New Models of Care.
Après avoir terminé ses études de médecine à Lausanne en 1998, le professeur Nicolas Senn réalise sa formation post-graduée en médecine interne générale et commence à travailler à la Policlinique médicale universitaire de Lausanne (PMU) en 2002. Depuis janvier 2019, à la création d’Unisanté, il est nommé médecin-chef et prend la direction du Département médecine de famille.
Professor Nicolas Senn, qualified in medicine in Lausanne in 1998 and trained both in family medicine and epidemiology. From 2005 to 2009, he worked in Papua New Guinea for the University of Melbourne (Australia) on a research project on the prevention of malaria in young children.
He was appointed director of the University Institute of Family Medicine in 2016 and, following the creation of Unisanté in January 2019, he was appointed Head of the Family Medicine Department. In this function, he his responsible for the teaching curriculum in family medicine at the faculty of biology and medicine of the University of Lausanne (Switzerland). His research interests are in health services and on the links between health and environment in clinical practice. He is co-founder in 2020 of the French-speaking Primary Care Group (www.gfisp.org).
“That’s something that really interests me, not just general practice, but the entire Primary Care setting. And, that has been my work for the last 10 to 12 years, working on primary care, new models of care, how we can improve the system, and how we can improve delivery of care in the community. “
An image from the 5ÈME SYMPOSIUM DU GFSP “Imaginer les soins primaires du future”
Les bénéfices du contact avec la nature sur la santé- watch the video on Unisanté
A special issue of the Revue Médicale Suisse was dedicated to family medicine in May 2023
Although based in Switzerland, you’ve had a very interesting career path including time spent in Papua New Guinea…
Nicolas Senn: I don’t like straight lines. So, that’s probably why I took the long way to come where I am now. Originally, I trained as a GP, training that I followed in Switzerland, but I was always interested in tropical medicine and in research and I was looking for an appointment somewhere in the world. And when it came up, it was in Papua New Guinea. I was working for the University of Melbourne in Australia and I was based there for three years. And that’s where I learned tropical medicine, but also epidemiology and research, and community medicine and, in fact, it was really complementary to what I had done as a GP. That’s why, when I came back to Switzerland, it was the perfect combination. I had training as a GP together with training as an epidemiologist, so I switched back again to general practice but with a broader perspective.
That’s something that really interests me, not just general practice, but the entire Primary Care setting. And, that has been my work for the last 10 to 12 years, working on primary care, new models of care, how we can improve the system, and how we can improve delivery of care in the community. Officially I’m the Head of the Department of Family Medicine at Unisanté and it gives me a great opportunity to explore many different fields, not only family medicine but family medicine as a part of the bigger picture of primary care.
DMacA: As we look at the future of primary care, and in many countries it’s quite uncertain, tell me about your thoughts on the different models of primary care.
NS: If I look at that from Switzerland I must admit that I’m not hopeful in the sense that the models of primary care in Switzerland have not evolved a lot in the last, let’s say, 20 years. It’s still very focused on the work of physicians, with very little inter-professionality, and little change. We can’t really blame the general practitioners for that. I think that it’s the way the whole system is organized in that you pay the physicians or fund systems that only allow physicians to do something. The model in Switzerland is very conservative with only GPs and, what we call, medical assistants, with a polyvalent role including administration and some basic technical activities. But, there are no nurses, no psychologists, no social workers, like we see in other countries and what really interests me is how we can develop this new model of care in Switzerland. For that we need to look at what is happening in these other countries. I don’t think there is an ideal model, you have to develop the model that is suited to the local context, that serves the local population. There is a large margin for improvement, I think, in Switzerland.
“I don’t think there is an ideal model, you have to develop the model that is suited to the local context, that serves the local population.”
In Switzerland GPs are paid according to the time spent with patients so, the more time you spend with the patients, the more money you earn. And, that introduces bias. It has some advantages, because it favours being available for your patients, but on the other hand, maybe doctors might do too much or spend too much time with patients. So I think that’s the element of the system that we need to modify to be comparable with other countries.
And, that’s the interesting aspect of doing research on new models of care, that you can do comparisons with France, with the Netherlands, with the UK, with Canada, or other countries. It’s very interesting to see that, when you talk to GPs in Switzerland, they are really astonished that it can work in a different way- we have always done a medicine like this, so why should it change? Yes, but we have a problem of cost. Healthcare is very costly in Switzerland and still patients have problems getting a physician. That means that something has to change, and having new model of care is one way to think about that.
We can have lot of theories about the best models of care but, what’s interesting is how you put that into practice. That’s exactly what we’ve been working on for about five or six years in the region where I work. So, in partnership with the public health authorities, we are developing new models of care and we’re trying to put them into practice with GPs, nurses and others. Other countries say: What? You’re just starting now with nurses. Yes, we have just started but the constraints of the system are important- we just don’t know how to pay them. So we have to beg with politicians to give us money to pay the nurses because there is no other way.
Some further thoughts about the developments in care: We need to take the physicians with us, which is probably one of the major problems- how to explain that the new model would be better than the older one. Because, if we say that it’s going to be like the UK, they say- I’ve heard it’s terrible in UK, I don’t want to work for a salary for the government. No, we’re not talking about that, we’re taking just the best parts. The other thing which I really like is to have a true collaboration between health professions on the ground, academics, and health authorities, and when you start to have all these people together you can start to do something. If you exclude one of these three key players, it doesn’t work.
…a true collaboration between health professions on the ground, academics, and health authorities, and when you start to have all these people together you can start to do something. If you exclude one of these three key players, it doesn’t work.
DMacA: It’s interesting looking at these new models of care. If the government was to give you unlimited resources what would your team look like?
NS: I think the first thing is the size of the team. It should not be too big. I believe that we need a team with different skills but it should not be too big. And the different skills that we need are GPs, nurses, ergo therapy – we often forget about what they can do, it’s very polyvalent- psychologists, social workers, but I think its not sufficient to think of these models in terms of professions, we need also to think in terms of roles and activities. Because, sometimes you have two people with different backgrounds who can do the same job and sometimes not, it depends on the context. I would include not only different professions but redefine roles with the aim to be available for the population.
The other thing which is very important. if I had unlimited resources, is to bring all these people together and to redefine the roles in the context of work. That’s what I would do but they certainly won’t give me unlimited resources- that’s another question!
Maybe another element I would add is to have a vision of population health at local level. We always see population health as public health -something at national level- but I think we really need to develop the sense of population health in a very local context- who is the population am I serving and do I know this population. Sometimes it’s just a few thousand people. The primary care facility should know which population they are serving. We know they have been experiments, such as in the UK with community oriented primary care, and similar models. I think it’s an interesting idea because you bring people with you and don’t just see a series of patients but try to give good care to a whole population and start to be proactive. That’s the other element – not only the roles and the professions, but the way it’s organized, and a population vision at the local level.
“So I think we need to act at different levels – to explain better what primary care is, and the specificities of research in primary care, but we also need to capture the young physicians and to promote research with them and to develop career plans with them.”
DMacA: As part of this new vision for Primary Care, you’ve been bringing in people internationally, and conferences are a terrific way of doing that. There are two aspects that interested me. First, that you’ve brought people from around the world, but secondly that it’s a Francophone population. Are there particular issues within the Francophone group that are different to the anglophone group?
NS: We haven’t done that because they are necessarily different, because I think in Quebec, for example, they’re probably quite close to Anglophone countries but the first reason we have created a Francophone subgroup is because it’s allows us to bring people around the table who would not come if you speak English. If we are among academics who are used to speaking English, it’s not a problem but you are only among academics. If you want to talk to people on the ground, and to bring them to discuss, you need to speak French. I think that was the first reason. Maybe at a broader scale there might be some differences in the way the healthcare system is organized between Francophone countries and the Anglophone countries but, for this specific association that we created, the first aim was not to think that there are major differences but the purpose is to bring all these people together.
DMacA: That’s fascinating. What you’re saying is that you can have academic presentations in English but if you want to have a conversation, you really must have it in people’s first language.
NS: Absolutely. They don’t come to academic conferences. For example, if you have a nurse from a primary care institution they won’t come. There is something very intimidating about academic conferences. It’s very formal usually. There are ‘codes’ and people don’t know these ‘codes’ and they won’t talk. And, they’re probably not aware of the event or interested in coming. I also think that at governmental level they won’t come if it’s in English- most of them.
DMacA: Let’s talk now about something slightly different. And that is, the difficulties of creating a research culture- it’s difficult when you have small units of general practice.
NS: Yes, I think this is a problem that we face everywhere, even in countries where they have bigger practices. And I think it also has to do with the specialty of primary care. It’s not seen as an academic discipline. There is still a big gap with the major disciplines, such as cardiology. People know what they are. To define primary care, and even more, to have an academic perspective on primary care is more difficult. I think that’s one of the problems we face. We are often asked the question- why are you doing research on primary care, what can we research in primary care? As soon as you say, for example, I’m going to do a research project on elderly people, the response is, but we have geriatrics so why are you doing research on that. And you have to explain that it’s because it’s a different approach, the prevalence of disease is different, so we need different research. I think that’s a difficulty- that we still have to explain primary care to a broader audience and to define research within primary care. We now have good journals and that’s probably helps.
Maybe the final point is about the health professionals themselves. As soon as they start clinical practice they are usually lost from research. They can’t afford to be part-time in practice and spend the rest of the time working on research because they won’t have money, or it’s very rare to find a position where you can do both. Very often you’re overwhelmed in clinical practice and research comes afterwards, at night or during the weekends and, after five years, they stop.
I think this is a worldwide problem. We try to promote research early and it’s also happening in other countries. Very soon after they leave medical school we start to bring them to do medical doctorates MDs or sometimes PhDs, trying to keep them in the system. The nightmare is how you combine your training as a physician and still keep involvement in research but we try to do that. We try to create professional development plans with younger physicians who want to have both careers, but it’s very difficult.
So I think we need to act at different levels – to explain better what primary care is, and the specificities of research in primary care, but we also need to capture the young physicians and to promote research with them and to develop career plans with them.
DMacA: It’s been a pleasure to talk to you. Thank you very much indeed for sharing all these issues. What really struck me was the importance of “conversation”, talking in one’s native language. Thank you so much- until the next time.
