The Changing Role of the General Practitioners in the Review of the Population’s Requirements

1. The Changing Role of the General Practitioners in the Review of the Population’s Requirements Brigitta Gyebnár Dóra Tonté

2. Act CLIV of 1997 on Health • The practical changes concerning the healthcare system started with the development of the system of GPs. According to the Act CLIV of 1997 on HealthSection 88 - Primary Health Care: • All patients shall be assured continuous long-term healthcare based on a freely chosenpersonal relationship, in or near their places of residence, irrespective of gender, age or thenature of their illness. The objective of the primary health care set forth in Subsection (1) is a) to provide the preventive services to the public served, as set forth under Section 79; b) with respect to the individual patient: ba) to monitor his state of health, and to provide health information and education, bb) to treat, care for, and provide rehabilitation for him, within the framework ofcompetencies set forth under separate statute, with a given diagnostic and therapeutic backup, bc) to refer him to specialists for diagnosis of an illness, preparation of a treatmentplan, or therapy, bd) to treat him, and to provide home nursing and rehabilitation on the basis of atreatment plan recommended by the attending physician; c) when necessary, to provide the services as in Sub-Paragraphs bb) and bd) within thepatient’s home, and to call for a specialist consultation to be held in the patients home.

3. The Role of the General Practitioners (GPs) - 2006 The professional protocol about the general practice’s competence list is defined by the College of General Practice. The list appraises the professional requirement system of the GPs basic activities: „The primary, secondary, tertiary prevention levels are altogether belong to the basic activities of the family doctors.”

4. Aim: • Howthe role of the General Practitioners has beenchangedin the review of the population’srequirementsduringthelastdecade? Fromtwoaspects of preventivemedicine: • Tertiaryprevention – self-helporganisations; ILCO a, The Patient’s Organizations and General Practitioners - 1997 Participants: The target population consisted of296 754peoplefrom75 settlementsfrom Békés county,who registered at the participating187 general practitioners. Method:A questionnaire based health surveyfromthe 187 GPs. • Primaryprevention– cervicalcancerprevention b, Behaviour of the female population regarding cervical cancer prevention –Epidemiological study in 11 counties in Hungary - 2008 Participants:The target population consisted of 59 730 women aged 25-65 years, registered at the participating 96 general practitioners. 1306 women were selected from the target population by age stratified random sampling. Additionally, 2000 people were randomly selected from Zala county practices, who participated not only in the survey but also in a model program about the involvement of general practitioners in the communication of the screening program. Thus the planned size of the study population was 3306. Methods:A questionnaire based health survey on a representative sample of 25-65 years old women in 11 counties. Source: Robert B. Wallace

5. Aspect I.:The Patient's Organizations and General Practitioners - 1997 • Observations: - Due to the difficult economical conditions the patients became secondary characters instead of being in the center of the healthcare system. - The relationship between the GPs and their patients is good in general, but superficial. It can be observed that clients from the countryside are treated better. - While diagnosing and treating the organic complaints, the nursing of mental and social problems did hardly get any kind of attention. - The patients’ rehabilitation is an important task of the GPs, so in theory the GPs should keep in touch with all self-help organizations. Unfortunately this is not the way how it works in reality. Patients do not know about these organizations and cannot turn to anyone for help.

7. Results: - To the question, whether a GP knows the ILCO club and its operation or not, 67% of the doctors answered yes, while 33% said no. Because of the lack of information the GPs do not rehabilitate the patients in an appropriate way, as 1/3 of them are not provided with information about the club and its existence. The nurse herself who goes after the patient and avoiding the doctors, she takes the patient to the club. - Among the GPs, not many of them know about the existence of the ILCO club and only 18% of them know stoma-therapy nurses. Most of the clients rather choose long journeys, because they think they are better treated in the club than by their GPs. - In 1997 there were44 self-help groups operating in the country, which could be additional to the GPs works, but to achieve that, the flow of information and cooperation would be necessary on behalf of the rehabilitation.

8. Aspect II.: Behaviour of the female population regarding cervical cancer prevention – Epidemiological study in 11 counties in Hungary* - 2008 We used logistic regression analysis to study the association between factors of socioeconomic and lifestyle and participation in the screening program. • Observation: - In Hungary the organised national cancer screening program could hardly involve those women into the cervical screening programme who otherwise would not regularly visit their gynaecologists. - Development of the cervical cancer prevention program is needed in Hungary to reduce the avoidable death due to cervical cancer, with the help of the GPs. * Contribution within the framework of GPMSSP- Medical University of Debrecen; Dr Zoltán Vokó

9. The distribution of questionnaires according to age-group, counties, and cervical cancer mortality in 2006 Év=year Total number of questionnaires Recieved questionnaries Sent out questionnaires Has’nt been involved

10. Results: • 74 % of the target population had a screening examination within 3 years, mostly outside the organised screening program. • An organized screening program can mobilize just a small part (26%) of those women who have never visited a gynaecologist before. • Only 15 % of women, who received an invitation letter but had never had any gynaecological examination before took part in the organised screening program. Participation rate significantly (p<0.05) decreased by age above 44 years, retirement, low income, living in small settlements and heavy smoking. • Within the target population the 61 % of the women as much often, while 26 % of the women more often visit her own GP to check her state of health, then with a specialist (gynaecologist). • The 66 % of the target population women would like to vaccinate herself (primary prevention) by her own GP.

11. Consultation + Invitation + Impact = ↑ effectiveness • The poorscreeningparticipationratescontributetothelowhealth-literacy of theHungarianpopulation: therole and importance of broadscreeninglayersarenotrealized. • The local solutionscould be more effectivetoreachthepopulation – suchas a centralizedscreeningprogrammewiththeusage of local communicationchanelslike-GPs, nurses, schooldoctors and nurses, civil organisations, church, local goverment. • Regionalinequaliescan be observedduetotheavailability and organizationalderogations. • The practiceshowsthatthemedicalcommunitydoesnotaccept a lowereducationleveldelegation of thescreenings. • Lack of interests among GPs and specialists.  examinations are not carried out extensively. In the case of GPs follow-up care and management are also belong to screening. Source: Dr. Zsuzsa Matejka; Róbert Kiss National Institute for Strategic Health Research - ESKI

12. Recommendations considering our researches: During the last decade the population’s requirements have been changed, morepeople prefer an extended professional guide on the field of prevention from their own GP. • Develop the doctor-patient relationship, not to be „just” superficial. • The screening programme is more effective if it is linked with a personal doctor-patient recommendation and counselling. • GPs would need a medical database which should be complied altogether with the organizations and the local governments to help the GPs to find out where to send the patients or where to get in touch with the director of agiven organization. • The organized screening programs should be improved on the field of communication, more over health workers and GPs, who are closer to the population should beinvolved in the promotion. The most important practical development is to promote the youngergeneration’s health-literacy. • For the patients, it would be useful to print brochures and leaflets or even newspapers to simplify the flow of information with particular names, addresses and services.

13. Conclusion: • 1. Changing in the general view of GPs • Instead of passive doctor-patient relation, the active–initiative role is needed. • Change is also needed in the population view • – motivationable; preventive view • 2. The professional protocol about the GPs competence list by the College of General Practice should be integrated by a general suggestion of the preventive medicine. • 1. Primary prevention • 2. Secondary prevention • 3. Tertiary prevention • 4. Special preventive actions: • Self-examination lectures for patients; • Age-group specific information sharing about basic health promotion and consulting programs; • Elements of a healthy life-style.

14. Next step: Innovative developments: Health Promoting Office (HPO) In201358 beneficiaries established, and began their operation from European Funds throughout the country - 18 of them in the most disadvantaged areas of Hungary Each HPO operates in a sub-region Servicesfree of charge and without the need of referral. Aim: Improve the health care system’s preventive capacities by involving clients (people in need of lifestyle change advised by the family doctor, outpatient or inpatient care services or seeking change on their own initiative) in lifestyle change programmes and following up their participation. Promotion of lifestyles that influence early and avoidable mortality. Improve individuals health through the prevention of cardio-vascular and tumorous diseases.

15. HPOsin Hungary

16. Compulsory activities preparation of a health promotion programme-plan, advocating cooperation between health promoting organisations in the local area. implementing lifestyle changing programmes, collection of data, establishment and continuous managementof local databases of on-going programmes, health promoting organisations and NGOs and their activities, establishing patient clubs, coordination of stimulating and motivating programmes that raise the public participation in screenings carried out by general practitioner, continuous follow-up of local health promoting activities, taking part in their professional monitoring process and giving methodological assistance if necessary, methodological and professional assistance for the primary health care providers, especially cancer screening among the population, implementation of local public and professional communication activities on health promotion,

17. Tasks to strengthen the health promoting role of primary health care with the involvement of the primary care providers screenings of risks of cardio-vascular diseases (including disorders of carbohydrate and lipid metabolism ) with related risk assessment and consultation, minimal smoking-cessation intervention, screening of people who struggle with alcohol abuse and providing minimum intervention for them, directing alcoholic patients to early treatment, suicide prevention through early identification of psychiatric conditions and guidance into therapy, guiding clients to patient clubs and providing professional consultations in them, supporting developments to improve patient compliance,

18. Thank you very much for your attention!