The delivery of primary care services
3.4 Comprehensiveness of services provided in primary care
The broader the range of services that are offered to patients in primary care, the smaller the dependency on secondary care services, and the stronger primary care is. Possibilities to provide services are related to the availability of medical equipment in primary care practices.
The range of services offered includes the following domains of care: first-contact care and triage; diagnostic services, treatment and follow-up care;
medical technical procedures; prevention and health promotion; and mother, child and reproductive health care.
This section deals with the important features of comprehensiveness of primary care in each of the countries analysed (see Appendix I for an overview of features and indicators).
Table 3.4 provides an overview of results of the comprehensiveness of primary care by country.
Primary care facilities are generally well equipped across Europe, although in Austria, Hungary, Italy, Luxembourg, Malta, Poland, Romania, Slovakia and Slovenia items such as gynaecological speculums, peak flow meters, ECG recorders, urine strips, instruments for stitching wounds or infant scales are not always in place. The diversity of problems for which patients can be helped in primary care (such as a severely coughing child, contraception problems, alcohol addiction) is highest in Bulgaria, Denmark, Finland, France, Hungary, Norway, Poland, Portugal and Sweden.
GPs often provide treatment and follow-up care for a broader scope of conditions in countries with more solo practices, although this may be a function of demographics; for example, in remote areas, GPs are more likely to work solo and offer a fuller range of services. Other frequently visited specialist providers for treatment and follow-up care are cardiologists, rheumatologists, gastroenterologists, psychiatrists, pulmonologists, oncologists, internists, endocrinologists, diabetologists and geriatricians. Overall, GPs handle more than 90% of their total patient contacts without referral in Denmark, Estonia, Finland, Iceland, the Netherlands, Norway, Portugal, Spain and Switzerland.
Table 3.4 Comprehensivenessofprimarycareservices,overviewofselectionofresultsbycountry
Country AvailabilityofequipmentinPC
facilities(9items)1 GPinvolvementinfirstcontact
care(10healthproblems)2 Otherspecialtiesinvolvedin firstcontactcare(for10health problems)3 GPinvolvementintreatment/
follow-upcare(9diseases)4 Otherspecialtiesinvolvedin
treatment/follow-upcare (9diseases)3
%oftotalpatientcontacts handledsolelybyGPswithout referral GPorG/PCnurseinvolvement inmedicaltechnicalprocedures (10activities)5 Otherspecialtiesproviding medicaltechnicalprocedures GPinvolvementinpreventive care(11activities)6 Otherspecialtiesproviding
preventivecare3 GPinvolvementinindividual healthcounselling(4cases)
Otherspecialtiesproviding counselling3 GPsusuallyinvolvedingroup
wisehealtheducation Totallevelof comprehensivenessof PCservices8
Austria7/91/10GYN;PAED;PSYT9/9INT;PSYT700/10GYN;IN;OPH; ORT;SUR4/11GYN;INT; PAED4/4INT;PSYTNo, incidentallyL Belgium9/97/10GYN;NEU;OTO; PAED;PSYL;PSYT9/9CAR;END;GAS; GER;NUR;ONC; PSYT;PUL;REU–6/10
ANE;DER; GYN;OPH; ORT; PHY;SUR8/11CAR;GYN; INT;OB;OCT; PAED;SCN4/4DIE;NU;PCN; PHT; PSYL;PSYTNo, incidentallyM Bulgaria9/910/10ENT;GYN;NEU; PSYT;SUR9/9CAR;END;GAS; NEU;PSYT; PUL;REU874/10DER;NUR; OPH;SUR7/11ALL;CAR; DER;GYN; INF; PAED;SUR
4/4END; PSYT;PULYesH Cyprus8/90/10CHE;ENT;GYN; NEU;PSYT5/9CAR;CHE;DIA; END;GAS;INT; ONC;PSYT;REU;–2/10DER;GYN; OPH;ORT; POD;SUR4/11GYN;PAED3/4CAR;CHE; END;PSYT–L CzechRepublic8/95/10ADD;ENT;GYN; NEU;PAED;PSYT5/9CAR;DIA;GAS;INT; PSYT;PUL;REU850/10DER;GYN; INT;OPH;ORT; PUL; REU;SUR5/11
CAR;DER; GER;GYN; INT;ONC; PAED; PUL;RAD
4/4END;INT; PSYT;PULNoM Denmark8/99/10ENT;ER;GYN;NEU; PAED;SPCL; PSYT;SW7/9CAR;END;GAS; HOS;INT;ONC; PAL;PSYL;PSYT; PUL;REU;SUR902/10ER;GYN;OPH; REU;SUR9/11ALL;ER;GYN; INF;INT;SPCL3/4DIE;PHN; PHY;SPCLNoH Estonia9/97/10ER;GYN; ONC;PSYT9/9CAR;END;GAS; NUR;ONC;PSYT; PUL;REU921/10GYN;OPH; REU;SUR;TR6/11ALL;CAR; DER;GYN; INF;MID; ONC;PAED0/4–No, incidentallyH
Country AvailabilityofequipmentinPC
facilities(9items)1 GPinvolvementinfirstcontact
care(10healthproblems)2 Otherspecialtiesinvolvedin firstcontactcare(for10health problems)3 GPinvolvementintreatment/
follow-upcare(9diseases)4 Otherspecialtiesinvolvedin
treatment/follow-upcare (9diseases)3
%oftotalpatientcontacts handledsolelybyGPswithout referral GPorG/PCnurseinvolvement inmedicaltechnicalprocedures (10activities)5 Otherspecialtiesproviding medicaltechnicalprocedures GPinvolvementinpreventive care(11activities)6 Otherspecialtiesproviding
preventivecare3 GPinvolvementinindividual
healthcounselling(4cases) Otherspecialtiesproviding
counselling3 GPsusuallyinvolvedingroup
wisehealtheducation Totallevelof comprehensivenessof PCservices8
Finland9/97/10CN;ENT;GYN;NEU; PAED;PSYL; PSYT;SPCL8/9CAR;GER;INT; ONC;PSYL;PSYT; PUL;REU;SUR9310/10ANE;DER; GYN;OPH; INT;ORT;SUR6/11GYN4/4DIE;INT;NU; PHY;PULNo, incidentallyH France9/99/10ER;ENT;GAS;GYN; NEU;PAED;SPCL; PSYL;PSYT;SUR7/9ADD;CAR;END; GAS;ONC;PAED; PSYL;PSYT; PUL;REU813/10ADD;ER;DER; GYN;NUR; OPH; ORT;SUR11/11 ALL;CAR; DER;END; GYN;MID;OB; PAED; PUL;SPCL
4/4DIE;END; GAS;PULNoH Germany8/93/10ENT;GYN;NEU; PAED;PSYL;PSYT8/9CAR;DIA;GAS; NEU;ONC;PSYT; PUL;REU774/10DER;GYN; INTOPH; ORT;SUR4/11ALL;DER; GYN;INT;MID; PAED; SUR;UR4/4INT;PSYL; PSYT;PULNo, incidentallyL Greece–0/10–4/9PATH–4/10PATH4/11GYN;PAED; PATH3/4PATHYesL Hungary7/93/10ER;ENT;GYN;NEU; PAED;PSYL;PSYT; PUL;SUR9/9CAR;DIA;GAS; GER;INT;ONC; PSYT;PUL;REU801/10ER;GYN;OPH; ORT; REU;SUR5/11DER;ER;GYN; INT;VE4/4DIA;DIE;INT; SPN; PSYT;PULNoM Iceland9/99/10GYN;NEU;PAED; PSYT;SUR5/9CARD;END;GAS; GER;ONC;PSYT; PUL;REU;SUR934/10DER;ER;GYN; OPH;ORT; POD;SUR2/11
CAR;DER; GYN;HCN; MID;NUR;OB; PAED;SPCL; SPN;VE
4/4INT;PUL;NUNo, incidentallyH Ireland8/98/10GYN;OB;NEU; PAED;PSYT;SUR5/9CAR;END;GAS; GER;INT;ONC; PSYT;PUL; REU;SUR–2/10DER;ER;GYN; OPH;ORT; POD; REU;SUR4/11CAR;DER;ER; GYN;INT;OB; PAED;PHN;VE4/4INT;SPN;PULNoL
Country AvailabilityofequipmentinPC facilities(9items)1 GPinvolvementinfirstcontact
care(10healthproblems)2 Otherspecialtiesinvolvedin firstcontactcare(for10health problems)3 GPinvolvementintreatment/
follow-upcare(9diseases)4 Otherspecialtiesinvolvedin
treatment/follow-upcare (9diseases)3
%oftotalpatientcontacts handledsolelybyGPswithout referral GPorG/PCnurseinvolvement inmedicaltechnicalprocedures (10activities)5 Otherspecialtiesproviding medicaltechnicalprocedures GPinvolvementinpreventive care(11activities)6 Otherspecialtiesproviding
preventivecare3 GPinvolvementinindividual healthcounselling(4cases)
Otherspecialtiesproviding counselling3 GPsusuallyinvolvedingroup
wisehealtheducation Totallevelof comprehensivenessof PCservices8
Italy4/96/10GYN;NEU;ONC; PAED;PSYT5/9CAR;DIA;GAS;INT; NUR;ONC;PSYT; PUL;REU–1/10 DER;GYN; INT;NUR; OPH;ORT; SPN;SUR5/11
ALL;GYN; LAB;MID; ONC; PAED;PHN4/4PHN;PULNo, incidentallyL Latvia9/95/10GYN;NAR;ONC; OTO;PSYT8/9ADD;CAR;END; GAS;INT;NEU; ONC;PSYT; PUL;REU
161/10GYN;NUR; OPH;SUR;TR6/11CAR;GYN; INF;INT; MID;PAED4/4END;NARNoM Lithuania9/910/10GYN;PAED;PSYT8/9CAR;END;GAS; INT;ONC;PSYT; PUL;REU704/10GYN;INT; OPH;SUR11/11CAR;GYN; INF;ONC; PAED;UR4/4CAR;END; PSYT;PULYesH Luxembourg7/95/10ER;ENT;GYN;NEU; PAED;PSYT8/9CAR;END;GAS; INT;ONC;PSYT; PUL;REU–2/10DER;ER;GYN; OPH;ORT; REU; SPN;SUR8/11ALL;CAR; DER;END;ER; GYN; INT;PAED4/4END;INT; NU;PSYTNoM Malta6/99/10ER;GYN;PAED; PSYT;SW9/9––4/10–5/11GYN;PAED4/4––L Netherlands8/99/10ER;GYN;PSYL;SW3/9CAR;DIA;INT;NHP; ONC;PSYL;PSYT; PUL;REU968/10GYN;INT; OPH;ORT; PHY;SUR6/11
ENT;GYN; LAB;MID; PAED; PHN;SPCL3/4PNNoM Norway9/97/10ER;CAR;CHE;GYN; SCN;SPCL;PSYT9/9CAR;GAS;INF; ONC;PSYL; PUL;REU955/10DER;GYN; OPH; REU;SUR9/11GYN;MID; PHN;RAD4/4PHN;PN; SCN;SPCLNoH Poland6/94/10END;ENT;GYN;OB; NEU;PAED;PSYT; SUR;SW9/9CAR;DIA;END; GAS;GER;INT; ORT;PSYT;PAL; PUL;REU
–0/10DER;ER;GYN; INT;OPH;ORT; PAED;SUR4/11ALL;CAR; DER;ER;GYN; INF;INT;OB; PAED;SUR 4/4END; PHY;PSYTNoL
Country AvailabilityofequipmentinPC
facilities(9items)1 GPinvolvementinfirstcontact
care(10healthproblems)2 Otherspecialtiesinvolvedin firstcontactcare(for10health problems)3 GPinvolvementintreatment/
follow-upcare(9diseases)4 Otherspecialtiesinvolvedin
treatment/follow-upcare (9diseases)3
%oftotalpatientcontacts handledsolelybyGPswithout referral GPorG/PCnurseinvolvement inmedicaltechnicalprocedures (10activities)5 Otherspecialtiesproviding medicaltechnicalprocedures GPinvolvementinpreventive care(11activities)6 Otherspecialtiesproviding
preventivecare3 GPinvolvementinindividual
healthcounselling(4cases) Otherspecialtiesproviding
counselling3 GPsusuallyinvolvedingroup
wisehealtheducation Totallevelof comprehensivenessof PCservices8
Portugal8/99/10ENT;GYN;INT; NEU;PAED; PSYT;SUR8/9CAR;END;GAS; INT;ONC;PSYT; PUL;REU941/10DER;ER;GYN; OPH; ORT;SUR10/11ALL;END;ER; GYN;INT;OCT; PAED;PUL4/4END;INT; PN;PSYTNo, incidentallyH Romania6/98/10PAED;SPCL;PSYT7/9CAR;DIA;GAS;INF; INT;PSYT; PUL;REU353/10–5/11–1/4PN–L Slovakia4/95/10GYN;NEU; PAED;PSYT6/9CAR;DIA;GAS;INT; ONC;PSYT; PUL;REU720/10DER;GYN; INT;OPH;ORT; REU;SUR5/11
ALL;CAR; DER;GYN; INF;INT;OCT; PAED;SUR;VE4/4END;INT;PHY; PSYT;PULNoL Slovenia7/95/10GYN;PAED7/9CAR;DIA;GAS;INF; ONC;PSYT; PUL;REU800/10DER;GYN; OPH; ORT;SUR5/11ALL;GYN;OB; ONC;SUR4/4–YesL Spain9/95/10GYN;NEU;ONC; OTO;PSYT8/9CAR;END;GAS; ONC;PSYT;PAL; PUL;REU943/10DER;GYN;OB; OPH;REU; SUR;TR6/11ALL;CAR;OB; GYN;MID; PAED;PUL4/4END;PHY; PUL;PSYTNo, incidentallyH Sweden9/97/10ENT;GYN;INT; PAED;PSYL;PSYT; SPCL;SUR;SW9/9
CAR;GAS;GER; INF;INT;ONC; PSYL;PSYT;PAL; PUL;REU;SUR808/10 ER;DER;GER; GYN;INT; NUR;OPH; SPCL;SUR6/11
ALL;ER;GYN; INT;MID;OCT; PAED; SPCL;UR4/4PSYT;SW–M Switzerland8/95/10ER;ENT;GYN; PAED;PSYT;SPCL9/9CAM;CAR;END; GAS;GER;GYN; ONC;PUL;REU993/10
ANE;DER; GYN;NUR; OPH;ORT; PHY;RAD; REU;SUR;TR
7/11
ALL;DER;ER; GYN;INF;MID; NUR;PHA; PAED; SCN;SPCL 4/4CAR;DIE; END;SPCL; PSYT;PUL;URNoM
Country AvailabilityofequipmentinPC facilities(9items)1 GPinvolvementinfirstcontact
care(10healthproblems)2 Otherspecialtiesinvolvedin firstcontactcare(for10health problems)3 GPinvolvementintreatment/
follow-upcare(9diseases)4 Otherspecialtiesinvolvedin
treatment/follow-upcare (9diseases)3
%oftotalpatientcontacts handledsolelybyGPswithout referral GPorG/PCnurseinvolvement inmedicaltechnicalprocedures (10activities)5 Otherspecialtiesproviding medicaltechnicalprocedures GPinvolvementinpreventive care(11activities)6 Otherspecialtiesproviding
preventivecare3 GPinvolvementinindividual healthcounselling(4cases)
Otherspecialtiesproviding counselling3 GPsusuallyinvolvedingroup
wisehealtheducation Totallevelof comprehensivenessof PCservices8
Turkey8/95/10–6/9CAR;END;GAS; GER;INF;INT;ONC; PAED;PSYT;REU–4/10DER;GYN; OPH;NUR; ORT;SUR8/11GYN;INT; PAED; SUR;UR3/4INT;PULYesM UnitedKingdom9/910/10–9/9CAR;DIA;GAS; GER;NUR;PAL;PN; PUL;REU;SPN–4/10ER;CHI;ER; OPH;OPT; ORT;REU; SPCL;SUR6/11ALL;GUM;HV; MID; PHA;SPCL4/4DIE;SPCLNoM 1 NumberofitemsofequipmentalwaysorusuallyavailableinPCfacilitiesfromalistof9typesofequipment:1.infantscales;2.glucosetests;3.dressings/bandages;4.otoscope;5.ECG;6.urinestrips;7.instrumentsforstitching wounds;8.gynaecologicalspeculum;9.peakflowmeter. 2 GPsalwaysorusuallyinvolvedinfirstcontactcarefor(10healthproblems):1.childwithseverecough;2.childaged8withhearingproblem;3.womanaged18askingfororalcontraception;4.womanaged20forconfirmationof pregnancy;5.womanaged35withirregularmenstruation;6.womanaged35withpsychosocialproblems;7.womanaged50withalumpinherbreast;8.managed28withafirstconvulsion;9.manwithsuicidalinclinations; 10.managed52withalcoholaddictionproblems. 3 ADD=Addictionspecialist;ALL=Allergologist;ANE=Anaesthesiologist;CAM=Complementaryandalternativemedicine;CAR=Cardiologist;NEU=Neurologist;CHE=Chestphysician;CHI=Chiropodist;CN=Communitynurse; DER=Dermatologist;DIA=Diabetologist;DIE=Dietician;ENT=EarNoseThroatSpecialist;END=Endocrinologist;ER=Emergencyroomofhospital;GAS=Gastroenterologist;GER=Geriatrician;GUM=GUMspecialist; GYN=Gynaecologist;HCN=Homecarenurse;HOS=Hospices;HV=Healthvisitors;INF=Infectionspecialist;INT=SpecialistofInternalmedicine;LAB=Laboratrician;MID=Midwife(ambulatory);NAR=Narcologist; NHP=Nursinghomephysician;NUR=Nurse;OB=Obstetrician;OCT=Occupationaltherapist;ONC=Oncologist;OPH=Ophthalmologist;OPT=Optometrician;ORT=Orthopaedist;OTO=Otorhinolaryngologist; PAED=Paediatrician;PAL=Palliativecarespecialist;PATH=Pathologist;PCN=Primarycare/Generalpracticenurse;PHA=Pharmacist;PHN=Publichealthnurse;PHT=Physiotherapist(ambulatory);PHY=Physiotherapist; POD=Podiatrist;PSYL=Psychologist;PSYT=psychiatrist;PUL=Pulmonologist;RAD=Radiologist;REU=Rheumatologist;SCN=Schoolnurseorhealthstation;SPCH=Speechtherapist;DEN=Dentist;SPCL=Specialclinic; SPN=Specializednurse;SUR=Surgeon;SW=Socialworker;TR=Traumatologist;UR=Urologist;VE=Venerologist. 4 GPsalwaysorusuallyinvolvedintreatmentandfollow-upcarefor(9diseases):1.Chronicbronchitis;2.Pepticulcer;3.Congestiveheartfailure;4.Pneumonia;5.UncomplicateddiabetestypeII;6.Rheumatoidarthritis;7.Mild depression;8.Cancer(inneedofpalliativecare);9.Patientsadmittedtoanursinghome/convalescenthome. 5 GPsorG/PCpracticenursesalwaysorusuallyinvolvedintreatmentandfollow-upcarefor(10activities):1.Wedgeresectionofingrowntoenail;2.Removalofsebaceouscystfromhairyscalp;3.Woundsuturing;4.Excisionof warts;5.InsertionofIUD;6.Removalofrustyspotfromthecornea;7.Fundoscopy;8.Jointinjection;9.Strappinganankle;10.Settingupanintravenousinfusion. 6 GPsalwaysorusuallyinvolvedinthefollowingpreventivecareactivities(11activities):1.Immunizationfortetanus;2.Allergyvaccinations;3.Testingforsexuallytransmitteddiseases;4.ScreeningforHIV/AIDS;5.Influenza vaccinationforhigh-riskgroups;6.Cervicalcancerscreening;7.Breastcancerscreening;8.Cholesterollevelchecking;9.Familyplanning/contraceptivecare;10.Routineantenatalcare(inlinewithnationalscheme);11.Routine paediatricsurveillanceforchildrenupto4years. 7 GPsalwaysorusuallyinvolvedinindividualhealthpromotioncounselling(4cases):1.Counsellingincaseofobesity;2.Counsellingincaseofpoorphysicalactivity;3.Counsellingincaseofsmokingcessation;4.Counsellingin caseofproblematicalcohol 8 H=RelativelyhighlevelofcomprehensivenessofPCservices;M=RelativelymediumlevelofcomprehensivenessofPCservices;L=RelativelylowlevelofcomprehensivenessofPCservices.Categoriesaremadebasedonthe relativedistributionofdataforallindicatorsofthisdimensionofthePCMonitorInstrument(whicharenotallmentionedinthistable).
Medical technical procedures are most frequently carried out by GPs and primary care nurses in Belgium, Finland, the Netherlands, Norway and Sweden.
Other providers who often perform typically primary care medical technical procedures are surgeons, ophthalmologists, gynaecologists, dermatologists, orthopaedists, rheumatologists, emergency room specialists, internists and nurses.
Preventive activities are provided by a large variety of providers in the majority of countries. Preventive care is frequently provided by gynaecologists, paediatricians, allergists, internists, cardiologists, dermatologists, midwives, emergency room specialists, infection specialists, obstetricians and special clinics, in addition to GPs.
Overall comprehensiveness of services by country
A summary of all comprehensiveness scores by country is presented in Fig. 3.4.
With all measures combined there are only small differences between countries.
Primary care services are most comprehensive in Lithuania, Norway, Bulgaria, Belgium, the United Kingdom, Spain, Finland, Sweden, Portugal and France.
A more narrow profile was found in Slovakia, Italy, Greece, Cyprus, Romania, Hungary, Poland, the Netherlands, Slovenia, the Czech Republic and Austria.
The other countries are in an intermediate position regarding comprehensiveness of primary care services.