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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] BMJ Open Workforce crisis in primary health care worldwide: the Hungarian example in a longitudinal follow-up study Journal: BMJ Open ManuscriptFor ID peerbmjopen-2018-024957 review only Article Type: Research Date Submitted by the 03-Jul-2018 Author: Complete List of Authors: Papp, Magor; National Public Health Institute Kőrösi, László; National Institute of Health Insurance Fund Management Sándor, János; Faculty of Public Health, University of Debrecen, Department of Preventive Medicine Nagy, Csilla; Public Health Administration Service of Government Office of Capital City Budapest Juhász, Attila; Public Health Administration Service of Government Office of Capital City Budapest Ádány, Róza; University of Debrecen, Faculty of Public Health, Department of Preventive Medicine; University of Debrecen, Debrecen, Hungary, MTA-DE Public Health Research Group of the Hungarian Academy of Sciences PRIMARY CARE, workforce crisis, vacancy, general practitioners, Keywords: socioeconomic status, deprivation For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 19 BMJ Open 1 2 3 4 Workforce crisis in primary health care worldwide: 5 the Hungarian example in a longitudinal follow-up study 6 7 8 Magor Papp1, László Kőrösi2, János Sándor3, Csilla Nagy4, Attila Juhász4, Róza Ádány3,5 9 10 1 National Public Health Institute, Budapest, Hungary 11 12 2 National Institute of Health Insurance Fund Management, Budapest, Hungary 13 14 3 Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary 15 16 4 Public Health Administration Service of Government Office of Capital City Budapest, Budapest, Hungary 17 18 5 MTA-DE Public HealthFor Research peer Group of the reviewHungarian Academy onlyof Sciences, University of Debrecen, Debrecen, Hungary 19 20 21 Corresponding author: Róza Ádány, MTA-DE Public Health Research Group, 22 23 Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, 24 25 Hungary 26 Debrecen, Kassai str 26, 27 28 H-4028 29 e-mail: [email protected] 30 Phone: +3652512764 31 32 Fax: +3652417267 33 34 35 Word count: 4335 36 37 Keywords: primary care, workforce crisis, vacancy, general practitioners, 38 39 socioeconomic status, deprivation 40 41 42 ABSTRACT 43 44 45 Objective To explore the development of the GP shortage as a secular trend and to 46 examine its characteristics from the perspective of an entire country, Hungary. 47 48 Design Longitudinal follow-up study over the decade 2007-2016. 49 50 51 Methods Analyses were performed on changes in number, age and sex of GPs by year 52 as well as on their geographical distribution and migration between areas categorized 53 into quintiles on the basis of the degree of socioeconomic deprivation. 54 55 56 Setting and subjects The study involved all general practices and GPs with territorial 57 supply obligations for Hungary in the period examined. 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 19 1 2 3 Results The analysis has shown a decrease in the number of GPs in all types of 4 5 practices during the examined decade, especially in the number of GPs in mixed and 6 paediatric practices. The results indicate both ageing and feminization of the GP 7 8 population. The distribution pattern of deprivation correlates well with the relative 9 vacancy rates, as it was confirmed by risk analysis showing exponential association 10 between relative vacancy rate and deprivation. The migration of GPs from the most- 11 12 deprived municipalities to the least-deprived ones was a definitive trend in the period 13 examined. 14 15 16 Conclusions The workforce crisis in primary care is progressively deepening, and 17 departmental intervention is needed. The deepening GPs workforce crisis is more 18 characteristic of theFor most-deprived peer areas review of the country. only The migration of GPs from 19 20 the most-deprived areas to the least-deprived ones further deepens the inequity in 21 access to health care for the most-vulnerable population groups and, in this way, 22 23 usurps their fundamental human right to health. These observations raise the decision- 24 making responsibility to support effective recruitment and retention of GPs for the 25 26 most-deprived areas. 27 28 29 STRENGTHS AND LIMITATIONS 30 31 32 - The study is based on a comprehensive longitudinal follow-up survey at a 33 national level to evaluate major changes in the number and distribution of 34 general practitioners (GPs). 35 - The survey used an area-based composite indicator to study the relationship 36 37 between deprivation and shortage in GPs in the country 38 - The study analysed the migration of GPs between practices, but the reasons for 39 leaving primary care were not investigated in detail. 40 - Data were available for the first day of each year; thus the study could not 41 42 detect transient changes in a year. 43 44 45 INTRODUCTION 46 47 48 The workforce crisis in primary care (PC) is a worldwide phenomenon. The shortage 49 in general practitioners (GPs) is particularly severe in low- and middle-income 50 51 countries in Africa, Asia and the Pacific,1-3 but it is becoming more striking in high- 52 income countries, as well. The Association of American Medical Colleges (AAMC) 53 54 projected a shortage of 46,000 primary care physicians by 2025,4 and it is estimated 55 by Petterson et al in a study designed to calculate the projected primary care physician 56 shortage at the current primary care production rates5 that if it remains unchanged, 57 58 the result will be a shortage in excess of 33,000 primary care physicians by 2035. In 59 the UK, research concluded that NHS England had substantially under-estimated the 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 19 BMJ Open 1 2 3 current shortage of GPs; according to this analysis, in 2016, England was already 4 5 approximately 6,500 GPs below the ideal number, a gap that would increase to 12,100 6 by 2020.6 According to recently reported findings from a regional survey, 82.0% of 7 8 responding GPs stated that they intend to leave general practice, take a career break 9 and/or reduce clinical hours of work within the next 5 years.7-8 Switzerland is also 10 11 facing an impending primary care workforce crisis since almost half of all primary 12 care physicians are expected to retire in the next decade.9-10 As the latest “Health at 13 14 a glance, 2016” report11 shows in the Organisation for Economic Co-operation and 15 Development (OECD)countries ― among them in the EU member states ― the 16 17 workforce crisis at the level of primary care is so deep that in the period of 2011-2013 18 a significant portionFor of thepeer emergency review department only (ED) visits occurred because 19 primary care was not available. In certain Central Eastern European (CEE) countries 20 21 (Czech Republic, Slovakia), this proportion of ED visits was as high as 52-74%. The 22 report concludes that in all countries, especially in CEE countries, there is a need to 23 24 further improve access to and the quality of primary care for the whole population. 25 26 The shortage of GPs seems to be the key issue of the workforce crisis in primary care 27 throughout the world. Data are available almost exclusively from cross-sectional rather 28 29 than longitudinal surveys;6, 12-14 therefore, these studies are unable to report on 30 previous and actual translations in the primary care system. In addition, these surveys 31 32 were conducted among GPs typically in a single region of a country,13, 15-18 which 33 may not be entirely typical of a country as a whole. 34 35 36 Our study on the development of the GP shortage and its characteristics in Hungary 37 illustrates a prime example of CEE countries with a workforce crisis in primary care, 38 and it is designed to characterize the secular trend of the changes in number and 39 40 distribution of GPs by age and sex in a longitudinal follow-up design, as well as to 41 describe the distribution of vacant GP positions by deprivation. 42 43 44 45 METHODS 46 47 Administratively, Hungary is divided into 19 counties as well as the capital Budapest; 48 49 thus, it has 20 European regions at the third level of the Nomenclature of Territorial 50 Units for Statistics (NUTS). The counties are further subdivided into 198 districts 51 52 constituting local administrative units 1 (LAU1), formerly known as NUTS level 4 of 53 Hungary1.
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