GP in crisis: how does European family medicine compare?

Mary McCarthy is a GP in Shrewsbury., She is on the GPC and is interested in comparative health systems. She is the BMA rep to UEMO.

The UEMO (Union Européenne des Médecins Omnipraticiens) represents GPs in 26 European member states. It develops policy and projects to support family medicine and to 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, a questionnaire was circulated by the UK delegation that asked about workload pressures in the differing EU member states. A total of 25 states replied (Malta gave two answers for their public and their private health care systems) and although the data set is incomplete, it still makes interesting reading and 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 that 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.

In Europe, family doctors may act as gate-keepers, as they do in the UK, or as signposts where they just act as a conduit to secondary care. The second course means that they do not deal with chronic disease management so do not have the pressures that the increasing shift to general practice of disease management that used to be dealt with in hospital clinics. In many EU states, children are seen by paediatricians not by GPs and gynaecological problems are referred for examination and investigation to gynaecologists.

Elderly people who are resident in nursing homes may be under the care of Community Physicians or, as in Holland, Nursing Home Doctors. Mental illness may be referred directly to secondary care.

Workload and practice

List sizes vary from 600 per GP in Belgium to 3,500 per GP in Turkey and consultation rates per GP vary from 10 a day to 50 a day. This figure is confused by the fact that some replies counted telephone consultations as well where 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 about 75%. The UK is still far ahead with more than 90% of practices being group practices and also have larger groups of doctors. In much of Europe practices have 2-3 doctors as opposed to our average of 6-7.

Most have list sizes of 1600 or lower and that itself makes for a less stressful environment. The working day generally approaches the normal for the working population of the country being 8 hours a day or fewer – in the Danish system GP surgeries close at 4pm on Monday to Thursday and at 2pm 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.

If the nations that think the workload in general practice is reasonable are examined, they tend to have some factors in common. They have a normal working day – that is, eight hours or fewer and mostly have a list size of 1600 or fewer per GP. They are more likely to have longer consultations and, of course, have easier access into 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 the Scandinavian countries veering towards 20-25 minutes. Those nations with 25 consultations or less a day find general practice manageable. Those nations who either have telephone consultations or face-to-face consultations that exceed 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 do little home visiting – though this may be due to the greater availability of 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, rather than, as in the UK, making huge efforts to keep patients out of hospital.

Summary

A profession under stress is a profession at risk. Maybe the answer is simply to reduce 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 be possible to educate the public to self-care, at least for minor illnesses.

General practitioners are expensive and time-consuming to train. It would be sensible to use their skills carefully.