Czech Republic

Rebirth of general practice

• 1978: Recognition of General Medicine (GM) as a basic branch
• Creation of GM Department within the Institute for Post-gradual Medical Education (IPME)
• Foundation of GM Society within the Czech Medical Society of J. E. Purkyně
• 1. and 2. attestation in GM

The Velvet Revolution

• 17. 11. 1989 Prague University students demonstration against the regime was roughly repressed by the state police
• Spontaneous uprising of millions of people
• The Civil Forum (CF) was founded as a state establishment opposition
• A new government with the CF deputies formed
• 29. 12. 89 Vaclav Havel elected President

Health Care Transformation

• 1990–1992 a broad discussion of politicians health profes-sionals and lay public led to consensual new Health Care Laws adopted by the Parliament
• Health insurance system based on mutual solidarity (State pays for children, students up to 26, pensioners, disabled, unemployed, Two thirds of costs paid by employer for employee)

Health Care Transformation

• 1993 Privatisation of HC activities started
• 1993 Privatisation of H facilities enabled (in fact it took more time because of the necessity to solve the original owners rights in many cases at first – restitutions)

Health Insurance Comps.(HIC)

• 10 HIC in total (formerly 24)
• General HIC according to a special law (a statutory under-taker) – covers cca 67{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} population
• The other HIC formerly founded like workers’ (departmen-tal) org. – mainly regional importance
• All HIC are open
• Change of HIC by insured: once per year
• HIC contract Health Care Facilities (private dr., hospitals, Homecare Ag., etc.) in a Selection procedure organized by Regional Authority (participants: Heath officer, Medical Chamber deput., particular profession deputy, HIC deputy) by ballot voting
• Contract duration: 8 years or indefinite period

Primary care structure

• GPs 5123 – cover population from 14 y. of a./ with 1600 in aver. on the list., 44 contacts/1day
• GPs for children 2120 – from 0 to 18 / with 950 patients on the list, 30 c./1 d.
• Gynaecologists 1237–3340 women, 34c./d.
• Dentists 6051– with 1720 patients, 14c./d.
• Home care agencies 550
• Health visitors, Social workers – outside HC

General Practice characteristics

• 5293 fully qualified GPs
• 5123 GPs providing care
• 59{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of GPs are female
• 55{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} in age group 50 + years
• 97{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of GPs are private
• cca 85{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of practices are computerised
• GPs have no gatekeeper function

General Practice and HIC

• Private GPs are independent contractors to HIC (10) run-ning their own practice or in rented premises.
• Payment by mixed capitation
  (cca 85{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} cap., 15{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} fee for service)
• Price of basic capitation in 2013 (CZK 47–50 = EUR 2) and fee for services (point sst.: 1p.=1 CZK) set by negotiation betw. CGPA and HICs
• Average income /month (2013) cca EUR 5000–6000 btto – before expenses and taxation
• Direct payments – cca 10–20{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} plus
• Regulation fee: CZK 30,- per visit connected with clinical exam. (cca 10{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} plus)

GP’s service structure

• Obligatory sevices: basic spectrum of services – every GP has to contract. Mostly included into capitation. Some (prevention,vaccination) to enhance motivation are out of capitation.
• Facultative services: mostly taken from other specialities (Surg ,ENT, Eye, Intern, RHB). Extent set by negotiation with HICs. GP can choose. Often special conditions must be fulfilled (qualification courses – ECG, Dia, Physioth., special practice equipment) In Capitation services
• Clinical examination and control
• Education of patient (family)
• Telephone consultation
• Home visit (transport + bonus payed extra)
• Injection application
• Wound dressing (1–30 cm2), topical anaesthesia • Alien particle extraction (ENT, eye)
• Etc.

Out of capitation services

• Prevention, Vaccination (TAT, Flu)
• Night or weekend home visit• Small surgery
• ECG
• BP Holter monitoring
• Diabetes management
• Physiotherapy
• ENT, Eye, Neu
• Diabetes education
• Blood (biological) specimen taking
• Quick laboratory test – INR, CRP, HbA1c, Glucose, Urine albumine • Allergological testing
• Etc.

Accounting of HC rendered

• Monthly
• New registrations of patients
• Services rendered + Capitation
• Cca 85{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} GPs use PC, accounting via internet is more and more used
• Maturity of claim: 15–30 days

General Practice characteristics

• Regulations of prescription, complementary exam.: within Global Costs Evaluation (compares expenses of each GP to the rest in District and Republic level)
• All private practices are single handed
• Typical employed staff is one nurse
• Other services contracted (cleaning, waste disposal, ac-counts, laundry, etc.)

GP’s Workload (contracted)

• 5 or 6 hours per day: in the surgery
• 2 hours per day: home visits
• 1 hour per day: administration
• 5 days a week
• 3 days off work per month without loss of capitation (clinical days)
• More than 3 days regardless of reason: locum must be pro-vided

GP’s Workload

• Out of hours (OOH) : not responsible (State run Emergency system)
• Night hours: not responsible
• Night duties: no obligation to provide a service, readiness varies from place to place. The service is seriously underpaid. There is no power to force independent GPs to sign a contract (to provide OOH)
• Inpatient care: is not covered

GP’s Work Profile

• 87{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} Clinical health care, Of it:
• 48{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} internal medicine
• 19{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} locomotive organs
• 16{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} small specialites (dermat., ENT, etc.)
• 4{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} injuries
• 13{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} nonspecified
• 12{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} Preventive care: 2 y exam., CoReCa screening (OBT), Mammography, Immunisation
• 1{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} Social care

Postgradual eduaction in GP

• 3 years postgradual curriculum under a senior GP trainer’s leadership, finished by a rigorous attestation (untill 2008 fully organised by the state-owned IPME)
• A new concept of PME since 2011 – Decentralisation: In an Accrediation process approved GP is responsible for a trainee until closing examimation. Claims for money to cover trainees income.

Accreditation process

• Personal requierements: Specialisation in GP, min. 5 y. practice, Whole-time working, List of professional or training activities in last 5 y.
• Equipment req.: Enables work of fully competent GP
• Training background: Space capability, Training competence of a trainer, Cooperation with a methodical educ. center
• Approval to an external control
• Agreement with external MF enabling trainee’s practice in other specialities
• Accreditation comittee formed by experienced GPs named by Minister of Health . AC controls and judges the applications, submits chosen GPs for approval to a minister.
• Ministry of Health – issues a Decision on accrediation with a 6 years validity.

PGT (Curriculum) in General Practice:
Basic strain – 24 m.
(doctor after graduation can perform certain activities only being supervised by a senior doctor)

• 8 month GP
• 8 m. Internal m., Pneumo., Infection d.
• 4 m. Surgery, URL Orthopaedics, Trauma., Rehab.
• 1 m. Paediatrics
• 1 m. Gynaecology + Obstetrics• 2 m. Urgent (Acute) medicine

Followed by a specific GP training before attestation – min. 12 m.

• GP supervisor arranges also a specific training in other fields of medicine including practice in outpatient specialists’: Practical Pediatrics, Psychiatry, Neurology, Ophthalmology, ENT, Dermatology, Hygiene, and other supplementary practice (facultative )

Czech General Practitioners Association

• 1990: CGPA was established to support and enhance Pri-mary Care with the leading position of GP/FD.
• Republic, regional and district structure
• Annual conference is the highest body
• 3 years election period of the President and the Board
• The biggest non compulsory medical association in CR (4200 members)
• Defence and promotion of GPs professional interests (ne-gotiations with Gvt,HIC, legal and economic aid – flood in 2002, 2013, etc.)
• Promotion of GPs skills
• Organisation of Continual Medical Education
• The biggest non compulsory medical association in CR
• 2 Journals, Web site: www.slpcr.cz

Problems of general practice

• Gatekeeping – no access regulation
• Secondary prevention – uncoordinated, lack of feedback, problematic co-operation with specialists in general
• Prescription limits – some drugs only appropriate specialists can prescribe Goals for CGPA
• Improve of the economical status of GPs
• Extend competencies of GPs
• Attract young doctors to general practice

Only a satisfied doctor can make his/her patients satisfied!