Abstract

Introduction

In developed societies the State is responsible for the protection of life, health promotion, prevention and the organization of provisional care to the sick. In terms of health outcomes, health care systems have a very valuable, specific, but limited role, since most health achievements are produced by other sectors of society such as: formal education, redistribution of wealth, effective deployment of democracy and transparency in public power, the development of a profession/work in acceptable working conditions, access to proper housing, clean drinking water, and basic sanitation (Gérvas, 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008.; WHO, 2009WHO - WORLD HEALTH ORGANIZATION. Milestones in health promotion: statements from global conferences. Geneva, 2009.). Therefore, prevention and treatment of diseases/illnesses are more directly dependent on the health system, while the other responsibilities belong mainly to other sectors of the State and society.

In Brazil, the Brazilian National Health System (SUS) has been growing as one of the main government instruments for the protection of citizens' lives, having at least two types of function: public health and the treatment of the sick. The proposed organizational model for Primary Health Care (PHC) services has been the Family Health Strategy (FHS). Taking into account PHC 'filter function' (Gérvas; Pérez-Fernández, 2005GÉRVAS, J.; PÉREZ-FERNÁNDEZ, M. El fundamento científico de la función de filtro del médico general. Revista Brasileira de Epidemiologia, São Paulo, v. 8, n. 3, p. 205-218, 2005.), which is essential to the effectiveness, fairness and rationality of care, FHS carries this dual nature: the clinical care and health promotion/disease prevention.

This relationship between clinical care and health promotion/disease prevention in the context of the organization of PHC services was first debated in Brazil by Campos (1991)CAMPOS, G. W. S. A saúde pública e a defesa da vida. São Paulo: Hucitec, 1991. and Schraiber (1990)SCHRAIBER, L. B. (Org.). Programação em saúde hoje. São Paulo: Hucitec, 1990.. Campos values individual care and public health measures as citizens' rights and being the purpose of PHC, based on clinical tradition, interdependence of clinical knowledge/technologies, and epidemiological studies. Schraiber values programmatic actions (whose object is the "health-disease in its collective dimension"), making a distinction between clinical practice and epidemiology. The latter being the main criteria for organizing PHC services based on the public health tradition and health planning in a time when PHC coverage was very limited and far from the desired universality. Other variants, such as the health surveillance (Paim, 2003PAIM, J. S. Vigilância da saúde: dos modelos assistenciais para a promoção da saúde. In: CZERESNIA, D.; FREITAS, C. M. (Org.). Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz, 2003. p. 165-181.) and local health systems based on health districts (Mendes, 1993MENDES, E. V. (Org.). Distrito sanitário. São Paulo: Hucitec, 1993.) were also proposed, but were similar to the programmatic logic.

Currently the expansion/construction of PHC/FHS and the simultaneous intensification of knowledge/technologies indicate the need for two approaches. Paim (2008)PAIM, J. S. Modelos de atenção à saúde no Brasil. In: GIOVANELLA, L.; ESCOREL, S.; LOBATO, L. V. C. et al. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz, 2008. p. 547-573. and Coelho (2008)COELHO, I. B. Formas de pensar e organizar o sistema de saúde: os modelos assistenciais. In: CAMPOS, G. W. S.; GUERRERO, A. V. P. (Org.). Manual de práticas de atenção básica: saúde compartilhada e ampliada. São Paulo: Aderaldo & Rothschild, 2008. p. 96-131., in synthesizing care models for the SUS and PHC, agree that these proposals are complementary rather than antagonistic and that health care practices should be included in them. Therefore, to find a balance between prevention, health promotion and treatment of illness becomes a daily challenge for professionals and PHC/FHS services (Gérvas; Heath, 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008.).

On the one hand, the discussion about disease prevention/health promotion and organization of health care services is not new, containing abundant literature, the same cannot be said about its operationalization, specifically regarding the balance mentioned previously, and the configuration in the routine care of PHC/FHS services. Under this latter perspective, the operational aspect, a non-systematic search that was conducted in bibliographic databases was frustrating, which suggests a lack of consensual background that represents a "state of the art" concerning this issue, with a shortage of clear operational guidelines to organize the practice of FHS teams (Tesser; Norman, 2014TESSER, C. D.; NORMAN, A. H. Repensando o acesso ao cuidado na Estratégia Saúde da Família. Saúde e Sociedade, São Paulo, v. 23, n. 3, p. 869-883, 2014.).

The objective of this article is to present and explain some guidelines for the organizational practice of professionals of the FHS, more specifically doctors and nurses, focusing on the issues of access and the need for balance between the practice of disease prevention/health promotion and the care for the sick. First, we show some ideas about the importance of access to the quality of PHC services. Second is a short analysis - based on Geoffrey Rose (1985ROSE, G. Sick individuals and sick populations. International Journal of Epidemiology, Oxford, v. 14, n. 1, p. 32-38, 1985., ²⁰¹⁰ROSE, G. Estratégias da medicina preventiva. Porto Alegre: Artmed, 2010.) - of the high-risk preventive strategy, which has had strong impact on care routines (Gusso, 2009GUSSO, G. D. F. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2a edição (CIAP-2). 2009. Tese - Faculdade de Medicina da Universidade de São Paulo, Departamento de Clínica Médica, São Paulo, 2009.). Third, it addresses health promotion related to the care in PHC/FHS³1Scholarship from CAPES - Proc. No 1032/12-7. Finally, reinforcing the previous discussion, this article discusses operational guidelines for PHC/FHS services that still remain almost absent in the discussion and practice of FHS teams, managers/policy-makers and public health.

Access: the pillar of health services quality

Avedis Donabedian was a pioneer in structuring a system for evaluating quality of health services in three dimensions: structure, processes and outcomes (Raffle; Gray, 2007RAFFLE, A. E.; GRAY, J. A. M. Screening evidence and practice. Oxford: Oxford University, 2007.). As stated by Donabedian (2005DONABEDIAN, A. Evaluating the quality of medical care. The Milbank Quarterly, New York, v. 83, n. 4, p. 691-729, 2005., p. 692), "[…] criteria of quality are nothing more than value judgments, which implies that the definition of 'quality' is a […] reflection of values and goals current in the medical care system and in the larger society of which it is a part." Thus, health services, due to the richness and the complexity of their environment, may receive a more comprehensive definition of quality ranging from a purely social construction to a more objective definition, which basically encompass two aspects: access and effectiveness (Kordowicz; Ashworth, 2013KORDOWICZ, M.; ASHWORTH, M. Capturing general practice quality: a new paradigm? British Journal of General Practice, London, v. 63, n. 611, p. 288-289, 2013.).

Regardless of the perspective adopted, the definition of quality of health services should cover both the individual level of care as well as the population. In this sense, Campbell and Roland (2000)CAMPBELL, S. M.; ROLAND, M. O. Defining quality of care. Social Science & Medicine, Boston, v. 51, n. 11, p. 1611-1625, 2000., adopt an "objective" view of quality of formal health systems, including its individual and population dimensions, and place access as a sine qua non condition for the quality of health services (Table 1).

As seen in Table 1, the quality of the health care system and the dimension of individual care, is oriented by the access and the effectiveness of the care provided; while the population dimension, depending on the optimization of resources, is anchored to the relationships between equity, efficiency, and cost. The commonality of the two levels is access because equity is only a subcomponent of access, relevant to both the structures and practices in health services. Equity refers to the social justice of access, to the extent that resources are mobilized to reflect the need of a given population (Chapman et al., 2004CHAPMAN, J. L. et al. Systematic review of recent innovations in service provision to improve access to primary care. British Journal of General Practice, London, v. 54, n. 502, p. 374-381, 2004.). In other words, equity on the horizontal plane implies effective care accessible to all patients, but on the vertical plane access is for those who need care the most (Starfield, 2011STARFIELD, B. The hidden inequity in health care. International Journal for Equity in Health, London, v. 10, p. 15, Apr. 2011.; Gulliford et al., 2002GULLIFORD, M. et al. What does "access to health care" mean? Journal of Health Services Research & Policy, London, v. 7, n. 3, p. 186-188, 2002.).

The theme of access is so fundamental to the quality of health care systems that the British government has determined that, from April 2004 onwards, the population would have access to a PHC medical professional in a maximum of 48 hours and any other PHC professional, usually a nurse, within 24 hours (Meade; Brown, 2006MEADE, J. G.; BROWN, J. S. Improving access for patients: a practice manager questionnaire. BioMed Central Family Practice, London, v. 7, n. 37, 2006.). This concern to facilitate access aimed to help people to have greater control over health resources, in order to preserve or improve their health (Gulliford et al., 2002GULLIFORD, M. et al. What does "access to health care" mean? Journal of Health Services Research & Policy, London, v. 7, n. 3, p. 186-188, 2002.). Although delineating access is a difficult task, especially what is considered to be a high level of accessibility to services, from the point of view of individuals, good access is one in which the patient is able to obtain "… the right service at the right time in the right place." (Rogers; Entwistle; Pencheon, 1999ROGERS, A.; ENTWISTLE, V.; PENCHEON, D. Improving access needs a whole systems approach: and will be important in averting crises in the millennium winter. British Medical Journal, London, v. 319, n. 7214, p. 866-867, 1999., p. 866); in essence: the patients get the care they need.

In this sense, Starfield et al. (2008)GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008. propose two questions. Firstly, is it justifiable that check-up appointments constitute almost half of all visits to health services in the United States, where many people are in need of medical care? And secondly, is the concept of prevention still useful with increasing focus on one or several diseases or particular risk factors? This concern reflects the importance of establishing priorities in care organization aimed at reducing inequities in population health, because the emphasis on preventative care can divert access for the asymptomatic, resulting in the inverse care law, " … that the availability of good medical care tends to vary inversely with the need of the population served." (Hart, 1971HART, J. T. The inverse care law. The Lancet, London, v. 297, n. 7696, p. 405-412, 1971., p.412). This emphasis on preventative health care can result in an escalation of medicalizing preventive care with little effect, and strengthening the marketing of medical procedures and the consumerism attached to it (Montori; Isley; Guyatt, 2007MONTORI, V.; ISLEY, W.; GUYATT, G. Waking up from the dream of preventing diabetes with drugs. British Medical Journal, London, v. 334, n. 7599, p. 882-884, 2007.).

Geoffrey Rose: criticism of the high-risk preventive strategy

The idea of prevention departs from a linear time concept - which aims to prevent an undesirable episode in the future - within which a distinction is made between preventive actions, those which aim to prevent the occurrence of diseases (primary prevention) and those that hold or delay its progression or sequelae (secondary prevention) (Leavell; Clark, 1976LEAVELL, H.; CLARK, E. G. Medicina preventiva. São Paulo: McGraw-Hill do Brasil, 1976.). There are simple preventive actions that are safely implemented and evaluated, while others, more complex, may be valued differently by people, can cause damage, and its benefits are not directly transferable to individuals (Gérvas, 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008.).

Geoffrey Rose (2010)ROSE, G. Estratégias da medicina preventiva. Porto Alegre: Artmed, 2010. discussed the foundations of preventive medicine in relation to the reduction of risk factors for cardiovascular diseases, classifying the preventive actions in individual high-risk strategy and population strategy. The present article focuses on measures of high-risk strategy because they are activities which are increasingly valued in PHC/FHS.

This approach refers to the strategy of classifying people by selecting high-risk groups for the application of a preventive measure: separate a "problematic" minority from the rest of society considered as "normal" (Rose, 2010ROSE, G. Estratégias da medicina preventiva. Porto Alegre: Artmed, 2010.). Although intuitive for patients and professionals, this approach has little impact on public health, because a large number of people subjected to a small risk will produce more cases of disease than a small group with high-risk (Rose, 1985ROSE, G. Sick individuals and sick populations. International Journal of Epidemiology, Oxford, v. 14, n. 1, p. 32-38, 1985.). For example, pregnant women below 30 years old, although they are low risk, as they are numerous generate 50% of the children born with Down syndrome, while high-risk pregnant women (≥ 40 years) generate only 13% of them (Rose, 1985ROSE, G. Sick individuals and sick populations. International Journal of Epidemiology, Oxford, v. 14, n. 1, p. 32-38, 1985.). This happens in the various situations in which the risk is universally distributed in the population, as in the case of hypertension (Chor; Faerstein, 2000CHOR, D.; FAERSTEIN, E. Um enfoque epidemiológico da promoção da saúde: as idéias de Geoffrey Rose. Cadernos de Saúde Pública, Rio de Janeiro, v. 16, n. 1, p. 241-244, 2000.) (Table 2). The more illustrative image is the iceberg: the tip (high-risk group) only indicates the existence of a much larger mass that sustains and produces it.

In spite of its small impact on public health, the high-risk strategy is expanding by lowering cut-off points and ranking large portions of the population progressively as "high-risk" or sick, multiplying its problems and generating more demands for PHC/FHS (Starfield et al., 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008.).

The high-risk approach is associated with secondary prevention which screens and treats risks, conditions and diseases, such as: hypertension, obesity, dyslipidemia, cancers, etc. Screening of diseases mimic the "function" of high-risk strategy with individual interventions being repeated, maintained by several generations, using "hard" and expensive technologies, and producing pre-diseases, pseudo diseases, overdiagnosis and overtreatment, as well as causing significant damage and social medicalization (Welch; Schwartz; Wolosin, 2011WELCH, H. G.; SCHWARTZ, L.; WOLOSIN, S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon, 2011.). Screen and treat does not reduce susceptibility, does not address causes and has little impact on population's disease morbidity and mortality rates. For example, the reduction in the mortality rate from breast cancer through screening was questioned (Jørgensen; Zahl; Gøtzsche, 2010JØRGENSEN, K. J.; ZAHL, P. H.; GØTZSCHE, P. C. Breast cancer mortality in organised mammography screening in Denmark: comparative study. British Medical Journal, London, v. 340, n. 7750, 2010. Unique identifier c1241.) and estimated at only 15% in other studies (Silva, 2012SILVA, G. A. Câncer de mama no Brasil: estratégias para o seu enfrentamento. Cadernos de Saúde Pública, Rio de Janeiro, v. 28, n. 1, p. 4-6, 2012.). Gøtzsche and Jørgensen (2013)GØTZSCHE, P. C.; JØRGENSEN, K. J. Screening for breast cancer with mammography. The Cochrane Library, Oxford, n. 6, June 2013. Disponível em: <http://www.ncbi.nlm.nih.gov/pubmed/23737396>. Acesso em: 12 jan. 2015.
http://www.ncbi.nlm.nih.gov/pubmed/23737... highlight the significant damages attributed to overdiagnosis and overtreatment (Bleyer; Welch, 2012BLEYER, A.; WELCH, G. Effect of three decades of screening mammography on breast-cancer incidence. New England Journal of Medicine, Waltham, v. 367, n. 21, p. 1998-2005, 2012.; Welch, 2011WELCH, H. G.; SCHWARTZ, L.; WOLOSIN, S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon, 2011.). The relationship between cost and benefits of this screening begins to be inconclusive or negative, questioning the generalized indication of mammography screenings, since radiotherapy in low-risk groups (women with pathological findings resulting from the screening) can bring important consequences, such as excess mortality attributed to heart failure (27%) and lung cancer (78%) (Gøtzsche; Jørgensen, 2013GØTZSCHE, P. C.; JØRGENSEN, K. J. Screening for breast cancer with mammography. The Cochrane Library, Oxford, n. 6, June 2013. Disponível em: <http://www.ncbi.nlm.nih.gov/pubmed/23737396>. Acesso em: 12 jan. 2015.
http://www.ncbi.nlm.nih.gov/pubmed/23737... ). Therefore, proposals for organized screening programs (Brazil, 2010BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Rastreamento. Brasília, DF, 2010. (Cadernos de Atenção Primária, n. 29).) need to be reviewed in the light of new evidence, so that information within the organized programs is decoded in a language that is easy to understand, which also portrays the potential harms (Spiegelhalter, 2011SPIEGELHALTER, D.; PEARSON, M.; SHORT, I. Visualizing uncertainty about the future. Science, Washington, DC, v. 333, n. 6048, p. 1393-1400, 2011.); empowering patients (in the case above, the women) to make decisions about their health and their bodies and help professionals to exercise quaternary prevention, essential to the quality of PHC (Norman; Tesser, 2009NORMAN, A. H.; TESSER, C. D. Prevenção quaternária na atenção primária à saúde: uma necessidade do Sistema Único de Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 9, p. 2012-2020, 2009.).

The ethical requirements for establishing preventive interventions are much more stringent than in clinical care situations, because health professionals conveying the notion of risk to their patients may be " […] like putting a drop of ink into the clear water of the patient's identity; it can never be completely clear again " (Sweeney, 2005SWEENEY, K. Science, society, suffering and the self: a commentary on general practice for the twenty first century. New Zealand Family Physician Journal, Wellington, v. 32, n. 4, p. 221-224, 2005., p. 222). Thus, some potential consequences of preventive measures include "[…] disruption of cultural and individual capacities to cope with sickness, pain, and death" (Gérvas; Starfield; Heath, 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008., p. 1997). The accurate evaluation of preventive interventions must be crucial for determining the type of preventive care services offered to the population, which should be made only when it is certain that it will bring more good than harm. This certainty is obtained by good quality scientific evidence that is backed by robust and reputable institutions (Raffle; Gray, 2007RAFFLE, A. E.; GRAY, J. A. M. Screening evidence and practice. Oxford: Oxford University, 2007.).

This is important because the medicalization of pre-disease and risk factors is becoming the rule, with increasingly strict and hard to reach targets - usually requiring the use of medication - for hypertension, cholesterol, osteopenia and obesity. The prospect of marketing drugs for healthy people greatly contributes to the expansion of the drug market, increasing the costs to society and health services, which may reduce the quality of life by converting healthy people into patients (Montori; Isley; Guyatt, 2007MONTORI, V.; ISLEY, W.; GUYATT, G. Waking up from the dream of preventing diabetes with drugs. British Medical Journal, London, v. 334, n. 7599, p. 882-884, 2007.). These preventative ideas may be hindering access to health services, which, from the point of view of equity, is ethically questionable (Heath, 2007HEATH, I. In defence of a national sickness service. British Medical Journal, London, v. 334, n. 7583, p. 19, 2007.), by favoring healthy people with some biomedical marker risk (raised to the status of patient by the medicalization of risks) to the detriment of significantly ill people.

Therefore, the biggest challenges when proposing preventive health policies are establishing priorities for improving health in general, such as: reduction of overall mortality rates for specific age groups, improving life expectancy and reducing disability, and the perception of poor health rather than disease (Starfield et al., 2008GÉRVAS, J.; STARFIELD, B.; HEATH, I. Is clinical prevention better than cure? The Lancet, London, v. 372, n. 9654, p. 1997-1999, 2008.). According to Rose (2010)ROSE, G. Estratégias da medicina preventiva. Porto Alegre: Artmed, 2010., institutions (i.e. ministries, Health departments, professional associations, political leaders, civil officials, and media) have an important role in debating mass population preventive and promotional policies as well as social, economic, cultural and infrastructure issues (food quality, work conditions, wealth distribution, leisure, safe and sustainable mobility, etc.), which are the fundamental pillars of health promotion (WHO, 2009WHO - WORLD HEALTH ORGANIZATION. Milestones in health promotion: statements from global conferences. Geneva, 2009.). This has been the key of convergence between the social determinants of health, considered as of great impact on the quality of life and collective mortality, among which stands out the distribution of wealth, since poverty and socioeconomic inequality are harmful to health care as a whole (Wilkinson; Pickett, 2010WILKINSON, R.; PICKETT, K. The spirit level: why equality is better for everyone. London: Penguin: 2010.).

Health promotion and relief of suffering

The change in mortality profile in developed countries, in recent decades, has not achieved the same effect with respect to suffering. Barsky (1988)BARSKY, A. J. The paradox of health. New England Journal of Medicine, Waltham, v. 318, n. 7, p. 414-418, 1988. referred to this phenomenon as the "health paradox" although objectively health has improved, subjectively people feel more "sick." The author points out four reasons for this discrepancy: 1) the reduction in mortality from infectious diseases has resulted comparatively in the increased prevalence of chronic diseases, 2) there was an awakening of consciousness with regard to health, leading to greater self-scrutinization of the body and awareness of symptoms and feelings of sickness, 3) the widespread commercialization of health and an increasing focus on health issues in the media created an atmosphere of apprehension, alarm and insecurity about diseases and risk factors, and 4) progressive medicalization of everyday life has brought unrealistic cure/prevention expectations causing intractable diseases, risks and discomforts to look even worse. These reasons, also present in Brazil, intensified by poor social conditions, generate a clear increase in demand for PHC.

The question of suffering and its relation to physical illnesses have been addressed little in the literature and in medical care practice (Sweeney, 2005SWEENEY, K. Science, society, suffering and the self: a commentary on general practice for the twenty first century. New Zealand Family Physician Journal, Wellington, v. 32, n. 4, p. 221-224, 2005.). Based on clinical observation, a distinction is made between physical suffering and distress; the suffering is experienced by people, not merely by their bodies, threatens its integrity as a complex social and psychological entity, and may include physical pain but is not limited to it (Cassel, 1982CASSEL, E. J. The nature of suffering and the goals of medicine. New England Journal of Medicine, Waltham, v. 306, n. 11, p. 639-645, 1982.; Helman, 2007HELMAN, C. Culture, health and illness. London: Holdder Arnold, 2007.).

The relief of suffering and the cure/treatment of diseases should be seen as an indivisible obligation of health professionals (Heath, 2007HEATH, I. In defence of a national sickness service. British Medical Journal, London, v. 334, n. 7583, p. 19, 2007.); however, if they do not understand the nature of the suffering of people, these professionals can produce interventions that do not relieve or even can be the sources of suffering. Thus, relieving suffering should be one of the fundamental purposes of health care (Cassel, 1982CASSEL, E. J. The nature of suffering and the goals of medicine. New England Journal of Medicine, Waltham, v. 306, n. 11, p. 639-645, 1982.).

On the one hand, health does not necessarily imply the absence of disease, on the other, health promotion involves relief of suffering, since these concepts, health and suffering, go beyond the boundaries of biomedicine. Therefore, to relieve suffering, the promotion of health needs a better understanding of the person; he/she cannot be reduced to parts, systems or risks. The analytical/reductionist scientific method, relatively successful in human biology, is of little help in understanding the whole person, and any proposed mechanical or biochemical-statistical simplification should be removed from the definition of suffering (Cassel, 1982CASSEL, E. J. The nature of suffering and the goals of medicine. New England Journal of Medicine, Waltham, v. 306, n. 11, p. 639-645, 1982.), implying a demedicalizing vision of PHC (Tesser, 2010TESSER, C. D. (Org.). Medicalização social e atenção àsaúde no SUS. São Paulo: Hucitec, 2010.), especially in mental health (Tesser; Teixeira, 2011TESSER, C. D.; TEIXEIRA, B. C. Saúde mental na atenção básica: estratégias de implantação a partir de uma experiência. Saúde em Debate, Rio de Janeiro, v. 35, n. 88, p. 83-95, 2011.).

Thus, health promotion (in its micro dimension) and the assistance of the individual can be synergistic for the relief of suffering, encompassing all aspects of the person - their past and family life, culture and society, roles, associations and relationships, body, the unconscious, the political being, their secret life, the perception of their future and transcendent dimensions - all these aspects are subjected to loss and damages (Cassel, 1982CASSEL, E. J. The nature of suffering and the goals of medicine. New England Journal of Medicine, Waltham, v. 306, n. 11, p. 639-645, 1982.). Therefore it emphasizes the inseparable character of health promotion and care, which converge in a clinical practice centered on the person, family and community (McWhinney, 2010McWHINNEY, I. R. Manual de medicina de família e comunidade. Porto Alegre: Artmed, 2010., ¹⁹⁹⁶McWHINNEY, I. R. The importance of being different. British Journal of General Practice, London, v. 46, p. 433-436, 1996.).

The integration of health promotion/disease prevention and access to care is the primordial value of PHC/FHS and may be strengthened by population-based approach measures, for example, advising individuals/communities about quitting smoking or encouraging physical activity. This population approach (for instance, public policies and legislation that create leisure spaces and sustainable mobility, etc.) produces contexts that can be exploited, with synergistic results when combined, the second being the most impactful. One must consider, however, the limitations of the effectiveness of individual and community guidance in face of social, cultural and existential adverse conditions, commonly seen in Brazil. Thus, professionals should not blame patients (Castiel; Guilam; Ferreira, 2010CASTIEL, L. D.; GUILAM, M. C. R.; FERREIRA, M. S. Correndo o risco: uma introdução aos riscos em saúde. Rio de Janeiro: Fiocruz, 2010.) when they see that their recommendations are ineffective in promoting "healthy lifestyles."

If health promotion (in its macro dimension) and the population preventive approach mainly depend on measures that are beyond the sphere of health services in PHC/FHS (although it might include it), the individual care through collective activities (micro preventive dimension) of health promotion is possible and desirable, only if there is a commitment to respond to the suffering of individuals. The local collective practice upon social determinants should be pursued, but should not affect the longitudinal care of patients, the intrinsic " raison d'etre " of PHC/FHS health professionals (Heath, 2007HEATH, I. In defence of a national sickness service. British Medical Journal, London, v. 334, n. 7583, p. 19, 2007.; Sweeney, 2005SWEENEY, K. Science, society, suffering and the self: a commentary on general practice for the twenty first century. New Zealand Family Physician Journal, Wellington, v. 32, n. 4, p. 221-224, 2005.). Thus, health promotion gets legitimacy by the daily commitment to the exercise of patient care (Tesser; Norman, 2014TESSER, C. D.; NORMAN, A. H. Repensando o acesso ao cuidado na Estratégia Saúde da Família. Saúde e Sociedade, São Paulo, v. 23, n. 3, p. 869-883, 2014.), which taken to the depth, returns to expanded and empowered approaches. Promotional and preventive actions detached from the needs felt by the population, can and should occur, but without taking up considerable amount of time of doctors and nurses, and this is essential to careful integrate practices of health promotion/disease prevention with quick access to continuing care in the PHC/FHS.

From the previous topics it becomes crucial for the operation of PHC/FHS services to provide easy access to demanding patients, reconciled and synergized, with insightful preventive and promotional activities. In doing so they eliminate the possibility of preventive practices of high-risk or even health promotion (for healthy individuals) to compete with the care of those patients already experiencing illness, in the daily demands for health services, therefore minimizing the medicalization of prevention. Accordingly, some strategies for organizing the schedules of doctors and nurses are hereinafter made by means of a concrete example.

Balanced Agenda: the example of the Tapera Health Center

In March 2007 the Integrated Program for Family Health Residency (IPFHR) began at the Tapera Health Center, linked to the Federal University of Santa Catarina (UFSC), in partnership with the Florianópolis Municipal Health. The introduction of IPFHR at Tapera HC produced major changes in services, as there was a substitution of previous health staff (such as physicians, nurses and dentists) by equivalent tutors and residents linked to the program.

Tapera is a suburb with difficult access and a population of approximately 12,000 inhabitants, one of the socioeconomically disadvantaged communities of Florianópolis. In the process of occupation of this neighborhood landfills were placed over mangroves, and sewage ditches were opened without proper treatment. There are few social facilities (schools, child care nurseries, police stations, no formal recreation area and precarious paving of the streets), and its residents are mostly employed in manual labor work and services. Currently Tapera HC has four teams of FHS (in 2007 there were only three), each with about three thousand assigned patients, and two offices for staff, in addition to other basic resources (auditorium for collective activities, dressing room, vaccines, etc.). Therefore, it is a relatively similar neighborhood to many realities of the FHS teams working in the country.

The renewal of professionals resulted in the need to change its practice to organize it in the FHS logic. The previous scenario to the adoption of IPFHR was a stiff and bureaucratic relationship with the population. There was a "menu" of services organized in the form of an agenda, doctor centered appointments (and, when available, nurse appointments) and other services such as vaccinations, dressings etc. The number of vacancies on the agenda was limited, with a "day" of the week for booking appointments: when the available slots ended, so did access to care, which Tesser, Poli Neto and Campos (2010)TESSER, C. D. (Org.). Medicalização social e atenção àsaúde no SUS. São Paulo: Hucitec, 2010. defined as a mixture of private office logic in synergy with a public office.

The strategy for operational changes was to dialogue with the organized population (the existing Community Council and local health forums, the latter a space set up by residents to stimulate the creation of a Local Health Council - LHC) to match service needs with community claims, whose priority was access to medical care. In these meetings it was proposed that each FHS team would take responsibility by the patients' demands in their area (since previously the daily work was not organized according to each FHS team catchment area) and that all team members would participate in some form of service. The medical and nursing schedules were reorganized into six appointment slots of 20 minutes each, in the first half of the clinical session, on any day of the week (each clinical session lasting four hours). In other words, the first two hours of the morning and afternoon were intended for drop-in appointments; the remaining clinical session time was reserved for pre-booked appointments, home visits (HV), team meetings and group activities (Table 3).

In Brazil, the health centers seeking to implement same-day access guidelines basically use two modes of practice organization: one that values the territory, continuity of care and spontaneous demand and the other that does not follow this approach. In the first, patients' demands are met specifically by each catchment area FHS team and in the second, these relationships are independent of each other. The latter is organized with an "on duty" team, where professionals are responsible for the spontaneous demand of the day during the health center working hours. For them this type of practice works as "the quota of suffering for the week." In this case, the demand is burdensome, not something the team considers as their duty and responsibility. At times an extra health care team is put in place only for attending the emergency care at the health center. This hybrid context is not appropriate in the PHC/FHS logic as it tends to reproduce a walk-in surgery (24 hour clinics), with little accountability of the health teams for their patients, breaking continuity of care and facilitating the medicalization of care (Tesser, Poli Neto; Campos, 2010TESSER, C. D. (Org.). Medicalização social e atenção àsaúde no SUS. São Paulo: Hucitec, 2010.).

The Tapera HC appointment system is based on the first-mentioned mode: fulfilling spontaneous demand, valuing continuity of care, and professionals' accountability for the people ascribed to their catchment area. Gradually gaining strength and being adopted in other health centers of Florianópolis municipality, this system has already been proposed in a Brazilian reference treatise for family and community physicians as a model for managing clinical appointments in PHC (Gusso; Poli Neto, 2012GUSSO, G.; POLI NETO, P. Gestão da clínica. In: GUSSO G.; LOPES, J. M. C. (Org.). Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Artmed, 2012. v. 1, p. 159-166.). Although the IPFHR was removed from the community in late 2007, the tutors who remained there, together with the existing health staff team, kept the system running and, even with the departure of the last two former tutors in 2010, Tapera HC have not only continued further but also improved the initial idea, as can be seen in the material available on the health care center's blog⁴4Available at: http://cs-tapera.blogspot.co.uk/p/equipe-260.html.. In this appointment schedule system the community feels reassured, because they know that they will have a professional to meet and listen to their needs, with whom they have developed a bond and respect. This is particularly crucial in mental health care (Tesser; Teixeira, 2011TESSER, C. D.; TEIXEIRA, B. C. Saúde mental na atenção básica: estratégias de implantação a partir de uma experiência. Saúde em Debate, Rio de Janeiro, v. 35, n. 88, p. 83-95, 2011.). This example of appointment schedule system can serve as a guideline for the organization of practices that seek equity and expanding access to FHS without neglecting other activities (i.e. health promotion, disease prevention, surveillance) of the health team's responsibility.

From health professional's point of view, this system allows for changes in order to reduce stress on them. Thus, the demand for certain periods can be altered by an "X" number of appointments per clinical session, and people can be seen either by doctors or nurses. Having an excess of patients, they are welcomed by health care assistants, who provides adequate guidance and the provision of appointment for the next clinical session either afternoon or next day. If necessary, they negotiate with their peers for immediate care. The volume of appointments is a constant balance between the health staff coping strategy and the community's needs, which might change over time (NHS, 2009NHS - NATIONAL HEALTH SERVICE. Improving access, responding to patients: a 'how-to' guide for GP practices, 2009.). Commonly, there is a great demand for appointments at the beginning of its implementation, when there is a repressed demand for consultations, requiring sometimes to offer unlimited same-day care access. This process tends to attenuate the pressure for appointments, as a result of a permanent reassured quick access to health services and by a mutual trusting relationship between patients and health professionals.

Table 3 illustrates other activities other than individual care: weekly staff meetings and HV, which can also create other spaces for collective activities (therapeutic, health promotion, and educational), continuing education programs and matricial support, according to the needs of service. These activities should be dispersed throughout the week, without taking up an entire clinical session, especially during the first two hours of the clinical session, preserving access by avoiding simultaneous absence of all team members. Only during the weekly staff meeting will all of the team members get together to participate in health management decisions, reflecting, evaluating and organizing the service, as well as projects and activities of various kinds (clinical, programmatic, territorial, HV, surveillance, educational groups, etc). Thus, the community activities (facilitated and carried out mainly by the community health workers) are discussed, evaluated and organized during the meetings of the interdisciplinary team as well as during the HV - moments also privileged to continuing education, especially of the community health workers. The main potential moments for interdisciplinary practice, in this appointment schedule system and in PHC services in general are: the accommodation of same-day appointments (spontaneous demand), HV, collective educational activities, the weekly meetings and the informal daily encounters in the hallways, kitchens, doorways and offices, where professionals work together and build the organizational atmosphere of qualified care, as reported by Madeira (2009)MADEIRA, K. H. Práticas do trabalho interdisciplinar na estratégia saúde da família: um estudo de caso. 2009. Dissertação (Mestrado em Saúde e Gestão do Trabalho) - Universidade do Vale do Itajaí, Itajaí, 2009.. As a result, this scheme facilitates the flow of same-day access (spontaneous demand), while maintaining and optimizing space and time for community activities (as well as intersectoral health actions), surveillance, health promotion and patients' education.

The above example is flexible, allowing a greater or lesser number of same-day access, according to the needs of the community (outbreaks/epidemics, local/regional needs and specificities - such as isolated communities that are deprived of resources) and the limitations of the service itself. It could also mean a reduction in the number of appointments in the event of employee vacations (without replacement), high rates of absenteeism, vacancy for conferences/training or when there is no policy for professional maintenance and training.

In addition, this system progressively reduces the queues, ending the need to a specific day for "making an appointment" - that many health centers still practice - since every day there is significant availability of same-day appointments. It also reduces the numbers of DNA patients (those who Did Not Attend), since they are booked by the health team staff for a few days or rescheduled as determined by the patients. It is therefore operationally important to avoid "blind appointments," performed at the request of the patients without mention of the reasons, respecting patients' privacy, to improve the easy qualified access to health professionals. It is necessary to minimize them in order to avoid unnecessary consultations for bureaucratic reasons (such as renewal of prescriptions/referrals, etc) or for acute conditions that needs to be immediately seen by the appropriate health staff. This contact can also be done by other forms of communication that do not affect the daily process of continuity of care by the FHS teams, as shown in Figure 1. For this reason, the agility of communication between patients and health team is paramount (via email, phone and community healthcare workers). Consequently, the pressure on the booking appointment decreases because many guidance, dialogues and decisions can be made by phone or (Hansen; Hunskaar, 2011HANSEN, E. H.; HUNSKAAR, S. Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios. British Medical Journal Quality & Safety, London, v. 20, n. 5, p. 390-396, 2011.) internet via e-mail (Atherton, 2013ATHERTON, H. Use of email for consulting with patients in general practice. British Journal of General Practice, London, v. 63, n. 608, p. 11811-11819, 2013.), however, these types of media are very rarely used in Brazilian PHC.

Other forms of first contact, keeping easier access on a daily basis, were drawn up in Brazil: experiences involving the entire FHS team in the first hour of their clinical session, streamlining listening and decreasing stress levels (Cavalcante Filho et al., 2009CAVALCANTE FILHO, J. B. et al. Acolhimento coletivo: um desafio instituinte de novas formas de produzir o cuidado. Interface: Comunicação, Saúde, Educação, Botucatu, v. 13, n. 31, p. 315-328, 2009.); appointment schedule system that intersperse same-day access for patients with prebooked slots (1:1); collective discussion of patients' problems as a triage process (except when patients request a private space for being listened) and/or making appointments interspersed with problematization, health education and democratization of information. Ways to expedite access to PHC (called same-day access) are also discussed internationally. In other words, proposals and experiences that are found in the literature and in PHC practice, point in the same direction as discussed here (Murray; Berwick, 2003MURRAY, M.; BERWICK, D. M. Advanced access: reducing waiting and delays in primary care. The Journal of the American Medical Association, Chicago, v. 289, n. 8, p. 1035-1040, 2003.).

But what about programmatic actions?

Programmatic actions as activities planned, implemented and evaluated in PHC - epidemiologically and/or collectively significant (Schraiber, 1990SCHRAIBER, L. B. (Org.). Programação em saúde hoje. São Paulo: Hucitec, 1990.), whether preventive, therapeutic or promotional - are distributed according to same-day access (spontaneous demand) and pre-booked appointments, coupled with personalized and longitudinal follow-up of the enrolled cohort of patients, with the same level of importance as the patients' spontaneous demands for same-day appointments.

The delineated working unit for organizing the health service is defined by its cohort of patients of all ages, including clinical care and public health actions. Any permanent or prioritization of some intervention (i.e. pregnancy, well-baby care, and other specific actions) does not affect the organizational flexibility and access to care. This facilitates health integration taking the dual responsibility of individual care and public health. If programmatic actions (or "problems" detected by the service) are the main criterion for organizing health provision, there is a trend to occupy almost all the practice available appointment slots with specific actions, which can hinder access and induce attempts to limit the spontaneous demand, subliminally undermining it as a responsibility of the PHC.

The criteria and frequency with which programmatic activities are carried out also depend on participatory planning and dialogue with the community (Pinto; Coelho, 2008PINTO, C. A. G.; COELHO, I. B. Co-gestão do processo de trabalho e composição da agenda em uma equipe de atenção básica. In: CAMPOS, G. W. S.; GUERRERO, A. V. P. (Org.). Manual de práticas de atenção básica: saúde compartilhada e ampliada. São Paulo: Aderaldo & Rothschild, 2008. p. 323-345.). For example, it is recommended that pregnant women attend a minimum of six visits to the health team during their prenatal care. There is flexibility in the organization because, generally, pregnant women have monthly monitoring and at the end of pregnancy, biweekly or weekly visits. Similarly, low-risk children may arrange their check-up visits up to six months, with appointments associated with their immunization schedule, in addition to other strategies, such as childcare collective educational activities. As for hypertensive patients and high-risk diabetics, they have priority over those of mild and moderate risk patients and represent small slice within that highest risk group, also subject to collective educational actions (Amaral; Tesser; Muller, 2013AMARAL, R. P.; TESSER, C. D.; MÜLLER, P. Benefícios dos grupos no manejo da hipertensão arterial sistémica. Revista Brasileira de Medicina de Família e Comunidade, Rio de Janeiro, v. 8, n. 28, p. 196-202, 2013.).

Age, diseases, and specific actions (i.e. pre-natal care, child health care) may be used as criteria for the evaluation of the FH teams' performance, but not used to organize the routine of services. During the weekly meeting the FHS team evaluates and decides which programmatic actions will be offered to the population and how, requiring the construction of a democratic-participatory culture of practice, co-management of the demands of the population, professionals and institutional guidelines (Campos, 2000CAMPOS, G. W. S. Um método para análise e co-gestão de coletivos: a constituição do sujeito, a produção de valor de uso e a democracia em instituições: o método da roda. São Paulo: Hucitec, 2000.) and also negotiation with the Local Health Council.

A significant part of preventive practice can and should be done "in parallel" to medical care. This is the case with screening programs, a public health service provided to the asymptomatic population with protocols that do not need to involve clinical care in its initial phase (Brazil, 2010BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Rastreamento. Brasília, DF, 2010. (Cadernos de Atenção Primária, n. 29).). For example: women may be invited to Papanicolaou by professionals (especially community health workers) by letter, telephone, or e-mail; where examinations are conducted and results received without the need for directly involving a physician or nurse consultation, which will take place if necessary, saving doctors and nurses time. Therefore, for a better balance between access to care and health promotion/disease prevention practices, FHS professionals should share tasks/responsibilities between individual and collective actions and preventive care practices, whether it requires clinical care or not, as in the case of spontaneous demand and pre-booked appointments.

Final Considerations

If the PHC/FHS aims to be the initial point of contact for the SUS and its structuring axis, it needs to promote and facilitate access, integrating care and disease prevention/health promotion and making a patient-centered practice (Merhy, 2002MERHY, E. E. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec, 2002.). The four principles that characterize PHC: 1) be an initial point of contact (with gatekeeping role for ascending the health system); 2) be the coordinator of care; 3) provide continuity of care and; 4) provide comprehensive care (that meet all the needs of common population) are also structural subcomponents of availability, i.e. the access (Campbell; Roland, 2000CAMPBELL, S. M.; ROLAND, M. O. Defining quality of care. Social Science & Medicine, Boston, v. 51, n. 11, p. 1611-1625, 2000.).

The operational guidelines presented emphasize access to care without neglecting disease prevention/health promotion, reversing certain preventative and promotional emphases in the organization of services of PHC (Tesser; Norman, 2014TESSER, C. D.; NORMAN, A. H. Repensando o acesso ao cuidado na Estratégia Saúde da Família. Saúde e Sociedade, São Paulo, v. 23, n. 3, p. 869-883, 2014.). The viability of access and patient centered care according to the FHS team catchment area (not fragmented by diseases and/or pathophysiological parameters) allows for a better understanding of population condition, especially for the most vulnerable, and an appropriate response to peoples' health needs (Starfield, 2011STARFIELD, B. The hidden inequity in health care. International Journal for Equity in Health, London, v. 10, p. 15, Apr. 2011.). The organization of practice in PHC/FHS should be aimed primarily to care for the sick, through better access to longitudinal, comprehensive and qualified care, incorporating complementary measures of promotion and prevention (carefully selected). Therefore, the issue of access in the PHC/FHS services, as a civil right, needs better standardization and regulation in the SUS, as in other countries, and requires further discussion of the structures and practices necessary for the qualification of the PHC/FHS as main entry of the health system.

Acknowledgements

Thank you to CNPq for financial subsidy to one of the authors (process 312989/2013-0) and thank you to the professionals and community of the Tapera Health Center, Florianópolis, SC.

References

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