Practice questionnaire
Recruitment of patients in the waiting room was successful, only 25% refusal was recorded. Opening hours were clearly indicated in 91% of surgeries, out-of-hours care was advertised in 88%. Eighty-eight percent of practices were located on the ground floor, 54% in multilevel buildings, having inbuilt elevators. Half of them offered free parking facilities for handicapped visitors and toilet accessible with wheelchair.
The cleanness of facilities was evaluated as very clean (45%) and rather clean (54%).
Intimacy was appropriately provided. Doors were usually closed in the waiting room, 80% of visitors did not hear what is being said at the reception desk and 94% could not hear or see what was happening in the doctor’s office.
GP questionnaire
Altogether 222 questionnaires were completed, by 118 (53%) male and by 104 (47%) female family physicians/general practitioners. Answers are presented according to the order of questionnaire.
The mean of their age was 53.4 (±10.9) years. Ninety two percent of them were born in Hungary, others come mainly from the neighbouring countries, where high density of Hungarian population is living (i.e. Ukraine, Romania).
Location and composition of practices
Most of the practices (31%) were in big (inner) cities, 8.6% in suburbs, 20.3% in (small) towns, 28.4%. in rural and 11.3% in mixed urban-rural locations. The mean of the practice population (number of enrolled patients) were 1857(±912) persons. Comparing to the national distribution, they rated the ratio of elderly people (over 70 years) in the practice as average (46.9%), above (39.2%) or 9% below average. Ratio of socially disadvantaged people was estimated as average (38%), above averages (42%), below average (18.5%). A quarter of family physician estimated that ratio of ethnic minority patients are closely to their national representatives, while 52% expected higher, 20% believed lower figures.
Most of the doctors considered the turnover of the patients enrolled in the practice, as average (57%) and 37% below average.
Workload
The means of weekly working hours were 37.7(±8.6), GPs spent 31.5(±8.7) hours with direct consultations, home visits, and telephone consultations. Doctors above 55 years worked longer 39.1(±7.5) hours/week, while younger (below 55y) spent 36.1(±9.5) hours only (p=0.059). There were no differences between genders. The reported means of face-to-face consultations were 50.4(±16.1) patients per working days. Besides these, 11.7(±7.9) patients needed telephone consultations, while 0.9(±0.6) persons were contacted by e-mails. Average patient consultations lasted 8.2 (±5.4) minutes. Participating family physicians done 14.5(±13.1) home visits per week, 5.7(±4.5) for elderly patients and 1.9(±1.3) institutionalized patients were visited in other settings.
In the past 3 working months, they reported 4.8(±3.9) night and 1.5(±1.2) weekend day shifts.
The highest part of GPs (86.5%) was working alone, or in shared accommodation with other GPs (11.3%) or medical specialists (4.1%).
GPs were rarely away from their practices. Their vacation lasted 2.6(±1.4) weeks, attended conference or educational activities in 1.2(±1.1) weeks, yearly.
Sick leave lasted for 0.45(±0.2) weeks a year; even less participation on scientific events were reported 0.4(±0.4) weeks.
Financing
Beside their daily work in the family practice, 33% of GPs had no other paid activities, while 7% worked as company doctor (occupational health), 41% of them performed teaching activities, mainly medical education. Almost all of the practicing GPs (93%) were working as a self-employed, contracted with the National Health Insurance Fund and local municipalities, 2% were self-employed without contract and 3.2% was a salaried employee.
The financing of GPs from the National Health Insurance Fund are based mainly on capitation, representing 52.9 (±32.7)% as mean of estimated income. Fee for service activities represented 9.6 (±8.3)%, performance payment 5.0(±4.8)%, other sources 11.8(±11.4)%, while out of pocket payments 4.7(±3.6)%. Other sources were mentioned in 11.8(±11.4%).
There are additional elements (quality indicators), represented in the financing. For the proper diabetes care 19.4% of GPs get a financial bonus, 37.8% for reaching the targeted screening activities, 21.6% for the proper referral rate and 5.9% for working in remote areas.
Professional competences
Applied clinical guidelines are widely known and used by GPs (chronic heart failure in 70%, asthma in 65%, diabetes in 79% and COPD in 64%), although there are no available specific primary care oriented guidelines.
Feedbacks regarding prescription are usually provided by the insurer (73%), less by health authority.
In case of referrals, the preference of patients is mainly considered (in 60%), while 35% of GPs prefer own decision, not shared with the patients.
The available devices and equipment’s in the questioned practices are listed in Table 1.
Regarding location of X-ray facility, it can be reached in the same building (4%) where the practice is located, 89% are accessible easily, only 7% are too far. The nearest GP practice was in the same building (39%), within a distance of 10 km (55%). The nearest outpatient’s clinic was in the same building (10%), or less than 10 km (57%). Half of the nearest hospitals were also within this range.
The questioned practices offered 6.7(±3.5) opening hours on weekdays. Consultations in the evening, access to the practices after opening hours was quite different, although 32% were still open after 18 hours (6 pm.). On a rota basis availability was reported by between 11 and 18% of them, while 14% of GPs were always available for their patients, even at weekends. Most of the hospital based emergency and centre-based non-emergency services are run by other physicians.
Recently, 23(±23)% of GPs provide consultations by appointment and 59(±39)% offer a walk-in hour.
Almost all of the GPs prescribe cheaper equivalent drugs (generics) and 87(±11)% provide free samples of medication, if available. Doctors estimated that 13% of patients are frequently, 61% of them are occasionally delaying their visits for financial reasons.
Enrolment into the practice
Almost half (48%) of the new patients, entering the practices provided their medical records or these were sent by the previous GP, while 41% of them enrolled without handling previous files. Thirty four percent refuse patients from other geographical area, 43% never use any restriction, 5% consider the past medical history of patients and 12% of GPs respect the number of their enrolled patients to avoid financial restrictions.
Forty one percent of family physicians always accept non-insured patients, but 24% of them only in case of emergency.
Cooperation with other specialists, referral
The previous experience of GPs is the determining factor in case of referrals(by 58%), other points of view which are always considered: travel distance for the patients(42%), patient’s own preference(37%), expected waiting time(39%), comparative information on the specialist getting from other patients(22%) and cost for the patients 46%.
Practice nurse is employed by 95% of GPs, other health care professionals in a much less extent: receptionist (28%), midwife (0.5%), and laboratory assistant (2.2%). In the same centres where the questioned GPs worked, other professionals were also available: home care nurse (7.7%), psychiatric nurse (1.8%), dentist (4.5%), pharmacists (2%), social workers (4.1%), and practice manager (1%).
Practice nurses independently give immunization/vaccination (in 70% of practices), provide advices regarding health promotion, lifestyle, smoking cessation (in 83%), check routinely chronically ill patients (80%) and perform minor procedures (ear syringing, wound treatment) in 83%).
Referral letters (including findings, provisional diagnosis and test results) are written by 48% of GPs for all, by 41% for most, and by 10% for the minority of the patient. After consultation with specialist, treatment or diagnosis of the patients is told always (40%), usually (25%), seldom or never (25%).
After a patient has been discharged from the hospital, 81% of doctors receive summary/discharge report within 1-4 days, 5% of them within 5-4 days. The other 13% complained that never or rarely get it.
Hungarian GPs are involved in the management of almost every chronic condition (diabetes, hypertension, cardiovascular, musculoskeletal, mental disorders) and even palliative care). Services when procedures or interventions needed are usually provided by surgical specialists (urologist, ENT etc.). Some examples were offered in the questionnaire, doctors were asked how frequently are they involved in these or similar cases. Ratios are presented in Table 2.
All Hungarian PC practices are using computers, with specific software for GPs. The functions and recorded data are presented in Table 3.
Blood pressure is usually measured by the staff, regardless of the reason for visit (79.3%). Advices in smoking cessation, diet, physical activity, misuse of alcohol are the most frequent topics of life-style consultations, discussed with the patients in about 90 %. Family physicians are routinely involved in antenatal care (51%), in immunisations (29%), and paediatric surveillance of children, influenza vaccination (96%) and palliative care (87%).
Occupational health problems are rarely discussed with family physicians even work accidents. If doctors diagnose frequent respiratory problems, repeated cases of food poisoning among people living in a certain district, they usually report them to the relevant authority.
Burn out
Job related stress was mentioned by 27 (±24.3)% of the GPs, overloaded with unnecessary administrative tasks by 48.2 (±36.6)%. Half (54%) of them estimate their job as still interesting, while only 13% believe that GPs have well respected jobs and even less (2.2%) found a good balance between effort and reward. There were no significant differences between genders and time spent in practice.