A lonely practice for some: primary care in Europe

On the home stretch of his tour of Europe, Dr Gerald Michael visits Holland, Belgium, Luxembourg and France

The last leg of my 12,000-mile journey in 12 weeks saw me visiting GPs throughout the Benelux countries, and into France before heading home to the UK.

In Holland, 60 per cent of GP income is a capitation fee for each patient, paid the same regardless of the patient's age.

The remaining 40 per cent is an item of service payment. There is a fixed fee for every face-to-face consultation and a larger fee for home visits. Telephone consultations reap a smaller fee and surprisingly there is a similar fee for an email consultation.

If a face-to-face consultation exceeds 20 minutes, the doctor is allowed charge for a double consultation.

Patients now pay nothing to see the doctor, GP services being paid through a state insurance scheme.

Up until last year it was a different system where the doctors were paid only by capitation fee. The new system has been found to be an incentive to do more.

In Belgium, Luxembourg and France the GPs are paid exclusively by the patients who are reimbursed mainly by the state, or a state sponsored insurance society.

Cost of consultation

In Belgium, the rate for a new surgery consultation is €21, Luxembourg €31 and France €21-€31 depending which system the GP has chosen to join.

These figures are cheaper than Ireland, where general practice is entirely private and the doctor I visited charged
€45. Apart from Holland, the main feature about GPs in this part of Europe is the loneliness of the workplace.

Not only are they mostly single handed, these doctors often have no staff at all.

The Belgian doctor I met has his surgery in his home and apart from a cleaner there is no one else. He carries two mobile phones (three during days on call) and a pocket computer, which synchronises with his PC.

Patients phoning him for an appointment get straight through. So, consultations are frequently interrupted.

Agency receptionists

In France and Luxembourg, some doctors use a virtual receptionist system, where messages are taken by a receptionist who in reality works in an agency covering several surgeries or businesses.

In France, if an injection is needed, the doctor refers the patient to a separate, privately run nurse clinic, where the patient pays and is largely reimbursed.

It is illegal to employ practice nurses in Luxembourg and all injections must be given by the doctor.

One GP I spoke to felt very strongly that the work done by UK practice nurses is the work of the GP and that taking BP, weights and managing diabetes and hypertension keeps them in contact with the patient.

In Belgium, they have co-ops for out-of-hours and most doctors are single-handed and are paid by item of service. Many GPs remain on duty for their patients, by staying on their mobile phone all the time.

If a doctor does not  want to be available, he can leave a message on his voicemail for patients to ring an emergency service, where patients can request a house call.

There are private out-of-hours services where they can charge what they like as they have no agreement with the health authority.

In Luxembourg, from early evening until 10pm the doctors have a compulsory rota of one in 10.

From 10pm until morning,  doctors up to the age of 54 must do one night a month. Patients go through a triage system before the doctor is called and if it is an emergency the GP is not called.

Doctors tend to be called out three times a night when on duty. Where fewer doctors cover larger areas, the system is unbalanced, but there are moves to ensure that doctors will cover the same number of patients each throughout this small country.

In France, GPs are responsible for 24-hour cover, using co-ops. In Paris this service is staffed by trained GPs who do not have their own surgeries but receive consultation or visit fees from patients, which are largely reimbursed. They leave a scribbled note for the regular GP.

Many practices in these countries are paperless, although I had the impression that France was lagging slightly behind the other countries in this respect.

In Holland and Belgium it is necessary to do a minimum of continual medical education to stay on the register. There are no such requirements in Luxembourg and France.

Dr Gerald Michael is a retired GP from LondonNext week: Dr Michael sums up his tour of 24 European countries

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