XIX Congresso CSeRMEG 26-27 novembre 2007 UNITA’ DI MEDICINA GENERALE la professione organizzata - www.csermeg.it

1. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Maria Milano, Giampaolo Collecchia, Lino Gambarelli,
Paolo Longoni, Massimo Tombesi, Antonio Nicolucci
CSeRMEG, Istituto Mario Negri
The TUCORI study part II: is a mailing list
a suitable tool for peer review about
organization and management of GP’s
practice?
HOW DID YOU DO IT ?
There is no conflict of interest

2. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Nowadays many different organizational
settings are possible in Italy and not much is
known about the adopted procedures
Background

3. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
“If there are no objectives
there is nothing to evaluate”
W.W.Holland, NIS, 1985
What could we learn from each other?
Could we build goals together?

4. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
is to share GPs’ experience about practicability,
efficiency and effectiveness of different
solutions adopted in their organizational
setting of practice
Objective

5. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Methods
Through a closed mailing list by Internet
1st step: Hanlon method -> selection of the
most critical priorities in the organization and
management of the GP’s practice
2nd step: simplified Delphi method -> sharing
adopted solutions for each critical priorities

6. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Criteria of selection
Only GPs, max 40, with special interest in
organization and management and with ability in
Internet use
The protocol in 2 closed mailing list of
researchers and trainers most of all GPs (about
800 people): 240 of them answered

7. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
• Bartoli Marco, Marina di Massa (MS)
• Bini Isabella, Ala (TN)
• Bondielli Giuliana, Massa
• Calcini Filippo, Santa Croce sull'Arno (PT)
• Capelletti Danilo, Cremona
• De Luigi Gianni, Moncalieri (TO)
• Del Carlo Alessandro, Viareggio (MS)
• Della Vedova Roberto, Gradisca d‘Isonzo (GO)
• Donato Giuseppe, Cerveteri (Roma)
• Filippi Severino, Pontremoli (MS)
• Giovannoni Stefano, Prato (PO)
Participating
Investigators:

8. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Participating
Investigators:
• Maggioni Alessandra, Ala (TN)
• Malavasi Paolo, Carpi (MO)
• Mantovani Licia, Soliera (MO)
• Marchetto Marco, Collegno (TO)
• Marino Rosanna, Venaria (TO)
• Mascaro Sonia, Greve in Chianti (FI)
• Maurri Sandro, Firenze
• Messina Emanuele, Firenze
• Mola Ernesto, Lecce
• Montanari Ugo, Fiumicino (Roma)
• Mori Maria Grazia, Regello (FI)

9. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Participating
Investigators:
• Musso Marina, Mathi (TO)
• Pastacaldi Guido, Agliana (PT)
• Perlot Maria Pia, Trento
• Piazza Gianpietro, Schio (VI)
• Polenzani Loretta, Prato
• Ranzani Luca, La Loggia (TO)
• Sabbi Diego, Arquata Scrivia (AL)
• Sarotto Maurizio, Fossano (CN)
• Suzzi Fabio, Imola (BO)
• Zoli Romeo, Scandicci (FI)

10. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Results
11 26
Have a secretary 85,7%
Have a nurse 34,3%
Give the cell n. to patients 77%
Work in more than 1 practice 40%
Solo practice 5,7% Patients files in computer database 77.1%
37 GPs:
52 61 years42
age:
88,5 % (47-56)

11. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Results 1st step
35 GPs
64 priorities
organized in
31 topics
5 Main
domains

12. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Main Domains
Local Health
District
difficulties Personal GP’s
development
Professional
communication
Practice
structure
management
Practice
clinical
processes

13. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
The 2nd step study
Simplified Delphi method:
every participant fills in an open questionnaire
the moderator weekly thread with his own experience
efficacy (score 0,5-1,5)
effectiveness through the PEARL factors (score 0 or 1)
for propriety, economic feasibility, acceptability, resource
availability, legality)

14. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
The open questionnaire
How does it work in your practice?
And for how long ?
Why have you adopted this method?
Is there anything you do not like? What would
you change?
What prevents you from changing it?

15. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Results
799 mails from 18/01/06 to 01/05/07
only 2 drop - outs in all this time
22% (8/37) declared they changed and improved
something during this experience

16. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007

17. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007

18. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007

19. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Interests
Everybody can express oneself completely
Everybody can take enough time when one wants
Everybody feels free from leader’s influence

20. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Drawbacks
Very exhausting job for the coordinator
Tiring for everyone because lasted so long

21. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Conclusions
A virtual professional community succeeded in meeting for 1
year and a half sharing reflections about organization and
management of GP’s practice
22% of them improve something in their own organizational
setting during this experience
… a qualitative sociologic analysis is running now on the 432
questionnaires

22. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
milanomar@gmail.com

23. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007

24. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Practice clinical processes
• Management of the urgencies
• Chronic diseases management
• Patients records visited at home
• Multi-therapies management
• Prevention to patients at risk
• The use of the computer
• Sharing guidelines in the team
• Audit

25. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Practice structure management
• Management of the access to the practice
• Management of more practices
• Secretary duties
• Administrative management
• Nurse duties
• Intrusiveness and utility of the telephone
• The pressure of the impatient patients

26. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Professional communication
• Problems of communication in
the team
• Rules, dynamics and objectives
• Choice of the partners
• Relationships with other operators of the area

27. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Personal GP’s development
• Professional and economic de-motivation
• Professional Solitude
• Management of the extra clinical
working time for research, review of
the patient’s records and to study
•The pleasure to work without exhausting performances
• Insufficient time for ones own general cultural
• Management fatigue: does free time exist?

28. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
Local Health District difficulties
• Excessive paperwork
• Management of certification for sick leave
• Drugs covered by the NHS only for some
conditions
• How to deal with Disease-mini-clinic
appointments
• Local Health District protocols, guidelines,
rules
• Legal Problems
• Inadequate sanitary programming

29. Re-Thinking Primary Care in the European Context
A new challenge for General Practice
Wonca Europe Regional Conference, Paris – October 17-20, 2007
The
critical
priorities
Critical priorities Number
of GPs
Score average
(range)
Management of the access to the
practice
23 9 (4-10)
Secretary duties 16 7 (3-10)
Intrusiveness and usefullness of the
telephone
14 7 (4-10)
Impatient Patients 13 9 (4-10)
Relationship with Specialists 13 8 (3-10)
Nurse duties 11 8 (5-9)
Management of the urgencies 11 7 (5-9)
Local Health District difficulties 11 7 (3-9)
Chronic Diseases management 10 8 (5-10)
Extra clinic working time
management
9 8 (3-10)
Relationship in the team 9 8 (1-10)
Sharing of the guidelines in the team 8 7 (3-10)