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 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.
