Provision of primary pre-medical health care. Problems of providing primary health care to the adult population in the conditions of a territorial polyclinic of a large industrial city

Order of the Ministry of Health and Social Development of the Russian Federation of May 15, 2012 N 543n
"On approval of the Regulations on the organization of the provision of primary health care to the adult population"

With changes and additions from:

In accordance with Article 32 of the Federal Law of November 21, 2011 N 323-FZ "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (Sobraniye Zakonodatelstva Rossiyskoy Federatsii, 2011, N 48, Art. 6724) I order:

1. To approve the attached Regulations on the organization of the provision of primary health care to the adult population.

2. Recognize as invalid:

order of the Ministry of Health and Social Development of the Russian Federation of July 29, 2005 N 487 "On approval of the Procedure for organizing the provision of primary health care" (registered by the Ministry of Justice of the Russian Federation on August 30, 2005, registration N 6954);

order of the Ministry of Health and Social Development of the Russian Federation of August 4, 2006 N 584 "On the procedure for organizing medical care for the population on the basis of the district principle" (registered by the Ministry of Justice of the Russian Federation on September 4, 2006, registration N 8200).

Registration N 24726

The Regulations on the organization of the provision of primary medical care have been approved. We are talking about helping the adult population in Russia.

This type of assistance is the basis of the system of medical care. It includes activities for the prevention, diagnosis, treatment of diseases and conditions, rehabilitation, monitoring the course of pregnancy, the formation of a healthy lifestyle and hygiene education.

Assistance is provided free of charge within the framework of the Program of State Guarantees for the Free Provision of Medical Assistance to Russian Citizens at the expense of Compulsory Medical Insurance Funds and funds from the relevant budgets, as well as in other cases established by law.

Assistance is provided in planned and emergency forms, on an outpatient basis and in a day hospital. It includes pre-medical, medical and specialized health care.

To improve the efficiency of care in case of sudden acute diseases, conditions, exacerbation of chronic diseases that are not dangerous to the patient's life and do not require emergency intervention, an emergency department (office) can be organized in medical organizations.

Orders on approval of the procedure for organizing the provision of primary medical care and on the procedure for organizing medical care for the population on the basis of the district principle were declared invalid.

Order of the Ministry of Health and Social Development of the Russian Federation of May 15, 2012 N 543n "On approval of the Regulations on the organization of the provision of primary health care to the adult population"

Registration N 24726

Present Order

Coursework in the academic discipline "Medical Law"

Completed by: 4th year student of group 404 Selyavko Yuri Aleksandrovich

Moscow State University named after M.V. Lomonosov

Moscow, 2007

Introduction:

Human life is very fragile. In the process of life, each person is in danger of the occurrence of circumstances that can most directly affect the state of his health and lead to the loss of means of subsistence. These circumstances include: illness, injury, disability, etc. They directly affect the social stability of society, so the state assumes a certain share of responsibility for their occurrence and creates a healthcare system aimed at preserving and strengthening the physical and mental health of each person, maintaining his long active life, providing him with medical care in case of loss of health.

A special place in the system of protecting the health of citizens is occupied by the provision of primary health care, which is the most common and one of the main types of medical care for the population.

Primary health care, as one of the types of medical care, is a direct source of legal relations, which are regulated by the relevant legal acts.

The adoption of many federal laws, mainly laws that delineate and establish the powers of state authorities and local self-government, has led to the need to rethink the structure of medical organizations, their belonging to a certain level of government, sources and mechanisms of financing and, as a result, to change the order of their functioning, including in the provision of primary health care to citizens. This led to the need to change the legal regulation in the field of primary health care to ensure the correct functioning of this component of the health care system. Thus, the improvement of laws governing the provision of primary health care to citizens has become one of the tasks of modern medical law.

Part 1. Primary health care (PHC). Legal basis for the provision of PHC.

1.1. The concept of PHC. The place of PHC in the health care system.

Health protection of citizens is a set of political, economic, legal, social, cultural, scientific, medical, sanitary-hygienic and anti-epidemic measures aimed at preserving and strengthening the physical and mental health of each person, maintaining his long-term active life, providing him with medical care in case of loss of health (FZ N 5487-1).

A special place in the system of protecting the health of citizens is occupied by the provision of primary health care (hereinafter referred to as PHC), which is one of the main types of medical care for the population.

According to the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens, PHC is the main, accessible and free type of medical care for every citizen and includes: treatment of the most common diseases, as well as injuries, poisoning and other emergency conditions; medical prevention of major diseases; sanitary and hygienic education; carrying out other activities related to the provision of health care to citizens at the place of residence (FZ N 5487-1).

However, the question of the place of PHC in the structure of medical care has long remained unresolved. According to the definition given at the International Conference on Primary Health Care (Alma-Ata, 1978), PHC is the first level of contact of the population with the national health system; it is as close as possible to the place of residence and work of people and represents the first stage of the continuous process of protecting their health (functional approach). According to another concept, PHC is a type of medical care that is clearly linked to an outpatient clinic (structural approach).

Modern legislation does not limit the mechanism for implementing the norm on organizing the provision of PHC by the type of institution. Thus, the legislator has resolved the long-term dispute of specialists about what type of medical care is primary health care. Medical care clearly linked to the outpatient clinic or medical care provided by outpatient clinics and hospitals in the area of ​​the patient's first contact with the health system, as interpreted by the Alma-Ata Conference (1978).

From the interpretation of this concept by the Alma-Ata Conference, it follows that health care, as a technology of medical care, is provided to the patient when he first contacts a medical organization. At the same time, there are no strict indications of the organizational form (polyclinic, hospital, etc.) and the form of ownership (state, municipal, private) of this organization.

Thus, health care is the main form of organization of medical care in outpatient, inpatient and outpatient and hospital facilities of the municipal district and urban district, and is provided mainly at the place of residence.

1.2. PHC in the system of medical law.

The set of normative acts that define organizational, structural, general legal relations in the provision of medical and preventive care to people, the implementation of sanitary and anti-epidemiological measures and other actions related to health protection, forms an independent branch of law - medical law.

The subject of medical law is legal relations in the implementation of medical and preventive, sanitary and hygienic activities and legal acts that determine the legal status of participants in these relations. PHC, as one of the types of medical care, is a direct source of legal relations, which are regulated by the relevant legal acts.

There are three subjects of medical law: a medical organization (institution), a medical worker and a patient. At the same time, the medical organization, providing the process of providing medical care, provides for this purpose premises, equipment, apparatus, instruments, consumables, medicines - everything without which it is impossible to provide qualified medical care and which therefore is an integral part of the essence of this service. Thus, the medical organization is the subject of the provision of medical care. The subject of assistance is a medical worker of the highest or middle level with professional knowledge. At the same time, it should be noted that the functions of a medical organization and the doctor himself can be combined by one person, for example, a private practitioner. The patient is the subject of receiving medical care.

Thus, legal relations in PHC are relations arising on the basis of legal norms of the connection of three subjects of medical law, which are characterized by the presence of certain legal rights and obligations in the field of medical activity.

One of the basic concepts in the field of law is the concept of the principles of legal regulation. The principles of medical law are guiding ideas that determine the essence and direction of development of the entire complex of legal norms in the field of medical care as a whole. Legal principles are either directly enshrined in legal norms, or directly follow from their content. The principles of organization of PHC are intra-industry principles of medical law.

The fundamental principles of the organization of PHC as the main type of medical care for the population are set out in the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens (FZ N 5487-1), these are:

Availability.

Free.

Residential service.

Mandatory provision of a complex of medical measures:

treatment of the most common diseases, as well as injuries, poisonings and other urgent conditions;

medical prevention of major diseases;

sanitary and hygienic education;

carrying out other activities related to the provision of health care to citizens.

The implementation of PHC in compliance with these principles is implemented due to the existence of legal methods of regulation in the system of medical law. The regulation of social relations included in the subject of medical law is carried out with the help of techniques and methods that exist in other branches of law: administrative-legal and civil-law methods.

Considering that the administrative-legal method is characterized by relations of power - subordination due to the presence of an authorized body of the state as a party to legal relations, and the civil-law method is characterized by the equality of the parties to legal relations, it is necessary to note the complex use in medical law of very different methods of legal regulation. As an example of the use of the administrative-legal method in the legal regulation of public relations in the field of healthcare and the provision of PHC in particular, one can give an example of organization and management in the system of state and municipal healthcare, when the heads of higher healthcare authorities interact with representatives of medical institutions subordinate to them. At the same time, the legal relations between a patient and a doctor in the provision of medical care in the system of private medicine are regulated by the civil law method, a manifestation of which is the equality of the subjects of legal relations and the possibility of self-determination of their behavior.

• HOSPITAL AT HOME
• POPULATION ATTACHMENT
• POLYCLINIC
• OUTPATIENT
• PRIMARY HEALTH CARE
• DAY HOSPITAL

The article deals with the issues of providing primary health care to the adult population in the conditions of a territorial polyclinic of a large industrial city.

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Introduction

Primary health care is the basis of the system of providing medical care to the population of the Russian Federation and includes measures for the prevention, diagnosis, treatment of diseases and conditions, medical rehabilitation, monitoring the course of pregnancy, the formation of a healthy lifestyle, including reducing the level of risk factors for diseases , and health education. According to the order of the Ministry of Health of the Russian Federation of May 15, 2012 No. 543n “On approval of the Regulations on the organization of primary health care for the adult population”, primary health care can be provided in medical and other organizations of the state, municipal and private healthcare systems, including individual entrepreneurs who have a license for medical activities, obtained in the manner prescribed by the legislation of the Russian Federation. The largest volume of this type of medical care in Russia is provided by budgetary healthcare institutions.

Budgetary health care institutions provide primary health care to the population both within the framework of the Program of State Guarantees of Free Medical Care for Russian Citizens at the expense of compulsory medical insurance, and as paid medical care at the expense of citizens and organizations. When providing primary health care to the adult population under the Program of State Guarantees of Free Medical Care for Russian Citizens, budgetary healthcare institutions face a number of problems. In particular, the issues of attaching patients to medical organizations, the awareness of patients about their rights and obligations, the availability and quality of implementation of standards of medical care are problematic.

Purpose of the study

Analysis of the activities of the territorial polyclinic of a large industrial city in organizing the provision of primary health care to the adult population within the framework of the Program of State Guarantees for the Free Provision of Medical Care to Russian Citizens.

Material and methods

To study the activities of the territorial polyclinic in organizing the provision of primary health care to the adult population, the reports of the medical organization and the legal framework for the provision of medical care to the population by outpatient medical organizations were analyzed.

results

In the Russian Federation, primary health care for the adult population within the framework of the Program of State Guarantees of Free Medical Care for Citizens is organized according to the territorial-district principle. The territorial-district principle of organizing the provision of primary health care is to form groups of the serviced contingent on the basis of residence (stay) in a certain territory or on the basis of work (training) in certain organizations and (or) their divisions. The distribution of the population attached to the medical organization by areas is carried out by the heads of medical organizations, depending on the specific conditions for the provision of primary health care to the population in order to maximize its availability. In order to ensure the right of citizens to choose a doctor and a medical organization, it is allowed to attach citizens living or working outside the service area of ​​a medical organization to district general practitioners, general practitioners; for medical supervision and treatment, taking into account the recommended number of attached citizens. However, today the budgetary healthcare institutions have problems due to the high migration of the population both from the village to the city and from the city to the economically prosperous regions of the Russian Federation, when the same resident changes his place of residence (stay, registration) 1-3 times a year .

In the conditions of a territorial polyclinic, primary health care is provided in the form of:

1. outpatient visits
2. day hospital
3. hospital at home

Outpatient visits are made up of (Fig. 1):

1. independent arrival of the patient to the office (s) of the medical organization providing primary health care, or its divisions.
2. the arrival of a doctor, nurse or mobile medical team to the patient at home.

To receive primary health care in a planned form, citizens exercise their right to choose a medical organization by attaching to a medical organization providing primary health care.

According to modern legislation, the choice of a medical organization is carried out no more than once a year (with the exception of cases of a change in the place of residence or place of stay of a citizen). A medical organization providing primary health care on a territorial-district basis is not entitled to refuse to attach a citizen to the place of actual residence (study, work) of a citizen. So she faces with the first problem : to date, there is no official way according to which a medical organization can confirm the actual residence of a citizen at the address indicated by him, therefore, the patient is attached “from his words”. A medical organization is not entitled to demand from a citizen a document confirming his actual residence (study, work) in the territory served by the clinic.

In the selected medical organization, a citizen selects a district general practitioner by submitting an application personally addressed to the head of the medical organization, taking into account the consent of the doctor. Here the medical organization faces with the second problem : Citizens are not aware that, according to the law "On the Protection of the Health of Citizens", that in addition to the consent of the administration of the medical organization, the consent of the doctor himself is required for attaching a doctor to a specific medical organization. Informing the population about this should come from the lips of insurance companies, however, this does not happen, which in some cases leads to conflict situations. Therefore, in most medical organizations, attachment is carried out regardless of the opinion of the district doctor.

According to modern legislation in the Russian Federation, medical care for a patient is carried out by attaching him to a specific (chosen by the patient) medical organization. Here the medical organization faces with the third problem : patients who live in the service area, but are not attached to this medical organization, apply to a medical organization. At a certain point in time, the patient has a “need” for medical care and he turns to the medical organization that is geographically closer to him, without thinking about the “attachment” that had to be done in advance. The attachment process is lengthy and requires coordination with the territorial compulsory health insurance fund. In some cases, attachment is not necessary, since the patient arrived in the service area for a relatively short period of time (from several weeks to several months), but it is at the moment of stay in the territory of the polyclinic to which there is no attachment that the need for medical care arises. Of course, I would like to note that we are talking about justified cases of seeking medical help. In this case, the medical organization does not have the right to refuse to provide medical care to a citizen who is not attached for service. The attachment process begins, which in some cases drags on for several months, and in some cases, by the time the attachment is received, the patient has changed his place of actual residence and the medical organization now faces the problem described above, on the territory of which this patient will now live. We believe that the reason for this problem lies in insufficient informing the population about their rights and obligations, namely, the persistent control by insurance companies over the presence of attachment to a particular medical organization.

Next fourth problem primary health care is as follows: in the existing system of medical care there is duplication, that is, a situation where the same patient seeks medical care and receives it at once in several budgetary outpatient health care institutions (polyclinics) for the same profile (for example, visiting a local therapist). Indeed, the Federal Law "On the Basics of Protecting the Health of Citizens in the Russian Federation" defines the possibility of choosing a doctor and a medical organization for service, but has not developed a control system, thanks to which attachment and medical care is routinely possible only in one clinic, the system of "punishing a patient for violation” there is no attachment, there is no system for exchanging information about the so-called “doubles”.

Fifth problem primary health care: the patient lives in the service area of ​​the medical organization No. 1 (MO No. 1), while he used the right to choose a medical organization and was assigned to the medical organization No. 2 (MO No. 2). With relatively good health, he visits MO No. 2, to which he is attached. In the event of a “call a doctor at home” situation, the doctor “MO No. 1” will serve the patient in accordance with the current legislation. To refuse to service a call received from a patient attached to another medical organization (in this case, to MO No. 2), but living on the territory of MO No. 1, the doctor of MO No. 1 has no legal right. A paradox arises when a patient is served simultaneously by two medical organizations (Fig. 2). We will not consider the issue of the financial side of this situation, although in this case, in the presence of a system of per capita financing, it is very interesting.

To date, there is no system (mechanism) of "encouragement for performance" and "punishment for non-performance" by citizens of the Federal Law "On Compulsory Medical Insurance in the Russian Federation" on issues of attachment to a medical organization. Of course, these problems are especially relevant for a large city. For rural areas, where the choice of citizens is more clearly limited by the area of ​​residence, these problems arise only due to the migration of the population from the village to the city and from the city to the village, which has a less significant scale compared to intra-urban movement. But in rural areas there are other problems in the organization of primary health care, which we will not touch on.

Day hospital The territorial polyclinic of a large industrial city is designed to carry out preventive, diagnostic, therapeutic and rehabilitation measures for patients who do not require round-the-clock medical supervision, using modern medical technologies in accordance with the standards and clinical guidelines for patient management. The purpose of organizing a day hospital based on a polyclinic is not only the timely provision of qualified medical care, but also an increase in the economic efficiency of medical organizations through the introduction and widespread use of modern resource-saving medical technologies for prevention, diagnosis, treatment and rehabilitation. The problem of the polyclinic day hospital is the lack of standards of medical care intended specifically for the day hospital. Health organizations have to use both the Primary Health Care Standards for outpatient care and the Specialized Care Standards for inpatient care. Only a small part of the "Standards of Primary Health Care" contains an indication of the possibility of their use in a day hospital. Clinical recommendations for a particular pathology do not at all contain information about the conditions under which (outpatient, day hospital, round-the-clock hospital) certain medical and diagnostic interventions should be performed. In a number of cases, in day hospitals, post-treatment of patients discharged from the hospital to complete treatment in an active regimen is carried out, followed by discharge to work. How and what standards of medical care to apply in this case, when most of the laboratory and instrumental examinations were performed in a round-the-clock hospital, is not clear.

In the last decade, there has been growing interest in expanding the scope of some types of care outside the hospital. This is due to the high cost of inpatient treatment, as well as the fact that out-of-hospital care will make it more accessible to certain categories of patients. Hospital at home as one of the types of primary health care is in demand by the population of a number of constituent entities of the Russian Federation and has shown its economic and social expediency. The hospital at home is designed to provide medical (diagnostic, therapeutic and rehabilitation) care to patients in need of home care. The organization of a hospital at home provides for a daily visit to the patient by a general practitioner, laboratory diagnostic examinations and drug therapy in accordance with the standards of medical care and clinical recommendations for the existing pathology. If there are indications during treatment in a hospital at home, specialist doctors are consulted on the profile of the disease. The organization of a hospital at home is carried out on the condition that the state of health of the patient and his home conditions allow organizing medical care and care for him at home and does not require round-the-clock medical supervision. On Saturdays, Sundays and holidays, patients can be monitored by order of the administration of the medical organization by doctors and nurses on duty.

An outpatient medical organization, when providing medical care in the form of a “Hospital at Home”, faces the same problem as a “Day Hospital”, namely, there are no standards for medical care for its provision in a hospital at home. The second problem for a home hospital is the lack of regulatory documents containing clear indications for the provision of medical care in a home hospital. It is believed that if the patient's condition and home conditions (social, material, and moral) allow organizing home care, then organizing a hospital at home is appropriate. Who should be inpatients at home: elderly? lonely? non-transportable? limited mobility? all of the above categories? Can patients of working age with acute illnesses and with exacerbations of chronic diseases, whose health condition may worsen when visiting a polyclinic, as well as persons in need of inpatient treatment, but not hospitalized for a number of reasons, be patients of a hospital at home? There are currently no answers to these questions.

Treatment of patients in a day hospital and a hospital at home is economically beneficial for a medical organization, it has an advantage from a deontological point of view, since most of the time the patient is in the usual comfortable home environment, surrounded by relatives. However, what standards of medical care to apply in the provision of medical care in this case remains open. The solution to the problem lies in a huge work in terms of its scale - the development of standards of medical care for its provision in day hospitals and hospitals at home, including at the regional level.

Conclusion

Currently, the process of structural and functional reorganization of the medical industry continues, research is being carried out aimed at updating the work of the healthcare system, taking into account the optimization of outpatient care for the population. The per capita principle of payment for outpatient care has been introduced. Therefore, the issues of enrolling patients for primary health care by budgetary health care institutions remain open. According to Article 10 of the Federal Law "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", the availability and quality of medical care are ensured by the organization of medical care based on the principle of proximity to the place of residence, place of work or education, the possibility of choosing a medical organization and a doctor. The understanding of the “choice of a medical organization” for the provision of medical care has a rather broad interpretation and requires specification. At the moment, the understanding of the “choice of a medical organization” from the standpoint of the population sounds like “when I want and where I want”, but the per capita financing system does not allow a medical organization to optimally plan and spend financial resources, part of which goes to the cost of providing medical care to the unattached population. There is a need to introduce a system of responsible patient information and the requirement that they comply with the above Federal laws, and, in addition to organizational issues, attention should also be paid to the problem of economic efficiency and expediency.

Since the advantages of organizing a day hospital and a hospital at home for a polyclinic are obvious - these are additional funds coming into the budget of the institution, the development of standards of medical care and legal support for the activities of day hospitals and hospitals at home is a paramount task of healthcare. It is quite natural that all innovations cause conflicting opinions and will be corrected and improved, focusing on the comments and suggestions of interested parties. The identified problems of medical care provided by budgetary healthcare institutions within the framework of the Program of State Guarantees for Free Provision of Medical Care to Russian Citizens will make it possible to determine priorities in optimizing the diagnostic and treatment process and managing the provision of primary health care.

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