The document provides information on primary care systems in four European countries: Italy, Spain, Portugal, and Greece. In Italy, primary care is delivered by general practitioners (GPs) and family pediatricians (FPs) working in individual practices or networks. GPs are paid mainly through capitation. In Spain, primary care is delivered through multidisciplinary teams centered around family doctors acting as gatekeepers. Most providers are salaried with some performance-based incentives. Portugal reformed primary care by establishing small family health units staffed by multi-professional teams paid by capitation and incentives. Greece has a fragmented system with difficulties in access, continuity, and coordination exacerbated by high private payments.

1. WONCA session:
Diversity in Europe - an asset and a challenge
Evangelos Fragkoulis, MD, MSc
Secretary General Greek Union of GPs
Member of the E.B. ELEGEIA

2. SOUTH Europe
Crete

3. Diversity in Primary Care in the South
Building primary care in a changing Europe. European Observatory on Health Systems and Policies. WHO 2015

4. • All Italians are enrolled in the National Health System (NHS) – founded in
1978
• People have the right to choose any GP or Family Paediatrician (FP) they
prefer at any time, provided that the physician’s list has not reached the
max number of patients allowed (1500 for GPs and 800 for FPs)
• Remuneration of GPs / FPs is per capita
• FPs treat children ≤6y or if parents wish ≤ 14–16y
• a regionally based NHS which still provides universal coverage, free of
charge at the point of service (1999 reform)
• GPs and FPs act as first contact for the patient and are expected to
provide most primary care. They act as gatekeepers for access to
secondary services
• No academic General Practice in Italy
• Since waiting lists can be very long and the quality of services is not
always satisfactory, many people seek care in private clinics, particularly
if they have voluntary health insurance
Primary Care in Italy

5. • Priority to achieve integration of GPs’ developing networks,
associations and other forms of grouping, including with other
health care professionals- a “slow, creative, but moving process”
• “participation of GPs in any existing form of group practice
becomes compulsory” National Agreement of 2009
• New organizational models based on the integration of different
professionals (GPs, FPs, out-of-hours physicians, nurses, outpatient
specialists, social workers, administrative personnel, etc.) working
together to improve accessibility, equity and continuity of care
• Oriented towards full implementation of multidisciplinary practices,
the Agreement of 2010 introduced the concept of “Primary Care
Complex Units” conceived as an additional evolution of existing
models of multi-professional practice, with a strong emphasis on
continuity of care, chronic disease management and integration
with social services.
• Reshape Italian primary care according to the Chronic Care Model,
moving from “reactive” to “proactive” medicine.
Primary Care in Italy
networks, associations and grouping

6. • 3 types of team-working – association, network, and group medicine –
imply an increasing level of collaboration and a progressively higher
financial reward for GPs joining in (Fattore & Salvatore, 2010)
• Group medicine requires that GPs share a clinic or practice where care is
provided;
in group medicine and networks, unlike in associations, GPs share the
clinical history of their patients through electronic medical records
• 59% of Italian GPs have joined a type of collaborative initiative and
• 22% created a group practice
(National Survey, Ministero della Salute 2004)
• Variability regarding ≥ 4GPs working in the same building without medical
specialists can range from 11.5% in Calabria - 35% in Umbria
(Regional data, 2006)
Primary Care in Italy
networks, associations and grouping

7. • GPs and FPs are self-employed physicians working for the NHS
through a national agreement
• Since 2005 the National Agreement for Primary Care defines
standards and objectives for professionals (mainly rewarded
through capitation)
• The National Agreement tends to reflect national priorities
(e.g. professional standards, immunization campaigns, evidence-
based guidelines, etc)
• The remuneration consists of an amount based on capitation (70%
of income) and a variable amount based on fees for services (e.g.
minor surgery, preventive activities, immunizations)
• €40 fixed per capita payment (2009 National Agreement)
Primary Care in Italy

8. Primary Care in Italy
• Delegating to regions the negotiation of additional objectives and
incentives (mainly delivered according to organizational standards and
pay-for-performance)
• Most regions do decide on additional priorities and organizational
aspects of service provision - chronic disease management programmes,
home care services, primary care delivery models
(e.g. provide the practice with nursing and administrative staff and
an information system, to enroll patients in disease management
programs, to improve adherence to clinical guidelines)
Incentives have been linked to process and output results and not to
clinical outcomes
• Variability in priority-setting and provision of care is increasing across
Italian regions.
• Average GP gross income ± €50.000

10. Primary Care in Italy
comprehensiveness of care
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

11. • The proportion of patients satisfied with GPs is
74.5% (European Commission, 2002)
• regions with the least satisfied respondents are
Calabria (35.9%), Puglia (28%) and Sicily (25.6%),
while those with the highest levels of satisfaction
are Bolzano Province (68.8%), Valle d’Aosta
(59.6%), Trento Province (58.8%) and Emilia
Romagna (46.8%) (ISTAT, 2007b)
Primary Care in Italy
patient satisfaction

12. Primary Care in Spain
• universal coverage with free access to health care
• public financing, mainly through general taxation
• integration of different health service networks under the
NHS structure
• a new model of primary health care, emphasizing
integration of promotion, prevention and rehabilitation
activities
• a gatekeeping system at the primary health care level
(BOE, 1986: Article 15.1)

13. • Gatekeeping at the primary care level since the 1970s
• Specialty of family community medicine since 1979
• University departments in family medicine do not exist in Spain
• Multidisciplinary teams in primary care innovative formula
introduced in early 1980s (BOE, 1984)
• Main pillars of primary care defined in the General Health Act, such
as gatekeeping, free access and multidisciplinary teams, had to be
guaranteed in all the Acs
• Quality indicators implemented in various ACs are mainly a mix of
performance, accessibility and cost–efficiency indicators (Gené,
2009)
Primary Care in Spain

14. • Multidisciplinary team, with a gatekeeping function: prevention and
promotion of health, acute and chronic care, home and community care
• Core of the team: family medicine specialists, paediatricians, nurses,
social workers, dentists and administrative staff
• Team works closely with midwives, gynaecologists, public health
professionals, pharmacists, radiologists, physiotherapists and laboratories.
• Good coordination with other health professionals and health care levels,
strengthened by the support of IT and the implementation of the
electronic clinical records (>97% of the practices) (Borkan et al,2010)
• <6% of the encounters at primary care are referred to another level of
care (Peiró, 2008)
• non-existence of barriers for family doctors to order laboratory and
imaging tests
• Primary health care centres equipped for minor surgery and diagnostic
purposes such as spirometers, ECG machines, retinal digital cameras and
first aid material
• CME allocated within working hours and the establishment of a
professional career for medical professionals has encouraged research in
primary care.
Primary Care in Spain

15. Primary Care in Spain
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

16. • Most primary health care professionals and personnel in Spain have civil
servant status
• mainly salaried, with a wide range of supplements
a variable salary (which takes into account geographical dispersion of the
population, teaching and transportation)
various degrees of economic incentives introduced since 2003, such as
professional career, achievement of quality indicators related to
performance and cost–effectiveness among others (BOE, 2003).
• the average wages of medical professionals either in primary and hospital
care are very similar
• The mean net income before taxes of a primary care physician ranges
from €39 000 to €60 000 depending on the AC and variables mentioned
(Magallón, 2009)
Primary Care in Spain

17. Primary Care in Spain
comprehensiveness of care
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

18. Primary Care in Spain
patient satisfaction
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

19. Primary Care in Spain
unattractive
• overlooked by health professionals and patients
• unattractive to citizens, increasingly demanding to see
hospital specialists rather than relying on their GP,
and to medical students, more of whom are choosing
hospital specialties over general practice
• Most doctors working in Spain’s public sector are civil
servants,
• but self employment initiatives launched over recent
years in Catalonia have broadened professional
involvement and increased patients’ satisfaction,
• public sector primary care is being marginalized,
the most informed, demanding and influential citizens
“escape” from it using private healthcare.
Aser García Rada BMJ 2012;344:e2508

20. Of the total healthcare budget
• 54% spent on hospital and secondary care specialist services,
• 16% is dedicated to primary care, where 70% of care provided
Primary Care in Spain
underfunded

21. Primary Care in Portugal
• NHS is defined as “universal, comprehensive and approximately
free of charge”
• primarily funded through taxation
• in the public sector is mostly delivered through publicly funded and
managed Primary Care Centres
• Since 1979 NHS has 350 Health Centres and almost 2000 small
health units covering most of the national territory.
• All NHS doctors are salaried government employees
• The fixed salary is established according to a matrix linking
professional category and duration of service, independently of any
productivity measure
• GPs’ patient lists of around 1500 people are the basis of the health
centres
• Only 5.56% of all general practice contacts are referred to
secondary health care (Fleming, 1992)
• By the end of 2005, a major primary health care reform was
initiated titled “Mission Unit for the Reform of Primary Health Care”

22. Primary Health Care Reform
• Accessibility, efficiency, quality and continuity of care, satisfaction of
both professionals and citizens
• Small, functional independent family health units (FHUs), providing
accessible health care closer to the citizens and offering better quality of
service
• encouraging more multi-disciplinary team working and achieving greater
co-ordination between providers
• small multi-professional teams, 3–8 family doctors and equal number of
family nurses and administrative professionals, provide primary care
services to a population of 4000 -18 000
• Technical, functional and organizational autonomy.
• Remunerated by a mixed payment system (a mix of capitation / salary /
professional incentives) that rewards performance, sensitive to
productivity, accessibility and quality of care (Ministério da Saúde, 2007c,
2008).
• Impressive depth of available primary care information with systematized
collection of a large number of indicators linked to the payment system
• The introduction of the newFHUs has been a success by indicators of high
quality. Satisfaction with Primary Care also appears high.

23. Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015
Primary Care in Portugal

24. Primary Care in Portugal
comprehensiveness of care
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

25. Primary Care in Portugal
patient satisfaction
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

26. Diabetes and Hypertension Control
37,8
59,8
68,6
49,3
41,5
61,6
70,3
53,0
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
UCSP-M USF-A USF-B Todas ARS | Todas
UF-M
2012
2013
35,4
52,6
64,0
45,3
37,8
53,8
65,2
48,0
UCSP-M USF-A USF-B Todas ARS | Todas
UF-M
2012
2013
Diabetes
control
BP control

27. Two-tiered system with
increasingly divergent levels of care quality
• Primary Care Quality doesn’t appear to be evenly
distributed across the Portuguese system, with some
concerning disparities in quality and outcomes between
PHCUs and FHUs.
• Balance between traditional Primary Health Care Units
and the innovative Family Health Units is now needed to
ensure that high quality care can be accessed by the whole
Portuguese population
OECD Reviews of Health Care Quality: Portugal 2015 Raising Standards

29. Primary Care in Greece
• In urban areas: contracted with EOPYY private physicians
• In rural areas: salaried GPs, internists in public health centres
• There is no system of gatekeeping or patient lists
(patients can visit any generalist or specialist they wish to)
• Private payments (formal and informal) are high
(> x2 than average among EU OECD countries,2010)
• Care is restricted to those who visit the particular service rather than community-
based
• lack of a comprehensive and national electronic patient record (EPR) system
• Referral letters are rarely used by GPs
• No communication of specialists with GPs after the completion of an episode of
treatment
• Not clearly defined role for the GP mainly in chronic disease management-
arguments with specialists
Groenewegen P, Jurgutis A. A future for primary care for the Greek Population.
Quality in Primary Care 2013;21:369–78

30. Fragmented healthcare system
patients can access any service they wish to
continuity
and co-ordination
impeded…

31. Primary care in Greece
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

32. too many physicians,
but too few general practitioners …
Health at a Glance 2015. OECD Indicators

33. Primary Care in Greece
underfunded

34. Unmet care
needs for those
with low income
Obstacles in
access…

35. Primary Care in Greece
comprehensiveness of care
Building primary care in a changing Europe. Case studies. European Observatory on Health Systems and Policies. WHO 2015

36. A health system diverted from
PHC core values
Primary Health Care, Now more than ever. WHO World Health Report 2008

37. EOPYY will change the way it provides primary
health care by
introducing compulsory patient registration with a
family doctor,
who will act as a Gatekeeper in charge of referrals
to specialists.
This shall become fully operational (key
deliverable)by 1st January 2018.
Regulation of patient flows
Enhancement of 4C’s of PC:
first contact care,continuity, comprehensiveness, coordination of care

38. Roll out of Primary Care
The authorities will adopt the necessary legislation of the roll-out of Local Health Units
(TOMYs) by May 2017.
Establishment of at least 240 TOMYs by June 2018, thereby achieving coverage of 35%
of the total population.
TOMYs:
• small, public family health units in urban areas
• multidisciplinary teams (GPs, FPs, nurses and administrative staff) caring for a
defined population
• 10000-12000 people enrolled
• Patient list of 2000-2500 for GPs, 1000-1500 for FPs
• GPs public servants, remuneration fixed salary
Quality, Freedom of choice of patient, Income- satisfaction of physicians
Greece has already the most dense network of private physicians in the world

39. Europe is a natural laboratory for
learning about health policies
and health systems.
With diverse systems to finance,
provide, and govern health
care across the 27 member
states of the European Union
and the wider European
region there are many
opportunities for international
comparative analyses and
natural experiments.
to enable countries to make their
systems more efficient and to
improve outcomes
Lancet: 2013, 382(9893), 668-669