The primary care workforce in Europe: a cross-sectional international comparison of rural and urban areas and changes between 1993 and 2011.

Rural areas have problems in attracting and retaining primary care workforce. This might have consequences for the existing workforce. We studied whether general practitioners (GPs) in rural practices differ by age, sex, practice population and workload from those in less rural locations and whether their practices differ in resources and service profiles. We used data from 2 studies: QUALICOPC study collected data from 34 countries, including 7183 GPs in 2011, and Profiles of General Practice in Europe study collected data from 32 countries among 7895 GPs in 1993. Data were analyzed using multilevel analysis. Results show that the share of female GPs has increased in rural areas but is still lower than in urban areas. In rural areas, GPs work more hours and provide more medical procedures to their patients. Apart from these differences between locations, overall ageing of the GP population is evident. Higher workload in rural areas may be related to increased demand for care. Rural practices seem to cope by offering a broad range of services, such as medical procedures. Dedicated human resource policies for rural areas are required with a view to an ageing GP population, to the individual preferences and needs of the GPs, and to decreasing attractiveness of rural areas.

Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries.

BACKGROUND: The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus achieving a higher quality of care and ensuring physicians' and patients' satisfaction. However, this communication is often not carried out properly. The objective of this study is to assess whether communication between GPs and medical specialists in the referral process is associated with the organisation of primary care within a country, the characteristics of the GPs, and the characteristics of the primary care practices themselves. METHODS: An analysis of a cross-sectional survey among GPs in 34 countries was conducted. The odds ratios of the features that were expected to relate to higher rates of referral letters sent and communications fed back to GPs were calculated using ordered logistic multilevel models. RESULTS: A total of 7183 GPs from 34 countries were surveyed. Variations between countries in referral letters sent and feedback communication received did occur. Little of the variance between countries could be explained. GPs stated that they send more referral letters, and receive more feedback communications from medical specialists, in countries where they act as gatekeepers, and when, in general, they interact more with specialists. GPs reported higher use of referral letters when they had a secretary and/or a nurse in their practice, used health information technologies, and had greater job satisfaction. CONCLUSIONS: There are large differences in communication between GPs and medical specialists. These differences can partly be explained by characteristics of the country, the GP and the primary care practice. Further studies should also take the organisation of secondary care into account.

Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries.

BACKGROUND: Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients' perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients. METHODS: We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients' perceptions of communication at the interface between primary and secondary care. RESULTS: In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients' perceptions of information shared by GPs with medical specialists, and the patients' perceptions of the GPs' awareness of the results of treatment by medical specialists. Patients whose GPs stated that they 'seldom or never' send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they 'seldom or never' receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care. CONCLUSION: Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care.

Experiences of adult patients using primary care services in Poland - a cross-sectional study in QUALICOPC study framework.

BACKGROUND: Patients as real healthcare system users are important observers of primary care and are able to provide reliable information about the quality of care. The aim of this study was to explore the patients' experiences and their level of satisfaction with the process and outcomes of care provided by primary care physicians in Poland and to identify the characteristics of the patients, their physicians, and facilities associated with patient satisfaction. METHODS: The study is based on data from the Polish part of the Quality and Costs of Primary Care in Europe (QUALICOPC) cross-sectional, questionnaire-based study. In Poland, a nationally representative sample of 220 PC physicians and 1980 of their patients were recruited to take part in the study. As a study tool we used 3 out of 4 QUALICOPC questionnaires: "Patient Experience", "PC Physician" and "Fieldworker" questionnaires. RESULTS: The areas of the best quality perceived by Polish PC patients are: equity, accessibility of care and quality of service. Coordination and comprehensiveness of care are evaluated relatively worse. The patients' and their physicians' characteristics have a limited influence on patient satisfaction and experiences with Polish primary care. CONCLUSIONS: Primary health care in Poland is of good overall quality as perceived by the patients. Study participants were at most satisfied with accessibility and equity of care and less satisfied with coordination and comprehensiveness of care. Longer patient-doctor relationship and older age of patients were found as the most influential determinants of higher satisfaction. However, variables used in this study poorly explain the overall level of satisfaction. Further research is needed to identify the other determinants of patient satisfaction in the Polish population. Rural practices deserve additional attention due to highest proportions of both extremely satisfied and dissatisfied patients.

Two decades of change in European general practice service profiles: conditions associated with the developments in 28 countries between 1993 and 2012.

OBJECTIVE: Evidence regarding the benefits of strong primary care has influenced health policy and practice. This study focuses on changes in the breadth of services provided by general practitioners (GPs) in Europe between 1993 and 2012 and offers possible explanations for these changes. DESIGN: Data on the breadth of service profiles were used from two cross-sectional surveys in 28 countries: the 1993 European GP Task Profile study (6321 GPs) and the 2012 QUALICOPC study (6044 GPs). GPs' involvement in four areas of clinical activity (first contact care, treatment of diseases, medical procedures, and prevention) was established using ecometric analyses. The changes were measured by the relative increase in the breadth of service profiles. Associations between changes and national-level conditions were examined though regression analyses. Data on the national conditions were used from various other public databases including the World Databank and the PHAMEU (Primary Health care Activity Monitor) database. SETTING: A total of 28 European countries. SUBJECTS: GPs. MAIN OUTCOME MEASURE: Changes in the breadth of GP service profiles. RESULTS: A general trend of increased involvement of European GPs in treatment of diseases and decreased involvement in preventive activities was observed. Conditions at the national level were associated with changes in the involvement of GPs in first contact care, treatment of diseases and, to a limited extent, prevention. Especially in countries with stronger growth of health care expenditures between 1993 and 2012 the service profiles have expanded. In countries where family values are more dominant the breadth in service profiles decreased. A stronger professional status of GPs was positively associated with the change in first contact care. CONCLUSIONS: GPs in former communist countries and Turkey have increased their involvement in the provision of services. Developments in Western Europe were less evident. The developments in the service profiles could only to a very limited extent be explained by national conditions. A main driver of reform seems to be the changes in health care expenditure, which may indicate a notion of urgency because there may be a pressure to curb the rising expenditures. KEY POINTS: Broad GP service profiles are an indicator of strong primary care in a country. It is expected that developments in the breadth of GP service profiles are influenced by various national conditions related to the urgency to reform, politics, and means. Between 1993 and 2012 the involvement of GPs in European countries in treatment of diseases increased and their involvement preventive activities decreased. The national conditions were found to be associated with changes in GPs' involvement as first contact of care, treatment of diseases, and, to a limited extent, prevention. More specifically, in countries with a stronger growth in health care expenditures, service profiles of European GPs have expanded more in the past decades.

Assessing the potential for improvement of primary care in 34 countries: a cross-sectional survey.

OBJECTIVE: To investigate patients' perceptions of improvement potential in primary care in 34 countries. METHODS: We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care - accessibility/availability, continuity, comprehensiveness, patient involvement and doctor-patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care - governance, economic conditions and workforce development. FINDINGS: In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor-patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care. CONCLUSION: In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries.

BACKGROUND: The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study. METHODS: The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. RESULTS: Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. DISCUSSION: The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries.

AIM: To describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems. BACKGROUND: Redistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains. METHODS: Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries. FINDINGS: Countries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs' working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation.

A snapshot of the organization and provision of primary care in Turkey.

BACKGROUND: This WHO study aimed to support Turkey in its efforts to strengthen the primary care (PC) system by implementing the WHO Primary Care Evaluation Tool (PCET). This article provides an overview of the organization and provision of primary care in Turkey. METHODS: The WHO Primary Care Evaluation Tool was implemented in two provinces (Bolu and Eskisehir) in Turkey in 2007/08. The Tool consists of three parts: a national questionnaire concerning the organisation and financing of primary care; a questionnaire for family doctors; and a questionnaire for patients who visit a family health centre. RESULTS: Primary care has just recently become an official health policy priority with the introduction of a family medicine scheme. Although the supply of family doctors (FDs) has improved, they are geographically uneven distributed, and nationwide shortages of primary care staff remain. Coordination of care could be improved and quality control mechanisms were lacking. However, patients were very satisfied with the treatment by FDs. CONCLUSIONS: The study provides an overview of the current state of PC in Turkey for two provinces with newly introduced family medicine, by using a structured approach to evaluate the essential functions of PC, including governance, financing, resource generation, as well as the characteristics of a "good" service delivery system (as being accessible, comprehensive, coordinated and continuous).

QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care.

BACKGROUND: The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described. METHODS/DESIGN: QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models. DISCUSSION: By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries.

AIM: To describe variation in task shifting from general practitioners (GPs) to practice assistants/nurses in 34 countries, and to explain differences by analysing associations with characteristics of the GPs, their practices and features of the health care systems. BACKGROUND: Redistribution of tasks and responsibilities in primary care are driven by changes in demand for care, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill mix of primary care teams. However, these developments are hampered by barriers between professional domains, which can be rigid as a result of strict regulation, traditional attitudes and lack of trust. METHODS: Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7200 GPs in 34 countries. The dependent variable 'task shifting' is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are: institutional development of primary care; demand for and supply of care; nurse prescribing as an indicator for professional boundaries; professionalisation of practice assistants/nurses (indicated by professional training, professional associations and journals). Multilevel analysis is used to account for the clustering of GPs in countries. FINDINGS: Countries vary in the degree of task shifting by GPs. Regarding GP and practice characteristics, use of electronic health record applications (as an indicator for innovativeness) and age of the GPs are significantly related to task shifting. These variables explain only little variance at the level of GPs. Two country variables are positively related to task shifting: nurse prescribing and professionalisation of primary care nursing. Professionalisation has the strongest relationship, explaining 21% of the country variation.

The breadth of primary care: a systematic literature review of its core dimensions.

BACKGROUND: Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level. METHODS: A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit. RESULTS: Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health. CONCLUSIONS: A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

The European primary care monitor: structure, process and outcome indicators.

BACKGROUND: Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care. METHODS: A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems). RESULTS: The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care. CONCLUSIONS: A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.

Primary health care in transition: Variations in service profiles of general practitioners in Estonia and in Finland between 1993 and 2012.

INTRODUCTION: Since the early 1990s, the Estonian and Finnish health systems have undergone various changes which are expected to have impacted the type and range of services provided by general practitioners (GPs). OBJECTIVE: To compare GP services between Estonia and Finland in 1993 and 2012 and draw a parallel with transformations occurred in the health systems of both countries during these two decades. METHODS: Data were collected through surveys among 129 and 288 GPs from Estonia and Finland in 2012 and 139 Estonian and 239 Finnish GPs in 1993. Descriptive statistics were used to compare between countries and years. RESULTS: Between 1993 and 2012, the number of working hours per week and consultations per day increased in Estonia and decreased in Finland. In 2012, GPs in were more often the first contact for psychosocial and women´s and children´s in Estonia, whereas this decreased in Finland. The frequency of treating acute patients mostly decreased in both countries. We observed a decrease in medical procedures in Finland and an increase in Estonia. Finnish GPs still conducted more procedures in 2012. CONCLUSION: Due to partly opposite changes, the services provided by Finnish and Estonian GPs became more similar. Still, there are large differences in services provided, possibly arising from differences in the organisation of health services, the training of doctors and patients' preferences.

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries.

AIM: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. BACKGROUND: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. METHODS: Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. FINDINGS: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. CONCLUSIONS: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

GP Practices as a One-Stop Shop: How Do Patients Perceive the Quality of Care? A Cross-Sectional Study in Thirty-Four Countries.

OBJECTIVE: To contribute to the current knowledge on how a broad range of services offered by general practitioners (GPs) may contribute to the patient perceived quality and, hence, the potential benefits of primary care. STUDY SETTING: Between 2011 and 2013, primary care data were collected among GPs and their patients in 31 European countries, plus Australia, Canada, and New Zealand. In these countries, GPs are the main providers of primary care, mostly specialized in family medicine and working in the ambulatory setting. STUDY DESIGN: In this cross-sectional study, questionnaires were completed by 7,183 GPs and 61,931 visiting patients. Moreover, 7,270 patients answered questions about what they find important (their values). In the analyses of patient experiences, we adjusted for patients' values in each country to measure patient perceived quality. Perceived quality was measured regarding five areas: accessibility and continuity of care, doctor-patient communication, patient involvement in decision making, and comprehensiveness of care. The range of GP services was measured in relation to four areas: (1) to what extent they are the first contact to the health care system for patients in need of care, (2) their involvement in treatment and follow-up of acute and chronic conditions, in other words treatment of diseases, (3) their involvement in minor technical procedures, and (4) their involvement in preventive treatments. EXTRACTION METHODS: Data of the patients were linked to the data of the GPs. Multilevel modeling was used to construct scale scores for the experiences of patients in the five areas of quality and the range of services of GPs. In these four-level models, items were nested within patients, nested in GP practices, nested in countries. The relationship between the range of services and the experiences of patients was analyzed in three-level multilevel models, also taking into account the values of patients. PRINCIPAL FINDINGS: In countries where GPs offer a broader range of services patients perceive better accessibility, continuity, and comprehensiveness of care, and more involvement in decision making. No associations were found between the range of services and the patient perceived communication with their GP. The range of GP services mostly explained the variation between countries in the areas of patient perceived accessibility and continuity of care. CONCLUSIONS: This study showed that in countries where GP practices serve as a "one-stop shop," patients perceive better quality of care, especially in the areas of accessibility and continuity of care. Therefore, primary care in a country is expected to benefit from investments in a broader range of services of GPs or other primary care physicians.

Primary care in a post-communist country 10 years later Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004.

OBJECTIVES: The study aimed, firstly, to assess changes in the service profile of primary care physicians between 1994, when features of the Soviet health system prevailed, and 2004, when retraining of GPs was completed. Secondly, to compare service profiles among current GPs, taking into account their positions before being retrained. METHODS: A cross-sectional repeated measures study was conducted among district therapists and district pediatricians in 1994 and GPs in 2004. A questionnaire was used containing identical items on the physicians' involvement in curative and preventive services. The response rates in both years were 87% and 73%, respectively. RESULTS: In 2004, physicians had much more office contacts with patients than in 1994. Modest progress was made with the provision of technical procedures. Involvement in disease management was also stronger in 2004 than in 1994, particularly among former pediatricians. Involvement in screening activities remained stable among former therapists and increased among former pediatricians. At present, GPs who used to be therapists provide a broader range of services than ex pediatricians. GPs from the residency programme hold an intermediate position. CONCLUSIONS: Lithuanian GPs have taken up new tasks but variation can be reduced. The health care system is still in the midst of transition.

Changes in primary care provision in Turkey: A comparison of 1993 and 2012.

Since the early 1990s, the primary care system in Turkey has undergone fundamental changes. In the first decade of the millennium family doctor scheme was introduced to the Turkish primary care sector and the name of the primary care doctors (PCDs) changed from "general practitioner" (GP) to "family doctor" (FD). This study aims to give an insight into those changes and to compare the service profiles of PCDs in 1993 and 2012. Data, based on cross sectional surveys among Turkish doctors working in primary care are derived from the 1993 European GP Task Profile study (n=199) and the 2012 Quality and Costs of Primary Care in Europe (QUALICOPC) study (n=299). The study focuses on the changes in the primary care service provision based on selected aspects such as the first contact of care, preventive care, and the knowledge exchange and collaboration with other health professionals. Compared to GPs in 1993, FDs in 2012 reported that their involvement in treatment of chronic diseases, first contact care, antenatal and child health care have increased. FDs have more contact with other primary healthcare workers but their contact with hospital consultants have decreased. Overall, the services provided by PCDs seem to be expanded. However, the quality of care given by FDs and its effects on health indicators are needed to be explored by further studies.

How patients would like to improve medical consultations: Insights from a multicentre European study.

OBJECTIVE: In a previous qualitative study (GULiVer-I), a series of lay-people derived recommendations ('tips') was listed for doctor and patient on 'How to make medical consultation more effective from the patient's perspective'. This work (GULiVer-II) aims to find evidence whether these tips can be generally applied, by using a quantitative approach, which is grounded in the previous qualitative study. METHODS: The study design is based on a sequential mixed method approach. 798 patients, representing United Kingdom, Italy, Belgium and the Netherlands, were invited to assess on four point Likert scales the importance of the GULiVer-I tips listed in the 'Patient Consultation Values questionnaire'. RESULTS: All tips for the doctor and the patient were considered as (very) important by the majority of the participants. Doctors' and patients' contributions to communicate honestly, treatment and time management were considered as equally important (65, 71 and 58% respectively); whereas the contribution of doctors to the course and content of the consultation was seen as more important than that of patients. CONCLUSIONS: The relevance of GULiVer-I tips is confirmed, but tips for doctors were assessed as more important than those for patients. PRACTICE IMPLICATIONS: Doctors and patients should pay attention to these "tips" in order to have an effective medical consultation.