Elsevier

Health Policy

Volume 122, Issue 10, October 2018, Pages 1070-1077
Health Policy

Community orientation of general practitioners in 34 countries

https://doi.org/10.1016/j.healthpol.2018.06.012Get rights and content

Highlights

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    There is a large international variation in community orientation between GPs.

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    In countries with a defined patient list GPs are more community oriented.

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    GPs more active in prevention and multidisciplinary cooperation are more community oriented.

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    GPs using medical records to make overviews are more community oriented.

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    GPs in areas with more ethnic minority people are more community oriented.

Abstract

General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.

Introduction

Current changes in demography, epidemiology and ecology require general practitioners (GPs) to strengthen their community oriented approach. Community orientation of GPs and – broader – of primary care, means that care providers assume responsibility for the population in their practice area instead of only for those people that visit the practice. Community oriented service provision is sensitive to the health needs of the population [1]. This is facilitated by insight in population health issues, involvement of GPs in the community and involvement of the community in health related issues [2]. In this article we try to explain differences in community orientation of GPs in 34 countries.

A community oriented approach of GPs has become more important for several reasons. Ageing of the population leads to higher prevalence of chronic disease and multi-morbidity [3]. Chronic diseases are to a large extent life style related. People increasingly age in place [4], partly due to policies to contain long-term care costs [5] and partly due to preferences of elderly people themselves [6]. These changes in demography and epidemiology add to long-known ecological hazards, such as environmental pollution and occupational risks. They can be observed by GPs by looking into patterns of ill-health in their patient population. According to Wonca Europe (the scientific and academic association of European GPs) one of the core competences of GPs is ‘the ability to reconcile the health needs of individual patients and the health needs of the community in which they live in balance with available resources’ [1]. Consequently, taking responsibility only for those who visit the practice is not sufficient. A responsive, active and outreaching approach is needed. Primary care and health care in general are shifting from disease oriented care, e.g. in the form of disease management programmes [7] to patient oriented care where patients are seen as more than their disease and finally towards people-centred care [8]. The latter includes both an orientation towards persons and towards the local community [9].

In the definition of its founders, Community Oriented Primary Care (COPC) is defined by the following elements: the use of epidemiology and clinical skills to characterize the health needs of the community, assuming responsibility for a defined population, clear-defined programs to address communities’ health needs, community involvement, and accessibility to services [2].

Against this background, we analysed data from a multi-country survey among GPs to answer the following research questions:

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    How does community orientation vary between countries and GPs or practices?

  • •

    How can this variation be explained by characteristics of GPs and characteristics of the organisation of their practices and of health care systems?

We use secondary data, collected in the international QUALICOPC study. In this study, community orientation has been measured by three survey questions on whether GPs would take action when confronted with repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. This measurement is less encompassing than the concept of COPC in its original formulations [2], but can be seen as approximation of the phenomenon.

Section snippets

Hypotheses

We have developed a number of hypotheses to guide the analyses. They relate to the potential influence of characteristics of the GPs, their practice, and the healthcare system they work in, as shown in Fig. 1.

At the country level, we expect that characteristics of thehealthcare system, the political composition of governments, and economic resources are related to the extent to which GPs have adopted a community oriented approach.

Data

The data on community orientation of GPs, GP practice and GP characteristics were collected in the EU co-funded QUALICOPC study (see Box 1) [30]. We use information from the survey among GPs in 34 countries, three of which are outside Europe and five European but not EU Member States. 7183 GPs participated in the survey; varying from 70 respondents in Malta to 535 in Canada. The development of the questionnaire and the data collection have been described elsewhere [31,32].

Measurements

The dependent variable

Results

The countries in our study substantially differ with respect to community orientation. GPs from Norway, Turkey, Spain and Italy perceived themselves as very community oriented. On the other part of the spectrum there are Cyprus, Estonia, Hungary and Germany (Fig. 2). Of the non-European countries Canada and Australia are in the lower third and New Zealand in the upper third of the distribution.

The variation between countries in the empty model is 13% (Table 1; random part).

The fixed part of

Discussion

In this article we have developed and tested a set of hypotheses about the community orientation of GPs. The hypotheses addressed differences between countries, between GP practices and between GPs. As regards country characteristics, our hypotheses about the strength of primary care, about the left-wing government and about economic resources were refuted. The hypothesis about national health systems is partly corroborated. The role of these health system characteristics is not specific for

Conclusions

Our study shows that countries vary in community orientation of GPs. In particular for policy it is important that we found relationships with having a list system, the employment status of GPs, using medical records to inform practice policies, a focus on prevention and multidisciplinary cooperation. We also found relations with the task environment. This suggests that community orientation can be influenced both by national policies and by policies of the practices themselves. New incentives

Conflict of interest statement

None.

Acknowledgements

This article is based on the QUALICOPC project, co- funded by the European Commission under the Seventh Framework Programme (FP7/2007-2013) under grant agreement 242141.

The authors thank their partners in the QUALICOPC project; J. De Maeseneer, J. Detollenaere, L. Hanssens, S. Willems (Belgium); S. Greß, S. Heinemann (Germany); G. Capitani, S. De Rosis, A.M. Murante, S. Nuti, C. Seghieri, M. Vainieri (Italy); W. Boerma, D. Kringos, M. van den Berg, T. van Loenen (the Netherlands). In addition,

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