GP JOURNEY THROUGH DECADESAn experience from the Czech Republic

Bohumil SeifertDepartment of General Practice

1st Faculty of MedicineCharles University in Prague

Zagreb, 13.12. 2014

The itineraire Personal introduction

A journey through decades: - a little bit of politics, history- health care / primary care function- general practice achievements and

perspectives

Czech Republic

Karlstein

Prague

Vltava riverMoravia

Charles University

The first University East of Paris and North of the Alps….

Founded in April, 7, 1348

Medicine + Law + Free Art + Theology

Fotka praxe

GP Department has been established 1996

Full academic function since 2003

Major development in 2009

Department of General Practice

First Faculty of Medicine

Charles University in Prague

Career path

General practitioner since 1985

Private practice since 1997

Academic career since 2003

Ph.D. completed in 2007, habilitation 2009

Head of the Department of GP Charles University since 2009

Scientific secretary of Czech Society of GP

GENERAL PRACTICE: 3 GPs and 2 nurses- population 3 000- teaching practice

A little bit of politics/history I.

Interval between world wars: The golden time of family medicine in the former Czechoslovakia

Austro-Hungarian empire until 1918 Czech Republic since 1993

A little bit of politics/history II.

1950´s An installation of the Soviet model with polyclinics and dense specialist network in countries of Central and Eastern Europe limited function and development of general practice.

GP has been recognised since 1978 (Alma-Ata conference) as a basic medical branch.

80´: starting a professional career

General Practice: 2nd choice discipline in 80´

Any other discipline was wide enough to satisfy my needs of complex approach to human person…...

Being too general v. too specialized The world also demands „the Great Synthesizers,“ people who specialize in interacting between disciplines and ideas. Communicating complex ideas that incorporate multiple bodies of knowledge is the skill that graduates and students need to have today.

General practitioners: „Great synthesizers“ in medicine.

Thomas L. Friedman, American journalist

and winner of Pulitzer prize

Choice of the discipline: Prerequisities for GP

Human prerequisites (patience, empathy) Communication/teaching skills Managerial skills Diligence Thoroughness

„If you are fascinated by ilnesses become hospital doctor, if youare fascinated by people, general practice can be your choice.“„If you get sick when entering the full waiting room, than avoid GP.“

A little bit of politics/history II.

The CEE countries have experienced dramatical changes,including the changes in the health care and in primary care

1989Velvet revolution

Windak A et al, EJGP 1998 Svab et al, Croat Med J, 1999 Seifert B et al., Family Practice, 2008Oleszyk M et al., BMC Family Practice. 2012

90´: difficult journey back to Europe Poor background of the GP discipline : - no theory behind - low recognition among other medical professions - low competence - bad image, low attractivity, „second choice discipline“ - no international contacts and experience- language barriers- high age averageBUT: - enthusiastic people - huge support from Europe

Support from European colleaguesRole of WONCA

In 90´s: new perspectives and possibilities• to travel and to meet colleagues• to participate at courses, conferences • to join WONCA networks, to learn and to adopt• to join research and quality projects

WONCA Region Europe, Prague 1997: the first meeting in CEE region

Personalities

Prof. Paul Wallace, Emeritus Professor of PHCInst. of Epidemiology & HealthFaculty of Population Health Sciences London, UK

Helge Bonlekke, GP in Thisted, Denmark, serving as a GP pensioner in Greenland

Prof. Richard Grol, a psychologist. Universities of Nijmegen and Maastricht

Prof. Roger Jones, Wolfson Professor of GPat The Guy's, King's, and St Thomas' School of Medicine, King's College, London. Since 2010 an editor in chief of Brittish Journal of GP

„Regional fellows“

Igor Svab, SLO J. Kersnik, D. Petric, M. Bulc

Adam Windak, PL Vaclav Benes, CZ

Mladenka Vrcic Keglevic, CR

PRIMARY CARE (96% privat contractors) GPs 5100(>15) average list 1 600 pts/1GP

PC PEDIATRICIANS 2200(<19) average list 900 pts/1PCP

PRIMARY CARE -Ambulatory gyneacologists-Home care agencies on referral-24 hours emergency services -Directly accessible specialists

General / Family Practice

in the Czech Republic

The point of the first medical contact within the health care system

Private providers List system Mixed reimbursement:

capitation +fee for service+bonus system No gatekeeping function but people seek

for care first by GP

Outpatient contacts per person per year

Norway 3,8Czech Republic 15,0 (contacts with GPs 6,0)

Czech Republic: - a lot of non medical reasons for encounter with GPs - open access to specialists - dense network of specialists

Since 2009:- regulative fee per visit - Rx OTC - 3 sick days not paid GPs: 4,2 (2012)

Comparison of practices in six European countries

Figure 3 Percentage of responses from small medium & large practices within each country

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

England

Netherlands

Czech Republic

Poland

Greece

Spain

missing data

large (7+)

medium (4-6)

small (1-3)

Seifert B, et al, The management of common gastrointestinal disorders in general practice. Digestive and Liver Disease, 2008; doi:10.1016j.dld.2008.02.020

Dr. Harold Frederick Shipman, GP born 14. 1. 1946, UKSerial murder : 215 victimsJudged to lifelong prison 31. 1. 2000Committed suicide 13. 1. 2004

Quality balance

• There is no evidence that systems with strict external control show higher quality

• These systems demand a lot of administration and demotivate providers.

CONTROL AUTONOMY

GP Task Profile Acute conditions, small injuries Chronic conditions: diabetes, hypertension, ICD, COPD, asthma,

musculoskeletal problems Systematic prevention + screening + vaccination Home visits Assessment for social services, sport, employers Occupational medicine

POCT technology: CRP, INR, glyk.Hgb, ECG, ABI, Holter BP monitoring,…

Alternative methods (homeopathy) uncommon

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aging of GPs in the Czech Republic 1990-2007

70+ 70+ 70+ 70+ 70+ 70+

do 39 do 39 do 39 do 39 do 39 do 39

60-69 60-69 60-69 60-69 60-69 60-69

50-59 50-59 50-59 50-59 50-59 50-59

40-49 40-49 40-49

40-49 40-49 40-49

1990 1995 2000 2005 2006 2007 5 224 GP 5 166 GP

Lack of GPs: Policies and interventions

GP academic dpt. + GP Society + Government improvement of pregraduate curriculum: - best examples in training practices- information campaigne about GP career

effective postgraduate training: 36 months

governmental support of residency programme since 2008

over 200 newly qualified GPs every year

Academic general practice An academic GP - a new kind of human in the Czech Republic How to assert in a competitive academic environment? Unique teaching! - one to one teaching, proximity to patients/people,

proximity to physicians, meeting healthy people, meeting not only diseases but problems, practice management

We have a strong message for students.

academic attributes: research, publications, academic life

Quality development in general practice in the CR

Organizational improvement:- appointment systém, more time for a patient

IT development

POCT technology + equipment

Competence in chronic disease management

Research in General Practice

the ultimate attribute of all disciplines which relate to a scientific context

evidence of the role of primary care in making the health care systems effective necessary for survival in academic environment

Research in primary care is difficult...

Colorectal Cancer Screening GPs have played a crucial role in screening in the Czech Republic; - in recruiting people, - counselling for screening, - distributing and performing FOBT, - dealing with negative and positive results and referring for a colonoscopy.

Guidebook for European general practitioners.

University education

Good clinical practice

Postgraduate education

Research

Quality improvement

Continuous education

Teaching

GENERAL PRACTICE…. offers all atributes of medical speciality for continuous professional development

QUALITY

CONTINUOUS PROFESSIONAL DEVELOPMENT

2005 2013

Margaret Chan, WHO general director

Out of the ashes built up by highly specialized, dehumanized, and commercialized medical care, family medicine rises like a phoenix, and takes flight, spreading its comprehensive spectrum of light, with the promise of a rainbow. This is the ancient historical covenant between doctors and patients, and this is where the health and medical professions need to return. I encourage all of you to continue to cultivate the human side of medicine.

The journey continues….

Thank you