Nils Schneider

Palliative care in urgent need of recognition and development in general practice: the example of Germany

BackgroundSpecialist palliative care is being increasingly recognised and developed to improve end-of-life care in many developed countries. However, only a small proportion of the total number of patients with incurable, progressive diseases actually has direct contact with specialist palliative care practitioners. Using the German situation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative care services without a similar encouragement of primary palliative care will deliver a constrained service.DiscussionFor the vast majority of people with incurable, progressive diseases, good palliative care delivered by General Practitioners and community nurses, with access to specialist support when needed, is the optimal response. In Germany, specialist palliative care in the community was established in the 2007 health care reforms. However actual and potential delivery of palliative care by general practitioners and community based nurses has been sorely neglected. The time-consuming care of palliative patients and their families is currently far from accurately reflected in German, indeed most European primary care payment systems. However, it is not just a question of adequate financial compensation but also of the recognition of the fundamental value of this intense form of holistic family medicine.SummaryIt is imperative palliative care carried out by community nurses and general practitioners is better recognised by health professionals, health insurers, government and the scientific community as a central part of the delivery of health care for people in the last phase of life. Health systems should be arranged so that this critical role of general practice and primary care is intentionally fostered. Palliative care carried out by generalists needs an identity at an academic and practical level, developing in concert with specialist palliative care.

Promoting palliative care in the community: Production of the primary palliative care toolkit by the European Association of Palliative Care Taskforce in primary palliative care

Background: A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. Aim: To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. Design: (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. Results: Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. Conclusion: Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

Krankheitslast und Gesundheit im Alter

ZusammenfassungIn der zweiten Lebenshälfte nehmen die körperlichen und psychosozialen Beeinträchtigungen besonders durch chronische Erkrankungen und Multimorbidität erheblich zu. Auch wenn sich in den vergangenen Jahrzehnten die Gesundheit der Älteren deutlich verbessert hat, bestehen weiterhin große und häufig unterschätzte präventive Potenziale. Der Beitrag gibt auf der Basis von Surveys, Daten der Kassenärztlichen Vereinigung und Krankenkassendaten einen Überblick über die Krankheitslast, die Gesundheit und das Gesundheitsverhalten der Älteren in Deutschland. Ziel ist es, präventionsrelevante Bereiche sowie Ansätze zur Prävention aufzuzeigen. Erforderlich sind Strategien, die neben der körperlichen auch die psychische und soziale Dimension des Alterns berücksichtigen. Noch hemmen vielfach system-, betroffenen- und professionenbezogene Faktoren ihre Realisierung. Als primäre professionelle Ansprechpartner für die Zielgruppe spielen Ärzte und Pflegekräfte eine besonders wichtige Rolle. Allerdings sind Prävention und Gesundheitsförderung im Alter gesamtgesellschaftliche Aufgaben, die die adäquate Einbeziehung weiterer Berufsgruppen sowie eine deutliche Weichenstellung in der Politik erfordern.AbstractDue to chronic illness and multimorbidity, the physical and psychosocial impairments increase significantly in the second half of life. Even though the health condition of the elderly has improved in recent years, the potential for prevention in older people is still undervalued. On the basis of surveys, data from the Association of CHI Physicians and health insurance data, this article provides a review of health and health behaviour of the elderly in Germany. It aims to point out areas of particular relevance for prevention and preventive approaches. Strategies that consider mental and social aspects of aging beside the physical ones are necessary. Systematic, personal and professional factors still inhibit the realisation of these strategies. In this context, doctors and nurses are particularly important as primary professional contact persons for the target group. However, prevention and health promotion in that age group are social tasks, which need the appropriate involvement of further professionals and an explicit political agenda setting.

Job Satisfaction Among Primary Care Physicians: Results of a Survey

BACKGROUND A shortage of primary care physicians (PCPs) seems likely in Germany in the near future and already exists in some parts of the country. Many currently practicing PCPs will soon reach retirement age, and recruiting young physicians for family practice is difficult. The attractiveness of primary care for young physicians depends on the job satisfaction of currently practicing PCPs. We studied job satisfaction among PCPs in Lower Saxony, a large federal state in Germany. METHODS In 2009, we sent a standardized written questionnaire on overall job satisfaction and on particular aspects of medical practice to 3296 randomly chosen PCPs and internists in family practice in Lower Saxony (50% of the entire target population). RESULTS 1106 physicians (34%) responded; their mean age was 52, and 69% were men. 64% said they were satisfied or very satisfied with their job overall. There were particularly high rates of satisfaction with patient contact (91%) and working atmosphere (87% satisfied or very satisfied). In contrast, there were high rates of dissatisfaction with administrative tasks (75% dissatisfied or not at all satisfied). The results were more indifferent concerning payment and work life balance. Overall, younger PCPs and physicians just entering practice were more satisfied than their older colleagues who had been in practice longer. CONCLUSION PCPs are satisfied with their job overall. However, there is significant dissatisfaction with administrative tasks. Improvements in this area may contribute to making primary care more attractive to young physicians.

Morbidity and health in old age. A challenge for prevention and health care

ZusammenfassungIn der zweiten Lebenshälfte nehmen die körperlichen und psychosozialen Beeinträchtigungen besonders durch chronische Erkrankungen und Multimorbidität erheblich zu. Auch wenn sich in den vergangenen Jahrzehnten die Gesundheit der Älteren deutlich verbessert hat, bestehen weiterhin große und häufig unterschätzte präventive Potenziale. Der Beitrag gibt auf der Basis von Surveys, Daten der Kassenärztlichen Vereinigung und Krankenkassendaten einen Überblick über die Krankheitslast, die Gesundheit und das Gesundheitsverhalten der Älteren in Deutschland. Ziel ist es, präventionsrelevante Bereiche sowie Ansätze zur Prävention aufzuzeigen. Erforderlich sind Strategien, die neben der körperlichen auch die psychische und soziale Dimension des Alterns berücksichtigen. Noch hemmen vielfach system-, betroffenen- und professionenbezogene Faktoren ihre Realisierung. Als primäre professionelle Ansprechpartner für die Zielgruppe spielen Ärzte und Pflegekräfte eine besonders wichtige Rolle. Allerdings sind Prävention und Gesundheitsförderung im Alter gesamtgesellschaftliche Aufgaben, die die adäquate Einbeziehung weiterer Berufsgruppen sowie eine deutliche Weichenstellung in der Politik erfordern.AbstractDue to chronic illness and multimorbidity, the physical and psychosocial impairments increase significantly in the second half of life. Even though the health condition of the elderly has improved in recent years, the potential for prevention in older people is still undervalued. On the basis of surveys, data from the Association of CHI Physicians and health insurance data, this article provides a review of health and health behaviour of the elderly in Germany. It aims to point out areas of particular relevance for prevention and preventive approaches. Strategies that consider mental and social aspects of aging beside the physical ones are necessary. Systematic, personal and professional factors still inhibit the realisation of these strategies. In this context, doctors and nurses are particularly important as primary professional contact persons for the target group. However, prevention and health promotion in that age group are social tasks, which need the appropriate involvement of further professionals and an explicit political agenda setting.

Spezialisierte ambulante Palliativversorgung

BACKGROUND The aim was to explore the expectations of general practitioners (GPs) towards specialized outpatient palliative care (SAPV) focused on older patients in the last phase of life. METHODS A standardized postal survey was carried out with 1,962 GPs in Lower Saxony with an analysis of physician and practice-related factors. RESULTS The response rate was 46% (n=897) and SAPV was known to 68% of the participants (n=599) of whom 48% (n=288) assumed that SAPV will improve the healthcare for older patients in the last phase of life. The GPs favored advice by and collaborative patient care with SAPV teams. Younger and female GPs, and GPs who had been practicing for a shorter period or working in a group practice showed greater interest in collaboration than other colleagues. CONCLUSIONS The perception of patients in specialized palliative care with its current focus on cancer patients is different from the perception in general practice with its focus on geriatric and multimorbid patients. This may be a reason for the skepticism showed in this study whether SAPV will actually improve healthcare in the community. However, with respect to the concept and framework SAPV has the potential to fulfill GPs expectations and should be focused on counseling and collaborative services. The knowledge about physician and practice-related factors shaping GPs attitudes towards SAPV can be helpful to further implement SAPV into practice.

Health care in seniority: crucial questions and challenges from the perspective of health services research

This paper gives an updated outlook on geriatric health care in Germany and on research demands with particular respect to advanced-age patients with multimorbidity. The paper is written from the perspective of health services research and addresses selected topics such as primary care, palliative care, health policies and patient orientation. It is pointed out that the structure of services and processes of health care delivery is not compatible with the complex demands of the target group, and that the priorities of improvement strategies may differ among the various professional groups involved (e. g. primary chare physicians as generalists and palliative and geriatric experts as specialists). Furthermore, it is argued that the current incentives for establishing integrated health care may not be adequate to ensure that sustainable changes are made in the long term. Dieser Beitrag gibt eine aktuelle Übersicht über die Gesundheitsversorgung der älteren Bevölkerung in Deutschland und den Forschungsbedarf mit besonderem Fokus auf hochbetagte Patienten mit Multimorbidität. Ausgewählte Themen wie die Primärversorgung, Palliativversorgung, Gesundheitspolitik und Patientenorientierung werden aus der Perspektive der Versorgungsforschung analysiert. Dabei wird herausgestellt, dass die Struktur der Leistungsangebote und -prozesse nicht die komplexen Bedürfnisse der Zielgruppe erfüllt und dass die Prioritäten bei den Verbesserungsstrategien zwischen den unterschiedlichen beteiligten Professionen maßgeblich differieren können (z. B. Hausärzte als Generalisten sowie Palliativ- und Geriatrie-Experten als Spezialisten auf diesem Gebiet). Weiterhin wird argumentiert, dass die gegenwärtigen Anreizsysteme für integrierte Versorgung nicht geeignet sind, um nachhaltige Veränderungen auf lange Sicht zu bewirken.

Palliative care in public health: a formal and content-related analysis of European journals

Public health and health care science take on an important role in the further development of palliative care. This study examines to what degree palliative care is represented in the pertinent academic journals of public health and health care science and what the major subjects are. We analysed the European journals that were listed in the Journal Citation Reports in the categories health care science and services, public, environmental and occupational health, as well as health policy and services. The literature search was conducted in the journals identified for the years 1996 through 2005, using the terms palliative care*, palliative medicine*, terminal care* and hospice care*. The analyses were based on the quantity of publications in the journals, the publication years, the impact factors and the subjects focused on. There were 82 journals included. Altogether, 57,737 publications appeared during the analysis period; 166 papers were on palliative care (0.3% of all papers). The majority of palliative care articles (55%, n = 91) were concentrated in a very small circle of journals (4%, n = 3). The absolute quantity of palliative publications and their percentage among all publications have continuously increased from 0.1% in 1996/1997 to 0.4% in 2004/2005. The largest group of papers on the subject (42%, n = 70) appeared in journals with impact factors less than 1, whereas the largest group of all papers was found in journals with impact factors of 1–1.999 (51%, n = 15,732). Most papers focus on patient orientation and health professionals’ perspective and education; subjects such as health care utilization and barriers are less frequently covered. There is need for more research on palliative care relevant for public health and health care science in terms of reach and top-level impact. For example, the research questions should deal with health care utilization and potential social and cultural barriers. The interdisciplinary community of public health sets the stage for the required collaborative research activities.

Hoher Entwicklungsbedarf und viele offene Fragen bei der Versorgung von Palliativpatienten

ZusammenfassungDer Versorgung von Patienten mit unheilbaren, fortgeschrittenen Erkrankungen wird in Deutschland zunehmend Aufmerksamkeit gewidmet, u. a. vor dem Hintergrund der Sterbehilfe-Debatte und der Kritik an den gegenwärtigen Versorgungsstrukturen und Prozessabläufen. Die Palliativversorgung richtet sich gleichermaßen an Tumorpatienten und an Patienten mit anderen, nichtmalignen Erkrankungen; in Anbetracht der demographischen Entwicklung wird die Palliativversorgung immer wichtiger für eine steigende Zahl alter und hochbetagter Patienten mit besonders komplexen Bedürfnissen (z. B. infolge von Multimorbidität, Demenz und chronischem Schmerz). Deshalb besteht ein hoher Bedarf, die Palliativversorgung zu verbessern. Die Stellungnahmen zur gegenwärtigen Situation und die Empfehlungen zur Verbesserung basieren allerdings nur in geringem Umfang auf aussagekräftigen wissenschaftlichen Daten. Dieser Übersichtsartikel aus der Perspektive der Versorgungsforschung fokussiert auf die speziellen palliativen Versorgungsstrukturen (z. B. Palliativdienste und Palliativstationen) und die politischen Rahmenbedingungen. Dabei werden zentrale offene Fragen auf unterschiedlichen Ebenen thematisiert und der Bedarf für interdisziplinäre, anwendungsorientierte Forschung herausgestellt.AbstractThe health care for patients with incurable, advanced diseases is increasingly attended to in Germany. Among other things, this is enforced by the debate on euthanasia and by the criticism of the inadequate structure of services and processes of care. The palliative care approach refers to cancer as well as to non-cancer patients; due to demographic changes, it becomes more and more important for an increasing number of old and very old patients with particular complex needs (e. g., caused by multimorbidity, dementia and chronic pain). Therefore, the need for improving palliative care is immense. However, the statements on the current situation and the recommendations for improvement are based only slightly on valid scientific data. This article (written from the perspective of health services research) provides an overview on the topic with particular respect to the structure of specialized palliative care services (such as palliative care teams and palliative care units) and to the political framework. Open questions on diverse levels are picked out as a central theme, and the need for interdisciplinary, application-oriented research is pointed out.

Improving palliative care in Germany: summative evaluation from experts’ reports in Lower Saxony and Brandenburg

The German Health Care System is in substantial change. New structuring of services and processes of care are necessary, particularly to meet the complex requirements of the ever-increasing chronic illness and multimorbidity. The main deficits and strategies of improvement can be pointed out clearly by illustrating the situation of palliative care, which is more and more in the focus of experts and public. However, current statements are only slightly based on scientific data. Therefore, policymakers and self-governing bodies in the federal states of Lower Saxony and Brandenburg have commissioned reports from a multidisciplinary study group of health system research. This article describes the cumulative evaluation of both reports, referring to literature findings, specific empirical surveys and expert discussions. The main findings include a high level of emotion among the involved caregivers and social groups, resulting in difficulties in rational discussions; furthermore, a large multiplicity of viewpoints on the assessment of the current situation and on the appropriate needs for improvement was shown. The current deficits are significantly caused by inadequate structuring of care processes. Therefore, better integration of the large and diverse number of involved services and professions is necessary, including new specialised services. Health policy has created legal conditions, but up to now, fulfilment is low. Other improvement strategies should focus on working conditions of personnel in the basic services, such as family doctors and nurses, because the current conditions seem not to meet the patient or caregiver needs. Furthermore, a debate on principles regarding responsibilities of the health care system is needed: What should be covered by social health insurances, and what should be part of other areas of public welfare?