Is there a place for a patient in European healthcare system? Primary care

A friend of mine together with his wife has temporarily moved to Germany from the US. Long flight, weather changes and stress were too tough for the female immune system: a woman got sick and had to see a doctor. The General Practitioner (in German “Haus Arzt”) nearby was brisk: he agreed to take this case, only because of its emergency. However, in the future the couple has to look for another doctor, since this practice was “fully booked”.

Another colleague of mine arrived to Germany from Moscow with his family including two small children. The priority of course was to ensure a proper medical coverage for the kids. Endless web browsing and numerous phone calls to GP practices resulted only in polite refusals. “Sorry, we have no capacities to assist you”.

It was not a question of money: both families were financially quite stable. Local GP practices were overloaded. Nobody wanted to take an additional patient irrespective of the reimbursement. After all, doctors are also human and have their right for leisure.
You may think this is all about foreigners and German citizens are treated differently. Certainly, locals in the neighbourhood have an advantage of getting an earlier access to their GP practice, but better attention they have not.

My family observed the evolution of our own GP with whom we are staying for almost 20 years. The peak of his attention (check-up alerts or other engagements) was the period when we had to pay 10 euros for our visits. After this legislation was abandoned our GP showed no curiosity in regard to our health. From time to time he was referring us to specialists, but I doubt he was ever aware if we had actually visited one or not.

One might argue that this is just one doctor who does not fulfil his duties properly. On the contrary. Our GP is quite experienced. He is even trying to find more time for complex cases by pushing them towards the end of the day. But he is receiving 30 patients per day, 150 per week, so basically each of us can count in average on 10 minutes of his time.

According to the  studies Primary care consultations in Germany lasted to under 10 minutes. Considering these statistics, our GP is even better than the average in Germany. And this is not a limit. A general practitioner in Germany on average sees 243 patients per week (31,4 hours of direct patient contact) and has a total workload of 50,6 hours per week, both indices being considerably higher than in many other comparable western healthcare systems. No wonder that with years our GPs are gradually turning into dispatchers having time just to prescribe a medication against rhinitis and in a more complex cases route patients to a nearby hospital.

The same study tells us that GP consultations in Belgium, Cyprus, Iceland, Lithuania, Luxembourg, Portugal, France, Switzerland, Finland and Norway lasted between 15 and 20 minutes. The longest (between 20-25 min) in Sweden.

So, what is the secret of the Nordic countries? Maybe they have more doctors? Apparently not: Germany has 170 GPs per 100.000 of population while in Sweden only 64. The reason seems to be somewhere else. Let us have a look at some of the Nordic GP practices that are not widely spread in Germany.

Team work

doctors-talking-two-doctors-discussing-a-patient-medical-records-BATJ13Healthcare is a team work. A GP visit is normally just a beginning of a patient journey. One often has to visit other specialists or physiotherapists. Hence coordination between GPs and medical stakeholders across care is crucial for a proper diagnostic and therapy strategy.

Sweden since 1970 has encouraged ‘one stop shop’ clinics. Team-based primary care facilities with four to six GPs, and other staff categories (district nurses, nurses and often physiotherapists, occupational therapists, psychologists, and social welfare counsellors), is the most common form of primary care practice in  Sweden. Private practices with only one GP exist but are rare.

Contrary to that, the dominant practice organisation in  Germany is 68% solo. Only recently Germany has amended its laws to allow more co-operation between GPs and specialists in medical centres. Still a typical GP visit presumes a brief 10 minutes contact followed by a long journey across geos for a relevant specialist visit. The “continuation of care” is almost  disrupted.  More than 50% of primary care physicians report that it takes more than 14 days for them to receive a full report from a hospital once their patient has been discharged for 15% it takes more than a month.

Doctors are anonymously exchanging official letters with patient’s examination data sent either by post or, in the majority of cases, delivered by a patient himself. Should my GP suddenly decide to dive deeper into a medical history of a given patient, he has to step down into his cellar and search through tons of documents stored there.

Would it not be better if our general practitioner personally knows a specialist he is referring his patient to able to discuss the case with his colleague over a cup of a morning coffee?

Role of nurses

nurse-checks-blood-pressure

Although the number of nurses in Germany is more or less equal to those in the Nordic countries, their actual role is different. In our small GP practice there are usually 2-3 nurses at the reception registering patients and simultaneously responding to numerous phone calls. In between, they can take blood and ECG tests (just measurements, not deciphering data for a preliminary diagnostics). In general, nurses in GP practices are neither trained nor responsible for monitoring chronic or elderly patients who constitute the majority of visitors.

Sweden e.g., on the contrary, was one of the first European countries to create nurse-led clinics for patients with long-term conditions such as heart failure and diabetes. Swedish primary care nurse are annually dealing with more than 30 million telephone calls concerning medical advice, guidance or counselling.

On top of that, there are online services such as KRY or Swedish express care virtual where a patients can contact “care guides” online or by telephone to find out if their symptoms indicate need for a visit to hospital or prime care and also receive medical guidelines, when professional care is not needed. Maybe because of such filters physicians in Norway and Sweden have the smallest numbers of patient contacts (80 and 50 per week respectively)?

Administrative workload.

buerokratie-aerzte-belastung-studie-kassenaerztlichen-bundesvereinigung.jpeg

Bureaucracy appears to be a plague of the European healthcare system. 54% of the German doctors and 37% of the Swedish ones complained that they spend more than enough time on administrative tasks such as account processing, insurance reimbursements and other procedures non-related to patients’ treatment.

Studies among 164. 000 German practices showed that doctors spend about 54,16 hours annually only on administrative tasks. Other evidence demonstrated that each GP Practice in Germany should spend one day per week to cope with all paperwork, half of which could have been easily ignored. No surprise that a very large fraction (82%) of German primary care physicians considered  “fundamental changes” or even “complete” reform of the prime care system necessary.

Conclusion.
I have no intention to highlight any healthcare system as an example for others. Rather it is the attempt to identify some practices that seems reasonable from a patient perspective. As citizens we would welcome an integrated care when specialists and GPs collaborate together to support patients’ health vs. sporadically addressing bits of the disease; physicians who have enough time and interest to listen to patients instead of mentally calculating reimbursements. In a word: we need healthcare system that works for citizens and not for itself. European world is getting more global. Maybe it is time to have a closer look at best practices across the advanced healthcare systems for the sake of a more effective patient centric care?

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