This part of the journey shows general practice going downhill.
In Greece there are no GPs as such, instead specialist internists who are general physicians do the work of GPs. In Malta and Cyprus, both of which are ex-British colonies, there are GPs but they are degraded by consultants. In Malta it is so bad that most GPs leave the state sector and work privately.
In Malta I interviewed a private GP, in Greece a private paediatrician and in Cyprus a state GP. All three told me about their state systems.
For all of them referrals are hand written and there is usually no reply.
In Cyprus, for example, the GP will have a discharge note from inpatient events, but after an outpatient consultation they will only know what the consultant relayed to the patient and medication prescribed.
GPs in Malta and Cyprus have to prescribe from a limited list and the only statin they can use is simvastatin.
Consultants can prescribe Lipitor, and if they do GPs must treat this as an order and continue to do so.
Repeat prescribing is not allowed in these countries although in Cyprus, where the maximum period is two months, it is common for the GP to write a second prescription, which is left in the patient’s notes and can be collected when required.
All three countries use paper records. When patients move the new doctor has to start again. With no electronic records, BP recordings, for example, are difficult to retrieve and there are no templates for chronic disease. But paperwork is plentiful. Patients in Malta need a certificate if they are off work for one day. In Cyprus it is two days, providing neither of these are a Monday or a Friday.
Cyprus is the only country here to offer smoking cessation clinics. In Greece and Cyprus many doctors smoke.
Neither practice nurses nor GPs do cervical cytology, which is performed by gynaecologists. Nurses do not syringe ears and in Cyprus patients with wax are referred to the local ENT outpatient department.
Greek and Cypriot GPs or internists have a full range of investigations open to them but in Malta — state and private sector — the range is limited. Thyroid disease and diabetes have to be managed in secondary care. GPs cannot even arrange X-rays to check for fractures.
Out-of-hours care is varied. In Cyprus and in Greek towns, hospital A&E departments and private doctors handle it. In Malta, the clinics are theoretically staffed all hours by 25 GPs working rotation shifts of five doctors. However, I am told that a patient turning up at 3am for a BP check would not be welcomed.
In rural Greece a patient can go to a health centre at night and the receptionist will wake the appropriate specialist.
Greece and Malta have no re-accreditation system. In Cyprus it is intended to bring in a system of points, acquired for attending learning experiences, such as lectures. Eventually it will be necessary to acquire enough points to stay on the register. In Cyprus, there is vocational training for GPs, but this involves only two to three months in primary care without trained trainers or tutorials. In Malta, there are plans for the trainers to attend ‘Training for Trainers’ courses.
All Greek doctors, after completing their military service, must work for a year in a village, during which time they have no training or supervision.
After this they start their four-year specialist training.
None of these countries have a system for dealing with poorly performing doctors.
Dr Gerald Michael is a retired GP from London