Martin Hefford, CEO Tū Ora Compass Health is writing from a 12 week sabbatical in the UK, hosted by the Kings Fund in London and the Health Service Management Centre in Birmingham.

14 September 2019

Primary care walkabout in the Republic of Northern Macedonia

“How many patients are enrolled with you?’’ I asked Dr Rosa (not her real name) in her Macedonian practice consulting room, and also ‘’how many patients do you see a day?’’.

“I have nearly 3,000 patients” she explained through her interpreter (who is also her daughter), and see “about 70 per day – but up to 200 on a really busy day’’. My face obviously broadcast my amazement at the numbers; I had already seen that the clinic was very small – just Dr Rosa and her nurse/receptionist.

Rosa’s daughter explained that the national GP contract is based on a list of around 1,700, and requires GPs to see any patient that requests to be seen that day, on pain of serious fines. GPs are capitated and cannot charge significant copayments for their services. These two parameters combine to create a heavily demand driven ‘’walk in’’ based approach to general practice in Macedonia. People don’t book to see their GP, they just turn up and are always seen. Rosa told us that sometimes over anxious parents will bring their crying baby in 3 times in one day. There aren’t enough GPs in her town, hence her list has grown.

Rosa is a paediatrician who became a GP when the Macedonian Government instituted reforms post the breakup of Yugoslavia, and the transition from a socialist to capitalist system 20+ years ago. Primary health care trained doctors (GPs, paediatricians, and gynaecologists) were given the option of staying as state employees, or become independent primary health care contractors looking after an enrolled population. The aim was to build a strong primary health care sector in a state that up to then was secondary care dominated.

Ten metres down the corridor from Rosa’s clinic we met the Government employed immunisation team. Dr Rosa and her nurse were not permitted to vaccinate children; instead infants were recalled by the Government employed immunisation team. This team also had doctors (the ones who chose to stay as state employees), who would examine the well babies coming in for vaccination and then hand them over to the nurses to administer the vaccines. Dr Rosa used an electronic health record system and could send referrals and scripts electronically. The vaccination team used paper records and sent reminders in the post. They did not coordinate with Dr Rosa next door. Similarly, Dr Rosa didn’t know if someone was overdue for an immunisation and so couldn’t take advantage of opportunistic screening. Not surprisingly, Macedonian immunisation rates are low - around 75%. The local team attributed the dropping rates to antivaccination sentiment based on discredited autism links spread on social media.

The fragmented system is obviously inefficient, wasting clinician and patient time and leading to worse outcomes. But sometimes it is easier to see this sort of gross waste as an outsider than an insider. I remember visiting a community hospital in rural NZ about 13 years ago. GPs and community services were collocated in one building, but there was no integration of the model of care or processes. So to get a patient to be seen by a mental health clinician 20 metres down the corridor, the GP sent a referral to the main centre hundreds of kilometres away, where it was triaged and then, maybe, forwarded to the local mental health clinicians. The rejection letters followed the same route in reverse.

Every time the NZ health system sets up (or continues) a community nursing service, or mental health service, or cancer screening service; without reference to how the service will work in with general practice, we entrench silos and waste people’s time.

A health care feature that I saw in Macedonia that I wish we could copy is the Moi Termin (My Appointment) health information platform. It allows for e-referrals, e-scripts, e-claims, and patient organised bookings into nearly every public and private clinic in Macedonia. Through APIs the system connects up with 80+ clinic and hospital patient management IT systems. The ministry and funders can see, in real time, volumes of scripts, referrals and appointment availability across the country. I remarked on the high number of referrals for diabetes outpatient services. Yes, they said, that’s because GPs aren’t permitted to prescribe a number of diabetes medications, including insulin. A familiar story.

Learning from the great Danish melt down of 2013

In Denmark I learned how bad it can get when Government funders lose the trust and respect of general practice. Danish GPs, like their kiwi counterparts, are autonomous contractors. They are funded about 30% by capitation and 70% by fee for service payments (paid by the funder, not the patient – the service is free to the consumer.)

In 2013 the national GP organisation and the national association of regional funders failed to reach agreement after 9 months of negotiation for the next iteration of the national GP contract1. I heard that the funders were trying to impose additional accountabilities and requirements on GPs, and that the GPs were trying to get Government investment to avert to a potential sustainability crisis from a declining GP workforce. Subsequently, to break the impasse, the Government announced a law that would force GPs to accept new working conditions if they wish to remain suppliers within the public healthcare system. In response the GPs collectively announced they would give up their public contracts and to charge full prices to patients for their services. It looked as though the Danes were about to lose free-at-point-of-care general practice.

The conflict dragged out very publicly for months, and although it was eventually settled by a compromise agreement, effects are still being felt 5 years later. The idea of mass resignation from the public system split the GP community (as well as society at large). GPs withdrew from a Danish national health care data-warehouse, resulting in loss of data for quality improvement and system planning. GP registrar numbers dropped, as young doctors were put off by the conflict and reportedly felt that general practice was becoming unsustainable. Hospitals started recruiting young GPs as ‘hospitalists’.

GP registrar applications are now increasing again, and it is expected the database will be in place again in a year or so. But more than half of Danish GPs are now over 55 years old. The GP association told me that they consider the conflict cost the country 4 years of progress and has made a sustainability crisis more likely. The new agreement has finally resulted invested in general practice, and rather than forcing ‘’accountability’ is funding a Scottish style clinical quality improvement clusters approach. GPs are now in local quality improvement peer groups, with mutual accountability to their professional peers rather than to the funders.

Hearing about the conflict sent shivers down my spine; there but for the grace of god… our PHO Service Agreement Amendment Protocol may be unwieldy, but at least we have a sense of common objectives in the forum. And GP registrar program applicants have been increasing year on year. Let’s hope the Government, when it considers the Heather Simpson Health and Disability Services review remembers the need to take general practice with them. Large scale industrial conflict can inflict long term damage of both parties – and on the overall health system. It’s worth investing a little more to get a happy, productive, and supported general practice workforce.

1Developing Danish general practice, Jørgen Nexøe, Scand J Prim Health Care. 2013 Sep; 31(3): 129–130. Published online 2013 Sep.