Documents

Dr. Mary McCarthy – Head of Delegation

Dr. Peter Holden – Member

Prof. Dr. Amanda Howe – Member

The National Health Service
Dr M McCarthy FRCGP
Zagreb 30th – 31st May 2014

The National Health Service has been described as the pride of the UK and akin to a religion in being a standard that all the population believe in and take comfort from. It, and the concept of a Welfare State, a safety net of benefits for children, the disabled and the out-of work, were introduced to post-war Britain in July 1948, at a time of austerity, and of social and economic problems. It was designed to cover all health care, “free at the point of use – from cradle to grave” and the thought at the time was that it would be used less and less as the population became healthier. It is funded through general taxation (National Insurance) and therefore depends on the contributions of the young and healthy to support the needs of those with Acute and Chronic Disease, both physical and mental. Those ideals continue to dominate the ethos of all who work in it, giving rise to extraordinary generosity of time and resources on the part of its staff, who feel they are working for the common good and are ready to stay, far beyond the end of their shift, if they feel it is needed. The public recognise this commitment and recurrent patient surveys have consistently shown satisfaction figures of above 95 for General Practice services and around 80 for hospital services. The basis is the system of GP registration where every person in the country is registered with a General Practitioner (Family Physician) who is responsible for all their care – “for everyone who is, or who believes themselves to be, ill”. The GP therefore knows their patient and their family well, has often treated three generations of the same family and acts as the gatekeeper to further investigations and for referral to secondary or specialist care. The GP holds all the medical records and patient notes along with letters from secondary care consultants and the results of all previous investigations. This creates a cost-effective health service that avoids unnecessary referrals and duplication of investigations. It also means than money or income is never a factor in accessing health care and the patient does not have to worry about the financial implications of a diagnosis of a Chronic Disease. In survey after survey, particularly in The Commonwealth Fund Report, The UK emerges as having one of the most cost-effective Health Care Economies.

www.commonwealthfund.org

Initially all prescriptions (medications) were free but this has gradually been replaced by a basic charge for prescription drugs of £8.05 (9.79 Euro). This will cover up to three months supply of medication but children under 18, those on social benefits, those over 60 years, pregnant women for up to a year after birth and those with exemptions due to Chronic Disease such as epilepsy, thyroid dysfunction, diabetes Type 1+2 (and other replacement therapies) and cancer drugs, do not pay for medication. The removal of money from the doctor/patient relationship has a liberating effect for both the patient and the doctor, and drug costs are kept low by medicine management agreements so that >70 of drugs are generically prescribed. The overwhelming majority of family doctor practices are group practices with from 3-10 doctors (or sometimes more) working together with Practice Nurses, Health Care Assistants, Receptionists, Secretaries, Counsellors and other Health Professionals in a team centred on the patient. Some Practices, if space is available, will have other disciplines such as Physiotherapists, Podiatrists, Benefit Advisors etc. District Nurses (for care of house-bound patients) and Health Visitors (care of new mothers and babies as well as children under 5 years old) support the practice team. Access to a general practitioner is straightforward with most practices offering appointments throughout the day, starting at 8.30 and ending at 18.00-18.30. Emergency appointments (with any doctor) are available on a same-day basis; routine appointments, for instance for Chronic Disease management, for which the patient may wish to be seen by their regular doctor, are given in 1- 3 weeks time. Out of Hours Care (OOH) is varied. Since devolution, the Celtic nations (Northern Ireland, Scotland and Wales) have not been affected by political changes as much as England has. The Health and Social Care Act 2012 largely applies to England only. Last year, in England, the government brought in NHS111, a phone number which would access OOHs Care. The phone system was inadequately planned with nonclinical call-handlers working their way through a set of questions to determine clinical need. Previously OOHs systems had developed from GP-led co-operatives which relied on heavy Doctor input and experienced clinical triage. It is being recognised that experienced clinician triage is the safest method of delivering emergency care and results in far less hospital admissions. The Implementation of NHS111 has been paused in some areas with the previous OOHs system taking back control. Ambulance disposal rates (to Emergency Room or for admission as in-patient) are 3 with experienced clinical triage as opposed to 10-14 with non-clinical call-handlers. There has been a perceived strain on Accident and Emergency Centres though in part this is due to different methods of collecting data. Accident and Emergency departments see 21 million consultations a year; GPs see 340 million consultations a year. There is also an increasing emphasis on targets; targets in the hospital system (not more than 4 hours wait in Emergency Room, referrals for suspected cancers must be under two weeks) and more targets in primary care (Cholesterol <5mmol/l for patients with cardiovascular risk, HbA1c <7.5 for Diabetics). The Quality and Outcome Framework, which incentivised good clinical management, was introduced in 2004 and has had a profound effect in standardising and raising the targets for managing Chronic Disease: for instance before 2004, 30 of diabetic patients achieved a HbA1c <7.5; by 2009 70 of diabetic patients reached this target: before 2004 the numbers having an annual record of a check for microalbuminuria were negligible; by 2009 90 had a regular check with ACE1 prescription if appropriate. There is no doubt that cardiovascular risk has been substantially reduced in the hypertensive population and statin use in those at risk has significantly lowered the rate of strokes and heart attacks. However reliance on protocols and pathways, while laudable in intent, may shift the focus from the patient themselves and an holistic assessment, to a concentration on biomedical markers. For instance, data on renal function (eGFR) in those over 80 years may reflect ageing kidneys rather than a disease process and lipid targets may lead to inappropriate prescribing in the very elderly. Over recent years, the reduction in the benefit system has had an impact on the poorer section of society with a rise in the numbers of children living in poverty and the increasing use of “Food Banks” by families who may be in work but whose pay is too low to constitute a living wage. It is recognised that deprived communities have poorer health outcomes as described in Sir Michael Marmot’s Review of Health Inequalities “Fair Society, Healthy Lives”.

www.ucl.ac.uk/whitehallll/pdf/FairSocietyHealthyLives.pdf

NHS Hospitals are under financial strain as is the whole NHS. Despite promises before the last election that the NHS would be left alone, the Health and Social Care Act 2012 has caused disruption and reorganisation which, along with the burden of having to save £20 billion by 2015, is causing huge strain to the system. The UK has one of the lowest hospital bed numbers in Europe with just over 300 beds/100,000 population and one of the lowest numbers of physicians per population and this is against a demographic of an ageing population with more complex and chronic disease. To save money, care and management of Chronic and Complex Disease is increasingly being shifted, out of secondary care and into primary care, without the appropriate resources necessarily following. The funding also militates against co-ordinated care: hospitals are paid on activity, so busier is better; GPs are paid on a block contract which works out at roughly £12/patient/month no matter how much resources the patient takes up. The government favours funding hospitals above funding primary care which has suffered from increasing disinvestment over the years. It now is allocated under 8 of the total NHS budget. The NHS suffers from lack of stability due to government measures, from recurrent financial cuts which have caused loss or down-grading of staff, and from micro-management with the recently reorganised Care Quality Commission undertaking an inspection of every health provider. With premises,the CQC has the authority to inspect every Medical Practice, Health Centre, Dental Service, Walk-in Clinic, Hospital and Care Home concentrating on staffing (up-to-date training, appraisal, CardioPulmonary Resuscitation, safe-guarding of children and vulnerable adults), safety (infection control measures, storage of vaccines and drugs), providing access for patients (entrances and toilets for the disabled), and Management. For doctors, annual appraisal has been in place for 8 years and revalidation was introduced in April 2013. This will occur every five years and requires 5 valid appraisals, a patient survey, a colleague 360 degree survey, a significant event audit, evidence of other audits, evidence of continuing education (250 hours over 5 years) evidence of reflective learning, evidence of updated skills (CPR, Child Safeguarding) and declarations of health and probity. This degree of surveillance of performance, of hospitals and of practices may have a tendency to promote what some have called “a culture of fear” as practices and their staff endeavour to make sure they have complied with every regulation. Morale among General Practitioners/Family Physicians is low, due to increased work load, reduced funding (and changes to the NHS Pension System), and the continuing rise of patient expectations, fuelled by the media and the government. The media, in particular, seem to blame GPs for whatever goes wrong in the health system and the constant barrage of articles castigating lazy GPs, for not having surgeries open on Sundays for routine appointments or not doing Out-of-Hours work (despite the fact that GPs staff the OOHs rotas) leads to low morale since most GPs are working harder than ever, due to increased bureaucracy, monitoring of biomedical targets and data collecting. GPs in an average practice (5-6000 patients, 3-4 doctors) now arrive at their place of work by 8.00 and, having seen 30-45+ patients for face-to-face consultations during a morning and an afternoon surgery, made 4-5 home visits, finally checked all pathology results, completed all phone calls to patients, reviewed and acted on all hospital correspondence and dictated all referral letters, leave at 19.00-20.00. This is leading to a recruitment and retention problem with older doctors considering early retirement (often when they are in the mid-fifties – that is with 10 years or more before they might otherwise have retired) and younger doctors not taking up training posts in family medicine, or not contemplating partnership in a practice, or emigrating to other English-speaking countries such as Australia, Canada or New Zealand. The Health and Social Care Act 2012 also created Clinical Commissioning Groups, to which all practices had to belong and the boards of which were drawn from local GPs. Their remit was to commission services in secondary care and although theoretically they could bring clinical judgement into commissioning decisions, in reality they are stifled by financial constraints and the bureaucratic control of NHS England which oversees their actions. Moreover the involvement in CCGs is taking GPs out of practice clinical work and causing further strain on an over-stretched workforce. Despite all this, NHS Staff remain loyal to the organisation. They have endured years of pay cuts and changes to the pension plans which induce stress fatigue, and staffs cuts which may impinge on patient care. I have talked to many people within and outside the NHS during the writing of this report. The one fact that they always mention is that the NHS does not cost the patient anything and those who had worked abroad commented that medical care costs did not factor in peoples lives. This, they feel, is the best aspect of this Health Economy. They also commentated that the financial constraints were making it increasingly difficult to maintain the standard of care needed.

For those who work in it, their pride in the NHS, as an ethos and a philosophy, is unshakeable.

Dr. Sonata Varvuolyte – Observer

Dr. Hilly ter Veer – Head of Delegation

Hilly ter Veer (1982) works as a GP in Assen, famous for its MotoGP TT. She finished her GP specialization in 2013 and has worked for 5 years in Ureterp, a village in the Northern part of the Netherlands. Standing up for a smoke free generation, she wants to protect children, preventing them to start smoking, so as to realize a healthier population in over 20 years. Hilly became a Member of the Board of the Dutch association of General Practitioners (LHV) in 2020. She hopes to unite GP’s of every kind, encourage them to embrace the common (“Woudschoten”) values and as such to realize future-proof GP-care together.

Dr. Geert-Jan van Loenen – Member

Geert-Jan van Loenen (1957) is Member of Board of the Dutch association of General Practitioners and GP in Hengelo. He is married and has four daughters.

In January 1991 he started the two year family medicine training at the Nijmegen Institute for General Practitioners and Family Practice. The first two years of his professional career he took over the practice of GP’s. Since 1995 he is a GP in Hengelo (in the East of The Netherlands), initially as ‘old-fashioned’ solo doctor with a practice at home. Since September 2007 he however works in a modern practice with five other GP’s and their assistants, 3 practice nurses, diabetes nurses and psychiatric nurses, next to the hospital in Hengelo.

Dr. Fritz Georg Fark – Head of Delegation

Dr. Daniel Widmer – Member

Dr. Carlos Beat Quinto – Member

General Practice in Switzerland

Switzerland has a liberal health care system. It is a system with primary and secondary health care. Patients have a free choice of general practitioner and specialist but not of hospital (necessity to be cured in a hospital in the same canton). Swiss GP do not serve as gatekeepers to higher specialised care. A probable revision of the law will possibly change this situation like free choice of hospital. The introduction of managed care is discussed and some systems of integrated care are existing now principally in the east part of Switzerland.

A few statistics:

The swiss health system costs 55 336 millions SFRS yearly. The hospital treatments represent 45.9{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of that total, the ambulatory care 31.3{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}, medicaments 10.3{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} (OFS 2007). The costs of practitioners (for general practitioners and specialists of the private sector) has increased by 17.58{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} from 1995 to 1999 while the non-stationary hospital services (the public sector) has increased by 47.5{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} in the same time (1).

Professional associations:

The general practitioners do not include all doctors engaged in primary care, of whom internists and paediatricians are also part.

GPs, internists and paediatricians all have a specialists status, since in all three cases the length of the post-graduate training period is five years, following the medical studies. Recently (2009) a new society has been created, “Medecins de famille Suisse (MFS)” (http://www.medecinsdefamille.ch/ ) to defend the 3 societies (Swiss Society of General Medicine (SSMG), Internal Medicine (SSMI) and paediatrics (SSP). At the UEMO, the Swiss Society of General Medicine (SSMG) is represented jointly with the FMH (Foederatio Medicorum Helveticorum), which is the umbrella organisation of all Swiss doctors. A new title has been created (2010) regrouping those of internal and general medicine: general internal medicine.

On the political level:

A revision of the law on health insurance (LAMal) is discussed. The most notable change may be the “abolition of the obligation to contract” or the “law on managed care”: until now, the health insurance companies had to reimburse all doctors, which was called “the obligation to contract”. It is very possible that under the terms of the revision, the insurance companies would be able to choose which doctors they will reimburse or with the law on managed care to select the networks of doctors (still in discussion at the Parliament – 2011). Some generalist practitioners see this modification positively, guessing that the insurance companies will decide to prioritize the GPs, offering them the role of gate-keepers in a system of networks. Others think that by establishing their choice on economic criteria of cost per case, the insurance companies may eliminate the most expensive GPs, who accept to treat patients with large co-morbidities, especially the psycho-social cases and the elderly. That would create discrimination in the society: by limiting the choice of the doctor, a two-speed medical care system may appear. In Switzerland it is possible to ask for a referendum when a sufficient amount of citizens wish for a new law to be submitted to vote or to present an initiative. Such an initiative is now presented by the association MFS to reinforce the role of family physician.

A new medical tariff is entered in force on the first of January 2004, on the national level, abolishing the diverse cantonal tariffs. The intention behind creating this tariff was to privilege the intellectual or relational act to the detriment of the technical acts, and to have each doctor be paid equally for the same service, regardless of his/her specialized area of medicine. In so doing, the time of consultation was divided in slots of five minutes, which enables administrative control of the content. The complexity of the measure seems to indispose a certain amount of colleagues who were first pleased by the idea of a single tariff. Other existing risks are that consultation time may be reduced in a will of rationing, or that a global budget would be introduced.

Dr Daniel Widmer, Head of UEMO Swiss Delegation – July 2011

Dr. Marina Tuutma – Head of Delegation

Primary health care in Sweden

Dr Anders Nilsson

Sweden has a population of about nine million. The Swedish healthcare system has by tradition been very hospital oriented, with about 80 per cent of total healthcare expenditures allocated to the hospital sector. In past years there have been financial cutbacks accompanied by structural changes in the healthcare sector. The number of hospital beds has diminished, partly due to more efficient treatments and shorter time spent in hospitals. The number of employees has diminished drastically. This has almost exclusively concerned nurses and nurses’ assistants. The hospitals have been restructured. Smaller hospitals no longer have emergency units for surgery. Highly specialised care is now concentrated to the big regional hospitals. These cutbacks on the hospital side have resulted in the primary healthcare sector receiving an increased and more complex number of cases than before. Primary care in Sweden shall provide the population with the entire basic healthcare, as well as preventive and rehabilitative care that does not demand the medical and technical facilities of a hospital. Today there are about 5000 general practitioners in Sweden. Eighty per cent are employed by the County Councils and 20 per cent are private practitioners. However, in order to work as a private practitioner within the social security system, an agreement with the County Council is necessary. The politicians claim to be open to other ways of organising practices within primary healthcare, as it is the contents of primary healthcare and not the way it is organised that matters.

General practitioners in Sweden are specialists in Family Medicine. All have a minimum of five years specialist training, which starts after the licence to practice has been issued. There are nationally stipulated goals for what the training must include. The specialist training is performed on a specially designed training post, and an individual plan for the training is designed for each trainee. Amongst other things, internal medicine, psychiatry, paediatrics, gynaecology and family medicine are included. Most general practitioners work in group practices, with GP: s working with nurses, secretaries and physiotherapists. Sometimes psychologists and counsellors are employed as well. In addition to their ordinary consulting hours, many general practitioners are also responsible for maternity/child healthcare and for healthcare in schools. Since 1997 there has been a law requiring all doctors to assure the quality of their practice. Today, the referral rate from general practitioners to specialists is less than ten per cent. Some County Councils operate a gatekeeping system. However, a national report states that there should be no compulsory gatekeeping system in primary healthcare. Primary healthcare should be the natural first line choice for the patient because of its competence, quality and accessibility, and not as a result of coercion. There are 20 County Councils in Sweden They can decide themselves how to organise primary healthcare in their respective areas. Some have a remuneration system per capita and some a budget-based system.

National Action Plan
A National Action Plan adopted by the Swedish Parliament in 2000 had as one of its targets that Sweden should have 6,000 family physicians in 2008; i.e. 1 family physician per 1,500 inhabitants. The Action Plane has proved to be a disappointment, depending on the fact that the County Councils have not fulfilled the intentions of the plan and the extra resources that the government granted the County Councils in this respect have been used for other purposes.
It is also important that primary care is organised in a way that permits the patient to have a continuous contact point in the healthcare system, i.e., with a GP/family doctor.

Recruitment
The biggest problem today is the shortage of specialist doctors which is a very real problem within the specialist field of Family Medicine/General Practice. The average age in the Family Medicine/General Practice population is high and many doctors will reach the retirement age of 65 in the next few decades. This problematic situation might also be aggravated by the fact that many general practitioners have declared that they intend to reduce their working hours from 60 years of age. This is a result of the fact that many general practitioners experience their working situation as unsatisfactory with a high degree of stress, too rapid a working pace and limited possibilities to have a decisive influence on their daily work. Therefore, it is a task of first order to find solutions to these problems.

In 2006 the DLF (the Swedish medical organisation of GP:s) made a thorough analysis of all available statistics on the number of professionally active family physicians, the degree of part time work, retirement age and other work assignments within the health care system (high level head positions e.g. and purely administrative work). We found that today the number of family physicians correspond to 3,900 full time working GPs. DLF has also looked in the rear mirror and found that the net addition per year of GPs has been no more than 48 per year during the last 10 years.

LF has also looked at all those doctors who at the moment are in Family Medicine specialist training in Sweden and when they can be expected to have finalised their specialist training. Taking retirements into consideration, the prognosis show that within a few years Sweden will have a DECREASED number of specialists in Family Medicine. Unless some radical steps are taken we can reach the target of 6,000 specialists in Family Medicine no sooner than in 30-40 years time! There is a clear discrepancy between the national goals and reality.

The Future
Today many counties work with a concept called local health service. The definition of this term is not uniform, however all models work with a base of GP:s who are closely tied to organ specialists. Remuneration models vary.

Since the election in September 2007 the new non-Socialist majority has focused on accessibility and customer choice models. The counties are strong and have the right to act relatively at their own will. The county of Halland has developed the so called Model of Halland which is monitored by other counties with great interest. The Model of Halland rests upon uniform remuneration for all care units and demand authorization from the county. All citizens are listed and the remuneration based upon weighted age interval. Demands to be approved as a care giver are that the unit has a system for guarantee of quality, economical stability, technical ability, capacity etc.

The renumeration comprises all contacts regardless of the care giver of the care unit. This means that there is no special remuneration for visits. Along with the agreement there are defined commitments. There is also a possibility negotiating added commitments. The county monitors accessibility, degree of coverage, medical quality, pharmaceutical prescription an health promoting activities. Seventy per cent of the listed consumption in open primary care is to be performed in the medical health centre that the citizens have selected.

In Stockholm you work with the so called Stockholm model. It was introduced in January 2008 and is based upon a uniform agreement and authorization throughout the county. A very strong driving force in the Stockholm model is that the political majority wants all primary care units to be run privately in a couple of years. The customer choice model that one wishes to introduce in Stockholm prevents that the continuity between doctor and patient is cut off by The Act on Public Procurement. The citizen will, by this model, be the procurer.

The Committee on Public Sector Responsibilities, which after a number of years, handed over a report to the government in February 2007. Among other things, this report suggests that regarding healthcare, the right and the influence of patient shall increase. Citizens shall have the right to have a continuous contact point in the healthcare system, i.e., with a GP/family doctor. However, the statutory claim that this continuous contact point shall be a specialist in Family medicine is to be withdrawn. Furthermore there is a commission working on the right of the patient in healthcare. The results that come out of this commission may have a substantial effect on a primary care in the future.

Many things are happening within Swedish healthcare today, not least within Primary Care and it is of great importance to carefully monitor the development and to find all possible opportunities to keep an ongoing dialogue with the decision makers.

Dr. Jerónimo Fernandez-Torrente – Head of Delegation

Dr. José Luis Almudi – Member

Dr. Serafín Romero – Member

General medicine in Spain

Dr. Fernando Perez Garzon

To understand the situation of general medicine in Spain, it is essential that we start in the year 1978, when Royal Decree 3303/78 was published, creating the speciality of Family and Community Medicine. This Royal Decree establishes a specialised training lasting three years, with an entrance examination similar to the other medical specialities (via MIR), a 1 7-month in-hospital residence training system, and 16 months at health care centres, making a total of 33 months of training.This Royal Decree (Article 8 and final transitional provision) furthermore regulates a number of transitional measures for access to the title of the new speciality by specialists who practised before this Royal Decree was published. We refer here to the system of acquired rights that applied to doctors who could accredit they had been working for five years, such that by following an advanced vocational training course they could obtain the title of ‘Specialist in family and community medicine’. Problems started to emerge as a consequence of applying this system of acquired rights, that would not be implemented for another 11 years and was not effective until the publication of Royal Decree 264/89 in 1989. At the time there were some 8,500 doi lors who accessed the system through this method in Spain, and 2,100 of them still have to attend the advanced vocational training course. Ten years have gone by since then and the practical application of this measure of acquired rights has still not been completed.In addition, this Royal Decree 264/89 did not cover all those doctors who were practising at the time, but only those who fulfilled a number of strictly defined requisites, which has meant that there is a considerable number of specialists who have not had access to this possibility.The Community Directive 86/457/EC, on specific training in general medicine, called for an immediate solution to this situation, because it established mandatory post-graduate training to be able to practise within the social security system.From 1989 until 1995, various promotions of doctors obtained the speciality in family and community medicine under the official MIR system, that is to say, by an entrance examination to the restricted places called each year. These specialists amply comply with the requisites ruled in Directive 86/457/EC, and in this respect we are satisfied with the training in our country, but there is still the problem of those doctors who, in 1989, were not able to access the acquired rights system because, for a brief period of time, maybe days or weeks, they fell short of reaching the requisites for five years of practice.The mentioned Directive, 86/457/EC, that was repealed and compiled in Directive 93/16/EC, set out that, from 1 January 1995, all medical graduates were to follow a mandatory postgraduate training for two years at least, guaranteeing the acquired right of graduates before 1 January 1995 to practise general medicine, even without the title of specialist, within the framework of the social security.This complicated the situation for those doctors who were unable to benefit from the transitional measures established back in 1989.Royal Decree 931/95 was published on 9 June 1995, relating to access to training as specialists in family and community medicine for medical graduates after 1 January 1995, that establishes the obligation for the MIR training system in order to practise in the public health system in our country (which is practically the only employer), to obtain the speciality of family and community medicine.Last year, the Ministry of Health brought out a new Royal Decree 1 753/98, on 31 July, on ‘exceptional access to the title of specialist doctor in Family and Community Medicine, and on the practice of Family Medicine in the national health system’ directed to the pre-1995 general practitioner group, that demands that the following requisites be fulfilled:

• five years of professional experience as general practitioner in the public system (leaving out those doctors who practise general medicine in a different way);

• at least 300 hours of complementary training, that are assessed;

• an objective test to assess the candidate’s professional competence, with final evaluation.

It seems this measure does not follow the principle of proportionality, because these are excessive requirements, especially considering these are general measures that do not take into account the situation of each doctor to whom they are directed.If we think about the fact that all these measures have been called for as a result of the publication of Directive 86/457/EC, the criteria adopted for their implementation as a domestic law should at least be ‘proportional’ to the end that is sought, to avoid any kind of discrimination. There is still much to be resolved, because from 1995 until the present time, an average of 600 doctors per year have not been able to enter any training system both for the speciality of family and community medicine and for other medical specialities, and consequently this has led to a new ‘pool’ of doctors who have no possibility of working in the national Spanish health system.

Continuing medical education (CME)
Continuing education of medical specialists in Spain is fundamentally implemented through the Professional Scientific Societies of each particular speciality, and also by the Professional Medical Colleges in each province, which in the past year have developed important co-ordination work with the so-called Target of the European Community (EC) for those autonomous communities with a Gross National Product (GNP) below the European average.

Dr. Vesna Pekarović Džakulin – Member

Dr. Marián Šóth – Head of Delegation

Dr. Călin Bumbuluț – Head of Delegation

Dr. Gindrovel-Gheorghe Dumitra – Member

Dr. Mădălina Vesa – Member

Family Medicine in Romania

By dr Călin Bumbuluț

From almost 37,000 specialists’ physicians in Romania, of all medical specialties, more than 11,800 are GP’s of which 9,588 are specialist family physicians, all members of the Romanian College of Physicians, which is a non-governmental National Medical Association and a National Accreditation Association in autonomous relationship to any public authority. Together with the Romanian Ministry of Health, the RCP is a competent authority in regulating the medical practice in Romania, and is part of the national mechanism of recognition of medical qualifications as shown in the Dir. No. 2005/36/CE.

The National Insurance Health House -NIHH (Casa Naţională de Asigurări de Sănătate-CNAS) was first established in 1999 and subsequently, the law was many times modified and completed. It settles a comprehensive providing a healthcare system for all citizens from birth to death. A new amendment is now being discussed, in the general context of a complete renewal of the National Health Bill.

Terms of practice are negotiated and contracted between the family physicians and the Departmental branches of CNAS, on yearly basis.

The family physician is the patient’s buffer and first contact with the healthcare system, as first person who is consulted and provides treatment and advice for any further medical act. This can take the form of a referral to a medical specialist or to the hospital system. The range of services provided by the family physician within the general medical services in Romania is considerable. As mentioned, the family physician is responsible for referrals of patients further in the system; each family physician is also responsible for current healthcare services of an average list of 1,800 patients. Care is delivered either by consultations at the physicians practice or by home visits including child and maternal care, vaccination of children, health examinations, and prescription of appropriate drugs. We are also in charge with the maternal care which consist in taking in evidence in the first quarter, monthly supervision from 3rd month to 7th month,Â supervision twice per month from 7th to 9th month and including control at discharge from the hospital – at home, the follow up at 4 weeks after birth. There are no gynecologists in primary care, but in case of problems with pregnancy, with a referral, the case is taken over by gynecologist in ambulatory system or from hospital. From 7th month the OG’s control of the patient is mandatory, and the delivering of the baby is in responsibility of OG’s.

From 12,000 GPs in Romania, aproximately 6000 followed the postgraduate course in prevention ofÂ cervical cancer, colorectal and breast cancer, which offer the posibility for doing the smear for PAP test. From those 6000 phisicians, who wanted, they signed contract with sanitary authorities for the smear test. The advice about contraception and also the pills or other means of birth control excepting the sterilet is given by GPs especialy in rural areas, and in towns by some of GPs with competencies in contraception.The treatment of cervical cancer is entire in the responsibility of gynecologist. The patient with positive smear test is referred by GP to the gynecologist.

Finally, family physicians/general practitioners are also responsible for on-call services when medical assistance is needed. Theses have been organized in on-call round the clock associations in each county. They provide emergency primary care especially during night hours, Saturdays, Sundays and holidays. In the system out-of-hours the patients can be consulted regardless of the doctor they are enrolled. In rural areas there are organized similar Centers which covers an area with few thousands patients. There are no consequences for physicians who don’t want to work in the system of out-of-hours, but their revenues are smaller for than those who are working. The patient in case of illness which cannot wait until he/she reaches the Family doctor where is enrolled, has an option to access freely and without paying the Urgency department, or the ambulance, or the out-of hours system of family physicians.

The general practitioner is in contact with each patient at least five times per year on average. The individual patient chooses from amongst a certain number of doctors within the area of the patient’s residence. A private practice must not have more than 2,200 patients, only if there is no other alternative. Most GPs are independent managers and some of them are working in a partnership or in group practices. The groups share auxiliary staff and facilities, not the patient’s lists. A very small share of GPs is employed in a practice owned by other specialists in family medicine. A full-time working GP has a practice list of approximately 1,800 patients.

The freedom to set up a new practice is restricted by general agreement between the National Health Insurance House, the county branches of Ministry of Health, the county professional association representatives, and the Romanian College of Physicians. The free practice is possible only for the members of the RCP. Under the terms of this agreement, an area where the overall ratio of patients on the list of a general practitioner is less than 2,200 will normally be declared closed to any new practices, but frequently this is not realized because of the intervention of governmental health authorities. However, a general practitioner may, in principle, practice outside the framework of the public social security system agreement but this is not a usual situation. In such a case, the patient would have to pay the entire fee by themselves.

Remuneration of general practitioners

General practitioners are remunerated partly according the number of patients on their list (50{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}) and partly according to the services offered to the patient (50{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}), paid both way by health insurance system accordingly to complicated national provisions. On-call service, smear tests and some prevention activities like the vaccinations are covered by funds coming from Ministry of Health.

GP training

It should be noted that Romanian GPs are medical specialists in Family Medicine on the same level as other specialists (surgeons, internists, etc) since 1992. To be allowed to practice as a GP/family physician, a graduate of a Medical School has to follow a postgraduate residency training program. The option for the residency in Family Medicine is made as for any other medical specialty and the only way to get the certification of specialist in Family Medicine, issued by the Ministry of Health.

The Romanian residency training program takes three years: 18 months in General Practice, 4 months in Internal Medicine, 4 and a half months in Pediatrics, 2 months in General Surgery, 2 months in Obstetrics and Gynecology, 2 months in Medical Oncology, one month each from Infectious Diseases, Psychiatry, Dermatology, Neurology, Diabetes, Epidemiology and Management, and last but not least two weeks of Bioethics. Hospital based training or rotations and monographic courses are considered as additional learning inputs in the training process. There is a Residency Booklet and Log-book with designated aims, general contents, specific targets and evaluation guidelines which guide trainees and trainers along the training program.

This training became mandatory for the new residents in Family Medicine training after 1993. Specific training programs and evaluation, in order to become specialists, were implemented between 2001 and 2003 for those GPs who did not pass the National Residency Contest (since 2005 only the specialists are accepted, according to the actual Ministry of Health regulations) and had been in general practice for at least 8 years.

The specialisation of Family Medicine is equal to the other medical specialties and should be recognised as such by EU legislation and primary care should be considered as a part of health care systems like all others.

If we all are going to reach a consensus on a european curriculum of specialisation in Family Medicine/General Medicine, as we are keen, included in the Professional Qualifications Directive, well, this is going to be a great succes and a deserved reward for our profession.

Dr. Tiago Villanueva – Head of Delegation

Dr. Catarina Matias – Member

Dr. Pedro Fonte – Member

General practice / Family Medicine in Portugal

By Luis Filipe Gomes
General Practice/Family Medicine (Medicina Geral e Familiar, MGF) is mostly a public activity in Portugal . General Practitioners/Family Physicians (GP/FP) are usually state employees working in Health Centers or Family Health Units together with other health professionals.

An important Primary Care reform is currently undergoing. Health Centres (HC) were clustered, and new Executive Directors and Clinical Directors (all GPs) were designated. Within the clustered HC there will be several kinds of smaller units – Family Health Units (FHU – the main focus of the reform, grouping small numbers of GPs, Nurses and Secretaries in order to provide care to a defined population, in respect of contracted indicators), Continuing Care Units, Public Health Units and Personalized Care Units (grouping GPs and staff not yet evolved to FHU).

Portuguese GP/FP work with patients of all ages and their families, managing and co-ordinating health promotion, prevention, cure, care, palliation and rehabilitation.

This includes caring for the elderly as for children and pregnant women, and perform family planning activities as well as managing adult health.

Their work is based on Patients Lists attached to every GP/FP, who acts as a gatekeeper – even if the system allows bypasses.

Portuguese General Practice/Family Medicine is a Speciality represented, like all Specialties in Portugal , at the Medical Association – Ordem dos Médicos – throughout its College; and a Discipline represented in all Medical Schools, where new curricula increasingly include its teaching and promote earlier exposure.

At the international level, Portuguese GP/FM is well represented, and the current Presidency of UEMO is Portuguese.

Portuguese GPs are also represented at WONCA and its networks such as EURACT (there are 64 EURACT members in Portugal ), Equip, EGPRW and the Vasco da Gama Movement.

Dr. Kjartan Olafsson – Head of Delegation

Dr. Ivar Halvorsen – Member

General practise in Norway – increasing its popularity?

A Some important issues in general practice/family medicine in Norway

By Unni Aanes and Eirik Boe Larsen
As a result of several years of bad recruitment to general practise/family medicine in Norway , a personal list system was introduced in June 2001 after years of testing in small scales and difficult negotiations. The system implies that each GP is responsible for a certain number of patients on hers or his list, and for a considerable number of GPs it implied a shift from salary employment to private practise. The system gives general practise/family medicine a key role as the foundation of the national health care system. It gives the patients defined rights to medical services in primary health care and to choose their GP from those available. Although it gives the GPs a clearer defined responsibility, it also gives them better abilities to regulate their workload, increases the GP’s autonomy over his or hers own practise, and for most GPs it has given a needed increased income. Today approximately 99{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all inhabitants in Norway and 99{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all GPs are members of the system. There has been ongoing, independent, scientific evaluation since the introduction, and the reports are generally very favourable both by patients, Government, GPs and other skilled workers in the health care system. Better continuation in patient – doctor relationship is the highest valued aspect from patients view. The amount of vacant GP posts showed a dramatic decline the first few years, but has flattened out, and there still is a recruitment problem especially to the rural parts of the country

To optimize patient care and GP’s workload we still need more GP posts in the cities and more GPs to the vacant posts in rural areas. Although an increased number of medical students have been educated over the last years, a vast majority goes to work in hospitals after finished education. The overall increase in female doctors in Norway is also a lot smaller in the field of general practise/family medicine than in hospital disciplines. Although a high stability among GPs within the system, only 4{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} left their job over a 2,5 years period, this percentage is higher among the younger doctors. As the average age of GPs is stable around 47 years, 25{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} being 55 years or more, it is import to recruit young doctors to be GPs as a large proportion of today’s GPs are approaching retirement age.

The resource gap between primary health care and secondary health care is increasing. Gradually more resources are being put into hospital care while the demanding continued work with elderly, chronic ill and psychiatric patients has been placed in primary health care without an appropriate increase of resources.

The last years there has been a trend of changing small medical districts for emergency wards into larger ones. This is slowly, but steadily gaining terrain, thereby reducing the amount of night duties for the individual doctor. However, in some parts of the country, especially in rural regions, the process still is slow, and frequent night duties is a very negative factor for recruiting GP’s to these areas.

Another problem for recruiting GP’s to rural areas is that the communities, because of bad economy, tend to remove some of the stimulating factors that were introduced some years ago to tempt doctors to come to work there.

GP’s income in Norway is partly a grant from the community depending on the number of patients on the lists, partly a sum paid by the patient, and partly a reimbursement from the Government depending on what medical procedures the doctors carry out. Over the last 5 years there has been a tendency for the Government to increase the amount of money paid by the patient, and reduce the reimbursement accordingly. GPs very strongly oppose this because it makes seeing a doctor more expensive for the patient and reduces the intended economical stimulation for the GPs to carry out certain procedures that should take place in general practise. In 2006 there was a 5{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} increase of the economic burden for the patient, in spite of massive protests from patients, patient organisations, and the Norwegian Medical Association. It is important for us to keep up the pressure on the Government to secure the economical burdens for our patients are not too high.

In 2003-2004 we have experienced a large reform in that the ownership of hospitals has been moved from the counties to the state. As a consequence of this, there has been a tendency to centralize hospital wards into larger units and remove several medical services from smaller hospitals. Although there are several good, both professional and economical reasons for this, many GPs, especially in rural parts of the country, feel uneasy about the increased responsibility for emergency treatment and transport over longer distances hereby placed on them. This new organisation of secondary health care still strives to find its optimal functioning form.

An internet based communication systems between GPs, hospitals, information systems and other actors within the field of medical care has been introduced. The discussion of how to share the costs of this has not found a solution accepted by the GPs, and the implementation of the system is a slow matter and yet not functioning well.

There has been considerable concern among doctors, especially GPs, that the extended control system, intended to control the expenses of the National Health Insurance, as well as the amount of medical information requested by private health insurance companies, could violate the professional secrecy of doctors. It is an important task for our medical organisation to secure that confident medical information about our patients is not spread unnecessarily.

There is still considerable concern among GP’s about the growing amount of GP tasks being taken over by other health workers with shorter education like nurses, physiotherapists, chiropractors, etc. Many GP’s feel that our medical field is being fragmented and partly taken away from us, thereby reducing the GP’s ability to know, and coordinate all medical services to our patients. This seems to be in great contrast to the idea behind the personal list system recently introduced and so strongly advocated both by the public and our politicians.

Over the last years a substantial work has been done to improve the quality of GP’s specialization program. The Norwegian Medical Association advocates the view that every GP having a list population responsibility should be a specialist in general practise/family medicine or take place in an education program aiming at such a speciality. Norway has recognised general practise/family medicine as a speciality since 1985. We have a good system both professionally and financially for CME/CPD, and most GPs participate in it.

After some years of planning and discussions, there has been a large change of structure within The Norwegian Medical Association. Most important is the formalisation of two different sections within the association. One section deals with economical factors, working conditions, health policy strategies etc, and the other section deals with medical skills, education, research and similar items. The structure has been made in a way we hope will enable the two sections to cooperate closely and thereby secure that educational and professional development are coherent with the political goals of the Norwegian Medical Association, without compromising the two bodies’ necessary autonomy to act within their own field of interest.

Dr. John-Paul Tabone – Member

General practice/family medicine in Malta: radical change by 2000?
Dr Philip Sciortino

The Maltese islands consist of Malta, Gozo and Comino, the three of which are inhabited and two uninhabited rocky islands, Cominotto and Filfla. They occupy an area of 31 6 square kilometres, with Malta the largest island at 27 kilometres long, 14 kilometres wide and lays 96 kilometres south of Sicily. There are about 370,000 inhabitants. Infant mortality for 1995 was 8.9/1000 births and life expectancy was 74.88 years for men and 79.49 years for women. Recurrent public health expenditure in 1996 amounted to about Lm 40,000,000 which is 3.3 per cent of Gross Domestic Product (GDP). The number of medical practitioners registered in Malta is around 1,150. This includes 60 foreign physicians/surgeons engaged by the government to occupy certain posts with the Department of Health. Eighty-one per cent of listed doctors are males and 19 per cent are females. Sixty-one per cent possess a first medical degree while 39 per cent have a postgraduate qualification. One thousand and twenty doctors are registered as Malta residents and 130 as overseas residents. Of the 1020 doctors in Malta, 560 are employed by the government. The rest are either in private practice or retired.It is estimated that the total number of doctors engaged in general practice/family medicine is in the region of 260, of which 90 are government employed while the rest practice as solo private practitioners.

Public primary healthcare
Until 1977 GP/FD services in Malta were provided by self-employed solo private medical practitioners and by around 50 salaried government employed District Medical Officers (DMOs)The latter offered free GP/FD services to a section of the population with low income. Each DM0 was responsible for patients within a defined geographical area, attended to patients in government dispensaries known as Bereg and at patients’ homes when so required. DMOs were allowed the private practice of their profession when off duty. The posts of DM0 were abolished as a result of a medical dispute in 1977 and in 1979 the first government health centres made their appearance. Today GP/FD services in Malta are provided by about 170 self-employed solo private medical practitioners and by about 90 salaried government employed doctors who run eight health centres over the island. There is no patient registration in Malta and GPs/FDs have no formal patient lists. Patients are free to access any doctor or specialist whenever they require medical attention. It is estimated that 20 per cent of the population always seek medical attention from Health Centres and 20 per cent always go to private GPs/FDs. The remaining 60 per cent make use of both services. It can be said that the workload is equally shared by the public and private sector

Health centres provide the following services:

Family doctor service
This consists of GP/FD services and emergency services to patients attending these centres. Health centre doctors also perform house visits when the need arises. The service runs on a 24-hour basis, seven days a week. Patients walk into the centre without appointment to see whichever doctor is available at the time. There is little to stop patients from attending at all hours for trivialities. The present system does not encourage the formation of,proper doctor-patient relationship or continuity of care.In addition to health centres, there are 45 government dispensaries in various towns and villages, this being a remnant of pre-1977 DM0 service. They are open for sessions of one to two hours on weekdays and are mostly used by patients requiring repeat prescriptions or medical certificates. Currently doctors and nurses are deployed during every session in these dispensaries.

Other services available through health centres;
• specialist services: health centres cater for specialist clinics in internal medicine, diabetes, psychiatry, ophthalmology, obstetrics, gynaecology, paediatrics and dentistry;

• paramedical services: these include nursing, midwifery, pharmacy, physiotherapy, radiography, podology, speech therapy, optometry and laboratory services;

• preventative medicine: these include immunisation, well baby clinics, ante natal care, cervical smears, glaucoma screening, smoking cessation clinics and weight control clinics. The morale of health centre doctors is low. They are on a salary and most of them feel it is necessary to engage in private practice or as company medical officers while off duty in an effort to supplement their income. This means they have to work a substantial number of extra hours per week in addition to the time they work in health centres. Furthermore, they are faced with an ever increasing work load in addition to unlimited access by patients. The full complement of 90 health centre doctors is rarely reached because doctors are either resigning from their posts or leaving long term temporarily hoping to establish themselves in private practice. Obtaining the highest grades can enter the Medical School of the University of Malta which takes about bO students every two years. Basic medical education takes five years following which medical graduates are obliged to work for two years with the government. Family medicine is not considered as a speciality and there is no Department of Family Medicine in the Medical Faculty. There is a post of one part-time lecturer in family medicine who delivers a number of lectures in general practice and encourages undergraduates to participate in the student-GP attachment scheme. Specific (vocational) training in general practice does not exist. The Malta College of Family Doctors is striving to elevate family medicine to a speciality and to this end has produced a document proposing a training scheme of three years duration for specialists in family medicine. The college also runs a programme of continuing medical education consisting of a three day meeting held in each term of the academic year.

The GP/FD and other professionals
The GP/FD in Malta does not act as a gatekeeper having the responsibility to manage all health problems of patients either at primary care level or by referral to specialists or hospitals. Patients have direct access to all specialists, especially in private practice. Most specialists hold appointments within state hospitals and also operate their own private practices. Patients seeking specialist medical care are either referred by their GP/FD or can go directly to specialists. With an ever increasing number of medical graduates, more doctors are specialising and the GP/FD has to compete with an increasing number of specialists. The number of paramedics such as psychologists, physiotherapists, chiropractors, pharmacists, nutritionists, etc, is also on the increase. Patients again have a tendency to access these professionals directly giving rise to more competition for the GP/FD. Increasing specialisation may easily lead to fragmentation of healthcare which is a threat to integrated, co-ordinatc’d and continued care resulting with ineffective and inefficient use of resources.

Private primary healthcare
There are about 170 self-employed solo GPs/FDs whose services are affordable to the majority of people. Private GPs/FDs rely exclusively on fees for items of service paid directly by patients. Although there is no formal registration private GPs/FDs have a core of patients that consult them most of the time for all their health needs. Most private GPs/FDs run a single handed practice without any secretarial or nursing support. In spite of their limitations, these practitioners provide their patients with an easily accessible, continuous, person orientated healthcare which integrates curative and rehabilitative care, health promotion and disease prevention. Health problems of individuals and families are considered holistically from the physical, psychological and social perspective. Although not forming part of a multidisciplinary team, the private GP/FD assumes the responsibility to coordinate referrals to specialists and hospitals when appropriate and becomes the patients’ advocate on all health matters.

The future
The status of General Practice/Family Medicine (GF/FM) in Malta is still nowhere near the standing it enjoys in many european countries. It can be said that neither the University of Malta nor successive governments have really taken any substantial steps aimed at improving the position of GP/FM in Malta.While the Medical Association of Malta looks mostly after the political interests of GPs/FDs, the more recently founded Malta College of Family Doctors is an academic body concerned with improving the status of GP/FM and acts as a pressure group to influence the development of undergraduate, post-graduate and continuing medical education in addition to promoting quality assurance and research. The future of GP/FM lies firstly with the Government, the University and the medical profession giving recognition to the importance of developing structures to generate appropriately qualified GPs/FDs who are properly trained to meet the challenges posed by Target 28 of the World Health Organization (WHO) which states that, ‘By the year 2000, primary healthrare in all Member States should meet the basic health needs of the population by providing a wide range of health promotive, curative, rehabilitative and supportive services and by actively supporting self-help activities of individuals, families and groups.’Secondly it depends on the disposition of the medical profession to persist with its efforts to persuade policy makers, decision makers, politicians and the general public that, as stated by WHO in its ‘Health for all Policy for Europe’, healthcare systems should be founded on primary healthcare. The medical profession must be clear in stating the changes necessary to provide a cost-effective, equitable, accessible and comprehensive system of primary healthcare embracing the principles as stated in the proposed WHO Charter for general practice family medicine in Europe and which should lead the country to the next millennium.process of recording the applications. The Council has received support from all the specialist advisory bodies in establishing criteria and procedures to deal with these applications. Specialist registration is a voluntary, not an obligatory procedure, but it seems likely that employers will increasingly seek evidence of specialist registration from candidates for career posts.

Workload and workforce
There are 1,647 doctors in the GMS Scheme. There are 600 doctors working in private practice. The current annual requirement of new entrants to the existing GMS Scheme to cover death, retirement and service expansion is only 25 to 30 per annum. There are 55 graduates from the specific training schemes annually. The only method of entry to the GMS Scheme is by interview for an advertised post, or as an ‘Assistant with a View’. This is now proving unacceptable to the excess 25 to 30 specifically trained doctors annually coming off the training schemes who do not succeed in getting a GMS position in a location suitable to them, usually where they have set up in private practice. This annual excess of suitably qualified doctors are seeking an ‘open access’ system to GMS posts. The IMO’s position is that if such were allowed and accepted, there would be a multiplicity of smaller lists (current average GMS is 720 patients). This would have a depressant effect on average GMS incomes and would lead to a lack of opportunity for ordered development in genera] practice. An ‘open entry’ system into the GMS could only be considered if GMS eligibility was extended and its introduction was part of an overall workforce plan for general practice. This plan would take into account the viability of practices and the planned distribution of lists, while maintaining the essential element of choice for the patient. An ‘open-entry’ system would have to take into account the important question of the number of medical school graduates and the number of specifically trained graduates to be produced each year – keeping in mind the lack of European consensus on strict ‘numerous clauses’ in other Member States. The general practitioner in Ireland is regarded as the doctor a patient sees in the first instance for medical treatment and advice. The GP treats individuals and their families in context and provides continuity of care. The GP is increasingly moving from treating acute episodic illnesses to more active management of many chronic illnesses. The recent National Survey 1996 showed the high workload the average doctor carries. This workload is steadily increasing. This issue of increasing workload and future workforce planning must go hand in hand. General practice is now becoming architecturally visible, the staffing and equipment levels are improving, but the resourcing (between private and state) is still inadequate to provide a modern competent service. The lack of full patient registration is hindering progress, especially any proposed National Cancer Screening Programmes. The skills mix required will put intolerable pressure on single handed doctors practising alone. The provision of an (increasingly demanding) out-of-hours service after a hard days work has become an unacceptable strain for many. New working methods will need to be piloted to alleviate this strain. For those without access to ‘doctor on call’ services, the United Kingdom (UK) model of cooperatives, providing out of hour cover from a central base with agreed community guidelines for home visits, may have some benefit for many rural doctors. Others may be happy to continue with rota arrangements.

Dr. Carlo Maria Teruzzi – Head of Delegation

Dr. Antonino Maglia – Member

Dr. Giuseppe Enrico Rivolta – Member

Dr. Liam Lynch – Head of Delegation

Dr. Lynda Hamilton – Member

Dr. Henry Finnegan – Member

Dr. Ray Walley – Member

Primary healthcare in a post-communist country devoted to the principles of the united Europe.

Ferenc Hajnal MD PhD, Head of the Hungarian UEMO Delegation

It is internationally accepted that the optimal method of general medical practice is family care. Over the last three decades, countries possessing developed healthcare system have introduced the family medicine model in the field of primary healthcare.It is based on the relationship between the patient’s family and community and the attending physician, as well as the mutual respect based on this, which leads to the ability to fulfil the criteria of the contemporary patient-doctor relationship. This system supposes the hiring of highly educated experts of the area. Following up and management of patients is the only way to meet the criteria of the principles of prevention, and the expenses are lower compared to any other models. In Hungary, a major part of the reform of the old healthcare system has been a transformation of the old primary healthcare system by the international standards of family medicine. In addition, each step of the reform has continuously raised the professional competence of the doctors employed in primary healthcare. The main shortage of the old ‘district doctor’ system which still exists in Hungary was that it assumed but did not guarantee and control its professional standards. The majority of doctors under that system did not have the necessary special education and/or qualification. Their former postgraduate education was often accidental, formal and ineffective. The state of the district system in pediatrics is exceptional. It was based on the willingness of educated paediatricians to work in outpatient community practices. However, due to the legal regulation and everyday practice, the general paediatricians were not allowed to provide care to adult population unless there was no general practitioner (GP) available, and vice versa. So except for the small villages, primary healthcare has been split, excluding even the chance of the model of family care in larger settlements. Therefore, the workers of the adult and child sides of a necessarily integrated profession have lost their interest in the opposite age group: their knowledge has become insufficient on one side, useless on the other. On the contrary, in the small rural settlements the least educated doctors had to take the responsibility for the health of the whole population. It is widely accepted that the diploma of general medicine, in any educational system, is not sufficient to maintain the necessary professional standard in primary healthcare. So the postgraduate medical education in the family healthcare modes is inevitable; necessary to raise the level of education to meet criteria. By the law on higher education accepted in 1993, either undergraduate or postgraduate education is designated as duties of the Universities. Order No 6/19993 of the Secretary of Welfare on the medical specialisation states: “A five-year training period is mandatory for freshmen medical doctors, after which the subject doctors may apply for the examination of family medicine specialty. The first two years of this period should be spent, as resident, in teaching hospitals. Doctors, working in the network of primary healthcare at the date of March 1, 1993, were in duty to take the exam of family medicine speciality, after completion of an individual postgraduate training programme, up until December 31, 1998.” Our family medicine residency programme is organised nationally, with 100 young colleagues enrolled every year. The starting conditions of the different Hungarian Medical Universities had been diverse. The Postgraduate Medical University in Budapest has been able to undertake this new task with its whole staff and budget. The National Institute of Family Practice, founded in 1992, and the Hungarian Scientific Association of General Medicine, both settled in the capital, could help the educational tasks.In contrast, the provincial medical schools used to have no such facilities because those have been charged with only the undergraduate education of medical students. By the end of 1998, the catch-up period for GPs concluded and practically all of them have passed the examination for specialty in family medicine. So from 1999 the whole Hungarian population is provided by specialists GPs in the primary healthcare. Now the Hungarian medical universities continue their work in the field of continuing medical education either for the primary or secondary care professionals.

The situation of general practitioners in Germany

Ullrich Weigeldt, Head of the German UEMO Delegation

There are essentially two types of public legal entities in the field of medicine in Germany: General Medical Council, which are concerned primarily with aspects of specific training and occupational law, and the “Kassenärztliche Vereinigungen” (Associations of Statutory Health Insurance Physicians), which all family doctors and specialists admitted to practice in Germany are required to join. These “Kassenärztliche Vereinigungen” negotiate a total fee for all services rendered by physicians in private practice with health insurers and distribute funds from this amount.
In the past, this distribution process has led to a relative increase in the proportion of fees paid to specialists in comparison to those paid to family doctors. Even the committed efforts of family doctors within these organizations have failed to reverse this trend.
German family doctors are organized within a strong association, the “Deutscher Hausärzteverband” (German Association of Family Doctors), composed of some 33,000 members out of a total of roughly 50,000 physicians registered as family doctors. According to information available to us, not all of these individuals actually work as family doctors, as a number of them provide services in such fields as psychotherapy, homeopathy, and other niche specialties.
Political activity in recent years has focused to an increasing degree on the implementation of competitive elements in the health care sector. During the same period, the number of statutory health insurance providers (public legal entities covering 90{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all insured individuals, in addition to private health insurance providers, which account for about 10{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}) has fallen from over 1000 to approximately 160.
Through lobbying and public relations activities, the Deutscher Hausärzteverband has taken advantage of this orientation toward competition to achieve autonomy for family doctors with respect to fee rates. A law was passed providing for direct agreements between the Hausärzteverband and health insurance providers. The legal entities are explicitly excluded from this process.
Through these contracts, which have now been concluded with all health insurance providers in Baden-Württemberg and Bavaria, and to which family doctors and insured may subscribe voluntarily, we have achieved significantly higher fees for family doctors, a reduction of red tape and an independent advanced training programme oriented towards the problems faced by family doctors. The insured bind themselfes to contact first a general practitioner.
The fee system consists of a flat-rate annual fee which does not depend on the number of contacts, a flat-rate fee for extended treatments and, in particular, a flat-rate fee for the treatment of chronically ill patients. The objective of this system is to reduce the frequency of patient-physician contacts in Germany (currently the highest in the world at 17.9 contacts per capita per year) while increasing the amount of time available for consultation with each patient.
On the basis of these contracts, participating physicians also accept certain requirements regarding the prescription of medications in accordance with contracts between health insurers and pharmaceuticals. They take part in quality forums and advanced education programmes for general practitioners, which are required by law to focus on such matters as physician-patient dialogue, psychosomatic disorders, pain and palliative treatment and geriatric medicine. The development of an independent IT structure which can be integrated into existing systems will facilitate billing and cost-effective prescription.

End of the merging family medicine and general internal medicine
Since May 2010, family medicine has once again become an autonomous field of medicine in Germany following the failed attempt to merge the fields of family medicine and general internal medicine since 2002. The Association of Internists was unwilling to relinquish the autonomous field of general internal medicine and withdraw from the field of general medical practice. The resulting advantage is that family medicine now – as it was before 2002 – has the status of an independent field of medicine, which has a favourable impact on education and research and promotes the development of a strong presence in university education. Specific training in family medicine lasts 5 years and includes at least 2 years of work in general practice . Exact requirements are established by the General Medical Councils in each state. Ideally, minimum periods of training in surgery and paediatrics will be required in addition to the mandatory period of training in internal medicine.
The purpose of funding support for specific training in general medicine provided by health insurers and the “Kassenärztliche Vereinigungen” is to halt the decline in the number of general practitioners working as family doctors. Consequently, only a small portion of compensation for physicians undergoing specific training as general practitioners will have to be paid by practice owners.
In spite of this increased funding support (which has not always been provided at consistent levels in the past, however), the number of physicians undergoing advanced training is significantly lower than that of retiring physicians. From 2000 to 2008, 1560 fewer general practitioners entered the field of family medicine than left it. The discrepancy amounted to 590 general practitioners in 2008 alone.

Cologne, 20th of July, 2010

Dr. Arto Virtanen – Head of Delegation

Dr. Jaana Puhakka – Member

Our healthcare is and will be financially based on taxation. The strong economic regression at the beginning of the 90s has led us to seek solutions in cost management. The high unemployment rate and the ageing of the population, as well as the new more expensive diagnostic and therapeutic possibilities, have led to a financial problem of the healthcare. With the renewal of the state participation system in 1993, there was a trend to shift the financial responsibility to the communities. At the same time the basic services were not clarified, and there is uncertainty about which services the communities should offer to their inhabitants. The responsibility for organising services has been understood in quite different ways in different communities. In this way the organisation of the healthcare service has been changing and growing differently in different parts of the country. The basic services should be based on legislation anyway, but the legislation has not been changed with the financing structure.

The basic health service has always been prioritised in preventive work. As early as in the 1940s we had our network of maternity and childcare instruction clinics. The Finnish mortality rate in maternity and perinatal groups is very low, even inside the European Union (EU). As the family doctor system emphasised the availability of medical care, at least in its beginning, there was a fear of preventive care decreasing. Fortunately this did not happen. Basic healthcare has taken responsibility for most of the preventive activities. The family doctors have understood the significance of this work for the welfare of the citizens. More than half the Finns already belong to the family doctor system, so the availability of the medical care has improved and there are no more queues for general practitioner (GP) consultation. Medical care takes place mostly in the hours of consultation and home visits are rare. There is a home care system in our health centres where nurses, together with the family doctor and with social care home helpers if needed, try to support very sick people in living at home. Home visits of doctors are still very rare, but the aim is to increase them in the future. Our system is also more focused on hospitals than any other systems in the EU, but this will be changed. Our family doctors function in health centres comprising several doctors, with x-ray and laboratory services produced by the health centres themselves at their disposal. Finland is very sparsely populated and particularly in the north of the country the health centres function more like hospitals. There are no common borders for the developing functions, even with expertise, so there are many healthcare units where the GPs operate more as if for specialised care. In more crowded areas, the health centres and the hospitals will increasingly co-operate, unified by the lab and x-ray functions, when the data systems develop and the same unit can serve both health centre and the central hospital.In developing healthcare, the pressure of increasing costs is high and the quality requirements have emerged. There are more and more investigations done to solve the overlapping and interpenetrating functions of hospital care, basic healthcare and social care. The evidence-based care has come where the medical care is always based on evidence. There are regional medical programmes increasing the quality and emphasising the differentiation, improving the co-operation and data chains. The regional care programmes are done in co-operation with specialists, GPs and nurses.Several quality programmes and projects have been started. Instead of regional care-taking programmes, the thinking is moving towards care chains, especially including the problems of interfaces. The aim is to improve the status of patients, offering high quality care and good co-operation between health and social care systems. The patient should always be in the right place to be taken care of and so the economic gain would be clear. The real time data change is obligatory for good care.Our healthcare system is based on strong basic healthcare in the health centres. The availability of services can be more important than the right to choose the doctor. The GP’s position as a gatekeeper has been emphasised and the family doctor system has made it possible. In the doctors salary system the availability of medical services has been emphasised, meaning that only a part of doctor’s income is salary: the rest is comprised of fees for service and fees for capitation. The fee for service system will direct the activities of the GP and emphasise preventive activities, especially in the last salary contracting movement.

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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of GPs are female
55{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} in age group 50 + years
97{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of GPs are private
cca 85{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} cap., 15{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} plus
Regulation fee: CZK 30,- per visit connected with clinical exam. (cca 10{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} Clinical health care, Of it:
48{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} internal medicine
19{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} locomotive organs
16{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} small specialites (dermat., ENT, etc.)
4{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} injuries
13{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} nonspecified
12{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} Preventive care: 2 y exam., CoReCa screening (OBT), Mammography, Immunisation
1{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} 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!

In general

Croatia is European country in transition with a population of about 4 300 000. It is located in central Europe, covering an area of 56 542 km2 and with 5835 km of coastline. Croatia’s political system is a parliamentary democracy. Regional and local government is organized on two levels: 20 counties plus the city of Zagreb, and 426 municipalities.

Organisation and financing of health care

Croatia’s health care system is based on principles of inclusivity, continuity and accesibility. The network of health care providers is organized in a way that makes it accessible to all citizens.

Croatia’s health care system is based on the principles of social health insurance. Provision and funding of services are largely public, although private providers and insurers also operate in the market. The health care system is dominated by a single public health insurance fund: National Health Insurance Institute (NHII) which is financially part of State Treasury. To ensure quality of access to all citizens, NHII-contracted health care providers operate within the framework of the national health care network. The network determines allocation of public financial resources between the 20 counties according to morbidity, mortality, demographic characteristics etc. The central government continues to play a dual role as the purchaser and provider of health care through its influence on the NHII funding, on the one hand, and as the largest owner of hospitals and public health institutions, on the other. Ownership of secondary and tertiary health care facilities (buildings) was distributed among the State, counties and cities. Tertiary health care facilities, comprising clinical hospitals, clinical hospital centers and national institutes of health, remained state-owned. Secondary health care facilities ( general and special hospitals ) and county institutes of public health became county-owned.

Funds for social health insurance are collected mainly from payroll taxes paid by employees, the self-employed and farmer’s contributions. Social health insurance for certain vulnerable categories of the population is partly cross-subsized from payroll contributions and additionaly funded by transfers from the central government budget and from county budgets. These categories include the unemployed, disabled, elderly, people under 18, students, war veterans and the military. Patients are required to pay for acess to certain publicly provided health services through co-payments or to buy complementary health insurance. Certain groups are exempt from paying co-payments. These include the unemployed, disabled, people under 18, students, the military, war invalids and multiple voluntary blood donors.

Position of GP/FM

According to the Croatian Health care Law, the two main roles to be fulfilled by primary health care are: being the foundation of the health care system, and gatekeeping. Primary health care is organized as a network of first-contact doctors. Each insured citizen is required to sign up with a specific GP. Primary health care is delivered through a network of individual offices, larger units comprising several offices ( some including small laboratories ), and health centers that provide general medicine consultations, primary care gynecology services, care for pre-school children, school medicine ( preventive medicine and vaccinations of school children ), occupational health services and dental care. Most of primary health care is provided through private practices comprising a team of doctor and a nurse, financed by capitation and some additional payments .

General practice/family medicine treats patients of all ages. GP/FPs are required to treat patients in their offices, provide home visits and provide preventive check-ups. Doctor and nurse teams are independent entrepreneurs owned by the doctor and contracted by the NHII. Each GP is expected to carry an average of 1700 people per year on the roster ( with huge differences, from more than 2000 at eastern part of Croatia to rural and island practices with 400 patients ).

The total number of licenced doctors in Croatia is about 18000 and according to the data from NHII in April 2012 there were 2340 GP/FPs. 47{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of them are specialists, and only 23{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} are men. Most of the GPs/FPs , 85{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}, work as self-employees with contracts to NIHI (official data from Croatian Medical Chamber, 11.01.2012). 15{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of GPs/FPs work as public employees at Medical Health Centers.

There is a shortage of all kinds of doctors in Croatia especially GP/FPs, so there is an urgent need to create the way to keep young doctors in family medicine. Young doctors do not want to go to mostly isolated family practices where they must take the responsibility for managing practice from medicine to administrative work, taxes, finding replacement for themselves and nurse in case of absence. Vocational training for FPs is also demanding so there is a great fall in interest for family medicine.

Education and training for GP/FM

There are four undergraduate medical schools in Croatia. They are situated in Zagreb and the regional centers Osijek, Rijeka and Split. Medical school is completed over six years. Prior to practicing, graduates must take a one-year internship and pass the state exam. Further specialization takes place after the internship.

Medical training for GP/FM according to the new law lasts 4 years. It consists of theoretical part with final exam ( 6 months ), period of visiting hospital departments and period with teacher (“mentor”) in family practice ( 6 months – 1 year ). At the end of training there is specialist exam with written part of exam, practical part ( OSCI ) and oral exam with cases from GP/FPs practice.

CME and relicensing

GP/FM gets the license for work by Croatian Medical Chamber (CMC) and CMC is National Authority for CME. The condition for relicensing is collecting of 120 points during 6 years. It can be done through few ways – CME courses, participating on local or international professional medical meetings or conferences, publishing the papers in magazines or books, participating in different kinds of lecturing in community. In case of not collecting the needing points GP/FM needs to pass the exam after period of 6 years.

Pharmaceutical supply

Patients in Croatia are supplied with medicines by public and private pharmacies. Pharmacies have largely been privatized, mostly by renting existing pharmacy premises to private pharmacists. Privatization has largely been successful in improving the supply of, and access to, drugs, but the undesirable consequence has been that pharmaceutical expenditure has increased.

Patients who are insured and additionally insured pay nothing for medicines from the main list and some amount for the additional list of medicines. Some of the medicines require additional paying by patients. The NHII controls drug prices and has been imposing price cuts.

To curb the volume of prescriptions, the NHII has imposed annual limits of the number of prescriptions per beneficiary and limited the number of drugs per prescription. Exceptions are permitted for special cases. Overspending by individual GP/FPs is subject to financial punishments.

Dr. Pierre Louis Druais – Head of Delegation

Dr. Patrick Ouvrard – Member

Dr. Jean Pierre Jacquet – Member

Dr. André Willy – Head of Delegation

Dr. Etienne Lemaire – Member

The Republic of Serbia

Role of General practitioners in Serbia Healthcare system

Dr Branka Lazić

Serbian Medical Chamber

The Republic of Serbia is a country situated at the crossroads of Central and Southeast Europe with a population of about 7 000 000 citizens covering an area of 88 361 km2. Its capital, Belgrade, ranks among the oldest and largest cities in Southeastern Europe. Serbia is a member of numerous organizations such as the United Nations, Council of Europe, Organisation for Security and Co-operation in Europe, Partnership for Peace, Organisation of the Black Sea Economic Cooperation , and Central Europian Free Trade Agreement , it has been an EU membership candidate since 2012.

Serbia is a parliamentary constitutional republic composed of municipalities/cities, districts, and two autonomous provinces – Vojvodina in the north, and Kosovo and Metohija in the south.There are 138 municipalities and 23 cities , which form the basic units of local self-government. Apart from municipalities, there are 24 districts, with the City of Belgrade constituting an additional district.

Organisation and financing of health care

Serbia’s health care system is organised by the Ministry of Health and is managed by the National Health Insurance Fund, which covers all citizens and permanent residents. All employees, self-employed persons, and pensioners must pay contributions to it. Contributions are based on a sliding scale, with wealthier members of society paying higher percentages of their income.

The state fund covers most medical services including treatment by specialists, hospitalisation, prescriptions, pregnancy and childbirth, and rehabilitation.

The aim of the organisation is to make the health system equal for every citizen no matter what their status.

Private healthcare is also available for those citizens who can afford it (pay from pocket and private insurance). The largest number of private institutions are small specialized clinics. Private practice still not included in national healthcare system. Still there is lot of space for developing in private practice.

Hospitals and clinics exist in all major towns and cities of Serbia. Patients are admitted to hospital either through the emergency department or through a referral by their doctor.

Dental care in Serbia is in the private ownership and is of a good standard. Prescription medicine is only available from a qualified and registered pharmacy or from a hospital pharmacy. There are two types of pharmacy, state-owned and private.

Primary level of health care in the Republic of Serbia is provided in 157 state-owned primary health centres (PHC) , which cover the territory of one or more municipalities or towns . PHC is based on a selected doctor, or “chosen doctor”, and a team of chosen physicians, which consists of doctors of general medicine and occupational medicine specialist for the adult population, pediatrician for children of preschool and school age (including antenatal care, immunizations, preventive programs in the health care of children ), gynecologists for women over 15 years and dentists for children and students under the age of 26 . Citizens can register with the doctor of their choice.

In addition there are emergency services, diagnostic services, certain specialist-consultative out-patient health care services, community nursing services etc.

A selection of various services in a primary (community) health centre depends on the number of citizens in a municipality, as well as on their health needs and distance to the nearest general hospital. From about 20.000 doctors (public service) in Serbia, 18{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} are working in PHC. Per doctor in PHC there are approximately 1450 citizens ( in urban area about 2000 and in rural 400). Total visits per doctor in PHC are 5876 (varies from service to service).

Position of GP

GPs make referrals, prescribe drugs, treat acute and chronic illnesses, and provide preventive care and health education. The 4031 doctor works in general medicine in state institutions, only 44{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} are general practitioner specialist.

The strengthening of the Department and the Health Center as a teaching base would increase the interest of young doctors for the specialization in general medicine and the acquisition of academic titles.

There is a shortage of all kinds of doctors in Serbia especially GPs, so there is an urgent need to create the way to keep young doctors in family medicine in Serbia.

Education and training for GP

There are five undergraduate medical schools in Serbia. They are situated in Belgrade and the regional centers Kragujevac, Niš , Novi sad and Priština. The University of Belgrade was founded in 1808. Since 2012. it has held a place on the Shanghai world ranking list of 500 best universities, in 2016. it was listed among the top 300 World universities

Medical school is completed over six years. Before practicing, graduates must take a half-year internship and pass the state exam. Further specialization takes place after the internship.

Medical training for a GP specialist according to the new law lasts 4 years. It consists of a theoretical part ( 12 months ), a period of visiting hospital departments (12 months) and a period with a teacher (“mentor”) in family practice (24 months ). At the end of training there is a specialist final exam.However, a licenced doctor can practice as a GP without postgraduate medical training and without a mentor.

CME and relicensing

A GP gets the license for work by the Serbian Medical Chamber (SMC) and the SMC is a national authority for the CME. The condition for relicensing is collecting 140 points during 7 years. It can be done through a few ways – CME courses, participating in local or international professional medical meetings or conferences, publishing papers in magazines or books. In case of not collecting the needed points a GP needs to pass the exam after a period of 7 years.

Medical Chamber of Serbia

MCS is an independent, professional, self-contained,self-financed organization, re-established in 2006 together with the chambers of other healthcare workers. Its status is defined by the Law on Chambers of Health Workers published in the “Official Gazette of the Republic of Serbia” 107/2005. All doctors of medicine who, as a profession, perform healthcare activity must be members of the SMC . In Serbia, the Medical Chamber was founded in 1901. at a time when chambers were established in other European countries, as professional associations, which can perform self-regulation and control of their membership. But at 1945. SMC`s work was subsequently interrupted by the decision of the Goverment

At present, 32 643 doctors are registered in the directory of medical practitioners, who hold a valid license, who carry out health care activities in state and private health institutions and private practice as a profession. One of the main strategic goals is to improve the status of a doctor of medicine as well as raising the level of expertise and ethics within the proofs. SMC join and actively participate in all international medical organizations such as CPME, WMA, ZEVA, EFMA, UEMS, and UEMO.

Austria Modal

EMO member: Austrian Medical Chamber (Österreichische Ärztekammer), www.aerztekammer.at

Head of Delegation: Dr Martina Hasenhündl (general practitioner)

The Austrian Medical Chamber

According to the Austrian Medical Act, the Austrian Medical Chamber represents the professional, social and economic interests of all doctors engaged in medical activities in Austria. Furthermore, it acts as umbrella association under public law for its nine members, the medical chambers in the Austrian provinces. Membership is obligatory for every doctor wishing to pursue medical activities in Austria.

Activities and Services

Legal responsibilities of the Austrian Medical Chamber include, besides others, admission to and administration of the medical register, as well as recognizing foreign medical qualifications. Furthermore, the Austrian Medical Chamber is the competent authority for issuing medical diplomas and for conducting specialist and GP qualifying exams. Further competencies comprise the elaboration of concepts, expert opinions and proposals regarding the Austrian health care system, including the right to comment on draft bills or enacting guidelines on medical fees, on the medical code of conduct etc., as well as concluding contracts with social insurance institutions and collective agreements. Executing disciplinary legislation and arbitration also belong to the responsibilities of the Austrian Medical Chamber. Moreover, the Chamber is involved in the elaboration of specialist and GP training programs, and it has its own institution offering CME/CPD for Austrian medical doctors called Austrian Academy of Doctors (Akademie der Ärzte). The Chamber provides counselling for its members in issues relating to professional law and in international matters. Information for members is provided on the website and in the journal of the Austrian Medical Chamber (Österreichische Ärztezeitung).

Education and training

Medical training in Austria is characterized by a dual system. Degree courses in medicine, which have a minimum duration of at least six years, can be taken at public and private medical universities. In the course of a comprehensive reform, obligatory practical training was integrated into medical university studies, in order to better prepare students for medical practice.

In order to work as a general practitioner, the medical training regulations currently prescribe 42 months (3 ½ years) of training, structured in 36 months of hospital training and 6 months of training in a GP practice or a group practice recognized by the Austrian Medical Chamber. However, the total duration will be raised to 45 months in 2022 and subsequently to 48 months in 2027.

At the end of training or after 30 months of training at the earliest, the GP trainees have to complete a written final qualifying exam in general medicine. The completion of the examination is a prerequisite for engaging in independent medical practice.

CME/CPD

In Austria, the practice of the medical profession is subject to mandatory CME/CPD requirements. This requirement is established both in the Austrian Medical Act and by the Regulation on CPD (DFP-Verordnung), a decree issued by the Austrian Medical Chamber. Since 2016, every licensed doctor, GP or specialist has to provide evidence of CME/CPD to the Austrian Medical Chamber on a regular basis. Within a period of 5 years, at least 250 DFP (CME) credits have to be collected. CPD activities can be documented in an online CPD account to which the CPD provider transfers credits. CME/CPD events are accredited by the Austrian Medical Chamber via the “Austrian Academy of Doctors”. Accreditation is given both to CPD providers and individual CPD activities. Non-compliance with CME/CPD requirements entails sanctions which may range from a written reprimand to an occupational ban in the case of firm refusal to meet the CME/CPD obligations.

E-Health (e-card, ELGA, e-Medikation)

In 2005, the so-called “e-card” has been introduced in Austria. The e-card is a personalized chip card of the electronic administration system of the Austrian social insurance institutions (health, pension, accident or unemployment insurance). The system supports administrative processes between the insured person, the employer, the contracting parties (doctors, hospitals, pharmacies etc.) as well as the social insurance funds. The card provides personal identification data such as name and insurance number and every patient is obliged to show it when visiting a doctor or hospital. By reading the e-card via the secure data network the doctor or hospital checks if a person is insured and which health insurance institution is responsible for paying the medical treatment. This data is requested online from the e-card system and is not stored on the card.

As the e-card is based on a key card principle, it also allows access to ELGA, the Austrian electronic health record (Elektronische Gesundheitsakte). ELGA aims to elaborate an information system that provides doctors, hospitals, care facilities and pharmacies access to a patient’s health record. Various health care facilities create different health records such as medical reports. ELGA processes this data and makes it accessible electronically for different users via a link. Since December 2015, hospitals in Austria are obliged to implement this system.

In Austria, the project of introducing “e-Medikation” as a feature of the electronic health record (ELGA) is in progress. E-Medikation is an application in the form of a database containing information on the medications that have been prescribed and dispensed. However, e-Medikation is not equivalent to purely electronic prescribing, and the patient will continue to receive an ordinary paper prescription. It will be mandatory for all self-employed doctors under contract with a health insurance fund. Physicians practicing only on a private basis, without holding a contract with a health insurance fund, can decide voluntarily if they want to use it. Patients have the possibility to opt out from the e-Medikation feature, or from ELGA as a whole.

Quality assurance

The obligation of medical quality assurance is stipulated in the Austrian Medical Act. For this purpose, the Austrian Medical Chamber established the Austrian Society for Quality Assurance and Quality Management in Medicine (ÖQMed) which is legally required to perform quality evaluation and quality control of medical practices at least every five years. Further responsibilities of ÖQMed include the elaboration of quality criteria for single practices and group practices, as well as the maintenance of a quality register on national level.

Number of physicians in Austria (as of January 12^th 2018)
Total number of physicians:	45 596
– male physicians:	24 004
– female physicians:	21 592
General practitioners:	13 523
– male:	5 539
– female:	7 984
Self-employed GPs:	6 590
– contract with social insurance:	4 002
– no contract with social insurance:	2 588

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