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Single handed, and happily independent

A common theme runs through GP services in the old Eastern bloc, finds Dr Gerald Michael

Leaving the Czech Republic, I headed for Germany and Poland before heading north on my visits to European GPs.

In Germany, I visited a doctor in the part of Berlin which was previously in East Germany. I noticed common themes with other former Warsaw pact countries.

Up to 15 years ago, general practice was tightly managed in large polyclinics with whole teams of directors and administrators. The doctors in these countries are now encouraged to run their own practices, sometimes single handedly and sometimes in groups. They value their independence and do not want any form of control from above.

In Germany, however, doctors are single handed but many share premises with others including specialists.

The doctors I interviewed in Germany and Poland are single handed and own their premises.

In Poland I was told that the average number of patients for a doctor is about 2,000, which is about the same for doctors in the countryside in the old East Germany. Berlin doctors’ lists are more like 650.

Pay per visit

In both countries the doctors are paid by capitation fee but the way the list is maintained in Germany is interesting.

When patients have any medical service, they have to pay the GP € 10 just once in each three month period. This puts the patient on the list and the doctor is then paid € 70 per quarter for that patient. If the patient does not attend for more than three months he goes off the list until he returns and the GP loses the capitation fee until that patient is next seen.

Consequently, doctors never give a repeat prescription for more than three months, and the patient must see the doctor to receive a prescription. This way the € 10 is paid and the doctor gets his € 70.

German doctors are able to prescribe what they like, but are expected to use generic drugs and the cheapest of a group such as simvastatin. The GPs are contacted by health insurance companies if their prescribing is found to be too expensive. Patients pay a small prescription charge.

In Poland, the patients pay a proportion of the cost of drugs so it is in their interest for the GP to avoid choosing an unnecessarily expensive drug.

In both countries GPs can look after children, but many prefer not to. At the German practice that I visited, the doctor would not accept children under the age of four. They are instead cared for by primary care paediatricians, who do all the immunisations.

Dr Kryzszto, the Polish GP, told me that while most GPs look after children from birth, he prefers not to take them on until the age of eight, as he does not feel experienced in that area. Mothers take their children to a primary care paediatrician in his building.

Neither Polish nor German GPs practice gynaecology, which is done by primary care gynaecologists. It would be unthinkable for a Polish GP to do a vaginal examination, and few in Germany would do so.

Health promotion is taken seriously in both countries, with regular BP checks and the usual blood tests. In the 40–84 age group there is a regular risk stratification for colon cancer and patients are points-scored for positive symptoms and family history. If a sufficient level is achieved, the patient is referred for colonoscopy.

Dr Gerald Michael is a retired GP from London

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