Although clear progress has been made in improving health systems, patients continue to experience shortages of primary care physicians (especially in rural areas) and longer waiting times. They are also asked to contribute more money to a system that seems insufficiently responsive, spending a vast proportion of its resources on specialized
curative services rather than preventing disease and promoting health: activities that could eliminate an estimated 70% of the global burden of disease (38). Rising care costs are of particular concern in the current global economic climate, increasing the risk of more people being without access to care.
Primary care physicians face challenges as well, such as too many, often older, patients with increasingly complex chronic comorbidity that would need more time for consultation, a growing administrative burden, inability to remain up to date with new clinical innovations and in general too little time to do a good job (46). This applies across the Region. For instance, a recent study in Kyrgyzstan showed that excessive reporting requirements adversely affect the quality of care by limiting the time available for patients. During an average working day, family doctors spend only 34% of the time available on direct patient care and the rest on documentation and reporting (47).
Aspects of practice organization that can explain the level of organizational access vary considerably between countries. Table 3.2 shows that GPs in Finland and Sweden can dedicate more time to their patients than their colleagues in the Netherlands and the United Kingdom. Nevertheless, waiting times between the appointment and the actual consultation appear to be higher in Finland and Sweden. GP workload is another aspect that affects organizational access and patient satisfaction, and is measured here as the average number of office consultations, telephone contacts and home visits. This varies considerably between countries, with GPs in Germany and Hungary working more than 10 hours per day.
High workload in some countries might also indicate shortages or a declining workforce in primary care. For instance, in Germany the number of GPs within the overall physician workforce declined by more than 10% from 1990 to 2007, while the number of primary care physicians remained more or less constant and at a high level in France (Fig. 3.1). Finland, a frontrunner in Europe for a strong primary care system, lost 25% of its primary care
Germany
In 2006, Germany attempted to strengthen the gatekeeping role of GPs, traditionally based on private practitioners operating mainly in solo practices and competing with specialists for patients. The social health insurance system offers voluntary gatekeeping contracts to the insured population. People register with a GP of their choice and agree always to see this GP first before contacting any kind of specialist. People entering into and complying with the contract save the obligatory €10 user charge per quarter.
By May 2007, 5.3 million insured people, many of them older or chronically ill, had subscribed to a gatekeeper contract. Evaluation of the effects shows that 90% of the people registered with a GP did not perceive any difference in care delivery after joining the contracting model (44).
Kyrgyzstan
Primary care was one of the cornerstones of the health sector reform programme that started in 1996. The main characteristics were an organizational and financial split between primary and hospital care, with newly created family group practices as the organizational locus of primary health care. In addition to nurses and midwives, family group practices were staffed by at least one physician (family doctor), and this team approach was introduced at all service delivery levels. Previously, people had been required to register with a family doctor of their choice, but each family group practice would serve up to 2000 people. The new family doctors thus act as gatekeepers to the secondary and tertiary levels.
As part of a second phase of restructuring the delivery system, traditional polyclinics were merged into comprehensive polyclinics for men and women and, from 2002, polyclinics were further reorganized and renamed as family medicine centres. They now combine primary care and secondary outpatient services, ranging from general health care to specialized care and diagnostics – the aim is to gradually decrease the number of specialists working in these centres.
Evaluation has shown that health care has shifted from secondary care to primary care. Increased volume and coverage of primary health services coincide with declines in referrals and unnecessary hospitalization (45).
Box 3.1. Aims of primary care reforms in Germany and Kyrgyzstan
1990 1995 2000 2005 2007
GPs (%)
Year Finland
France
Germany United Kingdom
Hungary Kyrgyzstan
Lithuania Slovenia 0
10 20 30 40 50 60
Source: European Health for All database (9).
Fig. 3.1. Percentage of GPs among physicians in selected European countries, 1990–2007
physicians between 2000 and 2005. This has been attributed to: physicians complaining about a loss of control and influence over their own work, less professional incentives in terms of support from colleagues, the sharing of on-call duties and limited opportunity for research and continuing education compared with specialists working in hospitals (48). The level of remuneration, which is relatively low compared with the Netherlands and the United Kingdom, has also contributed to opposition to primary care among GPs in Finland (49).
Table 3.2. Aspects of workload and practice organization in primary care in selected countries
Country Average inhabitants
per GP (list size)a Number of patients treated Average length of
patient consultation (minutes)
GPs with waiting time ≥ 2 days (%)b Office consultations (per day) Telephone contacts (per day) Home visits (per week)
Croatia 2010 44 6 6 12 11
Finland 1582 19 6 3 18 80
France 943 16 7 27 20 12
Germany 2110 50 11 34 13 25
Hungary 1975 48 7 27 15 0
Lithuania NA 17 3 15 17 0
Netherlands 2310 32 12 21 10 6
Slovenia NA 42 8 7 13 18
Spain 1970 39 4 9 10 23
Sweden 2870 16 7 2 24 91
United Kingdom 1892 34 6 19 8 31
a Data are from 1993.
b GP-reported days between appointment and consultation for non-acute problems.
NA: not available.
Source: adapted from Boerma (43).
In central and eastern Europe and central Asia, the picture of the primary care workforce clearly differs from that in western Europe, with a much lower baseline. Nevertheless, the challenge in establishing a more people-centred system is essentially the same: human resources in primary care remain scarce. Countries such as Kyrgyzstan, Lithuania and Slovenia have increased the number of physicians working in primary care since 1990, but the percentage of 12–20% is still relatively low compared with physicians working in other sectors (Fig. 3.1). In addition, countries such as Croatia and Slovenia are struggling with the fact that many of their GPs have retired or will retire soon, and the new generation is not yet ready to replace the old one (50).
Although such information on shortages in the primary care workforce is easy to find, dimensions such as coordination and integration are less demonstrable. There are no firm indicators or data, and they differ from country to country. Primary care is not a closed and controllable environment, such as a hospital, so sometimes only proxy indicators based on surveys can give some indications of existing barriers.
Turkey has embarked on large-scale reform of family medicine in primary care. A study of its effects in two provinces (Table 3.3) revealed, for example, that not all family doctors routinely kept medical records for each patient visit, a prerequisite for informational continuity. Since 2005, however, routine clinical records have been kept for all patient visits and, since May 2009, all records have been transferred to the Ministry of Health electronically. Most family doctors also had difficulty in generating a list of patients by diagnosis or health risk, which would be required to analyse the practice population and organize coherent treatment plans for individuals or groups in this population. Such data must be compiled for coordinated and integrated care. Although weaknesses in the coordination and interface between primary, secondary and tertiary care are quite common in a transitional process – Turkey is just one example – patients seem to value governments’ efforts to bring services closer to them.
About 95% of the patients sampled in the two provinces in Turkey declared that they were
“satisfied with how my family doctor treats me” (51).
Table 3.3. Availability and use of clinical information considered prerequisites for continuity and integrated care based on self-reported information from family doctors in two provinces in Turkey
Items Bolu (N = 37) Eskişehir (N = 41)
N % N %
Keeping patients’ medical records
Routinely 13 35 20 49
With some reservation 24 65 21 51
Generating a list of patients by diagnosis or health risk
Easy 10 28 11 27
Somewhat difficult 14 39 14 34
Very difficult or impossible 12 33 16 39
Using referral letters for all or most referred patients 20 56 5 12
Receiving information from medical specialist after treatment
Usually 1 3 1 2
In a minority of cases 8 22 5 12
Seldom or never 28 75 35 86
Receiving discharge report after hospitalization
Within 30 days 3 8 4 10
Seldom or never 30 81 30 73
Source: Kringos et al. (51).