Dit proefschrift is een uitgave van het NIVEL in 2003. De gegevens mogen met bronvermelding (Profiles of General Practice in Europe, Wienke G.W. Boerma, NIVEL 2003) worden gebruikt. Het proefschrift is te bestellen via [email protected]. Profiles of General Practice in Europe An international study of variation in the tasks of general practitioners Wienke G.W. Boerma ISBN 90-6905-626-7 http://www.nivel.nl [email protected] Telephone +31 30 2729 700 Fax +31 30 2729 729 ©2003 NIVEL, Postbus 1568, 3500 BN Utrecht, The Netherlands Cover design: Lisette Jansen Word processing / layout: Christel van Aalst Translation: Vertaalkantoor drs. H. Kerkhoven; Elaine Bohlken Printing: Twin Design All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of NIVEL. Exceptions are allowed in respect of any fair dealing for the purpose of research, private study or review. Profiles of General Practice in Europe An international study of variation in the tasks of general practitioners PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus Prof. Dr. A.C. Nieuwenhuijzen Kruseman, volgens het besluit van het College van Decanen, in het openbaar te verdedigen op woensdag 17 september 2003 om 14.00 uur door Wijnand Gerard Willem (Wienke) Boerma Promotores: Prof. dr. J. van der Zee Prof. dr. P.P. Groenewegen (Universiteit Utrecht) Beoordelingscommissie: Prof. dr. J.A.M. Maarse (voorzitter) Prof. dr. R.P.T.M. Grol Prof. dr. J.A. Knottnerus Prof. dr. M. McKee (London School of Hygiene and Tropical Medicine, UK) Prof. dr. B. Starfield (Johns Hopkins Bloomberg School of Public Health, Baltimore, USA) The study presented in this book was funded by the European Commission in the BIOMED 1 programme (grant no. BMH1-CT92-1636) and implemented by NIVEL in collaboration with coordinators in the participating countries. To NIVEL Contents 1 Problem, method and questions of the study 11 Introduction 12 Problem and research questions 13 Influences on the provision of GPs' services 15 Study design and methods 32 Contents 43 2 Service profiles of general practitioners in Europe 45 Introduction 46 Method 46 Results 49 Discussion 55 3 General practice in urban and rural Europe: the range of curative services 59 Introduction 60 Methods 62 Results 64 Discussion 72 4 The general practitioner as the first contacted health professional by patients with psychosocial problems 77 Introduction 78 Methods 79 Results 83 Discussion 86 5 Gender-related differences in the organisation and provision of services among general practitioners in Europe 89 Introduction 90 Methods 92 Results 94 Discussion 100 Profiles of general practice in Europe 7 6 Unity or diversity? Task profiles of general practitioners in central and eastern Europe 105 Introduction 106 Method and analysis 107 Results 109 Discussion 114 7 GP home visiting in 18 European countries 117 Introduction and aim 118 Backgrounds 118 Hypotheses 120 Methods and data 121 Results 122 Discussion 125 8 General Practitioners' use of time and time management 129 Introduction 130 Sources of variation in use of time 131 Patient demand consultations and home visits 132 Managing patient demand: practice organisation 133 Individual variation: personal characteristics 135 The country dimension: systems and cultures 136 Conclusions 139 9 Variation in workload and allocation of time under different payment systems in General Practice 145 Introduction 146 Hypotheses 148 Data and methods 149 Results 153 Discussion 158 10 Summary and conclusions 161 Introduction 162 Background to the study 162 Summary of results 163 Discussion 172 Implications 176 8 Profiles of general practice in Europe Samenvatting (Summary in Dutch) 183 Literature 193 Appendix 1: Local coordinators of the study 219 Appendix 2: Questionnaire of the study 221 Acknowledgement 237 Dankwoord 238 Curriculum vitae (in English) 239 Curriculum vitae (in het Nederlands) 240 Profiles of general practice in Europe 9 10 Profiles of general practice in Europe 1 Problem, method and questions of the study Profiles of general practice in Europe 11 Introduction Differences in the tasks and activities of general practitioners (GPs) do not only exist between individual GPs but also, at a higher level, between countries. The diversity in patterns of provision between individual GPs within a single health care system, is a well- studied phenomenon (Wilkin and Smith, 1987; Knottnerus et al., 1990; Van de Lisdonk and Schellevis, 1994; Delnoij and Spreeuwenberg, 1997). Variation at this level is related to individual characteristics of GPs, and the circumstances and population of the practice. Sources of variation between countries lie in the features of the health care system, such as organisation and mode of financing and regulation (Anderson, 1963; Mechanic, 1972; McPherson, 1981; Fleming, 1993; Gervas et al., 1994; Van den Brink-Muinen et al., 2000). Precise information on international differences in the provision of tasks by GPs is scanty, however, and little is known about the possible influence of features of health care systems, as a consequence. The study reported in this book is an attempt to fill the need for information on the diversity in the provision of services in general practice. Task profiles, crisply typifying the GPs' supply of services, have been compiled in European countries, and the differences will be explained by relating them to relevant characteristics of the health care systems in these countries, taking individual features of GPs and their practices into account. The need for comparative information on primary care and general practice has been fostered by developments in European health care systems during the late 1980s and the 1990s. Western European countries were confronted with sharply rising expenditure on health care while, at the same time, the systems were experiencing difficulties in responding to the changing health care needs of the population (Saltman and Figueiras, 1997; McKee and Healy, 2002a). New needs for health care resulted from demographic, medico- technological and societal developments. A major change has been the growing prevalence of chronic conditions resulting from the ageing of populations. The coordinative capacity of many health care systems was inadequate to enable the flexible involvement of various health care services and providers and to cope with demand for different long-term care arrangements. A coherent primary care system, with general practice as its integrative core, was thought to have the potential to improve cost-effectiveness as well as coordination and responsiveness (Starfield, 1996, 1998; Boerma and Fleming, 1998; Delnoij et al., 2000; Shi et al., 2002). The situation in the countries of central and eastern Europe was even more urgent. Freed from communism, they had no choice but to fundamentally restructure their extensive but not very effective health care systems. As happened in other sectors, they looked to the West for models of provision and financing of health care. Whichever models these countries chose, the choice implied a structure of health care with a firm base of primary care, including GPs in a more or less central role and a simultaneous reduction of the 12 Profiles of general practice in Europe hospital sector (Goldstein et al., 1996; Marrée and Groenewegen, 1997; McKee et al., 2002b). The results of the European Study on GP Task Profiles will show the state of affairs in general practice in the transitional countries and the diversity in the position of GPs in Europe as it was in the years 1993/4. The aim of this first chapter is to provide an introduction and background. The problem and research questions of the study will be stated, the relevant influences on the activities of GPs described, and details given of the study design, instruments, methods, response and analysis. Chapters 2 to 9 contain articles that resulted from the study. The book will end with a summary of the results, a discussion and the implications for science, practice and policy. Problem and research questions Lack of information Despite the trend towards increasing integration, the organisation and provision of health care in European countries continues to be diverse, even within the European Union. Indeed, health care is still largely a national affair in the EU, although there are indirect effects from other policy areas (the free mobility within the EU, for example). This (informal) process is not directly driven by competences in health care or initiatives on the part of the European Commission, yet it is resulting in the gradual convergence of national health policy agendas. It has become very clear in this situation how little information is available for comparison of health services in different countries - even at descriptive level. International studies on expenditure have frequently been undertaken in fact, but research on the provision of health care to the population is scarce and handicapped by lack of data. This lack of information and evidence is particularly noticeable in the light of the health care reforms that have occurred since the early 1990s, many of which have affected primary care. Examples are the introduction of GP fund-holding and the later Primary Care Groups/Trusts in the UK, the family doctor system in Sweden, policies in Germany, France, Norway and Finland leading to voluntary patient list systems and a stronger coordinating role for GPs (Vohlonen et al., 1989; Le Grand, 1998 Aguzzoli et al., 1999; Bundesministerium, 2000; Alban and Christiansen, 1995; Vehvilaeinen, 1996; Weiner et al., 2002). Traditional boundaries between primary and secondary care are shifting as a result of transfer and delegation of tasks. Policymakers assume that a stronger system of primary care and general practice will contribute to realizing the aims of more efficient health care systems that are more responsive to the health needs of citizens.