COMPARE AND CONTRAST
UEMO (Union Européenne des Médecins Omnipraticiens), the European Union of General Practitioners, represents GPs in 26 European member states. It develops policy and projects to support family medicine and share best practice. It also provides an opportunity to look at other health systems and to learn from them, studying alternative ways of working and investigating ideas that may help with UK general practice.
Earlier this year (January to April 2015), a questionnaire was circulated by the UK delegation asking about workload pressures in the differing EU member states. A total of 25 states replied (Malta answering both for their public and their private healthcare systems), and, although the dataset is incomplete, it still makes for interesting reading. An overview of the findings is presented here.
DIFFERENT MODELS, DIFFERENT RESPONSIBILITIES
Not all countries have registered lists of patients. Often it divides, as it does in the Irish Republic, into those who are covered by a means-tested, state-led system who have to be registered to take advantage of the financial benefits, and those who pay privately for health care, either through an insurance-based system or through their own pocket.
Sometimes, as in France, there is no requirement to register but, because insurance companies offer incentives, 90% of patients do.
Where European family doctors act as signposts, they refer all chronic disease management to hospital clinics, as indeed UK GPs used to do 30 years ago. This means that family doctors in Europe have not experienced the considerable extra workload, caused by the shift from secondary care to primary care of chronic disease management, that UK GPs face. In many EU states, children are seen by paediatricians and not by GPs, and women with gynaecological issues are referred for examination and investigation to gynaecologists.
Older people who are resident in nursing homes may be under the care of community physicians or, as in the Netherlands, nursing home doctors. Patients experiencing mental illness may be referred directly to secondary care.
WORKLOAD AND PRACTICE
Practice list sizes vary from 600 per GP in Belgium, to 3500 per GP in Turkey, and consultation rates per GP vary from 10–50 a day. However, this figure is confused by the fact that some questionnaire replies included telephone consultations, whereas other nations just rated face-to-face consultations.
Group practices are gradually becoming the norm throughout Europe, though Belgium still has only 3% of practices with more than one doctor. In Italy roughly 50% of practices are group practices, and in the Netherlands around 75%. The UK is still far ahead, with more than 90% of practices being group practices. In much of Europe, practices have 2–3 doctors as opposed to the UK average of 6–7.
Most practices have list sizes of 1600 or lower and that itself makes for a less stressful environment. The working day generally approaches the norm for the working population of the country, being 8 hours a day or fewer — in the Danish system GP surgeries close at 4 pm on Monday to Thursday and at 2 pm on Friday. The health of the Danish population does not seem to be adversely affected by this restriction of GP hours of access. However, despite this, 76% of EU nations feel that general practice workload is unreasonable and unsustainable.
When we examine the nations that believe the workload in general practice is reasonable, they tend to have some factors in common. They have a normal working day — that is, 8 hours or fewer, and mostly have a practice list size of 1600 or fewer per GP. They are more likely to have longer consultations and, of course, easier access to secondary care beds. However, the factor that seems to be the most important is the number of patient consultations per doctor, per day.
CONSULTATION LENGTH AND DURATION
Most nations have 15-minute consultations, with Scandinavian countries veering towards 20–25 minutes. Those nations with 25 consultations or less a day find general practice manageable. However, those nations having either telephone consultations or face-to-face consultations exceeding 25 patient contacts a day, per doctor, find general practice unsustainable. They have problems in both retaining GPs and in recruiting newly qualified doctors to a GP training programme.
HOME VISITS
Most doctors do little home visiting — though this may be due to the greater availability of hospital beds in European countries. The UK has the lowest bed numbers per 100 000 population in Europe, with France having double the beds and Germany three times as many. This means that admission of sick patients is more or less the norm. In contrast, in the UK, huge efforts are made to keep patients out of hospital.
SUMMARY
A profession under stress is a profession at risk. Maybe the answer is simply to reduce patient access to EU levels; to restrict doctor–patient contacts — both telephone and face-to-face consultations — to fewer than 25 a day. It may be possible to divert some demands to pharmacists, nurses, or other health professionals. It may also be possible to educate the public to self-care, at least for minor illnesses.
GPs are expensive and time-consuming to train. It would be sensible to use their skills carefully.
- © British Journal of General Practice 2016