From prevention to cure: which policies for primary care?

Catherine Gourbin* and Guillaume Wunsch**
(*University Center of General Practice and Institute of Demography; ** Institute of Demography University of Louvain (UcL)

  Introduction
  Though mortality has decreased dramatically in most of the industrialized countries, leading to life expectancies of over 80 years of age for females and slightly less for males, one cannot conclude that all public health problems are progressively being solved. Actually, as one knows, due to the increasing length of life and very low fertility levels, all populations in the developed countries are growing older and older. As health often deteriorates with age, as medical technology is growing both in quality and quantity but also in cost, and as our expectations for guaranteeing a healthy life are rising, health costs are soaring in all the developed world. Governments in Europe are trying to contain the costs by taking various measures, such as rationing of health-care interventions and reducing the coverage of the insurance funds to more basic services, increased co-payment or direct out-of-pocket payment by patients to providers, stimulating additional voluntary contributions to private health insurance funds, favoring competition among insurance funds, and more generally trying to improve the health system’s performance.
  Among this set of more or less ad hoc policies, one of the goals of policy makers in the health field is to develop better preventive medicine and its coverage for the whole population, as healthy behaviors and early detection of diseases can significantly keep the health costs down (CDC, 2004). General practitioners (GPs) or family doctors, being in the first line of medical intervention, are the obvious channel through which prevention and early detection can occur. As the WHO has stated, a major focus of public health interventions should therefore be to develop primary health care systems “that emphasize health promotion, disease prevention and the provision of cost-effective, equitable and dignified longterm care” (WHO, 2002). The same report stresses that “primary care should be the lynchpin of a well designed and performance-focused health care system”.
  As an example of policies developing in the health field, this paper aims at describing for Belgium the present situation of primary care in the broader framework of the general health system and the measures taken by governments for reorganizing the system. The Belgian system will then be compared to the one in Great Britain, as a case of a country with a quite different health system. Finally, the situation of primary care in Central and Eastern Europe will be briefly considered.
  Primary care in Belgium
  General practitioners
  Up till the governmental decree of 1997, the number of physicians was not regulated in Belgium. Once his/her degree in medicine obtained at the university, the GP could decide to work in the municipality of his choice. At the present time, a physician can still freely choose the area where (s)he will practice medicine but the number of doctors produced each year by the universities is legally fixed by a quota system, both for general practitioners and for specialists. For the population of Belgium of ten million inhabitants, only 700 new doctors are allowed each year, the number of new specialists allowed being 400 maximum and the number of GPs 300.
  In Belgium, the choice of a GP by a patient is entirely free and he may change his GP at will. The patient may also consult several GPs during a same period, or directly consult a specialist as there is no obligation of referral by a GP. GPs are self-employed and paid on a fee-for- service basis, with co-payment by the patient.
  In view of limiting the number of consultations of multiple GPs by a patient and the direct recourse to a specialist, the Ministry of Health has initiated in 2002 the system of a global medical file (GMF) per patient. The latter would freely choose his one and only family doctor and agree to consult the latter (with some exceptions) for having access to a specialist. The purpose is to improve the efficiency of care and to reduce the social security costs. The GMF should also improve communication among the physicians themselves. The file is held by the GP and contains the results of the medical tests and exams for the patient, including those possibly performed by a specialist and communicated by him. Vice versa, the GP informs the specialist upon request of all the information needed concerning the patient.
  The global medical file is presently not legally compulsory but if a patient accepts it and its constraints, he will benefit from a 30% reduction of his co-payment at each consultation of his family doctor. Patients over 75 or suffering from a chronic disease retain this benefit also when the GP performs a visit at home; contrary to some other countries, GPs still make home visits in Belgium. As to the GP, he receives 750 euros per year from the social security system, covering the software cost, if he accepts to computerize his files with such a system. The general objective of the Health Ministry is to hierarchize the recourse to care and to ensure a progressive access to health care with a view of reducing costs. The GMF is a first step in this direction. It is hoped it will lead to better exchange of information and harmonization of care through improved complementarity among care providers and institutions.
  Financing health costs
  Belgium has a compulsory health care system based on the social health insurance model. With very minor exceptions, the whole population is covered. Health care is publicly funded and mainly privately provided. In Belgium, health care insurance is part of the global social security network. Since 1995, financing is globalised: all means are put together under a common management before being distributed to the various branches of social security such as health care, pensions, family allowances, unemployment benefits, etc. Before 1995, employers and employees paid specific contributions for each of these branches. Nowadays, the employer transfers more or less 35% of the gross salary of his employees to the national social security fund while the employee transfers slightly more than 13% of his gross salary to the same fund. These social contributions from employers and employees represent the largest part of the means of the fund (74%) but in addition the fund receives subsidies from the State (12%) and 14% of its budget comes from alternative resources, mainly from VAT receipts but also from taxes on tobacco consumption, etc. Health care costs represent 35% (in 2005) of all social security expenditures in Belgium.
  Integrated health care
  Though the GP is in the front line of medical intervention and as such has a major role to play, as we have stressed in the introduction, efficiency of the health care system requires a structured organization of the system itself in which each care provider works in collaboration with others, each respecting the other’s own field of action. Ideally, the GP should be responsible for the integration and coordination of health care as he ensures global and continuous care for his patient, in contrast to the specialist. Structures for improving coordination of home care were set up in Belgium in the early 1980s, though some partial initiatives were much older. The purpose was to regroup various existing services such as social care, nursing, family help, household aide, etc, under a common management usually dependent upon the municipal social protection center (CPAS) or the mutual insurance companies (i.e. sickness funds called “mutualites”) redistributing health care benefits to the patients. Some coordination structures were set up by the GPs themselves, independently from the social protection centers and sickness funds.
  In 1989, a governmental decree has been adopted for approving and financing these coordination centers, but problems remain. Firstly, the existing structures are very different among themselves, taking account of the type of work performed, the training of their personnel, their modes of financing, etc. Secondly, many GPs do not collaborate with these centers, fearing the ‘sharing’ of their patients with outside actors. Moreover, the GP is often not fully aware of the formal network caring for the patient and does not clearly envisage his role in this network.
  Emergency department attendance of hospitals
  As pointed out before, in Belgium the patient may freely choose and change his GP, consult several GPs, or directly access a specialist. He may also go freely to the emergency department of a hospital for problems which normally should be addressed to a GP. The Belgian government has taken measures to avoid inappropriate use of emergency departments. Since March 2003, the federal government has introduced a fixed co-payment of 12.5 euros for the patient, for a visit in an emergency department if the patient was not referred by a general practitioner. The patient can be dispensed of this co-payment if e.g. he is brought in by an ambulance, by a medical intervention unit, referred by a GP or by the police. The purpose is to stimulate the patient to visit a GP or a primary care center instead.
  An international literature review conducted by one of the present authors (C. Gourbin et al.., 2004 ) leads however to the conclusion that there is no evidence demonstrating the impact of co-payment on changes in emergency department use. Moreover, it seems that patients attend an emergency department in Belgium because they have difficulty accessing a primary care provider (during holidays or during the night, for example). In addition, they consider that hospitals are much better equipped in case of need than are general practitioners. The solution to the problem seems to be a better organization of primary care providers to cope with the needs of their patients (such as out-of-hours primary clinics).
  Primary care in the United Kingdom
  The information in the following paragraph is taken from the WHO country highlights on health (2005), themselves derived from publications of the European Observatory on Health Care Systems and Policies.
  The United Kingdom has devolved responsibility for health care to its constituent countries: England, Scotland, Wales, and Northern Ireland. They mainly fund health care through national taxation, deliver services through public providers and have devolved purchasing responsibilities to local bodies: primary care trusts in England, primary care partnerships in Northern Ireland, health boards in Scotland and local health boards in Wales. As is more or less the case in Belgium, the British health care system is mainly funded through general taxation: direct taxes, value-added tax and employee income contributions. General practitioners are self employed. On 1 April 2004, remuneration of their services moved from a system mainly based on capitation and fixed allowances to one that combines capitation and quality points. In contrast to Belgium, GPs in group practices (with an average of three per practice) provide primary care. To register with a GP, a patient must be a resident of the designated practice area. There are also a small number of NHS walk-in clinics. GPs act as gatekeepers in the system, and a referral is required to gain access to specialist services, in contrast once again to the Belgian situation. The whole population is covered by the system and services are mostly free of charge at the point of use.
  Health expenditure in the United Kingdom has remained quite low relative to the European average (8% less per capita), contrary to Belgium where the level is above the European average (7% more). However, satisfaction with the British system is also low: waiting times for care are long, especially for gaining access to a specialist and even more for being treated in a hospital, though the system does provide ready access to care without regard to income (Blendon et al., 2002). A major plan for reform has been adopted by the NHS, in particular to reduce waiting time for surgery and improve the quality of hospital care, but devolution to the constituent countries is increasingly leading to reforms taking quite different directions across the United Kingdom.
  Primary care in central and eastern Europe
  We briefly present below the situation of some central and eastern European countries concerning the current situation of GPs, their choice by the patient, the recourse to a specialist, the cost of primary care to the patient.
  Bulgaria
  Since July 2000, general practice is private. One can choose his/her GP and can change twice a year. When the patient has a health insurance, consulting GPs is without cost. In order to have access to a specialist physician, it is necessary to consult the GP who provides a referral form. In the absence of a referral form, the patient must pay himself his visit to the specialist.
  Czech Republic
  General practice is private. Persons with health insurance may choose his/her doctor among those who have a contract with the patient’s insurer for the provision of health care. In that case, there is no cost for the patient. The GP can refer the patient to a specialist having a contract with the patient’s insurer but the patient may visit a specialist without recommendation from the GP. Primary health care covers both general practitioners and paediatricians, gynaecologists, and stomatolgists.
  Estonia
  General practice is private. However, as GPs have a contract with the health insurance, they may also be regarded as part of the state health system. The patient can choose his family doctor. Consultation is without cost except for home visit for which the cost is 3 euros. It is necessary to consult a GP to have access to a specialist. There are also a very limited number of private GPs without contract with the health insurance system.
  Hungary
  General practice is private but GPs have a contract with the local authorities that are responsible for primary care. Choice of the doctor by the patient is free but people have to declare their choice leaving their patient card with the doctor chosen. The local authorities are obliged to provide family doctor care free of charge. They make a contract with the family doctors, who are financed by the National Health Insurance Fund according to the number of patient's cards. However, there are also private doctors, clinics, and hospitals that are not financed by the National Health Insurance Fund. It is possible to visit such doctors paying all the cost of the care. Referral depends upon the specialization. Some specialists can be visited without a family doctor’s referral (e.g. gynaecologist, ophthalmologist, otolaryngologist). The others can be accessed only with a family doctor's assignment.
  Latvia
  Family doctors are either part of the state health system or are in private practice. Choice of GP is free and one can change one’s physician once or twice a year. There are fixed rates of medical treatment which do not depend upon the type of practice, state or private. A minimum cost does not have to be covered by the patient if he/she is insured. It is also possible to get tax refund for defined medical treatment. Some specialists can be visited without referral, such as psychiatrists, gynecologists, endocrinologists. The others need a referral form from the GP.
  Lithuania
  Family doctors are either part of the state health system or are in private practice. In both cases, there is no cost to the patient. Choice of GP is free. Referral by a GP is needed to have access to a specialist.
  Poland
  Family doctors are either part of the state health system or are in private practice. Choice of GP is free. Care is free of charge to the patient for GPs who are part of the state health system but otherwise has to be paid. Referral by a GP is needed to have access to a specialist except for ophthalmologists, gynecologists, dermatologists, psychiatrists.
  Romania
  Family doctors are either part of the state health system or are in private practice. In the former case, they have a contract with the national health insurance fund and are paid according to the number of patients and consultations. Choice of GP is free and one can change the choice after 3 months. It is necessary to be referred by a GP in order to visit a specialist. For doctors in the state health system, consultation is generally free of charge; private doctors are paid by out-of-pocket money.
  Russia
  In the state system, one can consult a GP in a polyclinic according to one’s place of residence or one’s company. GPs in private practice are also available in private clinics. In the fist case, care is free of charge to the patient; in the second case, it is not. In principle, one can choose another GP in the same polyclinic. In the state sector, referral is required to have access to a specialist. If one accepts to pay, a patient may go directly to a specialist in the private sector or to the specialized state clinic.
  Conclusions
  Primary care in Europe is devolved more and more to the private sector, both East and West, even in the countries having a National Health Insurance System. Free choice of the GP has become the general rule though in some countries this choice is constrained. But this relative liberty is however accompanied in the West by an increasing influence of the State, due principally to the fact that governments want to curb health costs. This regulation can be seen in various sectors:
  - a rationing of the number of general practitioners (and also of dentists, nurses, physiotherapists, etc.) . This numerus clausus was taken quite some time ago already in France for example and is of more recent origin in Belgium;
  - the establishment of structures such as coordination centers, in view of improving the continuity of care, a better communication and interdisciplinarity among care providers in the first line of medical intervention;
  - a policy favoring referral from the front line to the specialist, in effect since many years in Central and Eastern Europe but also in the UK, very recently in France, and under discussion in Belgium;
  - the progressive establishment of a data collection system (such as the computerized medical file) recording the activities of the first line in view of developing a better organization and management of these activities.
  Concerning cost to the patient, the present-day systems in Europe vary from free of charge for the patient to full payment by out-of-pocket money, with co-payment being intermediate between these two extremes. Full payment by the patient usually leads to inequities between those who can pay and those who cannot, but free of charge care often leads to excess consumption of medical services and long waiting lists. Co-payment of a variable amount depending upon the individual or household income seems a better solution in order to match supply and demand. For this reason, co-payment should be effective for all care providers in the front line.
  Acknowledgments
  Our thanks to the following colleagues who have given us information on their country: Tatyana Kotzeva (Bulgaria), Jitka Rychtarikova (Czech Republic), Kalev Katus (Estonia), Eva Gardos (Hungary), Juris Krumins (Latvia), Vlada Stankuniene (Lithuania), Anita Abramowska (Poland), Vasile Ghetau (Romania), Natalia Kalmykova (Russia). Any errors in the present text are due to our possible misunderstanding of some complex systems !

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