A COMPARISON OF EUROPEAN FAMILY PRACTICE WORKLOAD

Dr M McCarthy FRCGPHead of UK Delegation to UEMO

Nuts and Bolts 21.1. 2016

GENERAL PRACTICE IN EUROPE• General Practice/Family Medicine is different in Europe• Most EU states recognise GPs as Specialists in Family

Medicine• (except Austria, Italy and UK)• Europe advocates free movement of professionals• There is a lack of information about various health systems• Commonwealth Fund Report consistently praises the NHS as

being a cost-effective, equable and accessible system

A QUESTIONNAIRE CONCERNING GP/FD WORKLOAD WAS CIRCULATED IN 2015Emailed to EU delegates from January to March There were 3 questionnaires with 10 questions eachOthers were added after suggestions from delegates24 states replied (Malta gave 2 answers – public and private)Information is still incomplete but data is improvingThere is variation between statesThere is variation within states

EU GP/FDGATEKEEPERS OR SIGNPOSTS?

GATEKEEPERS• Denmark Portugal• Finland Spain • Iceland Sweden• Netherlands UK• Norway

SIGNPOSTS• Austria Italy • Belgium Malta • Croatia Slovakia• Czech Rep Slovenia• France Switzerland• Germany Turkey • Ireland

CHILDREN NOT ALWAYS SEEN BY GP/FDSEEN BY PAEDIATRICIAN• Austria Slovakia• Belgium Slovenia• Croatia Spain• Czech Rep Switzerland• France • Germany• Italy

SEEN BY GP/FD• Finland Sweden• Ireland UK• Lithuania• Malta• Netherlands• Portugal• Romania

LIST SIZE – NUMBERS PER DOCTOR 1600 OR LESS• Austria Italy• Belgium Lithuania• Denmark Malta• Finland Norway• France Spain• Germany• Ireland

1700 OR MORE• Croatia Slovakia• Czech Rep Slovenia• Hungary Sweden• Netherlands Turkey• Poland UK• Portugal• Romania

WHICH IS MORE COMMON - SINGLE OR GROUP PRACTICE?

SINGLE DOCTOR• Austria Hungary • Belgium (97%) Italy (50%)• Croatia Romania• Czech Rep Slovakia• France (70%) Turkey • Germany

GROUP PRACTICE• Denmark Malta Slovenia• Netherlands(75%) Spain• Ireland Norway Sweden

• Italy (50%) Poland Switzerland • Lithuania Portugal UK (90%)

IF GROUP, HOW MANY DOCTORS? 3 OR LESS• Austria Malta (private)• Belgium Netherlands• Croatia Norway• Czech Republic Poland• Denmark Romania• France Slovakia• Hungary Switzerland • Ireland Turkey

4 OR MORE• Finland Slovenia• Italy Spain • Lithuania Sweden• Malta (public) UK• Portugal

DO YOU HAVE OTHER STAFF? ONE NURSE OR FEWER• Belgium Slovakia• Croatia Slovenia• Ireland Turkey• Hungary• Malta (private)

NURSES, ADMIN AND OTHERS• Austria Lithuania

Romania• Denmark Malta (public) Spain• Finland Netherlands Sweden• France Norway

Switzerland • Germany Poland UK• Italy Portugal • •

NUMBER OF PATIENT CONTACTS/DAY?

25 OR FEWER• Belgium • Denmark Portugal • Finland Sweden• France Switzerland• Italy• Malta • Netherlands• Norway

MORE THAN 25• Austria Lithuania Slovakia• Croatia Poland Slovenia

• Czech Rep Romania Spain• Germany Turkey• Hungary UK

• Ireland

NUMBER OF HOME VISITS/DR/DAY? 2 OR FEWER• Czech Rep Netherlands Slovenia• Denmark Norway Spain• Finland Poland Sweden• Italy Portugal Turkey• Ireland Romania• Lithuania •

3 OR MORE• Austria Hungary• Belgium Malta• Croatia Slovakia• France Switzerland• Germany UK

LENGTH OF CONSULTATION? 15 MINUTES OR LESS• Austria • Czech Rep Norway• Denmark Poland• Germany Romania• Hungary Slovakia• Ireland Slovenia• Italy Spain• Malta Turkey• Netherlands UK

MORE THAN 15 MINUTES• Belgium• Croatia• Finland• France• Lithuania• Portugal• Sweden• Switzerland

WE SHOULD HAVE ASKED ABOUT OTHER PATIENT CONTACTS

• Phone calls from patients• Phone calls to patients• Prescription queries• Review of pathology results• Acting on letters from specialists• Acting as patients' advocate• Referral letters

DO YOU SIGN "SICK NOTES"• Yes• GPs/Family Doctors sign sick notes for workers in all states

that replied• It is recognised that this is bureaucracy – it is a state

requirement• It is a duty that is felt as a burden

HOW LONG IS YOUR WORKING DAY?8 HOURS OR FEWER• Belgium Lithuania• Portugal Malta(public)• Croatia Portugal • Czech Rep Turkey• Denmark• Ireland• Finland

8-12 HOURS OR MORE• France Spain• Germany UK• Hungary• Malta (private)• Norway

REGULATIONS OR BUREAUCRACY?POLICE CHECK• For New Practice only• Austria• Norway

POLICE CHECK• Ireland• Lithuania• UK

APPRAISAL/REVALIDATIONAPPRAISAL 12% OF STATES• Lithuania• Spain• UK

REVALIDATION 24% OF STATES• Lithuania• Netherlands• Norway• Slovenia• Switzerland• UK

HEALTH AND SAFETY INSPECTIONS• Practice inspections occur in 44% of states• Austria Slovenia• Czech Rep Spain• Ireland Sweden • Lithuania Turkey • Netherlands UK• Romania

CARE QUALITY COMMISSION• Most EU states were unsure what this entailed – and surprised to find outFit and proper persons End of life carePerson-centred care RecordsDignity and respect Safe-guarding – Adults and children Need for consent Premises and equipmentSafe care and treatment Receiving and acting on complaintsDuty of candour Good Governance

CQC CONTINUED• Staffing and checks Infection control • Equality/rights Data protection• Medicines management Cleanliness• Waste/water systems CPD/CME• Staff support and training Mental health• Risk assessment Quality monitoringComments received – “we wouldn’t have a GP left in our country in 2 years if that was in place here” “We still learn from the NHS – what not to do”

INSURANCE/MEDICAL INDEMNITYNO PERSONAL COST (OR VERY LITTLE)• Finland Spain• Lithuania Sweden• Malta (public system)• Norway• Portugal• Romania (5.5% of income)• Slovenia

PERSONAL COST• Austria Switzerland• Belgium Turkey• Czech Rep UK• Ireland• Malta (private)• Netherlands• Slovenia (private)

IS YOUR WORKLOAD SUSTAINABLE?

YES (24%) POSSIBLY (16%)• Austria Malta • Belgium Slovakia• Czech Rep Spain • Denmark Germany• Finland• Switzerland

NO (60%)• Croatia Poland Turkey• France Portugal UK• Hungary Romania • Ireland Slovenia• Lithuania Spain• Netherlands Sweden • Norway •

GENERAL PRACTICE/FAMILY MEDICINE IS UNDER STRESS

• Increasing demand• Changing demographics/older population• Shift of work from secondary to primary care• Increase in Chronic Disease – Diabetes/CVD• Retirement of older doctors• Shortage of medical graduates choosing a career in FM

A WORKFORCE UNDER STRESS IS NOT CLINICALLY SAFE

• High levels of "Burn-out“• Risk of CVD related illness• Increase in stress-related mental illness• Increase in alcoholism• Increase in self-medication• Increased levels of relationship breakdown/divorce• Early retirement• Difficulty in recruitment

THERE IS SOME CORRELATION BETWEEN WORKLOAD AND SUSTAINABILITY

Those states that say their workload is sustainable

Tend have lists <1600 patients

• They tend to spend 20 minutes in a consultation

• They don’t necessarily have less visits

• Having more staff does not seem to reduce stress

IS GENERAL PRACTICE SUSTAINABLE?States that feel it is, have two factors in common 1. They do work normal office hours 2. Strongest correlation is number of patient contacts/day• Fewer than 20-25 for one doctor and workload is reasonable• More than 25-30 and doctors feel overburdened• In UK face-to-face consultations are 40-50/day• Plus 10-20 patient queries/phone calls• Plus visits/letters/prescriptions/path results

BUREAUCRACY IS SIGNIFICANT IN UK• We have a degree of micromanagement unknown in Europe• Appraisal considered by Dutch – not yet in place• CPD/CME left to professional conscience• Revalidation automatic• CQC viewed with disbelief

WE NEED TO TAKE CARE OF OUR DOCTORS AS WELL AS OUR PATIENTS• Education of population may reduce demand• More reliable science reporting (media)• Teach resilience in medical schools• Limit hours of work for family doctors – build in education

time• Increase consultation time for patients – for clinical safety• Limit numbers of patients per GP/FD - for clinical safety• For doctor safety - Try and limit number of patient contacts

in a working day – as hospitals do

THANK YOU FOR YOUR ATTENTION

ANY QUESTIONS?

ANY SUGGESTIONS?WHAT OTHER INFORMATION SHOULD WE

COLLECT?

mary.mccarthy@nhs.net