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Throwbacks to the Soviet era remain

GPs from the Baltic states are slowly gaining professional independence, reports Dr Gerald Michael

After leaving Poland we drove to Vilnius, Riga and Tallinn, the capitals of Lithuania, Latvia and Estonia, where I had arranged to talk to GPs.  

I had difficulty finding a doctor to see me in Latvia, so I asked the concierge of a top hotel who he sends his guests to. He introduced me to two female doctors in a private clinic, who kindly arranged for me to meet their past trainer — a doctor in active national health general practice.  

Lithuania, Latvia and Estonia are adjacent countries each with their own language. Until the gained their independence in 1991, they were seen as an integral part of the Soviet Union.  

During that time, primary care services were handled in highly organised and controlled polyclinics as we have seen in other former Eastern bloc countries. The doctors were salaried and poorly paid and were mainly women. They had managers who controlled everything and they seemed to have had little professional independence.  

Changing systems  

In the past 15 years all these countries have been changing their system of primary care, encouraging GPs to be independent, working in clinics that they own and run themselves.  

In Lithuania about half the GPs have left the polyclinics and work in groups or on their own. The doctors are paid capitation fees, and consultations are free for patients.  

In Estonia, where I visited a large pre-communist polyclinic with many specialities, the consultations are also free to patients and GP income is from capitation fees.  

In Latvia, although most of the payment is by capitation, the patients pay a small fee for each consultation and a little more for house calls.  

House calls feature in all three countries. In Lithuania, it is the patient who decides if a visit is necessary and the doctor has to agree or there will be a complaint — there are about five a day in summer, doubled in winter.  

In Latvia, the patient also decides, but there is a small fee — GPs do about two a day. In Estonia, although free to the patient, it is still only about one or two house calls a day. All the doctors told me this was a legacy of the Soviet era.  

The status of GPs in Lithuania is a little worrying. A European organisation, Phare, has provided the GPs with equipment for some simple investigations including ECGs, full blood counts, creatinine and urine analysis. This was arranged to encourage GPs to move out of the polyclinics into privately owned surgeries.   

But the machines cannot measure HDL or HbA1c for example — the GP must refer to consultants on the state system or the patient must pay. Nor can Lithuanian GPs manage all chronic diseases.  

For example, they can treat illnesses such as upper respiratory tract infections, and prescribe for chronic illnesses like hypertension, but they must refer patients with ischaemic heart disease and diabetes every three to six months, to be allowed to continue prescribing.  

These problems are not present in Latvia and Estonia, although in Estonia all patients needing any kind of scan must be referred.  

Apart from GPs covering Saturday mornings, there is no state out-of-hours cover in Lithuania. Patients can go to A&E, call an ambulance or contact a private GP. In Latvia and Estonia out-of-hours services seem to be the equivalent of NHS Direct, but the doctors in both of these countries said that many doctors gave patients their mobile phone numbers.  

Dr Michael is a retired GP from London 

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