Katy Moult , ST3 in Grampian has recently completed a Hippokrates exchange. The Hippokrates Exchange Program promotes links between junior GPs (those within 5 years of completing training), and established GPs and trainers in different European countries. Katy has kindly allowed us to share her report with you.
IntroductionI am a GPST3 based in Aberdeen, Scotland, and I was fortunate enough to be awarded a Leonardo funded bursary for the Hippokrates Exchange 2013/2014.
The programme’s aim is to encourage exchange and to promote links between GP trainees and GPs within 5 years of training. It is hoped that this will offer a broader perspective into General Practice/Family medicine, as well as offering a unique opportunity to learn about the primary health care system in another European country.
My ExchangeI was offered an exchange in Spain, and arranged to visit a practice in Palma, Mallorca. Palma is the capital city of the Island of Mallorca, and has a population of 401, 270 which represents half the population of the entire island.
The practice I was attached to was Es Coll d´en Rabassa Health Centre 15minutes from the centre of Palma. It is split over two sites (Es Coll d'en Rabassa and Es Molinar). I spent the majority of my time at Es Molinar with Dr Atanasio Garcia Pineda.
Dr Garcia has been a Family practitioner for nearly 20 years, and a GP trainer for the last 10 years. Previously, he worked as the General Manager of the Primary Care System of Mallorca for 5 years, and was an excellent mentor to learn from. The team comprised of 11 family physicians, 4 peadiatricians, 12 nurses, 1 nursing assistant, 1 physiotherapist, 1 gynaecologist, 1 midwife and 1 social worker. Also, they currently have 6 GP trainees working with the team – and can take up to a maximum of 12 trainees per year.
The health centres together cover a population of 19.800 people. The health centre was located in a relatively deprived area, with a high rate of unemployment, and many patients are on state benefits. Interestingly, there were a number of older patients who have lived in the area since childhood. As a result the GP knew them, their families and their social set up well. With increasing unemployment in the UK following the financial crisis, and an aging population, this made for some interesting comparisons.
The health system in Spain is similar to the NHS in the UK in that it is free at the point of delivery, and funded mainly through taxation. There are of course many differences, which I will now describe further.
A Typical DayAt the health centre, the GPs worked from 8:00am to 3pm most days, except on a Monday when they worked until 5:30pm. This is because all practices in the area must work to cover ‘out of hour’ sessions at least once per week. The day started with a joint teaching session between the two sites. This took the form of a case presentation, a teaching presentation, or a journal club. Following this, clinics would start at around 10am and would run until 2 pm. Consultations were scheduled every 7 minutes, but any patient needing to be seen urgently could walk in and be given an emergency appointment to be seen there and then. This meant that doctors typically see between 34-40 patients per day! This seems a much higher number compared to the UK, however, the consultations were generally a lot quicker, and it seemed that patients attended with relatively minor problems or requests. For example, the majority of consultations were to request a sick line (which is needed in Spain after one day of absence), to ask for repeat medications, to ask for test results, or to deliver a letter or result from the hospital. Patients are only seen by the doctor with whom they are registered, unless it is an emergency appointment, or their doctor is off.
A major difference was the reduced variety in patients being seen. No obstetric, gynaecology or paediatric cases are seen by family doctors in Spain. Instead there is a Community Paediatrician who sees all cases. This includes baby checks – which occur at 7-14 days, further reviews are then conducted at aged 1, 2, 3, 4 and 12 months, AND then at 4 years, 6 years, 11 years and 14years. Clearly this means that a lot of ‘well’ children are seen, and appointments are generally used as an opportunity to ensure appropriate development, and to discuss health promotion. Gynaecological problems are seen in the first instance directly by gynaecologists – including issues related to contraception. Similarly to the UK, obstetric cases are looked after by the community midwife and obstetrician, and the midwife will continue to follow the case after delivery, as there are no Health visitors in Spain. Interestingly midwives also do all smears, including non-pregnant women.
The ConsultationI was interested in the consultation set up in Spain, which in some ways seemed more doctor-centered, and as a result was more formal. Surprisingly, at the health center all doctors and nurses wore white coats, yet were casually dressed underneath in jeans and T-shirts. The consultation rooms themselves were large clinical areas, with no personal effects or posters, which had communicating doors with the adjacent consulting rooms. This meant that consultations were frequently interrupted both by other doctors asking advice about management options, or by phone calls – either from the receptionist, or from another patient. There seemed to be no concern about discussing cases in front of other patients, and this method meant that second opinions could be sought there and then. Dr Garcia’s consultation style seemed very different to the general style we are ‘taught’ in the UK. He sat with a desk between himself and the patient, and there was no use of the concept of ‘Ideas, Concerns and Expectations’. Patients often presented with a number of issues or problems, which were dealt with within the same appointment without concern for time. Often patients came with their relatives who also had questions or problems and, surprisingly, relatives would also attend in lieu of a patient for test results or repeat prescriptions. Generally clinics ran to time – but on occasions when they didn’t, there seemed to be no need to apologise, which is clearly different to the UK! This appears to be a cultural difference, and would suggest a contrast in patient expectations between the UK and Spain.
I also spent a day with the Palliative Care team, which divides the island amongst 5 teams consisting of a Consultant and Palliative Care Nurse. Every palliative care patient (referred either from the hospital, or the GPs) are seen at home (a one hour appointment), and then followed up by that team as and when required. It was surprising to see a consultant on a home visit, and it certainly seemed that their resources were stretched. There were only 25 palliative care beds for the island, no Macmillan support teams, and only the offer of one time per day care (if available). The resources were clearly more limited than in the UK, but equally as stretched, and made me grateful for the services that are on offer at home, although limited at times.
I was surprised at the difference in number of house visits compared to the UK. In the UK, on average, I do at least 2 home visits per day – whilst my host only had one home visit throughout my 2 week stay! I suspect that this is as a result of all patients having to live close to their practice in Spain (within a mile radius) – and a cultural difference – with patients making more of an effort to attend, or their relatives coming on their behalf.
There seemed to be a higher referral rate to secondary care compared to the UK. Certainly there was less of a ‘wait and see’ approach, and often when suggested by the GP, the patient may demand a referral to secondary care. This was certainly true for musculoskeletal problems, which seemed commonly to be referred for imaging.
The computer system was much more efficient then at home. This means that although there were more referrals, they are more straightforward than in the UK. There is no paperwork, and are done during the consultation simply by selecting the place of referral, and whether it is routine, preferential or urgent. This was true even for emergency admissions, who would be given a printed copy of their consultation, along with their patient summary, and advised to make their way to the nearest A&E department. There was no phone call by the GP to arrange admission to a specific department, nor to A&E to alert them to the patient’s imminent arrival.
Clearly with no paper work the life of a Family doctor in Spain seems less tedious – and means that following the end of the clinic they can go home on time. Similarly, prescriptions were done via a computer system also – meaning that there were very few printed prescriptions, making prescribing much easier – and less time consuming,
TrainingNot only is the job in general very different, but the training also has notable differences. Following university, medical graduates use a year to study for the ‘Examen de Medico Interno Residente’ – an exam, which allows them to be ranked and then apply to enter a training programme throughout Spain. As a result, I got the impression that the majority of trainees of Family Medicine are those who were ranked lower in the system, as opposed to the minority who did well and chose it as a specialty. The training takes 4 years with the ‘Residents’, as they are called, spending half this time in hospital and half based in their health centre. Their rotations in the hospital are divided round all the specialties, which seems to provide a broader base of knowledge when compared to the rotations in the UK. In contrast to the UK, however, in their first year of general practice, the residents do not see patients by themselves. Instead they either shadow their trainer, or are observed consulting. There are no exams and although the concept of e-portfolio exists – entries are not monitored, and can be as little as 3 per year! Although this clearly simplifies the residents paperwork – I fail to see exactly how the training is monitored, and certainly there is no way of knowing the doctor’s knowledge is up to scratch.
Further discussion with Dr Garcia allowed me to realize that perhaps the biggest difference between Spain and the UK relates to the financial situation that much of Europe finds itself in. He explained that as a Family Practitioner he works as a civil servant, and is contracted by the government. Similarly to the UK, they have targets set by the government (like the QOF), which prior to the financial crisis were assessed and paid on an individual doctor basis (instead of as a whole practice). However, over the last 12 months, there is now no financial backing, or monitoring of these targets, and thus it is now doctor choice to perform them.
ConclusionsThe underlying health systems between Spain and the UK are essentially the same and based on the Beveridge report. There were differences in relation to the running of the primary health care system, which I think both countries could learn from in order to improve and develop patient care.
On a day-to-day comparison, although there were small differences in consultation styles, what struck me as a disadvantage was the lack of patient variety. On the other hand, clearly individual patient lists improved continuity of care, the patient-doctor relationship, and allowed a greater insight into all aspects of the patient’s family and social set up.
Although the referral system in Spain is easier, with less paperwork, there is less communication between primary and secondary care, resulting in longer waiting times. This was particularly evident with emergency admissions, who just arrived at A&E with a letter from their GP, and had to wait to be assessed along with other first time attendees.
Certainly it seemed that patients in Spain were less demanding, and it would be of some benefit if patients in the UK were more aware of the limitations of the public health system.
This was a fantastic and unique opportunity to gain an insight into the health system, and the culture of Spain. My hosts were welcoming and willing to teach, and equally eager to learn about the UK system as I was in theirs.