Erasmus+ funded Hippokrates Exchange Program
Project no.: 2014-1-UK01-KA102-000412
Participant report
Sarah Mills– Croatia – 26th March to 3rd April 2016
In comparing General Practice in Scotland and Croatia there are a number of
interesting and important differences. While at the heart both systems are dedicated
to providing for the needs of their patients in a community setting engaging in
undifferentiated illness with direct patient access and in a long-term and continuous
fashion, the way in which this is achieved is very different.
In Croatia 65%% of the practices are private practices, which was true of the practice
in which I worked. While in Scotland it is common to have 5-8 GPs per practice the
majority of GPs in Croatia are single handed. Practices in Croatia do work in loose
federations with other practices but this is more for insurance purposes than for any
logistical or practical reasons, and the doctors in these federations collaborate on
business matters or provide clinical support or cross cover quite rare . Private
practices are constantly under threat from the government, who are introducing
legislation to minimize private practice in order to have health centers employing GPs
(who are paid much lower salaries).
Croatian GPs usually have 1600-1700 patients per GP (standard is 1700). The
average patient at the practice I was working in consults 9 times per year. GPs have
10 minute appointments per patient, the overwhelming majority of which are booked
on the day of or the day before the appointment. Patients are left to organize their
own follow-up, and are usually reviewed for chronic disease management when they
attend to have prescriptions generated, rather than as a formal disease review
process. In Scotland we often book follow-up consultations for patients in 16 order to
monitor their progress; however, in Croatia the onus is put to the patient and the
patient is expected to be proactive in approaching the GP when needed, rather than
having follow-ups scheduled.
The GP practice timetable was very different in Croatia. In Scotland we work 8am6pm, with a morning and afternoon surgery of 4 hours each and 2 hours in the middle
of the day for home visits and admin. In Croatia the practice I was at was open from
7:30am-14:00 / with home visits from 14:00-15:00/ on Tuesdays and Thursdays and
Mondays from 13:00-19:00 with small group session from 19:00-20:00 and home
visits onward and on Tuesdays from 13:30-20:00 and home visits from 20:00-21:00
and finally on Friday from 09:00-15:30 with time for home visits from 15:30-16:30 .
They have obligation of work one Saturday in month and covering all patients from
group practices (5 of them) This meant overall that the GP’s days were much shorter.
They didn’t have call-back messages from patients but instead had two 30 minute
windows scheduled into their day – patients were told if they had any questions they
could call during this time. It was the only time all day that the GPs would take phone
messages from patients and when the 30 minutes was over anyone who had not
spoken to the GP was advised to try again later. Chronic drug reps and hospital
communication is organized by nurse during all working time.
General Practice training in Scotland is very structured; the program runs 3-4 years
and involved 18 months in hospital and the remainder in general practice. It is
mandatory and trainees sit the MRCGP examination at the end. GP training in
This project is funded
by the European Union.
Croatia is not compulsory and doctors can set themselves up in private practice as
GPs without having done vocational training. If doctors chose to do GP training in
order to enhance their skills then it is a 4 year program, with half of it spent in hospital
and 22 months in the GP office or premises of your trainer. The first part of GP
training is an educationally focused diploma in General Practice. At the end of
training trainees are expected to have 3 hours written exam (with 180 MCQ ) and
after that sit an oral examination with case scenarios . They also have to give a
presentation on a piece of research they have done during training in first year of
training . In Scotland practices are paid approximately £8,000 a year in order to train
trainees; however, in Croatia practices are made to pay in order to have their GP
trainees trained in a VTS program!. That money is reimbursed by Croatian Health
Insurance Company but private practices do not send trainees because they can’t
employ finished trainee. This difference dramatically disincentives practices from
sending a trainee to have formal GP training and makes it very difficult for GP
practices to take on trainees. As a result most GP trainees are employed by a health
center rather than a private GP practice; they are paid about 70% of the salary that
they would be paid in private practice and have worse working conditions.
During the Croatian Wars, Croatia saw an intense period of economic, political and
epidemiological transition which has significantly shaped the work of general
practice. There was no GP VTS training from 1992-2003, which is a large part of why
GPs are not required to have undergone vocational training. I saw few patients with
old war injuries – especially lower limb fusions and amputations from mines. It was a
stark reminder of how recently Croatia was at war and made me think that this is
what primary care in the UK must have looked like in the 17 immediately post-war
years in which the NHS was born.
There are a number of logistical differences between Croatia and Scotland. While the
NHS is a public health care system free at the point of use, Croatia has a single
insurance provider who underwrites all their healthcare expenditure, and where
insurance contributions are made from income tax. GPs continue to do occasional
home visits but the amount and frequency of these visits has declined sharply since
the Croatian War.
One of the biggest differences was the role of nurses. In Scotland nurses are very
clinically based and do a lot of our chronic disease management and monitoring, they
do phone triage, do all wound care and in some cases are able to prescribe. In
Croatia the nurse answers the telephone and acts in more of a ‘handmaiden’ role
where she is supporting the doctor but not practicing independently. Nursing seems
to be held in less respect and regard than in Scotland and nurses are in a more
supportive capacity than a clinical one.
What struck me the most was the difference in patient expectations and behavior.
Consultations seemed very physician-centered, where the patient would say what
their problem was and then be given a diagnosis and treatment plan. Though my
observations were limited by not speaking Croatian, watching the body language and
the flow of consultation in terms of how/when/how much patients and doctors spoke
respectively, was very insightful. The patients often didn’t sit down if their complaint
was minor, and the patients were very direct with their complaint – to the point of
undressing before coming into the consultation room if it was something that needed
to be examined. The doctor would often tell one patient to get undressed and get on
the examination couch and, while waiting for them to do this, would call the next
This project is funded
by the European Union.
patient and tell him to undress or order to nurse to prepare him/her in other room –
both patients could hear and see the consultation/examination of the other but
neither seemed to mind. In the UK there is a huge focus on confidentiality and this
level of privacy breech would never be tolerated; however in Croatia it was expected
and seemed to be normal. Patients had a far higher degree of interconnectedness
with their society and village, and there was a supportive structure in which everyone
seemed to know everyone else’s’ business. In Scotland people are more private but
there is nowhere near the level of support that society gives in Croatia. On the whole
Scotland might do well to relax its confidentiality in favor of more community support.
Drug representatives are more commonplace in primary care, and drug-related
paraphernalia and sponsorship is much more apparent. In Scotland we do not take
gifts from drug reps; however, in Croatia it seems to be a significant source of study
budgets for courses and resources.
There are a number of things that general practice in Scotland would do well to
emulate from Croatian primary care. One significant benefit of the Croatian system is
that GPs are able to book hospital appointments directly. For example, the GP in
Croatia can make a physio appointment for their patient during the consultation. In
Scotland we have to dictate a referral or give the patient information on self-referral,
and then they contact physio who post them out an appointment letter. There is no
information given to the doctor on the wait time the patient will have and it generates
a large volume of administrative work that the Croatian system avoids. The 20
(actually it is 10 so I suggest to skip this sentence) minute appointments were
certainly much better in terms of minimizing the sheer volume of patients seen in a
day and in enabling the GP to have enough time to practice safely. The idea of 30
minute phone windows was interesting and would help run to time as the doctors
never ‘ran over’, and would also help minimize the risk of a GP getting multiple
patient phone-back messages with no protected time in which to make those phone
calls. It does however mean that because the GP doesn’t know in advance which
patients may phone them that they don’t have the opportunity to read the patient’s
notes beforehand. There are some things in UK primary care that could benefit
Croatia. For example in the UK patients can self-certify for up to 7 days of illness
without seeing their GP. In Croatia patients need a doctors note for every day they
miss work or their child misses school, even for self-limiting viral things that they
don’t need to see a doctor for. As a result a lot of the GPs day is taken up with
managing minor illness, which is a drain on GP resources and a waste of both the
doctor and the patient’s time. Patients are often very apologetic for coming to the
doctor and say that they only present in order to get a sick line so they don’t have to
go to work. In Scotland we have Docman which electronically presents all the clinical
investigations, hospital letter, and emergency care summary information for patients.
In Croatia patients would be posted letters directly from the hospital and would bring
these, or hospital radiographs, in to the GP consulting room and hand them to the
doctor. This makes it very difficult to check results beforehand and makes any kind of
advice or audit trail impossible. I asked about electronic records and was told that the
GPs do have everything electronically but that because the administrative staff are
government employed they often persist in duplicating the electronic systems with
paper based systems so that ‘no one loses their job’. This high degree of redundant
systems is very costly both in terms of direct costs and in patient and doctor time. It
would streamline this process to have all results be electronic and to avoid sending
This project is funded
by the European Union.
paper copies to the patient. The enhanced clinical role that our nurses play is
something that Scotland should laud and celebrate internationally, and is certainly
something where Croatia would benefit from up-skilling their nursing population in
order to take on more chronic disease management and triage/minor ailments
management.
One of the biggest things I learned on this exchange was the importance of having
accord between patient expectations and the kind of healthcare that can be provided.
In Croatia the consultations were very doctor-centric and didn’t do as much of the
exploring of patients’ ‘ideas concerns and expectations’ that we are taught to do. It
was more a transactional than a collaborative approach to healthcare; however the
patients overall seemed happier! In Scotland we have bent over backwards to cater
for patients’ wishes, and no matter how hard we work it seems patients 19 continue
to be dissatisfied with the NHS care they receive. Much of this stems from
government and media sources advising patients of their rights and promoting patient
choice as the pinnacle of the NHS. Patients are told the NHS is an all -you-can-eat
buffet and are then disappointed if their favorite dish isn’t on the menu. In Croatia
patients don’t expect choice and don’t expect to be involved in ‘shared decision
making’ and, after a very GP-centric consultation where they are told what is wrong
and what they need to do, leave satisfied because their expectations have been met.
In the UK we need to do a better job of matching patient expectations with the level
of service we are able to provide, either by improving the service or by being honest
about the things that we cannot stretch our publically funded healthcare system into
covering.
This exchange has really affected the way I consult and how I see primary care. It
has given me a renewed respect for my nursing colleagues and for the stellar role
they fulfill within primary care. It has made me question whether the British ‘the
patient is always right’ model of primary care is in fact flawed and needs to be
brought more in line with the funding and service levels we are able to provide safely.
It has made me see that if we want to provide a safe healthcare service to all our
patients we must start by being honest about what the NHS is and is not able to do,
so that patients can have realistic expectations and so that we can meet those
expectations. I have been completely evangelized as to the benefit of a 20 minute
appointment system and protected time-limited slots for telephone consultations, and
would very much like to see Britain move towards this in culture.
This exchange has given me a new perspective on general practice and has taught
me to appreciate an devalue many aspects of UK primary care as well as identify
areas where we could improve our services by following the Croatian model. I would
highly recommend this exchange program to all GP trainees and Frist5s who are
interested in broadening and deepening their knowledge of primary care.
This exchange has given me a new perspective on general practice and has taught
me to appreciate an devalue many aspects of UK primary care as well as identify
areas where we could improve our services by following the Croatian model. I would
highly recommend this exchange program to all GP trainees and Frist5s who are
interested in broadening and deepening their knowledge of primary care.
This project is funded
by the European Union.