Abstract
During my ST3 year, I took part in the RCGP Erasmus Plus programme organised via the RCGP Junior International Committee. The programme involved hosting a German GP at my practice for 2 weeks, followed by a 2-week placement with a GP in Oldenburg, Germany, allowing me to compare and contrast general practice in the UK and Germany.
Education
General practice is a small specialty in Germany, with only approximately 10% of doctors becoming ‘Hausarzte’ (GPs). GP training takes 5 years in both countries, but is much less structured in Germany, with trainees having more choice over their rotations and training practice. There are no organised formal teaching schemes, and training requirements are fewer, with no portfolio, and one final viva examination which is shorter (and less feared) than the Clinical Skills Assessment! German GPs perform their own ultrasounds and a minimum number is needed to complete training. Personally, I prefer the British training system, which is more intensive, but focuses more on the ‘soft’ skills essential for general practice, such as consultation skills. UK training also benefits from a defined curriculum to ensure registrars are well equipped to manage a wider range of conditions.
Role of the GP
GPs in urban practices in Germany do not routinely see children or women’s health, and patients are able to self-refer to specialists, meaning the majority of GP workload is adult general medicine. This can perhaps lead to general practice being viewed as more tedious and repetitive by German doctors.
German GPs are more involved in preventative medicine, with every patient being eligible for a two-yearly ‘check-up’ from the age of 35 years. These ‘check-ups’ last 30 minutes and form a significant part of GP workload. They include a detailed lifestyle history, dermatoscopic screening for skin cancer, and often an abdominal or neck ultrasound. The risk of finding ‘incidentalomas’ leading to over-investigation made me feel quite uncomfortable, but I also felt that spending 30 minutes with ‘well’ patients leads to a better understanding of them as people, than we can achieve in our 10-minute problem-focused consultations.
Practices in Germany tend to be much smaller than in the UK, with only one or two partners and a purpose-built building is rare. Most GPs to not employ a practice manager and must deal with non-clinical matters such as finances and human resources. This adds to their workload.
Practices in Germany employ MFAs (Medizinische Fachangestellte) instead of practice nurses, receptionists and healthcare assistants. MFAs undertake 2 years of training, and perform administrative and basic clinical roles e.g. phlebotomy and dressings. As there are no practice nurses, GPs do more chronic disease management, which in the UK would be delegated, usually to practice nurses.
All staff members (GPs included) wear a practice-branded polo shirt and white trousers or jeans with trainers. This dress code did lead to a more unified team feel, with less perceived hierarchy (although identifying the doctors was more difficult!)
GPs tend to refer to specialists much sooner in Germany (or the patients self-refer). This means that patients presenting to the GP tend to be less unwell than in the UK, and GPs tend to be less incremental in their approach to investigation and management. I felt this led to GP work being less satisfying in Germany, with less emphasis on management in primary care for many common conditions, such as dyspepsia.
Additional services are offered in the practice by some GPs, including osteopathic manipulation for musculoskeletal conditions and an intravenous infusion service. There tends to be less emphasis on evidence-based care in Germany, with a perception among German clinicians that they are much less constrained by guidelines than NHS clinicians. Personally, as a newly-qualified GP in the UK, I like having clear evidence-based guidance which I can then tailor to the patient in front of me.
Sick certificates are prominent in the GP workload in Germany, as patients often require a certificate for any sick leave. This means that many young patients with a short history of self-limiting illness, like the common cold, are seen by the GP on the first day of illness. This would be seen as a waste of GP time in the UK. There is also the cultural phenomenon of shaking hands at the beginning and end of each consultation. This is not very pleasant for the doctor when the patient then explains they have been up all night with diarrhoea and vomiting!
The working day
In Germany, most practices close for the afternoon on a Wednesday and a Friday, as do many specialists. There is similar out-of-hours cover to the UK. On other days, GPs work from 8 am to 5 or 6 pm. Lunch breaks are shorter, but there is less administrative work generated. Appointment times are more flexible, with 10 minutes for acute patients, 15 minutes for pre-booked appointments, and 20–30 minutes for ultrasounds or check-ups.
Demand for appointments appears to be lower than in the UK, so telephone consultations and triage are less used, and ‘walk-in’ patients are more tolerated. However, German GPs also report feeling overworked, with a shortage of GPs especially in rural areas.
Patients
I found patient expectations in Germany were much higher than in the UK, due to the self-referral system. Patients do not need to be registered with a GP and there is no list system, so patients can present to as many different GP practices (and specialists) as they choose. The health system is insurance-based, so patients are viewed more as ‘consumers’ and doctors as ‘providers’.
I felt there was an increased risk of ‘over-medicalisation’ in Germany, due to patient demands, with more use of specialists and investigations than in the UK. The self-referral system increases the demand for specialist appointments, resulting in longer waiting times for some specialities than in the UK.
A patient’s records do not follow the patient around as they do in the UK, so notes start when a patient presents at the current practice. This means that the patient’s version of events has to be relied on more heavily. Therefore, when considering medication and past medical history, misuse of the system by patients to obtain certain medications would appear to be much easier than in the UK.
Two concepts not provided on the NHS are ‘Kor’ and ‘Reha’. These are intensive inpatient and outpatient programmes to treat conditions such as disc prolapses, chronic pain or psychosomatic complaints. A full-time programme of rehab activities is provided over several weeks, and is paid for by the patient’s insurance company, allowing more comprehensive care for certain conditions than we are able to offer on the NHS. However, some patients view these programmes as ‘free holidays’ and insurance companies are becoming stricter with what they will fund.
Finance
Many of the differences in the German system are due to differences in healthcare funding. There are over 100 insurance companies in Germany, with roughly 85% of the population having ‘normal’ insurance, and 15% having ‘private’ insurance. Patients who are unemployed are entitled to normal insurance coverage, although it is possible to be uninsured if forms are not filled in within a certain timeframe. The World Bank (2014) reported that Germany spends significantly more of its GDP on healthcare (11.3%) than does the UK (9.1%). However, despite this additional funding, life expectancy is similar in both countries (World Bank, 2015).
GPs and specialists are each paid a fee for every quarter of the year that each patient attends their practice. This incentivises a 3-month follow-up period for many conditions. Certain services, e.g. ultrasound, attract an additional payment, as does the consideration of a psychosomatic diagnosis. GPs have to set aside time to code the work done at the end of every consultation, with the cost of each intervention shown in euros. For private patients, doctors can bill for all work done, meaning that private patients are at higher risk of over-investigation and treatment.
A consumerist approach to healthcare is more apparent in Germany, with insurance cards scanned on entry to the practice, and a piggy bank on the reception desk for patients to contribute spare change to the staff coffee fund! I felt quite uncomfortable with the financial side of healthcare being much more apparent in each consultation. The German doctors I spoke to also felt disillusioned by this, but felt it was a necessary part of an insurance-based healthcare system.
The Erasmus scheme has enhanced my understanding of how a different healthcare system works, and the strengths (true generalism; GPs as ‘gate-keepers’; structured postgraduate education) and areas for improvement (flexible appointment times; use of technology) in UK general practice. Since returning, I have been much more appreciative of the service we offer in the UK with limited funding, and also the strength of British general practice, with enviable training schemes, and a vital role within the health service.