Models of Primary Care and Appraisal Frameworks

The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.


Introduction
The primary care values to achieve health, for all require health systems that 'Put people at the centre of health care'. (World Health Organization, 2008a) Thirty years after the Alma Ata Declaration (World Health Organization, 1978), the World Health Organization Report: Primary Care More than Ever (2008) highlights the increasing emphasis on person-centred care, as health systems adapt to rapidly changing social circumstances and increasing public expectations. It is in this context, and a decade later, that the Models of Child Health Appraised (MOCHA) project has attempted to appraise the current primary care systems for children and placing them very much at the centre of health care (see Chapter 3).
Children are not mini adults. Their needs for primary care services are specific in a number of ways: from clinical knowledge and skills required to treat them to means of access and types of advocacy. The MOCHA project set out to identify which models of primary care exist for children, whether there are particular attributes which might be different from those directed at adults and how might these models be appraised. To achieve this, it is essential to first be clear about what is meant by a 'model'. In the MOCHA project, we have defined a model as a simplified description of the primary care system, but one that is comprehensive enough to describe the complexity and coordination of its components. Pragmatically, the model allows an overall view of a system, and enables comparison between systems. Thus we have taken the multiple and interrelated dimensions of primary care and attempted to simplify them into a conceptual framework for appraisal in a number of attributes. Ultimately, in the same way as a model farm operates, in which exemplars are produced to maximise crop or animal yields, we set out to identify a validated effective and efficient model or model components which can be assembled in such a way as to lead to optimum health outcomes (Wade-Martins, 2002).
With this meaning in mind, a summary of the findings of an extensive review of the literature on primary care models with particular focus on the child and family led to building on the work of researchers such as Starfield, who was among the first pioneers to research what constitutes a 'good' primary care system (Starfield, Shi, & Macinko, 2005). Thus, we describe the model types and apply this to practical application of appraisal methodologies in the MOCHA project.

Model Types
The many different forms of primary child health care provision are described in Chapter 1.
Given the finite project resources and the greatest and most strategic foci of primary care activity for children, the MOCHA project has concentrated primarily on the general practice or family practice (seeing all ages but optionally with specialisation), primary care paediatricians (seeing only child patients), community nursing with their own child caseload, practice-based nurses working in tandem with a primary care and school health services. The other contributors to primary care received some attention in our scientific survey questionnaires analysing service patterns.
A MOCHA literature review (Alexander & Blair, 2016) identified a number of models used to classify primary care systems. In summary, these included one or more axes: European paediatric professional associations and country agent classifications of lead practitioner in terms of general practitioner (GP), primary care paediatrician or mixed systems (Ehrich, Namazova-Baranova, & Pettoello-Mantovani, 2016;Katz, Rubino, Collier, Rosen, & Ehrich, 2002;van Esso et al., 2010); the system of regulation, financing and service provision; and separately State, health insurance or private provider as 'actors' (Böhm, Schmid, Götze, Landwehr, & Rothgang, 2013), or a combination of state or professional control (hierarchy) and gatekeeping (Bourgueil, Marek, & Mousques, 2009).

Lead Practitioner Classifications
The lead clinician has often been the key focal point of a model and the classification by which it has been defined. The clinician is the point of entry into the primary care system in most, but not all, models. The clinician acts as a medical advocate for the patient and may coordinate further care (Kringos, Boerma, Hutchinson, & Saltman, 2015a, 2015b. This is a somewhat simplistic, but pragmatic means of describing a model of primary care. The MOCHA project has echoed previous research by describing models by means of three types of lead clinician (see Chapter 13): (1) a paediatrician-led model; (2) a GP/Family doctor-led model; and (3) a mixed model.
Within a country, there may be transition from one type to another, for example from paediatrician-led services to a GP-led service at a certain point in childhood (Alexander & Blair, 2016), and there is very little evidence to show outcomes related to the type of model or variation in outcomes within a country's model (Ehrich et al., 2016;Katz et al., 2002;van Esso et al., 2010).

Financial Classifications
In Europe, countries are generally divided into tax-based national health systems and social insurance systems (Saltman, Rico, & Boerma, 2006), but the manifestations of each funding system by societal and political decisions leads to a diversity in models. Funding is a very important factor in shaping a health care system, but it is unable to explain the diversity in Europe on its own (see Chapters 8 and 9). The Expert Panel on Effective Ways of Investing in Health (European Commission, 2018) recommends that all EU Member States have adequate financing for primary care, to guarantee a certain level of population health and wellbeing. Any system must have a degree of financial stability to function properly Models of Primary Care and Appraisal Frameworks 15 and to remain accessible and effective (European Commission, 2018). In most countries, there is free or almost free access to primary care for children, but there are also hidden costs that can result in inequity of provision (see Chapters 9 and 15), which is perhaps exacerbated by the recent financial crises in Europe.

Regulatory, Financial and Service Provision Classifications
Another means of classifying the diversity of models of primary health care is on the type of service offered and how it is organised. These have been described by Kringos et al. (2015aKringos et al. ( , 2015b among others in three model subtypes: (1) The public hierarchical normative model À this is where primary care is central to the health system and is run by the state rather than by health professionals. In these systems, health care facilities provide voluntary coverage and are governed by decentralised authorities or regions, and GPs or primary care paediatricians are usually salaried. Examples of countries with this type of system are Finland, Lithuania, Portugal, Spain and Sweden.
(2) The professional hierarchical gatekeeper model À in these systems, GPs are the cornerstone of primary care and usually hold a gatekeeper role to other services. The primary care professionals are accountable for the management of resources used for health care. Remuneration of professionals is mixed between fee-for-service, self-employed and salaried. Examples of this system are Denmark, Estonia, Poland, the Netherlands, Slovenia and the United Kingdom. (3) The free professional non-hierarchical model À health professionals organise care independently, without strong regulation from the state or insurance funding. This model emphasises patient and professional freedom. There is an absence of a list system or a gatekeeping role. Primary care professionals work alongside each other, but not necessarily in collaborative teams. Countries with this system include Austria, Belgium, France, Germany and Switzerland (see Chapter 9). Not all countries fit neatly into these classification systems, however. For example, Italy has a combination of a public hierarchical normative model and a professional hierarchical gatekeeper model. Other research has extended these classifications further, based on contextual factors including funding, clinic types and community settings. These are discussed in detail in Alexander and Blair (2016).
In the MOCHA project, a combination of our own country-based studies with reference sources and literature, we were able to map the different models in the EU and EEA countries. Table 2.1 was used to highlight the different classification types described above and to support the Work Package scientists in their task of appraising the model characteristics against a variety of outcomes.
A number of additions were made to the Table 2.1 as the project progressed; including workforce training, presence of multidisciplinary teams, school and adolescent health services, amount of funding, background factors such as GDP and PPP and types of record systems.

Identifying Appraisal Frameworks
Having described the model components and their variations across the 30 countries, the next and central MOCHA project challenge was how to appraise the various combinations. We used the World Health Organization 'building blocks' (World Health Organization, 2010) for high-performing health systems which might act as useful starting point when looking at primary care for children to try to establish what makes a good system and from which perspective. The building blocks are as follows: • Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources. • A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive). • A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status. • A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness and their scientifically sound and cost-effective use. • A good health financing system raises adequate funds for health, in ways that ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient. • Leadership and governance involve ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability.
Specifically for primary care, Starfield et al. (2005) identified six mechanisms, alone and in combination which may account for the beneficial impact of primary care on population health: (1) greater access to needed services; (2) better quality of care; (3) a greater focus on prevention; (4) early management of health problems; (5) the cumulative effect of the main primary care delivery characteristics (firstcontact access for each new need, long-term person (not disease)-focused care, comprehensive care for most health needs and coordinated care); and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.
Appraisal of the models of primary care for children and young people is considered through a number of different lenses. These include effectiveness or health gain, acceptability against child, family and societal expectations and economic efficiency.
To identify a suitable appraisal framework for MOCHA, we carried out a detailed literature review of the conceptual frameworks that could be applied. This work identified 13 specific frameworks that focused on the overall health system and eight specifically on primary care (Sampaio & Blair, 2018). No published literature was found to specifically focus on primary child health care in its own right. This reinforces our overall finding that despite the importance of child health, it is an inadequately studied field of health care (see Chapters 6 and 7). The 13 frameworks have been used at national, international and regional levels and are summarised in Table 2.2. Table 2.3 is a summary of the dimensions of the eight conceptual frameworks applied to primary health systems across different countries.
Tables 2.2 and 2.3 do not show the relationship between the dimensions, but they demonstrate that improved health status (or health outcomes/effectiveness) appear in all frameworks, while access, efficiency, equitable outcomes, responsiveness, human resources, physical resources, financial resources, political and socio-economic factors are present in most of them, both in general and in primary health frameworks. Although general and primary health frameworks have a similar pattern, it is possible to highlight some differences between their dimensions. Quality appears in most general health frameworks but in only two primary health ones. Health system use, governance, continuity and health system management appear in most primary health frameworks but are infrequent in general health frameworks.
Equity appears in many frameworks, but in different places, nevertheless highlighting equitable access to health services (procedural equity) as a cause of equitable outcomes (substantive equity). The World Health Organization (2008b) stated that health inequities (inequities in outcomes) are caused by unequal access to health care and many other visible or invisible circumstances, such as unequal distribution of power, income and goods. Nevertheless, no framework considered equity at a structural or contextual level.     Sampaio and Blair (2018) for further information).

Models of Primary Care and Appraisal Frameworks 31
Notwithstanding the importance social determinants of health, contextual dimensions were not included in seven frameworks (Hsiao et al., 2008;Murray & Frenk, 2000;Sibthorpe & Gardner, 2007;Tham et al., 2010;World Health Organization, 2007. Even when the objective is to appraise the primary child health system, which may not be responsible for changing variables out of its domain, health determinants were not present in any framework. Contextual factors allow a broader understanding of the system (see Chapter 17), and it has been shown that health determinants can have a higher impact on health outcomes than health care (Donkin, Goldblatt, Allen, Nathanson, & Marmot, 2017).
Obviously, 'it is hard to isolate the impact of health care from the impact of other determinants of health status' (Hurst & Jee-Hughes, 2001). However, a conceptual framework ideally will contribute to operationalise statistical models to measure the impact of each variable. Sometimes, a concept is not easily identified in the framework figure. Yet, it is implicit in the description of another concept. This is described in , which included effectiveness as a feature of quality dimension. A different situation occurred in Starfield's, 1998framework (Starfield, 1998, where the author acknowledges equity's importance as a system goal, but did not include it explicitly in her framework, not even in its description. Additionally, the frameworks vary in focus, being broader or more specific. For example, Starfield produced two separate frameworks with differing emphasis of the health system within the wider context of health (Starfield, 1998(Starfield, , 2001. Moreover, as already mentioned, there is variation in the definitions of the concepts, when available. Responsiveness, for example, varies between patient 'satisfaction and acceptability', which depend on expectations, and 'experience', which 'seeks to describe objective characteristics of health service delivery, such as whether patients were (factually) given a choice of treatment' (Hurst & Jee-Hughes, 2001).

Adapting Frameworks for MOCHA
A major concern for the MOCHA project is that none of the identified frameworks are child specific (see Chapter 6), which is important because of the specific needs of children from primary care (see Chapter 1).
Many of the appraisal frameworks are constructed on a structure-processoutcome theme; describe capacity-performance-health status; or are focused on input/output and outcomes. Thus, all attempt to relate the various components in a linear framework, rather than either looking at a dynamic interactive system or focussing on the individual child as the reactive and proactive subject of care. Nearly all of the frameworks recognise that health status of a population cannot solely be attributable to the health system but must be analysed in the context of broader environmental, economic and social situations. This raises the conundrum of how to estimate the balance between primary care combatting the adverse effects of external determinants of health as they adversely affect individual child, as opposed to the effort that can be invested in preventively addressing the determents such as by combating household smoking or advocating for better housing for families with small children. Overall, however, the utility of having such appraisal frameworks does allow a conceptual framework to be developed, which can contribute to seeking to operationalise statistical models to measure the impact of each variable.
The Primary Health Care Activity Monitor for Europe (PHAMEU) is a significant research group that has attempted to develop a scoring system following a structureÀprocessÀoutcome framework. This project concluded that a generic all-ages primary care system can be defined and approached as: a multidimensional system structured by primary care governance, economic conditions and primary care workforce development, facilitating access to a wide range of primary care services in a coordinated way, and on a continuous basis, by applying resources efficiently to provide high quality care, contributing to the distribution of health in the population. Primary care contributes through its dimensions to overall health system performance and health.  This European primary care monitor was subsequently tested to rate the strength of primary care systems across Europe (Schäfer et al., 2011). While this work did not consider the specific needs of children (such as different types of access), we have included this in our table of components as a variable that may be used to analyse the primary care systems for children.
Recognising the value of a conceptual framework, but the failings of the existing published ones to meet the specific needs of children, and in a primary care setting, the MOCHA research team devised an alternative conceptualisation. At the heart of this has been our core theme of child centricity (see Chapter 4) and the need to focus on delivery to the child through the development of the life course. The MOCHA working model focuses on the child, the life course, the primary care team and the societal and environmental context (see Figure 2.1).
The MOCHA model is based on three theoretical frameworks, Bronfenbrenner's ecological model of determinants of health (Bronfenbrenner, 1986), a modified PHAMEU; model of determinants of quality of primary care ; and a life course epidemiological framework for childhood health and disease (Kuh, Ben-Schlomo, Lynch, Hallqvist, & Power, 2003). The left-hand circle was inspired by the visualisation of positive and negative health determinant forces developed by the Child Health Indicators of Life and Development (CHILD) (Rigby & Köhler, 2002) project and describes influences on health and health policy decisions. Within the community setting, a family makes choices and decisions about health based on what is available, knowledge and cultural influences, and finally À potentially influenced by all of these practices À the child. Alternatively, viewed from the inside out, it can be seen as the child in the centre, able to influence and make decisions about what is available to him or her in terms of health in the context of the family, and with appropriate support the child can further exert some influence on the wider determinants. In practice, both situations occur in a dynamic process which is constantly in flux.
The variation in the respective widths of the coloured elements of the diagram as the child moves from one age range to another indicates how the various determinants are weighted for a typical child over time. For example, there is a relatively large influence from parents and family in the early years, and great influence of school, peer groups and external influences such as the media, as children grows older.
A combination of preventive care, physical and mental health and short-term and long-term conditions has been selected as tracer conditions, examples of which appear in the diagram above the circles. Project scientists have surveyed the country agents concerning various different aspects of the MOCHA Working Model so that there is a balance of acute conditions, long-term conditions, mental health and the well child. The primary care system is closely related, in the left-hand circle, to secondary and tertiary care, in other words, vertical, aspects and to social care education and justice as a horizontal axis of interaction.

Practical Application of Appraisal Methodologies
Identification of models to form a visualisation is one part of the appraisal process in the MOCHA project. A second necessary part has been empirical  analysis, though as will emerge this has been severely hampered by the lack of accessible data (see Chapter 7). To seek to achieve meaningful appraisal, the project's scientists looked in particular at the following aspects: health status of children and clinical outcomes which are theoretically attributable to the primary care system, patient perspectives of the primary care system derived from interviews with children in five countries, an economic appraisal in relation to infant mortality rates and the influence of incentives and penalty systems, the ability of the system to provide equitable provision (preventive care, immunisation, diagnosis of development disorders, diagnosis of congenital anomalies, ambulatory sensitive conditions) and appraisal in terms of children's rights (consent and participation).
A number of tracer conditions have been identified to allow us to assay the different structures and processes that exist in the 30 countries in relation to the key functions of primary child health care. Clinical scenarios were developed to illustrate how these functions operated in each country. These were first access care in acute illness, chronic management of disease and its impact, prevention of disease through screening and immunisation, early detection of developmental or congenital disorders, support in coordinating care for children with complex physical and mental health care needs. We also attempted to harvest data at national and regional level using the MIROI tool (see Chapter 7) and worked with a selected number of countries who had sufficiently granular data on different socio-economic dimensions to allow us to appraise the ability of the primary care system to provide equitable service provision/health outcome (see Chapter 7). The MOCHA approach to the model structures is summarised in Table 2.4. The appraisal process and the use of case studies to develop these in the different countries are described in Table 2.5. Table 2.6 describes the approach to the life course of the child. Each table represents a different appraisal lens whether from a pure health care system perspective, a child and family-centric perspective or using a developmental time basis. The following chapters describe in more detail how this was achieved and the results from the country agent's responses and scientific reviews of the literature.

Summary
In order to successfully appraise the models of primary care for children, the MOCHA project has systematically identified the different types of models that exist, acknowledging the complexity of doing this, particularly with respect to the lack of child focus in more previous researches. An analysis of the existing appraisal frameworks also highlighted the lack of a child-centric perspective, leading to the creation of the MOCHA working model. The project has addressed this appraisal in a number of ways, not least because of the range of expertise and subject focus on the different elements of primary care as they relate to children. The results are shown in the subsequent chapters of this report.