Our study summarises participants’ perspective on availability and provision of services in primary care in a pilot county. One of the first discussion point is access to primary care. In Brasov County only 2.6% of patients declared that they do not have a FD in the area where they live. The result is in concordance with the reduced number of settlements without a FD in the studied area (Data from Brasov Health Insurance House at 31/07/2019). Brasov county being highly urbanised and offering good employment opportunities is a region of choice for FDs.
In other regions of Romania, the problem of coverage with FDs is of a different magnitude. In 2015 reports from NHIH cited by authors of the Health System review published in 201612 showed that all over Romania, 300 communities did not have a FD. Despite the financial stimulants and the construction of modern facilities in remote regions, the problem of attracting and retaining of FD’s didn’t improve. A new regulation issued in April 2019 (Law 79/2019) stated that FDs can open a branch of his/hers practice in a settlement where there is a need. Recent data from NHIH are showing a slight reduction of the deficit of FDs (A report of the NHIH from August 2019). It accounts for 195 communities all over Romania with an uneven distribution, the range varying from 0–16 per county. Overall the deficit of FDs is inscribed in the general downward trends of the healthcare workforce in Romania, as it is encountered also in other eastern European countries. The phenomenon is due to migration of doctors to Western countries, aging of FDs, insufficient motivation for a carrier choice. Although data on the outflow of doctors in Romania are not accurate, official data on diploma verification applications in 2007 where showing that 10% of doctors had the intention to leave the country20. A report from the European Commission on the health care workforce published in 2012, estimated a shortage of 230 000 doctors by 2020 meaning that 13.5% of health needs are not being covered.
In Romania, under the framework of the National Health Insurance System (NHIS), 92.5% of the population is registered with an FD but registration is not a guaranty for good access. The free choice of the doctor has led to a phenomenon of migration of patients toward preferred doctors and consequently FD’s have lost their catchment areas. If in 2009, 70.8% of patient’s reported having to travel less than 20 minutes to the FD17 now things would need to be explored. This fact has brought problems especially in condition of an acute illness, fact that is triggering the use of emergency services.
Reaching the FD is also discussed in terms of opening hours and telephone contact. The compulsory working hours of FD’s in Romania are 25/ 35 a week, office time and another 10 hours a week for home visits. Working time is correlated with the size of patient list. Practices with over 2200 of registered patients, can offer increasing office access 1–2 extra hours a day). Services provided outside working hours are not payed to the provider. Fee for service can be charged but is seldomly solicited by FDs. Another characteristic of the working time is the work in shifts (morning and afternoon) especially in urban settlements due to the small dimension of the premises and sharing of the same office. This type of opening hours is leaving patients without access to their FD for 24h, fact that is encouraging the use of emergency services for conditions that could have been treated at the FD. Despite these facts 91.2% of responders of our study stated that the hours of operation of FDs offices allow them to access the practice easily.
Furthermore, asked in general 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.
Comparing opening hours of other European countries and the UK21, we see that opening hours vary widely across countries the majority having longer opening hours then Romania, ranging from 7 to 12h. Only Hungary and Lithuania are reporting lower times (2 to 6 hours a day).
The results of our study showed that only 26.6% of people could receive a same-day appointment with their GP. The pattern of access has changed since the beginning of the health insurance system. As it is reported by the regional WHO office in 2009 when 92.8% of people could schedule a same-day appointment with their FD17, today this has dropped to a quarter.
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 meaning that continuity of care cannot be insured otherwise than in OOH centres. But only 58.6% of cases, there is access to an out-of-hours (OOH) centre in the neighbourhood.
Access to FDs’ offices by telephone is available in 90.5% of practices. This pattern of access by appointment is compulsory in the Health insurance system. Easy phone access is a quality criterion in the evaluation of practice. Telephone consultations are not recognised as a type of consultation.
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. About half of the patients are registered with their FD for more than 10 years (53.6%) but more than 90% more than 1 year. Romanian patients perceive that FDs are meant to be close to the family and prefer to see the same doctor every time. This type of preferred relationship is impeding availability of access to healthcare services only to the working hours of the doctor. Accessing another FD is only recently possible in the contractual framework of the health insurance upon notification of the absence of the current doctor.
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. 19.8% of questioned people visited their FD 12 times. The highest frequency is registered at the group over 65. A European database23 (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 years17. 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.
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
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, adapting it to the needs of the population and responding to the needs of public health24.
Health improvement and education
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.
Availability of procedures
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 (0.98% of all services/year/2016) and well-child (2.26 % of all services provided by FD/year/2016). Underreporting is one of the causes, as well as a lack of education among the population accessing these services can be a cause.
Cervical cancer screening was included temporarily (5 years) in a payment scheme, during a cervical cancer screening organized by the Ministry of Health between 2012–2017. During the program, FDs had the opportunity to screen for Pap smears in their offices or to refer to a gynaecologist. Not many FD’s chose to do Pap smears in their offices. After the end of the program this service was not payed under the health insurance scheme.
Point-of-care testing, such as lab tests and electrocardiograms (EKGs), is not recognised as an offered service in the family doctor’s office.