María Pilar Astier: “Only a health system focused on primary care can guarantee people enjoy an autonomous, supportive and joyful life”

Family doctor María Pilar Astier, member of the World Organization of Family Doctors (WONCA) and member of the External Scientific Committee of IDIAPJGol, addresses the challenges and needs of primary care, the validity of Jordi Gol i Gurina's thinking, the importance of research at the first level of care and the role of WONCA in the development of the specialty of family medicine and its collaboration with the WHO in the development of primary care in the world.

 

Professor and researcher of the Chair of Professionalism and Medical Ethics of the Department of Medicine, Psychiatry and Dermatology of the Faculty of Medicine of the University of Zaragoza, member of the World Organization of Family Doctors (WONCA) –the entity that represents family and community medicine in the world–, coordinator of the patient safety working group of the Spanish Society of Family and Community Medicine (semFYC) and the Spanish Society of Healthcare Quality (SECA), and member of the External Scientific Committee of the IDIAPJGol, María Pilar Astier is the Spanish family doctor who holds one of the highest positions internationally. She is an expert in patient safety, professional competencies and clinical reasoning in the field of primary care.

During the last IDIAP Conference, which was held on May 16, 2024, at the Tecnocampus in Mataró (Barcelona), she gave the inaugural conference, together with the former director of the Institute, Bonaventura Bolívar. Her presentation focused on the needs and challenges of primary care, from the perspective of Jordi Gol i Gurina, whose centenary of his death is commemorated this year.

A few days after the Conference, Astier attended, representing WONCA, the annual meeting of the World Health Assembly, the executive body of the World Health Organization (WHO). During this meeting, he had the opportunity to raise some of the challenges he presented at the IDIAP Conference, to strengthen the relationship between the WONCA and the WHO and to launch joint projects aimed especially at improving the training of family doctors and the development of initiatives to reinforce patient safety.

Responses to new needs

Dr. Astier highlights that one of the greatest current challenges of primary care is being able to respond to the new needs of society: the increase in noncommunicable diseases, such as diabetes, cardiovascular diseases, chronic respiratory conditions or cancer –linked to the aging of the population and people’s lifestyle habits–, as well as mental illnesses, especially among the young population. Astier considers that the Spanish primary care model is one of the best prepared to face these challenges, since, “as the WHO highlights, it is the one that comes closest to the ideal of care provision, which guarantees comprehensiveness, closeness, coordination, and longitudinality.”

Even so, the doctor recognizes that our primary care has room for improvement: the integration of social resources with health resources, the development of information systems, the incorporation of new services and new professional profiles and competencies, and the reinforcement of teamwork.

To achieve this, “we must invest, undoubtedly,” and, in the end, he emphasizes, it is a political issue, which implies establishing priorities: “it is key to have a state of well-being that allows all people to enjoy an autonomous, supportive and joyful life, using the words of Jordi Gol”, and this involves “guaranteeing a health system oriented towards primary care that does not cause economic harm to people.” 

 

Astier during her intervention at the World Health Assembly

 

A thought more relevant than ever

Astier has had the opportunity to learn in depth about the figure of Jordi Gol i Gurina during the preparation of the presentation he made at the IDIAP 2024 Conference. She highlights that “he was a person ahead of his time, whose thinking is more current than ever.” Although we now have new challenges, “the comprehensive conception that Jordi Gol had, his vision of the person as a whole, is today essential to combat the fragmentation of patient care.”

Gol’s definition of the concept of health, as an autonomous, supportive and joyful way of living, is, for the family doctor, very accurate. “These three words are very important, because autonomy is the most important thing for the individual, since it makes him or her a person; the fact that it is supportive makes it communal, since the autonomy of the person is relational, and joyful, because if you don’t enjoy, you directly get sick.”

Astier also highlights the ethical dimension of Jordi Gol’s thinking, who during the Franco era defended the right to abortion and euthanasia, and the implementation of a palliative care model. “Thirty years have passed since Jordi Gol died and we are still implementing the right to die with dignity in our portfolio of services, although it must be said that we are one of the few countries in the world that recognizes it,” she explains.

Longitudinality saves lives

The WONCA member recognizes the essential role that Jordi Gol has had in the creation of our primary care model, which is quite unique in the world. “In most European countries and in many other developed countries, family doctors work in a solo practice model, that is, in individual consultations, with the support of nurses and some paramedics whom they hire, and they are not assigned a reference population nor do they have a structure that gives them support or a work team,” reflects Astier, who explains that some countries such as France, the Netherlands and Belgium are trying to change the primary care model, because they have realized that the system they currently have “is detrimental to longitudinality.”

In this sense, the professor from the University of Zaragoza talks about a study carried out in Norway that concludes that longitudinality allows for considerable improvement in health outcomes. The authors of this work have shown that “if you have been with the same family doctor for more than fifteen years, the risk of mortality is reduced by up to 30 % and hospital admissions and urgent care are reduced. This evidence is key to investing in primary care; no drug guarantees such strong results. Still, in free market healthcare system environments it is very difficult to start making major changes. However, we must continue to promote the production of scientific evidence in this regard to enhance the reorientation of health systems to primary care.”

Change of look

Astier considers research at the first level of care essential “to make known and answer questions that arise from primary care, which have an impact on people’s health.” However, the doctor recognizes that “in our country, the research we are doing in primary care needs a change of outlook.” He warns that, in many cases, professionals who work at the first level of care do research in their free time and “research projects that are based on professionals’ vacation time or leisure time cannot be sustained, because in the end “they get exhausted.”

In this sense, Astier applauds the initiatives that are being carried out at the IDIAPJGol, in coordination with the Catalan Institute of Health, such as the intensification scholarships, which allow professionals to be partially freed so that they can dedicate themselves to research. “The main limitation that professionals have is not being able to free themselves from the healthcare activity, but at the same time they need to ground themselves, not lose contact with the patients, and in this sense the IDIAP scholarships make it possible to cover part of the time of the professionals so that they can dedicate to research, without abandoning clinical activity.”

Dr. Astier also highlights the Institute’s role in promoting research in primary care, through SIDIAP, the information system with real-life data, and encourages IDIAPJGol “to continue promoting these two key tasks: giving time to primary care professionals to research, promoting scholarships, and to make clinical practice data accessible in order to create scientific evidence of the positive impact of primary care on the health of the population.”