“We need to stop thinking in sectors”
Jun. 2023Strengthening the interfaces between healthcare and social factors
There is much to be said for integrating social workers into the provision of basic healthcare. General practitioner Michael Deppeler and René Rüegg, a social work expert, explain in an interview that this facilitates better management of complex cases.
Mr Rüegg, in your research project you evaluated the impact of social workers in doctors’ practices. What emerged from this evaluation?
René Rüegg: This type of cooperation model is fairly common in other countries, in Belgium for example, but still very rare in Switzerland. We studied and observed four pilot practices. The most important finding in my view was that all the doctors concerned said that the social workers in their practice enabled them to focus better on their medical work. They were very satisfied with the cooperation and felt that the counselling provided by the social workers made their jobs much easier. The patients also reported that their mental state improved in the course of social counselling, and that they didn’t need to see their doctor so often.
Mr Deppeler, your practice is one of the pilot models.
Michael Deppeler: Yes, although we’ve actually been working this way for over 20 years. One of the reasons for this is that my early professional experience in the 1990s was shaped by the medical approach taken by the Lory Hospital in Bern, where we lived and practised biopsychosocial medicine under Professor Rolf Adler. There we were also used to working in interprofessional teams. I then followed this approach when my colleagues and I set up our general practice. We worked with psychologists from the very start, mainly in sensitive areas such as determining an individual’s suicide risk, or when crisis intervention was necessary.
We have also been working with a social worker for nearly ten years. He advises our patients if they have acute financial problems or need to find a care home. And he knows how to apply for a helplessness allowance or a personal assistance allowance.
That sounds like an all-round success. So why are there so few medical practices with integrated social work in Switzerland? Because it costs more?
Michael Deppeler: I need more time in my practice to counsel patients with their complex life stories and medical histories. Because of this, every three years I have to discuss with santésuisse, the organisation that represents health insurers in Switzerland, whether or not what I do is economically efficient and effective. These are nerve-wracking negotiations during which I have to explain why I need 16 or 17 minutes for my patients instead of only 13. But if, within my network, I can avoid the need for somebody to go into hospital, I save thousands of francs.
René Rüegg: It’s difficult for a single practice to prove that costs were reduced further down the line. To do this, health insurance data from groups of individuals or risk groups would have to be evaluated and compared. Unfortunately it is still very difficult to get hold of such data. However, last year the federal government decided to promote coordinated care networks as part of its cost-containment measures. This means that the federal government acknowledges that these networks are economically efficient and offer added value. So that aspect is not really being contested. Yet it’s still difficult for a doctor to base their practice on an integrated care model because it takes a lot of effort to establish a network, particularly at the start.
Michael Deppeler: But I think it’s very important to integrate healthcare and social welfare with each other. At the moment we are putting a lot of effort into shuffling costs from one source of funding to the next. For example, take the many invalidity reports that I write for people who lose their jobs because of a chronic health condition. Often, their applications are rejected after months in the review process and they end up on welfare benefits. We need to stop thinking in sectors and rethink the whole funding issue.
To what extent do social problems – such as loneliness or poverty – have an impact on health?
René Rüegg: The theory teaches us that people generally become ill in response to a whole range of psychosocial determinants. And equally that an illness can have many social consequences. Somebody who is diagnosed with cancer, for example, is at risk of losing their job. This means that they suffer not only from loss of income but also from the lack of contact with former colleagues.
Michael Deppeler: This is why we take a salutogenic approach. The first thing we want to know is: how does the person sitting opposite me perceive the problem? And the second thing is: what resources does this person already have and what do I need to provide them with temporarily, in the form of a professional support network? The third aspect is then the person’s sense of purpose. In my practice I encounter so many people who have given up. It is known that a feeling of helplessness and powerlessness places a physiological strain on the cardiovascular system. Studies show that these feelings cause as many strokes and heart attacks as smoking. But the cardiologist does not take this psychosocial stress into account at all. They are always focused solely on cholesterol, blood glucose and blood pressure.
«Ich habe gelernt, dass das KVG relativ viele Freiheiten lässt, man muss sie einfach nutzen. Denn grundsätzlich gibt es nur sehr wenige ärztliche Tätigkeiten, die sich nicht delegieren lassen.»
Administering an injection or a tablet is more in keeping with what society expects doctors to be doing than establishing a support network.
René Rüegg: Yes, in this country doctors are responsible for treating diseases. Textbook medicine has little time for maintaining or promoting health.
Michael Deppeler: Nor are these things items of service that can be reimbursed under the Health Insurance Act (HIA). But I have learned that the HIA does allow for a relatively large degree of freedom: you just have to make use of it. There are basically very few activities performed by a doctor that cannot be delegated, such as certifying death or carrying out post-mortem examinations. Everything else can be outsourced. In the same way that I delegate blood sampling or taking X-rays to my medical practice assistants, I can organise expert social counselling for my patients and invoice this counselling as a medically prescribed service.
«Ich denke, dass das Gesundheitswesen der Zukunft konsequent bevölkerungsorientiert sein muss, denn so entstehen auch attraktive Arbeitsplätze, wo man nicht einfach nur Dossiers abarbeitet.»
Zum Schluss: Was, denken Sie, erwartet uns in Zukunft?
René Rüegg: Meine Vision lehnt sich eng an das Modell der «maisons médicales» in Belgien an. Das sind über das ganze Land verteilte Gesundheitszentren, wo Sozialarbeitende nahe bei den Menschen sind – und als gleichberechtigte Partner zum medizinischen Team dazugehören. Ich denke, dass das Gesundheitswesen der Zukunft konsequent bevölkerungsorientiert sein muss, denn so entstehen auch attraktive Arbeitsplätze, wo man nicht einfach nur Dossiers abarbeitet, sondern im direkten Austausch mit der Bevölkerung steht – und gemeinsam aufbaut, was gewünscht und geschätzt wird.
Michael Deppeler: In der Grundversorgung ist die Zeit der Einzelkämpfer meiner Meinung nach vorbei. Beratende und koordinierende Tätigkeiten werden immer wichtiger. Wir sollten deshalb schon jetzt andere Schwerpunkte in der Aus- und Weiterbildung setzen. Mir schwebt als Vision ein Bachelor an der Fachhochschule für die Grundversorgung vor, wo Medizinerinnen, Sozialarbeiter und Pflegefachleute während dreier Jahre eine gemeinsame Sprache entwickeln und dabei lernen, wie man gut zusammenarbeitet. Denn die Zukunft gehört den interprofessionellen Teams.
