Dickson M. (2002). Is GP Restratification Beginning in England?. Social and Policy Administration, 36, 7: 765-779, December.
  77. Surender R., Fitzpatrick R. (1999). Will Doctors Manage? Lessons from GP Fundholding. Policy and Politics, 27 (4): 491-502. DOI: 10.1332/030557399782218317
  78. Suschnig C. (2001). Reforming Ontario’s primary health care system: one step forward, two steps back?. International Journal of Health Service, 31(1): 91-103. Sutherland K., Dawson S. (1998). Power and quality improvement in the new NHS: the roles of doctors and managers. Quality in Health Care, 7 (Suppl.): 16-23.
  79. Tynkkynen L.K., Chydenius M., Saloranta A., Keskimäki I. (2016). Expanding choice of primary care in Finland: much debate but little change so far. Health Policy, 120 (3): 227-234.
  80. Visco M., Donatini A., Gini R., Federico B., Damiani G., Francesconi P., Grilli L., Rampichini C., Lapini G., Zocchetti C., Di Stanislao F., Brambilla A., Moirano F., Bellentani D. (2013). Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs. Health Policy, 113(1-2): 188-98. DOI: 10.1016/j.healthpol.2013.05.016
  81. Wagner E.H. (1998). Chronic Disease Management: What will it take to improve care for chronic illness?. Eff Clin Pract., 1(1): 2-4, Aug-Sept.
  82. Ward J.H. (1963). Hierachical grouping to optimize an objective function. J. Am. Statist. Assoc., 58: 236-244.
  83. Warwicker T. (1998). Managerialism and the British GP: the GP as manager and as managed. International Journal of Medical Management, 12: 331-348.
  84. Carbone C., Compagni A., Corsalini E. (2012). Logiche e strumenti per la valutazione dell’integrazione territorio-ospedale-territorio: un’analisi su tre processi. Mecosan, 21 (83): 23-43.

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Sara Barsanti, Manila Bonciani, Federico Vola, Luca Pirisi, Innovatori, indecisi, bisognosi o autonomi. I medici di medicina generale tra integrazione e accountability in "MECOSAN" 98/2016, pp 9-39, DOI: 10.3280/MESA2016-098002