1. A COMPARISON OF EUROPEAN FAMILY PRACTICE WORKLOAD Dr M McCarthy FRCGP Head of UK Delegation to UEMO Nuts and Bolts 21.1. 2016

2. GENERAL PRACTICE IN EUROPE General Practice/Family Medicine is different in Europe Most EU states recognise GPs as Specialists in Family Medicine (except Austria, Italy and UK) Europe advocates free movement of professionals There is a lack of information about various health systems Commonwealth Fund Report consistently praises the NHS as being a cost-effective, equable and accessible system

3. A QUESTIONNAIRE CONCERNING GP/FD WORKLOAD WAS CIRCULATED IN 2015 Emailed to EU delegates from January to March There were 3 questionnaires with 10 questions each Others were added after suggestions from delegates 24 states replied (Malta gave 2 answers – public and private) Information is still incomplete but data is improving There is variation between states There is variation within states

4. EU GP/FD GATEKEEPERS OR SIGNPOSTS? GATEKEEPERS Denmark Portugal Finland Spain Iceland Sweden Netherlands UK Norway SIGNPOSTS Austria Italy Belgium Malta Croatia Slovakia Czech Rep Slovenia France Switzerland Germany Turkey Ireland

5. CHILDREN NOT ALWAYS SEEN BY GP/FD SEEN BY PAEDIATRICIAN Austria Slovakia Belgium Slovenia Croatia Spain Czech Rep Switzerland France Germany Italy SEEN BY GP/FD Finland Sweden Ireland UK Lithuania Malta Netherlands Portugal Romania

6. LIST SIZE – NUMBERS PER DOCTOR 1600 OR LESS Austria Italy Belgium Lithuania Denmark Malta Finland Norway France Spain Germany Ireland 1700 OR MORE Croatia Slovakia Czech Rep Slovenia Hungary Sweden Netherlands Turkey Poland UK Portugal Romania

7. WHICH IS MORE COMMON - SINGLE OR GROUP PRACTICE? SINGLE DOCTOR Austria Hungary Belgium (97%) Italy (50%) Croatia Romania Czech Rep Slovakia France (70%) Turkey Germany GROUP PRACTICE Denmark Malta Slovenia Netherlands(75%) Spain Ireland Norway Sweden Italy (50%) Poland Switzerland Lithuania Portugal UK (90%)

8. IF GROUP, HOW MANY DOCTORS? 3 OR LESS Austria Malta (private) Belgium Netherlands Croatia Norway Czech Republic Poland Denmark Romania France Slovakia Hungary Switzerland Ireland Turkey 4 OR MORE Finland Slovenia Italy Spain Lithuania Sweden Malta (public) UK Portugal

9. DO YOU HAVE OTHER STAFF? ONE NURSE OR FEWER Belgium Slovakia Croatia Slovenia Ireland Turkey Hungary Malta (private) NURSES, ADMIN AND OTHERS Austria Lithuania Romania Denmark Malta (public) Spain Finland Netherlands Sweden France Norway Switzerland Germany Poland UK Italy Portugal

10. NUMBER OF PATIENT CONTACTS/DAY? 25 OR FEWER Belgium Denmark Portugal Finland Sweden France Switzerland Italy Malta Netherlands Norway MORE THAN 25 Austria Lithuania Slovakia Croatia Poland Slovenia Czech Rep Romania Spain Germany Turkey Hungary UK Ireland

11. NUMBER OF HOME VISITS/DR/DAY? 2 OR FEWER Czech Rep Netherlands Slovenia Denmark Norway Spain Finland Poland Sweden Italy Portugal Turkey Ireland Romania Lithuania 3 OR MORE Austria Hungary Belgium Malta Croatia Slovakia France Switzerland Germany UK

12. LENGTH OF CONSULTATION? 15 MINUTES OR LESS Austria Czech Rep Norway Denmark Poland Germany Romania Hungary Slovakia Ireland Slovenia Italy Spain Malta Turkey Netherlands UK MORE THAN 15 MINUTES Belgium Croatia Finland France Lithuania Portugal Sweden Switzerland

13. WE SHOULD HAVE ASKED ABOUT OTHER PATIENT CONTACTS Phone calls from patients Phone calls to patients Prescription queries Review of pathology results Acting on letters from specialists Acting as patients' advocate Referral letters

14. DO YOU SIGN "SICK NOTES" Yes GPs/Family Doctors sign sick notes for workers in all states that replied It is recognised that this is bureaucracy – it is a state requirement It is a duty that is felt as a burden

15. HOW LONG IS YOUR WORKING DAY? 8 HOURS OR FEWER Belgium Lithuania Portugal Malta(public) Croatia Portugal Czech Rep Turkey Denmark Ireland Finland 8-12 HOURS OR MORE France Spain Germany UK Hungary Malta (private) Norway

17. REGULATIONS OR BUREAUCRACY? POLICE CHECK For New Practice only Austria Norway POLICE CHECK Ireland Lithuania UK

18. APPRAISAL/REVALIDATION APPRAISAL 12% OF STATES Lithuania Spain UK REVALIDATION 24% OF STATES Lithuania Netherlands Norway Slovenia Switzerland UK

19. HEALTH AND SAFETY INSPECTIONS Practice inspections occur in 44% of states Austria Slovenia Czech Rep Spain Ireland Sweden Lithuania Turkey Netherlands UK Romania

20. CARE QUALITY COMMISSION Most EU states were unsure what this entailed – and surprised to find out Fit and proper persons End of life care Person-centred care Records Dignity and respect Safe-guarding – Adults and children Need for consent Premises and equipment Safe care and treatment Receiving and acting on complaints Duty of candour Good Governance

21. CQC CONTINUED Staffing and checks Infection control Equality/rights Data protection Medicines management Cleanliness Waste/water systems CPD/CME Staff support and training Mental health Risk assessment Quality monitoring Comments received – “we wouldn’t have a GP left in our country in 2 years if that was in place here” “We still learn from the NHS – what not to do”

22. INSURANCE/MEDICAL INDEMNITY NO PERSONAL COST (OR VERY LITTLE) Finland Spain Lithuania Sweden Malta (public system) Norway Portugal Romania (5.5% of income) Slovenia PERSONAL COST Austria Switzerland Belgium Turkey Czech Rep UK Ireland Malta (private) Netherlands Slovenia (private)

23. IS YOUR WORKLOAD SUSTAINABLE? YES (24%) POSSIBLY (16%) Austria Malta Belgium Slovakia Czech Rep Spain Denmark Germany Finland Switzerland NO (60%) Croatia Poland Turkey France Portugal UK Hungary Romania Ireland Slovenia Lithuania Spain Netherlands Sweden Norway

24. GENERAL PRACTICE/FAMILY MEDICINE IS UNDER STRESS Increasing demand Changing demographics/older population Shift of work from secondary to primary care Increase in Chronic Disease – Diabetes/CVD Retirement of older doctors Shortage of medical graduates choosing a career in FM

26. A WORKFORCE UNDER STRESS IS NOT CLINICALLY SAFE High levels of "Burn-out“ Risk of CVD related illness Increase in stress-related mental illness Increase in alcoholism Increase in self-medication Increased levels of relationship breakdown/divorce Early retirement Difficulty in recruitment

28. THERE IS SOME CORRELATION BETWEEN WORKLOAD AND SUSTAINABILITY Those states that say their workload is sustainable Tend have lists <1600 patients They tend to spend 20 minutes in a consultation They don’t necessarily have less visits Having more staff does not seem to reduce stress

29. IS GENERAL PRACTICE SUSTAINABLE? States that feel it is, have two factors in common 1. They do work normal office hours 2. Strongest correlation is number of patient contacts/day Fewer than 20-25 for one doctor and workload is reasonable More than 25-30 and doctors feel overburdened In UK face-to-face consultations are 40-50/day Plus 10-20 patient queries/phone calls Plus visits/letters/prescriptions/path results

30. BUREAUCRACY IS SIGNIFICANT IN UK We have a degree of micromanagement unknown in Europe Appraisal considered by Dutch – not yet in place CPD/CME left to professional conscience Revalidation automatic CQC viewed with disbelief

31. WE NEED TO TAKE CARE OF OUR DOCTORS AS WELL AS OUR PATIENTS Education of population may reduce demand More reliable science reporting (media) Teach resilience in medical schools Limit hours of work for family doctors – build in education time Increase consultation time for patients – for clinical safety Limit numbers of patients per GP/FD - for clinical safety For doctor safety - Try and limit number of patient contacts in a working day – as hospitals do

32. THANK YOU FOR YOUR ATTENTION ANY QUESTIONS? ANY SUGGESTIONS? WHAT OTHER INFORMATION SHOULD WE COLLECT? mary.mccarthy@nhs.net