East Looks West for Role Model
General practice in the UK may not be perfect, but it is the model for a brand-new system in eastern Europe. Janina Struk reports.
For the past four years doctors from Poland have been training in Britain under a European Commission programme to help the former Communist country restructure its primary health care service.
Until the scheme was set up in 1992 the concept of the General Practitioner had hardly existed in Poland, but now it is attracting increasing interest among doctors.
Most Polish health care is centred on hospitals, though there are district-based clinics where small groups of specialist doctors work - often including a paediatrician and physician - but patients do not register with them.
Now the Polish government wants to train up to 15,000 GPs, to be the "gatekeepers" to the rest of the Health Service. A mixed system of care is likely, with regions being given power to develop their own models of care, which will include trusts, primary care systems and some private practice.
The EC set up the Poland and Hungary Aid and Development project and awarded the contract for primary health care in Poland to the European Consortium for Primary Care (ECPC), which is administered by the British Council. There are also sites in Holland, Denmark, Spain, Ireland, Germany and France.
One of the British doctors most involved is Dr Teresa Pawlikowska of the Department of Primary Care and Popular Sciences at the Royal Free Hospital in north west London. She is a GP herself and, as her name indicates, she is from a Polish family, which gave her an interest in the project since its onset.
Dr Pawlikowska says the training is based on a "cascade principle". She adds: "It was decided to divide Poland into 12 regions, mostly based around universities, which wanted to develop a department of general practice or already had some interest in that direction ".
Already two groups of six pairs of doctors have taken part in six months of training in London and Manchester. These, she says, will form "the core of trainers of trainers of general practice in Poland".
Dr Pawlikowska explains that the training covers both the way in which primary care is delivered at grass roots level, and educational issues. She says: "We look at the structure and function of general practice and the primary health care system, at various models of general practice, at the financing interface with the health authority and with secondary care. We examine educational issues at undergraduate and postgraduate level and in vocational training and continuing medical education".
During their training the Polish doctors are attached to UK GPs' surgeries. Dr Pawlikowska says that the doctor-patient relationship is of great interest to them.
She says: "Poland didn't have family doctors providing continuing primary health so it's vital for them to look at communication and consultation and what goes on in the consultation.
"It's a slightly different philosophy - treating patients as partners in care, as opposed to the former Polish system, in which they were told what to do. They were familiar with a more hierarchical system".
The GP-patient relationship is the strong point of the UK system, according to Dr Piotr Mielcarek, who trained for six months with Dr Pawlikowska at the Royal Free. He is now one of her "trainers of trainers", teaching Polish doctors at the Department of Family Medicine of Gdansk Medical University.
"People here have a strong desire to have their own doctor," he says. "At present there is no personal responsibility for the patient and no clear registration".
But changing the medical culture inevitably causes problems, and one highlighted by Dr Mielcarek involves the relationship with specialists. "Our specialists are different from those in western Europe. In the UK you have only a few consultants, but here every doctor is allowed a private practice, and it is easy to be a specialist, so you can imagine that the introduction of GPs could be quite difficult for some specialists, as GPs could threaten their private practice".
With his colleague Dr. Pawel Nowak, who trained with him for six months in London, Dr Mielcarek is opening a GP practice in refurbished premises in the grounds of the university later this year. This will be a step they are eagerly anticipating - putting their theory into practice.
Some Polish doctors have advocated the development of general practice for a long time. Professor Marek Hebanowski of the same department has done so since the 1970s. He has helped develop six-month training courses for GPs aimed at doctors already practising in the primary care field.
He believes primary health care doctors need education in effective communication. Professor Hebanowski says: "They are now taught psychiatry and trained in how to get across difficult issues to patients, such as breaking the news about terminal disease".
The new system can be seen in action at a pioneering GP surgery in a small town 100 km from Gdansk. Dr Stefan Krajink's practice is in a large, friendly converted house in Czarna Woda. He is one of the trainer-trained, having completed Professor Hebanowski's course in Gdansk, and spent two weeks at the Royal Free in London.
The practice covers Czarna Woda (which translates as black water) and two nearby villages, involving a total population of 3,500. It is one of the model practices to which trainee Polish GPs in Poland will be allocated.
Since last July Dr Krajink has been an "experimental fundholder" - the only one in the Gdansk region. He took his ideas on GP fundholding from his training in the UK and says that for the first time he is able to do the kind of work he wants.
The possibilities for fundholders are obviously more limited than in the UK. Capitation is 180 zlotys (about £40) per patient per year, but from this Dr Krajink buys in a regular ophthalmology service and a dentist - as well as paying for hospital and other care, along the lines of UK fundholding.
The patients, he says, are delighted with the dentist - but he resents the 18 per cent of his budget the service takes up and believes it should not come from his funds.
He can also afford to employ a woman doctor to ruin a paediatric service. Dr Kalamon works two days a week in a prenatal capacity. She plans to qualify as a family doctor specialising in paediatrics. And Dr Krajink contracts his practice nurse for extra hours to visit people in their homes three times a day as a part of a palliative care scheme, which is a developing part of primary care in rural areas.
His equipment includes an ultrasound scanner, which is actually owned by the local timber factory, where Dr Krajink runs a daily occupational health clinic. This has made early diagnosis possible, notably for a young man with bladder cancer who was operated on within two days, whereas before he would have had to wait two months just for an initial consultation at the nearest hospital, 40 minutes' drive away.
Dr Krajink hopes that the tide of health care in Poland will turn in his direction, though he warns that it can only do so if primary care doctors like himself, and hospital-based doctors work together. But he points out that GPs can save scarce resources for the health service by treating disease earlier.
According to World Health Organisation figures for 1995 Poland is able to allocate only £54 a year to spend on patients, compared to the UK's £663 and the Netherlands' £962. This means money must be well directed.
Dr Krajink summarises the new philosophy saying: "The first and most important thing is that we should listen to what the patients want to tell us and build our system around that".
The approach to change favoured by Professor Hebanowski and Dr Krajink could mean an increase in status and pay for family doctors, a smaller, more efficient administration, and, with the GP as gatekeeper, an end to unnecessary specialist consultations and a more equitable access to hospital beds.
Dr Mielcarek argued that Poland should have an insurance-based system for financing the health service. At present it is financed out of general taxation. He says that an insurance system would ensure better funded, higher quality care.
Asked how she sees the development of training in Poland, Dr Pawlikowska is optimistic but says: "The primary-secondary care interface issue will have to be addressed for it all to work- and so will the question of how the system will be funded, with increasing patient expectation and, in the general economy, high unemployment".
And she says the training programme for Polish doctors has helped her assess the UK system in a new light. She explains: "There are a many difficult issues in UK general practice and it might help if, to put our practice in context, if we look outside ourselves and see how people are having to work in other countries. It might gives us a different perspective".
© Janina Struk, 1996