The demographic characteristics of the sample are summarized in table1. It is to be noticed that the population over 65 is higher (18,2%) than the average of the County (15,8%) as published by the County Statistical Department. Gender distribution is favouring women, 67,2% female and 32,8% male. The level of education is as following: 11,6% have a basic education level (8 classes and under), 61,1% have graduated a high school or a professional school and 27,2% have a university background. This distribution is covering the broad spectrum of education in the community.
In terms of visits to the FD, 15,6% of patients have visited their FD once in the past 12 months and 19,8% have visited the FD for 12 times 12 months and only 3,9% more than 12 times.
Table 1. Demographic data of the sample
Data
|
Category
|
|
|
|
|
Age distribution (%)
|
18-30y
|
31-50y
|
|
51-65y
|
Over 65y
|
|
19,7
|
39
|
|
22,4
|
18,9
|
Gender distribution (%)
|
Female
|
Male
|
|
|
|
|
67,2
|
32,8
|
|
|
|
Level of education (%)
|
Primary school
|
Professional
|
High School
|
University and more
|
|
|
11,6
|
13,7
|
47,4
|
27,2
|
|
Residence (%)
|
Urban
|
Rural
|
|
|
|
|
48
|
52
|
|
|
|
Years with same FD
|
Less than 10 years
|
More than 10 years
|
|
|
|
|
|
|
|
|
|
|
46,4%
|
53,6%
|
|
|
|
|
|
|
|
|
|
Number of visits with
FD in the past 12 Months (%)
|
One
|
Less than 12
|
More than 12
|
Average number
|
|
|
15,6
|
19,8
|
3,9
|
11,25
|
|
|
|
|
|
|
|
The study was a typical approach to Health needs assessment (HNA). HNA is recognised as a method to identify gaps in care. Health needs are various: felt needs, expressed needs, normative needs4. All of these can be met or unmet at a certain moment, in correlation with the three dimensions: need, supply and demand. The patient is central to this equation and not always consulted.
Our study is offering the responses of a significant sample of the population of the County showing the positive and the negative parts of primary care as it is perceived by the population.
Access to primary care
In Romania, in the framework of the National Health Insurance System (NHIS), nearly all patients are registered with a FD. The main limitation of access to a FD is the lack of family doctors in certain regions. In Brasov County only 2,6% of patients declared that they do not have a FD in the area where they live. In other regions of Romania this problem is bigger. In total, after an estimation made by professional organizations in 2014, there is a lack of over 500 GPs in Romania (unofficial data). The phenomenon of the deficit of professional resources in family Medicine is known worldwide and policies to stimulate retention of this workforce should be developed especially by local communities.
Asked if reaching their FD was a problem (in the past 6 months) 88,6% of the population answered not having had this problem and only 11,6% answered that they encountered problems. In comparison with other types of specialists, accessing FD’s seems not to be a problem. Responders signalled difficulties in reaching an eye specialist (37,3% couldn’t reach in the past 6 month) or a cardiologist (43,1% couldn’t reach in the past 6 month).
Furthermore, the results of our study showed that only 26,6% of people could get a same day appointment with their GP. This is lower than the report of the Regional WHO office from 2009 that showed that 92,8% of people could get same day appointment with the FD5.
Nevertheless, our study is showing that next day appointment is possible in 53,9% of cases.
Being asked if there was an alternative doctor to see if their FD is missing, in 27,6% of cases, people affirmed that there was no other doctor to replace their FD in the community.
In only 58,6% of cases there is access to an Out- of- Hour (OOH) centre in the neighbourhood.
Opening hours of FDs offices allow most people (91,2%) to access the practice. Access to FD’s office by telephone is available in 90,5% of practices.
Although in a study published in 2015 data showed only occasional access by telephone and or to an appointment system in the FDs office, this situation has changed in the past years, since the introduction of a compulsory appointment system by the National Health Insurance House (NHIH)6.
Table 2. Health needs in relation to access to the FD’s office
Questions
|
Yes (%)
|
No
(%)
|
|
|
|
|
|
In the past 6 Months did you feel the need to be seen by a FD and you couldn’t reach him or her?
|
11,4
|
88,6
|
|
In the place you live the opening hours of the FD allow you to access it whenever you need it?
|
91,1
|
8,8
|
|
In the place you live is there an Out-of- Hours centre?
|
58,7
|
41,1
|
|
In the place you live, FD’s office is easy to access by telephone?
|
90,5
|
9,5
|
|
In the place you live if your FD is not present is there any other FD you can refer?
|
72,4
|
27,6
|
|
Do you have a GP in the place you live?
|
97,4
|
2,6
|
|
How long do you have to wait for an appointment to the FD?
26,6% same day/ 53,9% 1 day/ 12,1% - 2 days/7,4% more than 2 days
|
Longitudinal continuity of care
Our study showed that patients prefer long-term relationship with their FD, even though there is a possibility for the free choice of the doctor. Most patients are registered with their FD for more than 10 years (53,6%).
Seeking for medical care at the FD
The average number of visits at the FD in the past 12 months in our study was 11.25. Most patients visited their FD for 12 times (19,8%). People aged more than 65 are the most frequent accessors at the FD (Figure 1). A European data base7 (Eurostat, Healthcare activities statistics- consultations) is showing an average of 5.7 contacts with the GP and a National report from 2009 is showing 7.7 visits per years5. The increase in number of visits is due to the Contract Framework of the National Health Insurance House (NHIH) that is specifying the gatekeeping role of the FD.
Figure 1. Seeking for medical care at the FD according to age
Limitations of access due to system organization
- Limited number of consultations per day
Although the number of payed consultations in the contract is limited to 20 (24) a day, FD’s are covering extra patients every day reducing the length of the consultations that is normally set to 15 minutes per patient.
In Romania FD’s offices are open only 5-6 hours a day, many practices working in alternative shifts (morning and afternoon). The results of the study are showing that people do not find this as a barrier of access, although same day visit is available only in 26,6% of cases. In our opinion it is probably linked with the lack of another perspective. If alternative model practices, with more time availability, could be an option, perhaps patient’s options would have been more differentiated.
- Access to continuity of care - Out-of - Hours (OOH) and or other health resources
Access to Out-of-Hours services is a problem due to the lack of coverage in the hole territory of the County. It is a result of the fact that OOH is a service organized by FD’s at their one decision, without a rigorous planning of the service by the District Health Authorities. In 27,6% of cases the FD is the only health resource in the community. Community and school nurses are unavailable in most of the rural communities.
Person centred care and trust ( Table 3)
In terms of the process of care, responders have shown that they consider FDs a reliable health resource. The FD who knows their history and medication, can inform and educate them in relation with their disease. This result is showing that even though there is a reduced variety of services that FDs can provide (in the situations of the restrictive contractual framework) patients are still counting on their FD’s. The potential of this relationship is important, and FD’s are to be encouraged to practice at their full potential, broadening the spectrum of services that they deliver to patients, especially those that are important to public health.
Table 3. Health needs in relation to the processes of care in FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
Does your FD know the history of your diseases?
|
93,8
|
6,2
|
|
Does your FD know the history of medication you take?
|
93,5
|
6,5
|
|
Did you receive clear information from your FD regarding your illness?
|
88,8
|
11,2
|
|
Did you receive clear information regarding the way to prevent illnesses?
|
87,7
|
11,2
|
|
Is your FD spending enough time with you?
|
86,8
|
13,2
|
|
|
|
|
|
At the FD you can address any medical problem?
|
87,6
|
12,4
|
|
In FD’s office can you get facilitation to the appointments for
Secondary or tertiary care
|
82,1
|
17,9
|
|
|
|
|
|
Health improvement and education ( Table 4)
Results of our study are showing that most of the responders are satisfied with results of care.
Health education and medical advice is recognized to be valuable in 88,8% of cases concerning diseases and 87,7% for preventative measures.
52,3% of patients suffered from a chronic disease and 91,9% of them affirmed that they understood form medical advice of their FD how to take this medication.
Table 4. Health needs in relation to outcomes of care in FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
After the consultation with the FD did you feel your Health has improved?
|
88,2
|
11,8
|
|
After the consultation with your FD did you feel more informed on preventative measures?
|
87,4
|
12,6
|
|
After the consultation at your FD did you understand how to take your medication?
|
91,9
|
8,1
|
|
|
|
|
|
Availability of procedures ( Table 5)
We looked at some of the procedures relevant to public health like well child, pregnancy monitoring, cervical cancer screening. Access to this service is appreciated by patients. Despite this, data from the NHIH are showing that there is a reduces number of reported services like pregnancy monitoring and well child and cervical cancer screening. Underreporting is one of the causes but also lack of education of the population in accessing these services.
Point of care testing like lab tests, electrocardiogram (EKG) is not recognised as an offered service in family doctor’s office.
Table 5. Health needs in relation with procedures in FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
In the place you live, do you have access to iv injection or infusions?
|
92,4
|
7,6
|
|
In the place you live do you have access to flu- vaccine?
|
94,4
|
5,6
|
|
In the place you live do you have access to pregnancy monitoring?
|
85,6
|
14,4
|
|
Is your FD doing well child monitoring?
|
90,7
|
9,3
|
|
In the place you live do you have access to Pap-smear in FD office?
|
46,2
|
53,8
|
|
|
|
|
|
In the place you live do you have access to blood draw in FD office?
|
63,1
|
36,9
|
|
|
|
|
|
In the place you live do you have access to an electrocardiogram.
|
56
|
44
|
|
|
|
|
|