GP JOURNEY THROUGH DECADES The Experience from the Czech Republic c

1. GP JOURNEY THROUGH DECADESThe Experience from the Czech Republicc Bohumil Seifert Department of General Practice 1st Faculty of Medicine Charles University in Prague For University Days, Almaty, Kazahstan, December 2015

2. The itineraire • Personal introduction • A journey through decades: • a little bit of politics, history • health care systems • primary care function • Public Health issues and prevention in general practice

3. A little bit of politics/history I. • Interval between world wars: The golden time of family medicine in the former Czechoslovakia Austro-Hungarian empire until 1918 Czech Republic since 1993

4. Bismarck model • Otto von Bismarck: SicknessInsuranceLaw 1883 • based on mandatoryhealthinsurance • paidpartly by employeeand partly by employer • equity in access to health care: providedfree ofchargeforall • providers are independent contractors

5. Semashek model Semashek model • NikolaiSemashek, 1874 – 1949 Public healthofficer in Soviet Union Model in function in theCzechRepublic 1951-1989 • directivecentral management and planning • equalaccess to free ofcharge care forall • lowmotivationforproviders (stateemployees) • low status ofhealth care professionals in society • unfavourableoutcomes

6. A little bit of politics/history II. • 1950´s An installation of the Soviet model with polyclinics and dense specialist network in countries of Central and Eastern Europe limited function and development of general practice. 1978: GP as an independent discipline

7. A little bit of politics/history III. 1989 Velvet revolution The CEE countries have experienced dramatical changes, including the changes in the health care and in primary care Windak A et al, EJGP 1998 Svab et al, Croat Med J, 1999 Seifert B et al., Family Practice, 2008 Oleszyk M et al., BMC Family Practice. 2012

8. Health care system models: options in 90´ • Semaschek model • US model (ver liberal, individualresponsibility) • Beveridge model (NHS: UK, Denmark, Portugal) • Bismarck model (Germany, Austria, Switzerland)

9. Czech health care system: Social health insurance • Insurancepaid by employee + employer • Statepaysforchildren and seniors • 8 insurancecompanies(freedom limited) • Health care is free ofcharge, small co-paymentformedicaments

10. 90´: difficult journey back to Europe Poor background of the GP discipline : • no theory behind • low recognition among other medical professions • low competence • bad image, low attractivity • no international contacts and experience • language barriers • high age average BUT: • enthusiasm and huge support from Europe

11. Support from European colleaguesRole of WONCA • In 90´s: newperspectives and possibilities • to travel and to meetcolleagues • to participateatcourses, conferences • to join WONCA networks, to learn and to adopt • to joinresearch ad qualityprojects • WONCA Region Europe, Prague 1997: thefirst meeting in CEE region

12. GPs in the health care system • Independentinsurancecontractors • List ofpatients/ free choiceofdoctor • Mixedcapitation + feeforservicepayment • Bonuses: - teaching (accredited) practices - appointment systém - lateafternoonofficehours - targets (prevention, screening)

13. General Practicein the Czech Republic • Polyclinics  solo practices (90´s) • Solo practices  group practices (25 years later) • Primary care: GP + PED + GYN - home care, social services • No gatekeeping function but people seek for care first by GP.

14. Typical General Practice • Solopractice team: 1 doctor + 1 nurse • Facility: rentedorowned • Organization: open access/ appointment systém • Clinic: commonacuteproblems, chronicdisease management , systematicprevention + screening, house calls, assessmentmedicine, socialadministration • Hardware + software • Equipment: POCT LAB (CRP, coagulationcontrol, glucometr, glycHgb), ECG, ENT examinationdevices, Doppler, BP 24hours, ABI measurement, spirometry, RHB 35 000 physicians, 18 000 in ambulatoryservice 5200 GPs, 2200 pediatricians, 1400 gynaecologists

15. Characteristics of the medicine in the 3rd millenium • Keychallenge: non-communicablediseases • Fascinatingtechnology development • Successesin diagnostics, treatmentand improvementofprognosisofseriousconditions Furtherexpectationspushmedicine • towardsprevention • towards pro-activeinteventions in asymptomaticpeople

16. Prevention and screening Consequencies: • Ethics (natureofpatient – doctorrelation, individuals v. population ) • Safety • Costs • Capacity

17. By Charles Boelen

18. Prevention and primary care GP • istranslatingpopulationstrategiesforpreventionandhealthpromotionintoindividualized / personal care • iscompetent • knowspatient, his/her personalandfamilyhistory, placewhere he livesandworks. • isable to understandpatient´s valuesandpreferences • has possibility to influence patientssystematically • has possibility to use everyconsultationfor risk assessment and briefintervention

19. Prevention Primaryprevention: - actions to promotehealth prior to thedevelopmentofdiseasesorinjuries Secondaryprevention: - actions to detectdisease in early (asymptomatic) stages Tertiaryprevention: - actions to reverse, arrestordelayprogressionofdisease Quaternaryprevention(by WONCA): - actionstaken to identify a patientat risk ofover-medicalization, to protecthimfromnewmedicalinvasion and to suggestinterventionsthat are ethicallyacceptable.

20. Prevention in primary care in the Czech Republic regularpreventivechecks (biannualy) systematicscreeningprograms opportunisticbriefinterventions vaccination Extraordinarychecks (forassessment) Occupationalhealthchecks Chronicdisease management (followup) Travelmedicine

21. Personalattitudes to prevention • I am free to make decisions… • I have other preferencies, prevention later • Is it realy quality of my life what matters? • I do not want to became a hostage of doctors and health service .… • 30% attendance of preventive checks

22. Preventive checks and EBM B. Starfield, Epidemiol Community Health Med 2008;62:580-583 Whilewe are not sureaboutthebenefitofpreventivechecks, weknowthattheycanharm; cause uselessdiagnosis, uselesstreatment, risk ofinvasivetests, stress fromfalse positive results, falseassurancefromfalse negative tests, psychosocialconsequencesofdiseaselabelling, increaseofexpenses,…… US paradox: In country where the equity in access to health care is a problem, almost half of contacts in primary care are due to routine preventive check. UK: NHS preventive checks since 2009 The Netherlands, Denmark: No!

23. Preventive checks and EBM There is no evidence on the usefulness of preventive checks COCHRAN REVUE • 14 studies, 182 880 persons(76 403 PP, 106 477 controls) • Followup 1-22 let Results RR 95% conf.interval • Total mortality 0,99 (0,95-1,03) • Cardiovascular mortality 1,03 (0,9-1,17) • Cancer mortality 1,01 (0,92-1,12) • 0 effect: morbidity, hospitalizationrate, invalid benefits, practicevisits, sickdays • 20% increase in numberofdiagnosis in 6 years v. controls • More hypertensionsandhyperlipidemia

24. Co-referates • Systematicpreventionincreasesthechanceforequity in access to healthandtherefore a reductionofthe risk of CV andoncologicaldiseases. • Theeffectofpreventiondepends on participationrate. New Zelandreportsparticipationrate 75%. • Good health policy must take in account both public health priorities and medical research based evidence.

25. Cardiovascular prevention issues Participation paradox Peopleatlow risk are more likely to participateattheprevention, whilepeopleathigh risk lesslikely. Thepreventiveexaminationoflow risk is not effectivewhiletheinterventions in peoplewithhigh risk iseffective. Thresholds: hypertension, serum cholesterol, bloodsugar • 97% of US adultsaged 50 and overhaveoneor more these three risk factors

26. GPsatthefrontlineofcancerprevention • Primaryprevention • Early diagnosticsin symptomatic • Secondaryprevention: • screeningprogrammesforhigh risk persons • screeningprogrammesforaverage risk p. • Care forcancerpatients

27. Early diagnosticsofcancer • The principal method of identification of colorectalcancerstayssymptomatic presentation to GPs who are source of referral to secondary care………………………90-95% ofcolorectalcancers KeyIssues: • Help-seekingbehaviour • GP performance • Access to diagnostics

28. Early diagnosticsofcancer: Help-seekingbehaviour • Delayprocesses on patient´sside: • cognitive: lowrecognitionofseriousnessofthe symptom • emotional: fearofrecieving a cancerdiagnosis • behavioural: a reluctance to interactwiththe HC system Forbes et al, Brit JourofCancer 2013 Simon et al, CancerEpidBiomarkers and Prevention, 2010 Quaife et al, Brit JourofCancer2014 Whitaker et al, Brit Jourof GP, 2015

29. Early diagnosticsofcancer. GP performance Clinicaldecisionmaking in primary care isbased on risk estimation. Theaimis to identify in a timelywaythosepatientswith a high risk ofseriousdisease Winkens et al. BMJ 2002, Elstein et al, BMJ 2002 Symptoms are common, but cancerisrare. Conceptof alarm symtoms(rectalbleeding, weightloss, anemia, abdominalpain, apetite loss, alteration in bowel habit). Probability ofcancerincreaseswith a combinationofsymptoms. Jellema et al, BMJ 2010, Astin et al, BJGP 2011, OldeBekkink et al, BJC 2010

30. Early diagnosticsofcancer.Access to diagnostics • capacity • organizationofreferrals • waitingtimes • qualityofservices • CRC: Dueto increasingdemandofscreeningcolonoscopiesoptimalizationofreferralsforcolonoscopyisnecessary. • Waitingtimes 6-12 weeks • interdisciplinarycooperation.

31. Theprinciplesofscreening The aim of screening is to lower the burden of cancer in the population by discovering disease in its early latentstages • SAVING LIVES, IMPROVING QUALITY OF LIFE • USING OF APPROPRIATE METHODS - NO HARM • RATIONAL FUNDING: costeffectivity Europeanguidelines, Segnan, Patnick, Karsa, 2010

32. GPsshouldbeeducated in screeningin orderto: • understandprevention and screening • communicateprevention and screening • increaseuptake in prevention and screening • providebalancedinformationforinformedchoice • performscreeningorrecruiteforscreening • interprete results, dealappropriatelywithfindings • support a patient in surveillanceprograms

33. Prevention Imperativesforprimary care physicians • Promotehealthy life style • Communicateprevention and screening • Organizepractice in order to havetime and capacityforprevention and screening • Identifyhigh risk patients (CV, Ca) • Do not miss a symptomaticcancer/refer in time.

34. Global emerging challenges in general practice in Europe • Effectivestrategies on CV and cancerprevention • Chronicdisease management • Agingofpeople– integratedsocial-health care • - primary care preparedness • Quality and Patientsafety • International professional mobility – standardized curriculum. Sustainableattractivityofthediscipline. • Multiculturalmedicine

35. Praha 22-23.4.2016 49thEQuiP Assembly Meeting 2016  International conference on PATIENT SAFETY EQuiPisaninternational network ofexperts and peopleinteresting in quality and safetyimprovement in primay care. Itisoneofprincipal WONCA networks. Theconferencewill také place in a beautifulKaisersteinpalace in theold part of Prague. Conference Secretariat GUARANT International Na Pankráci 17 140 21 Prague 4 Czech Republic E-mail: equip2016@guarant.cz Webpage: www.equip2016.cz

37. GP yourney continues….. Thank you for your attention