The demographic characteristics of the sample are summarised in Table 1. It should be noted that the population over 65 is greater (18.2%) than the county average (15.8%), as published by the County Statistical Department. The gender distribution favours women (67.2% female and 32.8% male). The level of education is as follows: 11.6% have a basic education level (8 classes and under), 61.1% have graduated from a high school or a professional school, and 27.2% have a university background. This distribution covers the broad spectrum of education in the community.
In terms of visits to the FD, 15.6% of patients visited their FD once in the past 12 months, 19.8% visited the FD 12 times, and only 3.9% visited the FD 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 higher
|
|
|
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 to
FD in the past 12 months (%)
|
One
|
Less than 12
|
More than 12
|
Average
|
|
|
15.6
|
19.8
|
3.9
|
11.25
|
|
|
|
|
|
|
|
The study is a typical approach to a health needs assessment (HNA). The HNA is recognised as a method to identify gaps in care. Health needs are various: felt needs, expressed needs, normative needs4. All these needs can be met or unmet at any given moment with respect to three dimensions: need, supply and demand. The patient is central to this equation and is not always consulted.
Our study offers the responses of a significant sample of the county population, thus showing the positive and the negative parts of primary care as 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 an FD. The main limitation of access to an 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 larger. In total, after an estimation made by professional organisations in 2014, there is a lack of over 500 GPs in Romania (unofficial data). A deficit of professional resources in family medicine is a worldwide problem, and policies to stimulate the retention of this segment of the workforce should be developed, especially by local communities5.
Asked if reaching their FD was a problem (in the past 6 months), 88.6% of the population answered not having had any problems, and only 11.6% answered that they encountered problems. In comparison with other types of specialists, accessing FDs seems not to be a problem. Responders signalled difficulties in reaching an eye specialist (37.3% could not reach one in the past 6 months) or a cardiologist (43.1% could not reach one in the past 6 months).
Furthermore, the results of our study showed that only 26.6% of people could receive a same-day appointment with their GP. This percentage is lower than that reported by the regional WHO office from 2009 that showed that 92.8% of people could schedule a same-day appointment with their FD6.
Nevertheless, our study shows that next-day appointments are possible in 53.9% of cases.
When asked if there was an alternative doctor to see if their FD was missing, 27.6% of participants 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-hours (OOH) centre in the neighbourhood.
The hours of operation of FD offices allow most people (91.2%) to access the practice. Access to FDs’ offices by telephone is available in 90.5% of practices.
However, in a study published in 2015, data showed only occasional access by telephone and an appointment system in the FD office; this situation has changed in recent years since the introduction of a compulsory appointment system by the National Health Insurance House (NHIH)7.
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 an FD and you couldn’t reach him or her?
|
11.4
|
88.6
|
|
In the place where you live, do the opening hours of the FD allow you to access services whenever you need them?
|
91.1
|
8.8
|
|
In the place where you live, is there an out-of-hours centre?
|
58.7
|
41.1
|
|
In the place where you live, is the FD’s office is easy to access by telephone?
|
90.5
|
9.5
|
|
In the place where you live, if your FD is not present, is there any other FD you can visit?
|
72.4
|
27.6
|
|
Do you have a GP where you live?
|
97.4
|
2.6
|
|
How long do you have to wait for an appointment for 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 relationships with their FDs, even though they have the option of choosing and consequently changing their doctor. Most patients are registered with their FD for more than 10 years (53.6%).
Seeking medical care at the FD
The average number of visits to the FD in the past 12 months in our study was 11.25. Most patients visited their FD 12 times (19.8%). People older than 65 years of age access their FDs most frequently (Figure 1). A European database8 (Eurostat, Healthcare activities statistics- consultations) shows an average of 5.7 contacts with the GP, and a national report from 2009 shows 7.7 visits per years. The increase in the number of visits is due to the contract framework of the National Health Insurance House (NHIH), which specifies the gatekeeping role of the FD.
Limitations of access to the FD are caused by system organisation. In the contract a FD has a limited number of consultations per day (20 or 24 according to the number of patients registered in the patient list) and only 5- or 6 opening hours a day. Despite these limitations, that could cause waiting lists, there is no significant waiting time to see a FD, only 7.4% of the patients having to wait more than 2 days to reach their FD. It can be explained by the fact that FDs cover extra patients every day, thus reducing the length of the consultations that are normally set to 15 minutes per patient. This aspect can be a cause of lowering the quality of care and lead to burnout for the physician.
Although a same day visit is possible only in 26.6% of cases people do not consider this feature to be a barrier to access. 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 the patient’s options would have been more differentiated.
A possible option to cover the reduced consultation time at FD office is access to continuity of care through out-of-hours (OOH) services and or other health resources (ambulatory subspecialty care, private medical services). It is necessary considering that in 27.6% of cases, the FD is the only health resource in the community.
Access to out-of-hours services is a problem due to the lack of coverage in the whole territory of the county. It is a result of the fact that OOH is a service organised by FDs at their sole discretion, without rigorous planning of the service by the District Health Authorities.
Person-centred care and trust (Table 3)
In terms of the process of care, respondents have shown that they consider FDs a reliable health resource. FDs who knows their history and medications can inform and educate them regarding their disease. This result shows 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 FDs. The potential of this relationship is important, and FDs 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 the FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
Does your FD know your disease history?
|
93.8
|
6.2
|
|
Does your FD know your medication history?
|
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 ways 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 problems?
|
87.6
|
12.4
|
|
In the FD’s office, can you get referrals for appointments for
secondary or tertiary care?
|
82.1
|
17.9
|
|
|
|
|
|
Health improvement and education (Table 4)
The results of our study show that most of the responders are satisfied with the results of care.
Health education and medical advice is recognised to be valuable in 88.8% of cases concerning diseases and 87.7% of cases for preventative measures.
A total of 52.3% of patients suffered from a chronic disease, and 91.9% of them affirmed that they understood the medical advice of their FD on how to take medication.
Table 4. Health needs in relation to outcomes of care in the FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
After the consultation with your FD, did you feel that your health had 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 with 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, such as pregnancy monitoring and well-child and cervical cancer screening. Access to these services is appreciated by patients, yet data from the NHIH show a reduced number of reported services, such as pregnancy monitoring and well-child and cervical cancer screening. Underreporting is one of the causes, as well as a lack of education among the population accessing these services.
Point-of-care testing, such as lab tests and electrocardiograms (EKGs), is not recognised as an offered service in the family doctor’s office.
Table 5. Health needs in relation to procedures in the FD’s office
Questions
|
Yes
(%)
|
No
(%)
|
|
|
|
|
|
In the place where you live, do you have access to IV injections or infusions?
|
92.4
|
7.6
|
|
In the place where you live, do you have access to the flu vaccine?
|
94.4
|
5.6
|
|
In the place where 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 where you live, do you have access to Pap smear services in the FD’s office?
|
46.2
|
53.8
|
|
|
|
|
|
In the place where you live, do you have access to blood draw services in the FD’s office?
|
63,1
|
36,9
|
|
|
|
|
|
In the place where you live, do you have access to an electrocardiogram?
|
56
|
44
|
|
|
|
|
|