Within two years after the audit report of the State Audit Office on the effectiveness of outpatient health care was made public, one has not managed to implement any recommendation to make the role of general practitioners (GP) in health care much more compliant with the best interests of the patient and improve GP availability.
The State Audit Office made recommendations to promote timely diagnosis and prevention of diseases, to provide patients with all services that fall within the professional competence of general practitioners, and to reduce referrals to specialists when the general practitioner can provide primary care. The Ministry of Health must continue the work commenced in the sector and monitoring the impact of the changes made strictly, and look for new solutions to build a result-oriented healthcare system if necessary. Therefore, the State Audit Office postpones the timeframe for implementation of audit recommendations until September 1.
“The methodology that the Ministry of Health introduced to assess the quality of GPs’ performance is ineffective and does not achieve its goal of promoting better patient care. The results of a survey of GPs conducted by the National Health Service evidence that as well. Although the Ministry of Health, as the leading authority in the sector, is responsible for this situation, it will be difficult to expect any improvement without involvement of GPs in the processes and their constructive support. Positive changes are possible only through the cooperation of all the stakeholders,” emphasised Auditor General Elita Krūmiņa.
More money, fewer requirements
Since 2018, the Ministry of Health has raised the capitation fee for GPs (state budget payment per person registered in GP’s practice per month) by 63%, has increased the annual performance appraisal fee by 56%, and manipulation fees payable to GPs. However, the State Audit Office considers there is no reason to believe that access to health care has significantly improved.
In 2017, the Ministry of Health made changes to the GP’s annual performance appraisal system by reducing the number of quality criteria (from 13 to 8) significantly and excluding significant patient care indicators such as cancer screening supervision, cardiovascular risk assessment, and health assessment. Thus, quality assessment criteria became “financially more valuable”, GPs are rewarded more generously, and the requirements set to GPs are lowered. While the fees for GPs’ annual performance appraisal were nearly 700,000 euros for 13 quality criteria in 2015, then general practitioners were paid almost 2 million euros or 171% more than before with the number of quality criteria decreased by a third (to 8) in 2018. At the same time, the results of 2018 clearly showed that the new system did not provide sufficient motivation for general practitioners, as only 4% of general practitioners fulfilled all eight quality assessment criteria and 60% of them met less than half of all criteria.
Surveys of GPs also show that 36% of GPs still find the system difficult to understand or are unfamiliar with it, with 32% of general practitioners focusing on patient target groups only when there is less influx of other patients, and there is time left for that, whereas 18% do this work occasionally.
The newly introduced measures do not provide the expected result yet
When abandoning several significant quality criteria for the performance of general practitioners, one has not introduced any new measures or the offered solutions are more expensive, but no significant improvements were made. For example, the excluded criterion of Mammography and Cervical Cancer Screening has been replaced by a pilot project where the GP is eligible for an additional payment (500 euros per quarter) if the screening response rate of patients enrolled in practice is 50% for cervical cancer screening and 60% for breast cancer screening. However, 46% of the 424 GPs who participated in the pilot project failed to pass either of the two screening rates. According to the National Health Service, overall cancer screening response rates are also improving insignificantly.
Instead of the excluded quality criterion of Cardiovascular Risk Assessment, one has established a cardiovascular disease prevention program to motivate GPs to pay particular attention to the prevention and early diagnosis of those diseases and to relieve the work of higher-level health care providers by envisaging appropriate pay. Nevertheless, the prevention and early diagnosis of cardiovascular diseases at primary healthcare level have not been implemented as planned because patient coverage is 18% (Stage 1 – in primary healthcare practice) and 3% (Stage 2 – further examinations) of the planned coverage.
Exclusion of the criterion of The Number of Calls of the Emergency Medical Service When Patients Are Not Transported to a Hospital does not provide for other mechanisms to reduce the number of secondary emergency calls and to increase the activity of general practitioners to promote rational use of the state budget funds available for healthcare. One has still not found effective tools to reduce the number of referrals by GPs to secondary outpatient healthcare professionals. The number of referrals tends to increase. Year after year, the number of referrals per 1000 registered patients exceeds 2000.
The State Audit Office draws attention to the fact that the number of general practitioners is still decreasing in the country. Hence, the number of patients in the practices of general practitioners is well above the optimum ceiling of 1,500 patients planned by the Ministry of Health and exceeds 1,800 patients. There is not always a second nurse or doctor’s assistant in big practices of general practitioners.