FIRST STEPS
Ask most people in the West about Kosovo and they will think of an ethnic war where NATO intervened. Yet from that inauspicious start, one of the 21st century’s newest republics has nurtured its primary health care to a level where it is now a beacon of excellence in the region. The first steps were taken in late 1999 by a group of family doctors enthused by their experience of training by visitors from the American Academy of Family Physicians and the International Medical Corps.
Forming the Association of Family Physicians, they ran workshops promoting the concept of primary care throughout the country despite opposition from secondary care specialists. The mission was later supported officially by the Ministry of Health, which set about rebuilding health centres, establishing the Centre for the Development of Family Medicine. This centre was tasked with developing and delivering a strategy for primary care and its role has been vital for the creation of a modern service.
FORMATION
Initially, a cadre of Family Medicine Specialists (FMSs) was created through accelerated training from the ranks of doctors already established in primary care. Then, in 2005, the centre launched a 3-year specialist training programme for FMSs modelled on the UK system and with guidance from the RCGP. The programme would be instantly recognisable to trainers and trainees in the UK, with a mix of hospital posts and time in Family Medical Training Centres (FMTCs). So too would the assessment at the end of training, with workplace-based assessments, an applied knowledge test, and a clinical skills exam. Some of the content would be less familiar, however.
The first stop for all acute illnesses, both in and out of hours, FMSs are trained for emergencies such as arrhythmias (more akin to our A&E departments than our practices). Success in the assessment leads to entry on the specialist register and award of MRCGP International. This is not, as the name may suggest, an international version of the UK exam, or an international qualification to practise. The curriculum has been written by the Kosovo exam board to cover the epidemiology and health needs of the Kosovan people. The exam tests that curriculum and is conducted by trained FMS examiners in Kosovo. MRCGP International denotes that the quality of the assessment has reached international standards meriting its accreditation by the RCGP.
Primary care is delivered through medical centres administered by the municipalities. FMSs work alongside other primary health practitioners in large Family Medical Centres (FMCs). The larger FMCs are training centres for family medicine residents and are well equipped with laboratories and imaging equipment, such as X-ray and mammography machines. Smaller FMCs may be less fully equipped but both act as hubs for a network of smaller Ambulatory Centres. Some of the latter are staffed by GPs, doctors who have had limited supervised work but have not been on the specialist family medicine programme. Registered lists do not yet exist.
Patients can go to a specialist privately but such uncoordinated care can lead to unnecessary investigation and treatment. Doctors in the state service are poorly remunerated — a public FMS earns about €600 a month. Primary care is still regarded by the public as being of poor quality and low status. However, attitudes are changing with the success of the residency programme and the inclusion of family medicine in undergraduate education, some of it delivered in FMCs.
THE FUTURE
Success is partly due to the willingness of the pioneering FMSs to accept guidance from abroad, such as the work of Professor Bob Hedley and Nottingham Medical School. Professor Bob, as he was known, was widely admired and loved. He spent the early years from 2001 to 2004 working on formative assessments and curriculum development. He introduced MCQs, pre- and post-module, sitting in on consultations, the MRCGP 15 criteria video assessment tool and log books, as well as contributing greatly to the development of the trainers and trainees. More recently, guidance has come from the Internal International Development Advisor appointed by the RCGP. However, the bulk of the credit is due to the hard work, often unpaid, by a dedicated group of FMSs. The Kosovan government is firmly behind developing family medicine further and has begun by taking over the funding from international development agencies. It is also collaborating with FMS representatives to raise the profile of the specialty.
This small country of 1.8 million, which has seen many citizens leave — including FMSs enticed by higher wages in Germany in the past 3 years — is now finally in a position to host a conference (planned for May 2017) spreading the philosophy and practice of family medicine in the region.
- © British Journal of General Practice 2016