CAIRN-INT.INFO : International Edition

■ Introduction

1In all countries in Europe, the underlying concern in the reform of primary care is the achievement of a better match between supply and demand with a view to rationalising, if not improving, access. The proportion of doctors in the community, their geographical distribution and the productivity of general practitioners, whose role as gatekeepers is being developed, constitute key criteria in determining supply regulation policies.

2On the one hand, improvements in the standards of living, the progress of technology in medicine, ageing and the growing expectations of the population vis-à-vis the health care system are all factors that contribute to the greater demand for health care; on the other, even with no change in the proportion of doctors in the community, the provision of care is likely to shrink under the influence of several factors upon the supply of general practitioners.

3This has to do with the new social expectations of young doctors and the growing number of women joining the profession. Empirical studies in some of the OECD countries show that women doctors generally prefer primary care specialities (or medical specialities), are less willing to work in rural areas, are willing to interrupt their activity temporarily or work part-time, work fewer hours overall and retire earlier. The ageing of the medical profession will mean a decrease in the supply of doctors from the baby-boom generation, because of large waves of retirements.

4Lastly, the working hours of general practitioners (following the European Directive of 1993 fixing a maximum working week of 48 hours) also closely depend on payment schemes that affect the productivity of medical services, in both quantitative and qualitative terms, as they have a direct impact on the allocation of working time to various care activities.

5The proportion of doctors in the community was largely driven in several countries by quota or numerus clausus policies instituted in the 1980s and 1990s under the pressure of policies designed to control health expenditure without regard for the growing demand for medical care. This quantitative manpower planning was not necessarily accompanied by any geographical control and has resulted in considerable regional inequalities in the provision of medical care in several European countries.

6Furthermore, general medicine has become less attractive to medical students, who turn to this specialisation as a last resort. This situation is changing gradually in some countries with the enhanced role of the general practitioner in the primary care system.

7Finally, substitution or complementarity opportunities between specialist care and GP care has obviously had an impact on the labour supply of the latter.

8This contribution aims to provide an overview of the current organisation of general practitioner provision in several European countries, i.e. Germany, Spain, France, Italy, the United Kingdom and Sweden, selected because of their diversity in terms of the degree of centralisation of their health systems and the modalities of access to care. The purpose of this comparison is to put the French health system into perspective, faced as it is with some important choices to preserve some of the established features of access to care. This survey is based on up-to-date, precise information specifically collected for this purpose from national experts on a jointly established data collection basis emphasising comparability.
Three main aspects of the organisation of the system giving access to primary care are considered in this paper: the geographical distribution of doctors, the rules governing access to health care and those governing payment of general practitioners. [1]

■ Proportion of doctors in the community and GP location factors

9Comparing health systems in terms of medical densities prompts a preliminary observation: it would be unwise to set a standard by which to point to the existence or not of a shortage or surplus of primary care provision. According to an OECD report (Hurst and Simoens 2006), the great diversity in medical densities is to be viewed not only in terms of the state of health of the population and the proportion of health expenditure in the GDP but also the very architecture of the health systems. The basic concern with ensuring that the number of doctors matches the demand for primary care in the near future seems largely shared by all these countries, which leads to various courses of action being taken to anticipate possible deficiencies.
Somewhat paradoxically, it appears on the basis of information collected for this study that the countries having the most doctors (especially general practitioners) view medical density as a serious or potentially serious problem, unlike those with a low proportion of doctors in the community. A more tightly focused analysis of methods of organisation for the supply of primary care – and particularly the schemes relating to access to care and the location of primary care providers – helps resolve this apparent contradiction.

Table 1. Demographic characteristics of general practitioners (GPs)

tableau im1
Country Proportion of GPs per 100,000 inhabitants (inter-regional variation) Proportion of GPs in total medical population Proportion of women GPs Francea 172 (141 to 203) 51% 39% Germanyb 135 (106 to 199) 37% 33% Italyc 91 (88 to 109) 29% ng Spaind 74 (56 to 108) 23% ng (not given) Swedene 54 (42 to 63) 16% 39.2% United Kingdomf 72 (Scotland) and 56 (England) 31.8% ng Sources a: data from 2005, CNOM (2006). b: data from 2003, BÄK statistics. c: data from 2001, Ministero della Salute. d: data from 2003, Consejo Interterritorial del Sistema Nacional de Salud. e: data from 2003, Socialstyrelsen. f: data from 2003, National Unit Costs.

Table 1. Demographic characteristics of general practitioners (GPs)

High proportions of doctors but marked regional inequalities in Germany and France

10Although Germany and France display relatively high medical densities, the prospect of inadequate provision of medical care arouses great concern and is the subject of many demographic projections. The freedom of establishment prevailing in these countries (with varying degrees of restriction) results in considerable patient inequality in access to general practitioner care: some regions are characterised by a very large supply of general practitioners while others (often more rural and remote) are faced with severe deficiencies.

11In Germany, while the density of general practitioners still seems adequate, there are considerable disparities between the old and new Länder, particularly between the Land of Hamburg (199) and that of Brandeburg (106). This situation results from the freedom enjoyed by doctors until recently to set up practice freely: thus, some cities, such as Berlin, have attracted young doctors. Consequently, the retirement of the baby-boomers and the subsequent closure of some private practices is a matter of concern. However, the number of medical students is not regulated by the public authorities but depends on the number of places made available by the faculties of medicine. While geographic manpower planning was only indicative until 1993, restrictions have been applied in West Germany in the main urban centres and other areas with high medical densities. The number of doctors is generally considered insufficient overall in a geographic area if it is below 75% of the national average and in excess if it is higher than 110% (in which case doctors theoretically no longer have the right to set up practice establishment in the area). However, for public authorities there is no consensus on the thresholds defining under or excess supply. These thresholds are sometimes considered to be arbitrary since they take no account of such factors as age, gender, overall morbidity or the socio-economic status of the population or even the number of hospital beds. De facto, the various modes of medical density regulation lead to a relative disparity in the measures adopted between the different Länder. However, in 2003, 137 geographical areas out of 406 were declared closed to young general practitioners.

12In France, doctors are still free to set up practice once they have completed their medical studies, which last nine years for the students having opted for the DES (diploma of specialised studies) in general medicine. Admission to the second year is subject to a numerus clausus. [2] At the end of six years of general training students take a competitive, nationwide examination and the choice of specialities is awarded on the strength of individual
ranking. Young doctors usually refuse to set up practice in rural areas, a situation that may eventually lead – according to the most pessimistic forecasts – to the emergence of “medical deserts”. Projections to the period 2010 – 2015 indeed suggest that there will be shortages of doctors. As a result, recent measures tend to raise the numerus clausus without, however, placing any restriction on the freedom to set up practice.

Low medical densities and vacant posts in the United Kingdom and Sweden

13In countries where the right to set up a new practice is subject to vacancies offered by the regional authorities, and where some under-supplied areas are regularly faced with vacant posts, the number of doctors appears globally inadequate. To alleviate these shortages, the bodies in charge of regional medical planning are attempting to identify the factors likely to influence a doctor’s choice of location (living conditions, proximity of universities, income, equipment, partnerships, workload, place of origin).

14In Sweden, the central authorities consider a ratio of 50 general practitioners per 100,000 inhabitants as an absolute minimum, implying an inadequate provision of primary care for five out of the 21 counties. These inequalities have nonetheless been reduced over the last few years under health policies run by the regions, but the projections still point to there being severe shortages in the near future. At present, student quotas are controlled by central government. Medical training over the first five years is carried out in one of the six medical faculties and is subsequently carried in one of the counties on the basis of training places declared vacant for new graduates. Note that some of the medical faculties are located in rural areas and consequently offer students more rural-health-oriented courses. The student continues with his or her general training for 18 months, at the end of which, after examination, he obtains the right to practise. A specialist certificate – which can be in family medicine – is obtained after additional training. This speciality is often selected by women because of the quality of life it can offer (more part-time work).

15In the United Kingdom, GP care is expected to suffer shortages from 2009 and is already considered today to be inadequate. Vacancies for primary care doctors are still relatively high in the remote Scottish islands but also in England (about 3% of posts), especially in rural areas. The numerus clausus setting the number of medical students has increased substantially over the last few years. Following their training, general practitioners are free to apply for any post vacant in a practice, with the health authorities responsible for the provision of care in a geographical area and for strictly regulating the location of new practices. Yet the present low medical densities have to be assessed with due consideration for the considerable number of practice and district nurses to whom part of the care is delegated.

Average medical densities with a fairly homogeneous distribution in Spain and Italy

16Spain and Italy differ from the other countries in the homogeneous distribution of doctors, at least between regions. This low variability is essentially due to the method of selection and assignment of general practitioners: the location depends on the student’s ranking in general medicine. While imposing restrictions on the freedom to set up practice seems effective in terms of regulating patient access to care, it also generates obstacles to subsequent doctor mobility.

17In Spain, the central authorities consider that there should be at least 67 general practitioners per 100,000 inhabitants, with an optimal number of 83 (greater than the current medical density). The quota of doctors trained is determined by the central authorities. Once their training is over, the new doctors are employed under temporary contract working as locums (replacement doctors) and it is only after several years of experience that they are able to apply for a post in the public service, provided they pass the national examination. Doctors often work in both the public and private sectors. Those who forgo the private sector ( “exclusive-contract”), which is the most common case, receive a monthly allowance. It is generally considered that accessibility to care in the rural areas has considerably improved thanks to the creation of multi-disciplinary care teams, with the traditional image of the country doctor evolving into that of “care provider”. Moreover, the recognition of family medicine as a speciality has undeniably improved the prestige of the profession. Provision of care thus appears satisfactory overall, even though there is some variability in resources between the country’s autonomous regions. The location of Spanish GPs (who have a civil servant status) is dependent on their results in the regional examinations; consequently posts in rural areas rarely remain vacant because of the large number of young doctors. Mobility during their career is, however, more restricted.

18In Italy, the public authorities have fixed the minimum proportion of doctors at 67 general practitioners per 100,000 inhabitants. The geographical distribution of general practitioners appears homogeneous between regions and satisfactory. The provision of care by GPs is backed up by “emergency-care doctors” at a proportion of 27 per 100,000 inhabitants. The “emergency-care doctors” and aid centres are not distributed equally between regions but depend greatly on geographical conditions, the location of hospitals and seasonal patient flows (the concentration is therefore high in the southern and island regions). [3] General practitioners are not free to choose where to set up their practice but have to follow the geographical distribution defined by the “national contract”: vacant posts are published every six months by the regions, with assignments determined by the ranking achieved on the regional lists after a competitive examination. Once assigned to a locality, a doctor has the possibility of practising in several places within the district.

Geographical regulation of general practitioners: financial and non-financial incentives

19In Spain and Italy, it is the decentralised system itself that determines the geographical regulation of doctors. In Germany, France, the United Kingdom and Sweden, the local regulatory authorities use a series of measures, both financial and non-financial, to induce GPs to set up practice in the deficient areas (see Table 2).

Table 2

Financial and non-financial measures designed to induce general practitioners to set up practice in underserved areas

Table 2
Country Financial incentives Non-financial incentives France • payment per procedure +20% for each procedure if group practice; • payment of locums +20% for each procedure. • tax exemptions on income from on-call duty; • possibility of combining pension and self-employed income for doctors over 65 (excused on-call duty); • study and accommodation allowances for trainee doctors. • transport facilities available from patient to GP’s surgery; • professional premises or accommodation made available. Germany • income levels guaranteed for private practices; • financial loans and consultancy services available for the setting up of a new private practice; • premiums for the improvement of access to care; • exemption from regulatory schemes for doctors in activity over the age of 55. • authorisation to leave the system and establish a second practice; • specific approvals; • right to employ an assistant; • KBVa equipment made available; • special authorisations for hospital doctors and doctors of foreign origin; • mobile medical equipment made available. Sweden • higher wages; • remuneration according to arrangements other than wage-earning (capitation + payment by procedure). • free time for research or doctoral studies; • possibilities for hospital doctors wishing to retrain as GPs; • aids for enhancing working conditions. United Kingdom • bonus study and accommodation allowances for trainee doctorson arrival (“golden hellos”) (from 7,000 to 10,000 euros); • high flat rates for on-call duty. • career and professional training opportunities (counselling services available); • facilities for promoting professional quality of life; • facilities for promoting work flexibility (mainly for working hours); • provision of equipment or financial aid for purchase of paediatric facilities; • provision of accommodation; • aid with finding employment for spouse.

Financial and non-financial measures designed to induce general practitioners to set up practice in underserved areas

20In addition to these measures, short-term policies aim to attract foreign doctors, with a view to consolidating the profession, increasing flexibility and even reducing costs; in the UK, for instance, foreign doctors account for more than 20% of the care provided. At the same time, these policies aim to reduce the departure of primary care doctors by improving flexibility of working time, professional mobility and professional courses and training, while also seeking to delay retirement and promote the return to practice of doctors already in retirement.

■ Rules of access to general practitioner care

21Apart from the proportion of doctors in the community, the activity levels of GPs depend on the way their role links up with the activity of the specialists, in other words the rules of access to care in every health system. In Germany, France and Sweden, the single family doctor principle is quite well established (although only recently in France) but is not always adhered to (the only sanction being the amount charged to the patient). Elsewhere, in Spain, Italy and the UK, the “gatekeeper” principle operates, a limitation offset by the very low charge for care. [4]

22Furthermore, general practitioners may operate individually or within a group practice, and although there is a gradual move towards group practice, medical activity in Germany and France is still dominated by an individual approach: solo medical practice still accounts for 75% and 56% respectively. [5] Conversely, in the other countries, medical practice is more radically oriented towards integrated organisational models, whether on a monodisciplinary or multidisciplinary basis, largely driven by recent primary care reforms. Primary care centres bring together general practitioners and paramedics in small geographical areas (Spain, Italy, Sweden), but there is a trend for groups of general practitioners (co-operatives in the UK) to integrate with secondary care providers, thus constituting multidisciplinary teams.
The various measures taken recently (particularly as part of the harmonisation of working conditions in the European Union) have sought to upgrade the role of the GP in the six countries considered in this study, by recognising the profession as a medical specialty and also by reducing the income differential between specialists and GPs. GPs’ role of ensuring the continuity of care is being strengthened, as they acquire new or increased responsibility as the regular contact for primary care. There are, however, relatively large variations in the proportion of GPs among doctors as a whole (see Table 1), this proportion having reduced overall during the last decade.

Freedom of access and partially substitutable medical services in Germany, France and Sweden

23The German, French and, to a lesser degree, Swedish systems are characterised by a potentially competitive offer of medical care, as patients are free (more or less, as indicated above) to consult either a general practitioner or a specialist. [6]

24In Germany and France, the boundaries between primary and secondary medical care are still very vague despite recent schemes designed to encourage patients to make prior contact with their regular general practitioners. Specialist care is accessible in the outpatient sector, usually at private practices.

25In Germany, in the absence of a real “gatekeeper” system, patients are free to choose a doctor affiliated to the state health system; however, they are required to remain with the same family doctor for a period of three months of reimbursement. In this context, patients often choose to seek specialist care directly in the outpatient sector. Issues surrounding the introduction of a “gatekeeper” since the 1993 reform (which had provided for experiments to be carried out) met with a strong resistance. However, the 2004 reform has the health insurer develop the family doctor model with an incentive policy: in the Land of Saxony-Anhalt, for example, patients having entered into a health insurance contract only pay half for a house call and have their waiting time for surgery attendance reduced, the same procedures applying to consulting a specialist).

26In France, the “family doctor” scheme was instituted by the 2004 reform, which lay down the obligation for every patient over 16 years of age wishing to obtain fuller refund from his or her mandatory health insurance to choose a doctor (general practitioner or specialist) who will coordinate his or her access to secondary care. If patients do not join the scheme, any access to a doctor will imply a higher charge for the patient. [7]
In Sweden, the distinction between care from “family medicine specialists” at primary care centres and that from specialists practising exclusively in hospital is clearer. However, GPs may practice in private surgeries while being linked annually to the state system for a maximum number of house calls fixed by the county: this concerns a minority of doctors mostly working in one of the three major Swedish cities. As any patient is free to make an appointment with GPs or specialists, access to care does not necessarily follow prescribed routes, although the public authorities have instituted higher patient charges in the case of direct access to specialists. Although the choice of a regular GP is laid down by law nationwide since 1994, few counties fully implement this provision. The share of the population having a regular family doctor thus varies from 41% in the county of Jämtland to 79% in Västmanland, so the Swedish system is hybrid, reconciling a distinction of care (primary and secondary) with freedom of direct access to both types.

Complementary medical care and integrated services in Spain, Italy and the United Kingdom

27In the Spanish, Italian and UK systems, the general practitioner represents the only entry point for patients to non-emergency care and, as gatekeeper to the care system, he or she refers them, when necessary, to secondary care. In this context, general practitioners generally work in teams (in which one or more medical specialities may be represented), usually in primary care centres or group practices. Primary care teams generally comprise a general practitioner, a paediatrician, a nurse, a social worker, and perhaps other paramedical staff specially trained in coordinating tasks in group work. Access to care is free but occasionally a charge is made to limit direct unauthorised use of hospital services, often considered as a way of avoiding waiting lists.

28In Spain, the family doctor model has prevailed for the last 20 years: this central role given to the general practitioner leads to a gatekeeper system in which the GP (also “family medicine specialist”) handles all primary care treatments. The GP also takes part in a multidisciplinary primary care team [8] in which the field of competence of each member is precisely defined.

29In Italy, despite participating in primary care teams, GPs and paediatricians are independent contractors with their own practices. The premises provided by the local authorities cover the activities of other primary care professionals and doctors in charge of emergency care. Since 1996, doctors involved in primary care (GPs, paediatricians and emergency care doctors) may set up horizontal, monodisciplinary (and, since 2000, multidisciplinary [9]) partnerships.
In the United Kingdom, general practitioners operate as independent contractors vis-à-vis the health authorities. Practices are increasingly concentrated in health centres and are generally composed of three GPs (solo practices are strongly discouraged). Continuity of care, which is the cornerstone of the traditional model of general medicine, is ensured by patient records being kept in the group practice (doctors can have access to a patient’s case-history at any time). This organisation of care is developing gradually into a highly integrated care service in primary care centres open 24 hours a day in urban areas.

■ Rules of payment for general practitioners

30Remuneration methods for general practitioners are highly diversified and tend to be hybrid in nature, which limits the comparability of income between countries and requires caution when interpreting the results.

31In economic terms, hybrid rules of payment are designed to reach optimal trade-off between incentives to reduce treatment costs (provided by salary or capitation) and incentives to improve the quality of care and to treat a sufficient number of patients (fee-for-service). [10]
Payment methods such as capitation, salary and fee-for-service can thus be combined. Other monetary transfers are sometimes introduced to promote performance in terms of quality of care or reduction of costs (individual and/or group) among GPs. The variability of average incomes between countries (even between regions in the same country) is substantial (generally high in the United Kingdom, Germany and France, relatively low in Sweden, Spain and Italy) and only partially reflects the expected GPs working hours.

Mixed payment, with salary as main component: Sweden and Spain

32It is in Sweden and Spain that salary is the predominant form of payment for general practitioners, associated with relatively short working hours compared with the other countries, together with lower income levels.

33In Spain, the majority of general practitioners is employed by the public sector, which increases social recognition in the country. General practitioners’ remuneration takes the form of a monthly wage with an additional pay-for-performance component (about 10% of total income) for a working week ranging from 37.30 to 40 hours. The choice of family doctor is free and the number of patients per doctor is limited to 1,500.

34Wage levels depend on experience and family expenses or the rural/urban location of the doctor (in rural areas, for example, an additional allowance (called “dispersion superior”) is paid for and lists are shorter). Teaching and research activity also give entitlement to an additional payment (as well as increasing geographical mobility). There are three distinct contracts: two civil service contracts, one with emergency duties and without exclusive commitment, the other with exclusive commitment and 50 hours’ emergency duty per month – including 12 hours at weekends – and a temporary contract with exclusive commitment to the public sector, 50 hours’ emergency duty per month including 12 hours at weekends. Income differentials between GPs and specialists are relatively low. It should be noted that all specialists have the same income level throughout their region: for example, a civil service GP with an exclusive contract and 21 years seniority has a net average monthly wage of the order of 3,600 euros while a specialist with a similar contract receives 3,900 euros. [11] On the other hand, variability of income levels between regions is still very high, but this should be phased out by the end of the harmonisation process currently under way. Payment by performance (that only two regions have not yet introduced) is generally attributed individually, sometimes collectively. Supplementary payments or benefits in kind may be obtained for professionals taking part in a primary care team on the basis of objectives related to care quality achieved.
In Sweden, the majority of doctors are employed by the public sector on a salary basis, after applying for one of the vacant posts. GPs work in primary care centres and specialists in hospitals. Private GPs work in individual or group practices, generally in one of the three main cities, and their remuneration is a combination of capitation and fee-for-service. Reimbursement for care provided by private doctors [12] depends on the provisions of the contracts between these doctors and the county, if the latter deems their presence necessary to meet local demand. The net average monthly income of a GP amounts to 3,282 euros, that of a specialist 3,370 euros, and that of a head of department 3,930 euros for a working week of 40 hours. [13]

Mixed payment, with capitation as main component: Italy and the United Kingdom

35While in both these countries capitation still constitutes GPs’ main source of income, it is trending downwards in proportion to other kinds of monetary transfers based on activity indicators (procedures) or quality of care (performance indicators). This results in some variability in income levels. In Italy, general practitioners are remunerated on the basis of a capitation fee of about 50 euros per patient per year, yielding a net monthly average income based on capitation of 3,000 euros (likely to double under the impact of the other financial incentives). [14] The various sources of income are capitation (70% of income on average) – the patient list depending on the doctor’s experience and the demographic characteristics of the patients – subsidies for investments (10 to 15%) for medical integration, staff employed, equipment, remuneration by performance (about 10%) in terms of meeting regional programme criteria or adopting cost control measures, fee-for-service for vaccinations, house calls, minor surgery and issuing certificates. General practitioners must work at least 20 hours per week and cover home care from 8 a.m. to 8 p.m. from Monday to Friday (i.e. 38 hours per week on average).
In the United Kingdom, remuneration of general practitioners by the National Health Service – although GPs are considered as independent contractors – is somewhat similar to the Italian system and combines four sources of income: capitation payments accounting for more than 50% of gross income, subsidies for medical expenditure and operating expenses, remuneration based on performance indicators (relating to promoting good health, managing chronic illnesses, vaccination and screening) and feefor-service for certain medical services likely to increase a GP’s workload (such as contraception). The income accordingly depends on four types of variables, prices being negotiated at central level. The net average income per GP is of the order of 8,300 euros monthly for a 46.5-hour [15] working week. The General Medical Service contract, introduced in 2003, sets out a commitment to quality that translates into remuneration for GPs who have met certain quality standards, encouraging the collection of data to ensure, in particular, satisfactory medical management of chronic illnesses. The Quality and Outcomes Framework (QOF) is the central feature of this contract. The QOF recently introduced a major change regarding the way chronic illnesses are henceforth to be managed in general practice. In particular, this agreement provides financial bonuses (in quality points) to practices providing high quality care for chronic illnesses in accordance with best clinical practice standards. The achievement of these objectives represents a substantial increase in income for the practices that have signed the contract. Performance is assessed not only on the basis of clinical indicators (including secondary prevention indicators in coronary diseases, cardiac or ischaemic attacks, hypertension, diabetes, pulmonary diseases, epilepsy, hyperthyroidism, cancer, mental health and asthma) but also organisational indicators (patient records and information management, professional teaching and training, practice management, medication management, as well as a range of indicators based on the patient’s experience and on the provision of additional services).

Mixed payment, with fee-for-service as main component: Germany and France

36In Germany and France, doctors working in hospitals are generally remunerated on a salary basis (except for private clinics in France where feefor-service remuneration applies). Self-employed doctors are paid on a fee-for-service basis, but the rules vary considerably between the two countries. Levels of remuneration for specialists are fairly similar.

37In Germany, doctors are paid on a fee for service basis within an overall envelope of pre-determined expenses. Social insurance funds directly set a remuneration envelope for regional doctors’ associations linked to the state system, which is intended to cover the entire activity of GPs and specialists. The envelope is generally set on the basis of capitation per person insured. This allocation is determined on a quarterly basis and is redistributed to the doctors according to a uniform scale of values, with each type of medical procedure rated in terms of points. At the end of the quarter, the remuneration for each doctor is established in relation to the points his or her activity has yielded. It is supplemented by monetary transfers from private complementary insurance companies and direct payments by patients. Income levels for doctors are fairly high as they are generally estimated at three times what a “white collar” worker earns. For a GP they amount to 5,800 euros average net monthly for an average working week of 48 hours. [16]

38In France, fee-for-service applies according to a nomenclature assigning a key letter and a technical weight to each procedure. A unit price is attached to each key letter and the price of the procedure depends on its degree of technicality. Attempts to regulate medical expenditure that were initiated in the 1990s did not come to fruition; new approaches are currently being considered. Levels of remuneration are relatively heterogeneous between specialities, with GPs doing less well than specialists, [17] whose income level is of the order of 5,300 euros net monthly with a longer working week (bordering on 50 hours a week, excluding emergency calls) (Niel and Vilain 2001; Legendre 2006).
The provision of medical care depends primarily on the length of the working week, which is itself largely determined by the choice of payment scheme. Our comparison shows that the countries where social insurance prevails (as is the case in Germany and France) are characterised overall by longer working hours than the countries with national health systems.

■ Conclusion

39In Europe, the current reforms are gradually moving health care systems towards a more vertical organisation of care, in which general practitioners are (in principle) the patients’ first contact. The identification of a regular primary care doctor forms part of an approach to generally establishing care channels whose principles are based on a more formal arrangement between primary care providers [18] and secondary care providers – specialists and other care services.

40Issues related to the impact of medical density on medical practice, the relationship between primary care doctors and other health care professionals, payment schemes and non-financial incentives are central to recent research in health economics.

41In Europe, recent policies aimed at controlling health expenditure attempt to better coordinate care. [19] This move is all the more necessary in that the activities of other care providers (providers of secondary and ancillary services and suppliers of medical goods) are generally subject to medical recommendations and are thus influenced by the way the medical profession is managed. Apart from financial constraints, current developments in the doctor’s role following these reforms are closely tied to the characteristics of supply and demand for care: the main trends observed in medical densities are likely to reduce supply while epidemiological risk is on the increase owing to the development of chronic diseases stemming from the ageing of the population.
In this context, in all the countries surveyed, the changes in the GP’s role operate at different levels:


  • in the setting of medical density targets so as to reduce both avoidable mortality and waiting lists without encouraging an increase in the number of procedures;
  • in the enhancement of GPs’ role through better coordination of their services in relation to those of specialists and other health care professionals;
  • in the search for the “fairest” method of compensating both the skill of and level of effort put in by doctors (including payment as well as other non-financial incentives) in order to encourage them to make efficient choices at several levels: both in terms of making compromises between work and leisure, but also with regard to quality of care and reduction of cost of treatment and prescriptions, as well as activities devoted to prevention and cure.
Even though the countries are tending towards a hybrid approach to remuneration, notable differences remain because of the very architecture of health systems and the place of the general practitioners among health care professionals.
A survey of the conditions in which the GP operates, beyond remuneration, highlights the importance of the environment in which he or she practises on a day-to-day basis. This survey brings into focus the central role of the general practitioner. To fully assess the importance of medical density issues, consideration must be given to the impact of new forms of care organisation. These feature differing degrees of integration and are characterised by the innovative ways in which health care professionals increasingly interact and, in addition, the growing use of new technologies of information and communication to guide patients in their search for care.


  • [*]
    Laurence Hartmann: Lecturer at the University of Lille II, Regional Epidemiology Service (Faculty of Medicine), and Institute of Public Economics (IDEP) (France).
    Philippe Ulmann: Lecturer at the Conservatoire National des Arts et Métiers – chair of Economics and Management of Health Services – (France).
    Lise Rochaix: Professor at the University of Aix-Marseille II, member of the Executive Board of the High Health Authority (Haute Autorité de Santé), Chair of the Health Strategy Evaluation Committee (CE2S) (France).
  • [1]
    This contribution derives from a study carried out for the social security division of the French ministry of health, the main features of which appear in a companion article entitled “GPs and access to out-of-hours services in six European countries” in the present publication. The references appearing in the report by Ulmann et al. (2005) are not reproduced here owing to lack of space.
  • [2]
    This numerus clausus is currently set at 7,000 students, whereas it was down to 3,500 in 1993, its lowest ever.
  • [3]
    Thus the average density of emergency-care doctors varies from 12.4 (3.15 aid points; Piedmont) to 60.4 (16.88; Calabria).
  • [4]
    It should be recalled that under the “gate-keeper” system, those insured are required to consult their family doctor or primary care doctor in the first instance (except in emergency, naturally). The family doctor decides on the follow-up treatment with the patient.
  • [5]
    See particularly for France what has been done by the DREES, (Audric 2004). For selfemployed GPs, group practice covers 39% of them, which still does not mean that their activity is coordinated.
  • [6]
    Most of the time, consultations require a prior appointment and the waiting time on average is several days.
  • [7]
    The patient’s charge, it should be recalled, is the amount to be paid by the insured person or his or her complementary insurer, as the case may be. Patients may freely consult a paediatrician, an opthalmologist, a gynaecologist and a psychiatrist without following the prescribed consultation route.
  • [8]
    Equipo de atencion primaria (EAP).
  • [9]
    These forms of association may take the shape of a partnership practice (three to eight GPs sharing the same clinical and diagnostic protocols), a network practice (a partnership with shared information to ensure better continuity of care) or a group practice (three to eight GPs sharing resources).
  • [10]
    The economic rationale underlying these hybrid forms of remuneration is analysed in Rochaix (2004).
  • [11]
    Data 2004, Medical Council of Grenada. Data OECD (2006): not available.
  • [12]
    Representing only a marginal proportion of medical care provision, approval for which is issued periodically by each county board based on regional policy.
  • [13]
    Data 2003: Socialstyrelsen. Data OECD (2006): 62,468 USD in 2002, gross annual income of a wage-earning GP.
  • [14]
    Data 2003: Ministerio della salute. Data OECD (2006): not available.
  • [15]
    Data for 2003: National Unit Costs, 2005. Data OECD (2006): 100,998 USD in 2002 in gross income. It is to be noted that GP income has increased very substantially over the last three years, hence this differential.
  • [16]
    Data from 2000: KBV 2002; data from OECD (2006): 86,719 USD annual in 1999 (average gross income).
  • [17]
    Along with paediatricians, dermatologists and psychiatrists.
  • [18]
    Thus, in most cases GPs play the role of gatekeepers, but not exclusively, because in Europe certain specialists or other health professionals may play this role.
  • [19]
    The Beveridge approach to organising medical care implies a more or less clear split between primary and secondary services and care.


In all countries in Europe, the underlying concern in the reform of primary care is the achievement of a better match between supply and demand with a view to rationalising, if not improving, access. The proportion of doctors in the community, their geographical distribution and the productivity of general practitioners, whose role as gatekeepers is being developed, constitute key criteria in determining supply regulation policies.
This article provides an overview of the current organisation of health care provision by general practitioners in several European countries, i.e. Germany, Spain, France, Italy, the United Kingdom and Sweden. Three main aspects of the system giving access to primary care are considered: the geographical distribution of doctors, the rules governing access to health care and those governing payment of general practitioners.


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Laurence Hartmann
Philippe Ulmann
Lise Rochaix [*]
  • [*]
    Laurence Hartmann: Lecturer at the University of Lille II, Regional Epidemiology Service (Faculty of Medicine), and Institute of Public Economics (IDEP) (France).
    Philippe Ulmann: Lecturer at the Conservatoire National des Arts et Métiers – chair of Economics and Management of Health Services – (France).
    Lise Rochaix: Professor at the University of Aix-Marseille II, member of the Executive Board of the High Health Authority (Haute Autorité de Santé), Chair of the Health Strategy Evaluation Committee (CE2S) (France).
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