Structure and organization of primary care (2024)

Vision on primary care

The availability of an explicit governmental vision on the role of primary care in the health care system is among the indicators of governance. A vision on current and future primary care has been identified as far as it has been explicitly laid down in policy documents. Such visions on primary care were not always available. They were poorly developed, in particular, in Austria, Belgium, the Czech Republic, Germany, Hungary, Iceland, Latvia, Poland, Slovakia, Sweden and Switzerland. In a number of countries visions were focused on (partial) reforms of the primary care system; this was the case in Cyprus, Finland, Ireland, Italy, Portugal and Romania.

In general, results show that countries with a gatekeeping system produce more formal governmental pro-primary care policies, and vice versa. Furthermore, the characteristics of the type of health system in the countries, such as social health insurance (SHI) or a national health service (NHS), were not found to be related to the extent that supportive primary care policies were in place.

One of the most consistent policy characteristics in countries with strong primary care is the governments’ attempts to distribute resources equitably and avoid inequalities.

Central, regional and local responsibilities for primary care

In a relatively small number of countries, including Estonia, Hungary, Latvia, Malta, Slovakia and Switzerland, responsibilities for primary care have been centralized at national level. In other countries essential functions, such as priority setting, financing, supply planning and management, provision of services or quality monitoring are the responsibility of regional or local authorities or regional health insurance funds, hospitals or primary care trusts. Countries where the most functions in primary care have been decentralized are Denmark, Italy, Norway, Spain and Sweden. In Malta, Norway and Romania (further) decentralization of primary care has been included as a system target. A possible disadvantage of decentralization is the existence of inequalities in policies, and eventually in access to and quality of primary care. Some countries where important responsibilities for primary care have been decentralized have national policies to ensure an even distribution of providers and services. Such explicit national policies are not in place, however, in the Czech Republic, Finland, Greece, Iceland, Norway, Poland and Turkey.

Promoting responsiveness and quality of care

Responsiveness of health care systems can be facilitated either through stakeholder involvement in policy development or by community participation in the organization and provision of services. In most countries stakeholders and the community are involved in some way in these issues. In Cyprus, Italy, Luxembourg and Malta only one form occurs, while neither one occurs in Hungary and Slovakia.

Aspects of patient rights, such as informed consent for treatment, the possibility of patients having access to their own medical records, regulation on confidential use of medical records and the availability of patient complaint procedures in primary care facilities have a legal basis in all countries except Cyprus, France, Iceland, Ireland, Luxembourg, Malta and Switzerland. The least protected patient right in these countries is the availability of patient complaint procedures.

Quality assurance by means of formal medical educational requirements for providers to work in primary care is in place in all countries. However, Cyprus, Finland and Hungary are more lenient with these requirements in times of shortages of supply, allowing nonspecialized physicians to practise in primary care. In addition to personal educational requirements to practise, in most countries primary care facilities need permission to operate. Such permissions are not required, however, in Belgium, Finland, France, Germany, Ireland, Luxembourg and Norway.

Quality assurance through the development of evidence-based clinical guidelines for GPs exists in all countries except Ireland, Malta and Switzerland. Usually such guidelines have been produced by a combination of stakeholders, including ministries of health, a college or association of GPs and medical specialists. Sometimes foreign guidelines are used and adapted for the national situation.

Overall governance of primary care by country

Fig. 2.1 provides an overview of the overall scores on primary care governance by country, showing the performance of each country on all indicators that have been used on the governance dimension. Details on the scoring system can be found in Appendix II.

The figure shows that in most countries governance structures aiming to enhance the commitment towards primary care are relatively well developed. Furthermore, consistency among countries can be identified in the scores on the various indicators.

Three variables of (state-related) governance turn out to be weakly developed. In only eight countries is there a specific unit responsible for primary care within the Ministry of Health, while five countries have a state inspectorate to maintain the quality of care. Besides, in one-third of the countries no governmental policy on multidisciplinary collaboration could be identified.

The results show that countries with a gatekeeping system have a stronger primary care orientation in their governance than those without (Pearson correlation of 0.64; p-value 0.00).

Despite the modest variation in primary care governance scores across Europe, two contrasting groups of countries can be identified. Among the countries with strong primary care governance are: the Netherlands, Spain, the United Kingdom, Portugal, Italy, Denmark, Norway, Slovenia, Romania, Estonia, and Lithuania. The group of countries with weakest primary care governance consists of Switzerland, Cyprus, Luxembourg, Hungary, Iceland, Malta, the Slovakia, Ireland, and Poland. The other countries hold an intermediate position on primary care governance.

Primary care expenditure

Primary care expenditure strongly varies among countries. To some extent this results from the services included in the expenditures for primary care. A uniform methodology for calculating primary care expenditure across countries is not available and this hampers the comparability of this indicator. For example, in some countries it is limited to costs for family practice only, while in others freely accessible specialist care services are also included. Additionally, costs for community nursing, primary mental health care, dentistry and emergency care may be included in primary care costs. Even in family practice fund-holding, elements for laboratory tests and other investigations can be included. Finally, uniformity in the allocation of costs of prescribed medicines is absent.

Given these reservations, for 21 of 31 countries a comparison can be presented on primary care expenditure. In these countries the share varied from 4.7% in the Czech Republic to 25.6% in Switzerland. The share of prevention and public health expenditure varied from 0.6% in Cyprus to 18.4% in the Netherlands. It is difficult to draw comparisons from these data because of the wide variability in calculating expenditure.

Primary care benefits package

In general, the coverage of the population for medical expenses is quite comprehensive. In half of the countries coverage for primary care costs is complete, while most of the other half have coverage close to that. There are two exceptions: Cyprus with 80% and Ireland with 33%. For Turkey no exact data on coverage were available. In most countries the coverage for prescribed medicines is close to the coverage for primary care costs in general, with the exception of Bulgaria, where the coverage for prescribed medicines is 40%. No data were available for Romania and Turkey. In Cyprus the coverage for medicines is complete, and thus better than the overall coverage for primary care services.

Employment status of GPs

Countries differ in the dominant employment status of primary care providers, in particular GPs. In the following 18 countries GPs are predominantly self-employed: Belgium, Bulgaria, the Czech Republic, Denmark, Estonia, Germany, Hungary, Ireland, Italy, Latvia, Luxembourg, the Netherlands, Norway, Romania, Slovakia, Switzerland, Turkey and the United Kingdom. In these countries the large majority of self-employed GPs usually have contracts with health insurance or a health authority.

In Finland, Iceland, Lithuania, Poland, Portugal, Slovenia, Spain and Sweden all or most GPs are salaried either with the national, regional or local authorities or by other GPs. In most of these countries health care is funded through governmental budgets, not by health insurance. Countries with salaried GPs often offer them the possibility to work part-time in private practice.

The payment scheme of independently working GPs is usually a mix of capitation and fee-for-service payment. Fee-for-service payment is only reported for Cyprus, France and Switzerland. In half of the countries with salaried GPs these have a flat salary while in the other half the salary is combined with pay-for-performance elements and related to the number of patients served.

The comparison of annual income of GPs is complex as different components are included in the overall income in the countries. In some countries practice costs, practice staff costs and even costs for laboratory expenses are included. In countries where the data do not include practice costs, the average estimated annual income of a GP ranges from €10 782 in Lithuania to €150 000 in Luxembourg. In the group of countries where the data include practice costs, it varies from €13 688 in Bulgaria to €71 514 in Belgium. Comparisons of net incomes are even more difficult as taxation systems strongly differ.

As the level of funding of health care and primary care in a country are related to indicators of economic development, it is not surprising that, in general, in countries with a high gross domestic product (GDP) GPs have relatively high incomes as well. However, there are other determinants of the income of GPs, as the different income positions of GPs in the high-GDP countries Belgium and the United Kingdom show.

Overall economic conditions of primary care by country

Fig. 2.2 provides an overview of the total economic conditions of primary care scores by country, considering the performance of each country on all economic conditions indicators (see Appendix II for an overview of the features and indicators used for the scores). The figure shows that the general economic conditions of primary care are most favourable in Belgium, Denmark, Finland, Germany, Italy, the Netherlands, Portugal, Slovenia, Spain and the United Kingdom. Countries where economic conditions for primary care are relatively poor are Bulgaria, Cyprus, the Czech Republic, Greece, Iceland, Ireland, Malta, Romania, Sweden and Turkey.

The variation between countries in the overall economic conditions of primary care is limited; scores range from 1.90 in Bulgaria to 2.26 in the United Kingdom. Still, there seems to be room for improvement in some countries on specific indicators. The expenditure on primary care, for instance, is relatively low in Bulgaria, the Czech Republic, Estonia, Italy, Latvia, Norway and Slovakia. Another point is that in 10 out of 31 countries primary care expenditure data could not be identified in the total health expenditures. Concerning the income of providers, a major observation is the considerable gap in most countries between the financial status of primary care providers compared to hospital specialists. The only countries where GPs have a financial status comparable to medical specialists are Cyprus, the Czech Republic, Hungary, Ireland, Portugal, Spain and the United Kingdom. In all other countries, the income of GPs is, usually considerably, lower than the income of most medical specialists. However, in these countries GPs earn considerably more than nurses and allied health care professionals.

No significant relationship was found between the national income (GDP) of countries and their overall economic conditions of primary care. This suggests that the financial policies and mechanisms applied are of greater influence than the financial resources available.

Professions active in primary care

The only primary care professionals that were found in each of the 31 countries included in this study are GPs, also referred to as family physicians. On average there are 68 GPs per 100 000 population in Europe, although the variation is very large. The contrast between the neighbouring countries Belgium and the Netherlands is very large. In the Netherlands, the number of GPs per 100 000 population is 47, while there are 115 per 100 000 in Belgium. Also dentists belong to primary care in most (27) countries. Also quite common in primary care are nurses; they are a regular discipline in 23 countries. However, nurses may have quite different roles in primary care, varying from specific nursing tasks, for instance with chronic patients, to more general support tasks. Specialized nurses and home care nurses are less prevalent as part of the primary care workforce (in almost half of the countries only). In 22 countries midwives are working in primary care.

Furthermore, in many countries patients have direct access to a number of medical specialties, and so these are also part of primary care. In two-thirds of the countries gynaecologists, paediatricians and ophthalmologists are considered as primary care professions. In about half of the countries specialists of internal medicine, ENT specialists, cardiologists, neurologists and surgeons are active as primary care providers.

Availability of GPs

Ageing among GPs may become a problem in many countries. In well over half of the countries studies are available or institutes are working on primary care demography and future capacity needs. With the exception of Turkey, where the average age is 39 years, GPs in the remaining countries are mostly between 45 and 55 years. Again, the age distribution varies strongly from one country to another. In countries like Cyprus, the Czech Republic, Italy, Norway, Spain and Sweden around half of the general practice workforce is over 55 years old. Countries seem to react differently to the imminent effects of the ageing of their GPs. In some countries the number of GPs has strongly increased in recent years, such as in Greece, Lithuania, Poland and Slovenia, while in others the numbers are decreasing steadily, for instance in Germany and Slovakia.

In addition to the age structure of the profession, workforce capacity is also related to the opening hours of practices and working hours of staff. The opening hours of general practices across Europe, excluding possible hours on-call, vary from 35 hours per week in Hungary to 100 hours per week in rural Austria. The average is 44 hours a week. These hours include both direct patient care and other activities. In some countries opening hours are subject to mandatory regulation, which also applies to GPs who are self-employed and work in their own practice.

Professional and academic status

The professional status of general practice has been identified through several indicators. The first is the existence of an official job description, either on a legal basis or in a professional code. This is the case in 20 countries in Europe. Fifteen countries have established a job description by law; most did so in the last 15 years. In Austria, Germany and the United Kingdom the tasks and duties of GPs are included in the contract between the financing body and the GP, while in Lithuania and Luxembourg job descriptions have been established by the professionals themselves. A second indicator of professional status is income level. With the exception of Portugal, Spain and the United Kingdom, which have NHS-type health care systems, GPs earn less or much less than medical specialists (although paediatricians and internists sometimes earn the same as GPs). However, if earnings of GPs are compared to those of other professions in primary care, such as specialized and home care nurses, physiotherapists, midwives, occupational and speech therapists, they always earn more to much more. In some countries dentists seem to earn more than GPs, while in others it is the other way around.

The attractiveness of general practice or primary care is also reflected in the preference of medical students choosing to become a GP or family physician. Except for Austria and France, around 17% of medical students throughout Europe choose to become GPs. In Austria, the rate is high because all physicians start off as GPs, before specialization to become a medical specialist. In France the rate is high because the number of positions in each medical specialty is determined by law and allocated according to the results of a mandatory ranking examination.

The situation of nurse training, specifically for primary care, varies. Eight countries offer no such training at all. In 13 countries nurses can specialize either to become a community nurse or a primary care practice nurse. In eight countries both specializations are possible.

Professional associations

In nearly all countries there is at least one professional organization for GPs, either an association or a college of GPs. Mostly they are involved in scientific, educational and professional development (guidelines, continuing medical education). Frequently, GPs also need to register with a physician’s register, including all specialties.

Professional organizations for primary care nurses are rarer. Associations or organizations of primary care nurses exist in only 10 of 23 countries where primary care nurses are working. In most European countries a journal on family medicine is published, but not all of them are peer-reviewed or even have at least 50% of scientific content. On primary care nursing only six journals are available.

Overall primary care workforce development by country

Fig. 2.3 shows the total primary care workforce development scores by country, considering the performance of each country on all workforce development indicators (see Appendix II for an overview of the features and indicators used for the scores).

Compared to the governance and economic conditions of primary care, differences in workforce development of primary care are larger. They range from 1.62 in Iceland to 2.34 in the United Kingdom.

Relatively high levels of primary care workforce development are found in Denmark, Finland, Ireland, Malta, the Netherlands, Portugal, Slovenia, Spain, Switzerland and the United Kingdom. Workforce development is relatively low in Cyprus, the Czech Republic, Greece, Iceland, Latvia, Luxembourg, Malta, Poland, Slovakia, Slovenia and Sweden.

National strategies and plans

In many countries some explicit and public strategy or more detailed plan is available to guide the development of primary care and against which progress can be assessed. Indeed, the endorsem*nt and effectiveness of such documents are influenced by the political will of administrations and they may be reviewed, changed or completely reformulated as political or economic conditions change. However, guiding documents on primary care can be an important basis and reference for health service provision to the population. National strategies can be the basis for a comprehensive primary-care based health system. In Spain, for instance, this has been the case during a process of regionalization of its governance and in France a start has been made on developing team-based primary care.

Still there are countries where an explicit plan for the development of primary care, including more comprehensive service provision and better care coordination, is absent. Strong primary care does not develop spontaneously but requires a deliberate explicit policy specifying the division of roles between levels of care, the curative and preventive services provided at the primary care level, the coordination function in the health care system and incentives for providers. Current evidence has shown that health care systems based on a well-developed primary care system perform better in terms of population health and cost-containment. In the absence of explicit policies and regulation on primary care such advantages may be missed.

Inter-professional collaboration

Maintaining the responsiveness of health care systems is a continuing challenge for decision-makers and health professionals. For instance, the ageing of the European population and the increased prevalence of noncommunicable diseases require new ways to cope with changing health needs. Chronic conditions and multi-morbidity can be treated more effectively by different closely collaborating health care workers among whom tasks may be reshuffled. In prevention and anticipatory medicine an integrated primary care level has a major role to play, preferably in relation to community and occupational services. It will be a challenge to realize this, especially in the many countries where the heart of primary care consists of GPs working in solo practice.

Furthermore, professional education should prepare workers for new skills, new skill-mixes and teamwork. Continuing education should also be tuned to changing demands for care and the development of new tasks. Finally, it will be the role of regulation and funding of primary care to create the right incentives to make this work.

Countries that have a better professional infrastructure or a stronger academic tradition in primary care are more often ahead of others in this development. If a vision on the future role of primary care has been developed and formulated countries can learn from each other how to go in this direction.

Education and training

In recent years significant progress has been made in preparing physicians for working in primary care. Mandatory periods of postgraduate training, varying from three to five years, both in universities and in primary care practice, have upgraded the primary care workforce in various countries, although there is much still to be improved. The extent of the training and subjects studied vary considerably, and in a number of countries the domain of general practice is still limited (for instance because GPs are not trained to provide care for children). In some countries postgraduate training for GPs is very limited.

Regarding the professional development of other primary care professions, such as home care nurses and community nurses, the situation is less positive. For these professions the opportunities for obtaining advanced education are limited, mainly to countries in western Europe with well-developed systems of primary care. An integrated and comprehensive primary care service requires investment in people as well as in systems.

Strategies to promote performance

Approaches to encourage better performance in primary care vary across the countries and are related both to the culture and the structure of the health care system. As, in most countries, GPs have a key role in reforms to achieve more efficiency and create more responsive services, performance-related incentives are mostly directed to general practice. Countries may use the force of law without much measurement of actual performance, or they may try incentives, such as pay-for-performance, to make health care workers develop prioritized services and, at the same time, monitor innovative approaches.