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Primary care in Europe: Southern European GPs have little help

GPs have no clinical audits, poor career development and few staff, finds Dr Gerald Michael

In the second leg of my European odyssey to talk to GPs about their work,  in Lisbon I met the president of the Portuguese College of General Practice, Dr Mendes, who is a doctor in a health centre in the city, then a GP from Madrid, also in a health centre, and a doctor from a group practice in Rome.

The health centres in Spain and Portugal are similar in that they have about 14 salaried doctors.

Patients do not pay, although some in Portugal will fund a small portion of the prescriptions. The GPs have an average of about 2,000 patients each.

All three premises appeared more than adequate, although the Lisbon centre is older.


In Italy, the GP in Rome owns her practice premises and works with two younger partners. She has 1,500 patients, which is the maximum allowed in Italy.

Her most junior partner only has 500 patients. Payment is almost entirely by capitation fee,  although extra is paid towards the premises and computer.

All three doctors work by 15-minute appointments. In Spain and Portugal, patients are normally seen the same day, but in Rome patients can wait up to a week for an appointment with the senior partner.

All three GPs are interrupted by patient phone calls, and only if they are busy will they refuse the call and ring back. 

I saw few ancillary staff and in Spain there were no secretaries in the practice I visited.

I was told that Italy does not have practices nurses, but they do exist in Spain and Portugal. However none do cervical smears — in Portugal these are done by the GP, in Spain by the midwife or gynaecologist and in Italy by the hospital or by the GP if she has a special interest in gynaecology. None of the countries have recall registers.

Home visits

Home visits are infrequent in Portugal and Spain, but in Italy the GP does about 15 a week, many of which seemed to me to be social calls.

Prescribing is open to what the doctors want to prescribe. In Portugal and Italy there is little interest in generic prescribing, and the patients do not like it. Only if a doctor’s prescribing bill goes well above average will any action be taken and this will be a mild remonstrance with no sanctions.

Chronic disease is managed in all three countries by international and national guidelines. There are no audits or targets, and so none of the doctors know for certain how well chronic disease is managed.

In Spain and Italy notes are virtually paperless, but records in Portugal are paper-based as they await a national computing health system.

There are vocational training schemes in Portugal and Spain similar to ours, but more time is spent in general practice. Vocational training seems to last three months in Italy with one month in general practice.

Continuing medical education is voluntary in Spain and Portugal but is compulsory in Italy where points are given for approved learning events. There is a minimum number needed each year which increases after five years. If the required figure is not achieved the doctor cannot take on new patients.

None of the countries have appraisal, personal development plans, means of identifying poorly performing doctors or expectations of reaccreditation.

Only in Portugal is there any weekend or night work, where GPs have to take their turn in a Saturday rota. Otherwise the work is done by co-ops working out of hospitals or the health centre. The out-of-hours doctors seem shadowy figures about whom little is known by the daytime doctors, and in Spain and Italy they have not necessarily been vocationally trained or had GP experience.

Portuguese GPs are paid more than Spanish doctors, while Italian doctors are paid around € 96,000 a year, which is double the Spanish rate.

Dr Gerald Michael is a retired GP from London

Primary care in Europe

1. How our European neighbours run their GP practices

2. Ireland — closest to home

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