Czech Republic

Czech Republic

Rebirth of general practice

  • 1978: Recognition of General Medicine (GM) as a basic branch
  • Creation of GM Department within the Institute for Post-gradual Medical Education (IPME)
  • Foundation of GM Society within the Czech Medical Society of J. E. Purkyně
  • 1. and 2. attestation in GM

The Velvet Revolution

  • 17. 11. 1989 Prague University students demonstration against the regime was roughly repressed by the state police
  • Spontaneous uprising of millions of people
  • The Civil Forum (CF) was founded as a state establishment opposition
  • A new government with the CF deputies formed
  • 29. 12. 89 Vaclav Havel elected President

Health Care Transformation

  • 1990–1992 a broad discussion of politicians health profes-sionals and lay public led to consensual new Health Care Laws adopted by the Parliament
  • Health insurance system based on mutual solidarity (State pays for children, students up to 26, pensioners, disabled, unemployed, Two thirds of costs paid by employer for employee)

Health Care Transformation

  • 1993 Privatisation of HC activities started
  • 1993 Privatisation of H facilities enabled (in fact it took more time because of the necessity to solve the original owners rights in many cases at first – restitutions)

Health Insurance Comps.(HIC)

  • 10 HIC in total (formerly 24)
  • General HIC according to a special law (a statutory under-taker) – covers cca 67% population
  • The other HIC formerly founded like workers’ (departmen-tal) org. – mainly regional importance
  • All HIC are open
  • Change of HIC by insured: once per year
  • HIC contract Health Care Facilities (private dr., hospitals, Homecare Ag., etc.) in a Selection procedure organized by Regional Authority (participants: Heath officer, Medical Chamber deput., particular profession deputy, HIC deputy) by ballot voting
  • Contract duration: 8 years or indefinite period

Primary care structure

  • GPs 5123 – cover population from 14 y. of a./ with 1600 in aver. on the list., 44 contacts/1day
  • GPs for children 2120 – from 0 to 18 / with 950 patients on the list, 30 c./1 d.
  • Gynaecologists 1237–3340 women, 34c./d.
  • Dentists 6051– with 1720 patients, 14c./d.
  • Home care agencies 550
  • Health visitors, Social workers – outside HC

General Practice characteristics

  • 5293 fully qualified GPs
  • 5123 GPs providing care
  • 59% of GPs are female
  • 55% in age group 50 + years
  • 97% of GPs are private
  • cca 85% of practices are computerised
  • GPs have no gatekeeper function

General Practice and HIC

  • Private GPs are independent contractors to HIC (10) run-ning their own practice or in rented premises.
  • Payment by mixed capitation
    (cca 85% cap., 15% fee for service)
  • Price of basic capitation in 2013 (CZK 47–50 = EUR 2) and fee for services (point sst.: 1p.=1 CZK) set by negotiation betw. CGPA and HICs
  • Average income /month (2013) cca EUR 5000–6000 btto – before expenses and taxation
  • Direct payments – cca 10–20% plus
  • Regulation fee: CZK 30,- per visit connected with clinical exam. (cca 10% plus)

GP’s service structure

  • Obligatory sevices: basic spectrum of services – every GP has to contract. Mostly included into capitation. Some (prevention,vaccination) to enhance motivation are out of capitation.
  • Facultative services: mostly taken from other specialities (Surg ,ENT, Eye, Intern, RHB). Extent set by negotiation with HICs. GP can choose. Often special conditions must be fulfilled (qualification courses – ECG, Dia, Physioth., special practice equipment) In Capitation services
  • Clinical examination and control
  • Education of patient (family)
  • Telephone consultation
  • Home visit (transport + bonus payed extra)
  • Injection application
  • Wound dressing (1–30 cm2), topical anaesthesia • Alien particle extraction (ENT, eye)
  • Etc.

Out of capitation services

  • Prevention, Vaccination (TAT, Flu)
  • Night or weekend home visit• Small surgery
  • ECG
  • BP Holter monitoring
  • Diabetes management
  • Physiotherapy
  • ENT, Eye, Neu
  • Diabetes education
  • Blood (biological) specimen taking
  • Quick laboratory test – INR, CRP, HbA1c, Glucose, Urine albumine • Allergological testing
  • Etc.

Accounting of HC rendered

  • Monthly
  • New registrations of patients
  • Services rendered + Capitation
  • Cca 85% GPs use PC, accounting via internet is more and more used
  • Maturity of claim: 15–30 days

General Practice characteristics

  • Regulations of prescription, complementary exam.: within Global Costs Evaluation (compares expenses of each GP to the rest in District and Republic level)
  • All private practices are single handed
  • Typical employed staff is one nurse
  • Other services contracted (cleaning, waste disposal, ac-counts, laundry, etc.)

GP’s Workload (contracted)

  • 5 or 6 hours per day: in the surgery
  • 2 hours per day: home visits
  • 1 hour per day: administration
  • 5 days a week
  • 3 days off work per month without loss of capitation (clinical days)
  • More than 3 days regardless of reason: locum must be pro-vided

GP’s Workload

  • Out of hours (OOH) : not responsible (State run Emergency system)
  • Night hours: not responsible
  • Night duties: no obligation to provide a service, readiness varies from place to place. The service is seriously underpaid. There is no power to force independent GPs to sign a contract (to provide OOH)
  • Inpatient care: is not covered

GP’s Work Profile

  • 87% Clinical health care, Of it:
  • 48% internal medicine
  • 19% locomotive organs
  • 16% small specialites (dermat., ENT, etc.)
  • 4% injuries
  • 13% nonspecified
  • 12% Preventive care: 2 y exam., CoReCa screening (OBT), Mammography, Immunisation
  • 1% Social care

Postgradual eduaction in GP

  • 3 years postgradual curriculum under a senior GP trainer’s leadership, finished by a rigorous attestation (untill 2008 fully organised by the state-owned IPME)
  • A new concept of PME since 2011 – Decentralisation: In an Accrediation process approved GP is responsible for a trainee until closing examimation. Claims for money to cover trainees income.

Accreditation process

  • Personal requierements: Specialisation in GP, min. 5 y. practice, Whole-time working, List of professional or training activities in last 5 y.
  • Equipment req.: Enables work of fully competent GP
  • Training background: Space capability, Training competence of a trainer, Cooperation with a methodical educ. center
  • Approval to an external control
  • Agreement with external MF enabling trainee’s practice in other specialities
  • Accreditation comittee formed by experienced GPs named by Minister of Health . AC controls and judges the applications, submits chosen GPs for approval to a minister.
  • Ministry of Health – issues a Decision on accrediation with a 6 years validity.

PGT (Curriculum) in General Practice:
Basic strain – 24 m.
(doctor after graduation can perform certain activities only being supervised by a senior doctor)

  • 8 month GP
  • 8 m. Internal m., Pneumo., Infection d.
  • 4 m. Surgery, URL Orthopaedics, Trauma., Rehab.
  • 1 m. Paediatrics
  • 1 m. Gynaecology + Obstetrics• 2 m. Urgent (Acute) medicine

Followed by a specific GP training before attestation – min. 12 m.

  • GP supervisor arranges also a specific training in other fields of medicine including practice in outpatient specialists’: Practical Pediatrics, Psychiatry, Neurology, Ophthalmology, ENT, Dermatology, Hygiene, and other supplementary practice (facultative )

Czech General Practitioners Association

  • 1990: CGPA was established to support and enhance Pri-mary Care with the leading position of GP/FD.
  • Republic, regional and district structure
  • Annual conference is the highest body
  • 3 years election period of the President and the Board
  • The biggest non compulsory medical association in CR (4200 members)
  • Defence and promotion of GPs professional interests (ne-gotiations with Gvt,HIC, legal and economic aid – flood in 2002, 2013, etc.)
  • Promotion of GPs skills
  • Organisation of Continual Medical Education
  • The biggest non compulsory medical association in CR
  • 2 Journals, Web site: www.slpcr.cz

Problems of general practice

  • Gatekeeping – no access regulation
  • Secondary prevention – uncoordinated, lack of feedback, problematic co-operation with specialists in general
  • Prescription limits – some drugs only appropriate specialists can prescribe Goals for CGPA
  • Improve of the economical status of GPs
  • Extend competencies of GPs
  • Attract young doctors to general practice

Only a satisfied doctor can make his/her patients satisfied!

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