International opportunities

Learning opportunity

In March 2018, the Erasmus grant allowed me to observe primary care in Bucharest, Romania for 2 weeks. Located in the south of the country, Bucharest is the capital and commercial centre, which prides itself as an industrial centre and transportation hub for Eastern Europe. It is believed to have been founded by a shepherd called Bucur, in the Middle Ages.

This exchange programme gave me privileged insight into daily life in Romania and the primary care system beneath the veneer of tourism. I was mainly based in the city centre with Dr Ileana Efrim, the GP (called a family doctor in Romania) responsible for setting up the clinic, after completion of her training, in a building previously used by the Department for Transport. As is common with many Romanian GPs, Dr Efrim has a ‘cabinet’ or single-handed practice run from a single room. Her practice employs a nurse, who is also the receptionist, assistant, chaperone and secretary.

Primary care in Romania

Healthcare in Romania is funded by mandatory social health insurance contributions. Each patient has a health card that must be presented at each healthcare consultation. Public healthcare is free for those insured (85% of people), but with limited funding, patients often have to pay for services such as blood tests and X-rays to avoid the considerable wait for routine investigations. Patients may choose to pay for private care or investigations, but this can be expensive. Romanian GPs have a close relationship with their patients, often having in-depth knowledge of medical, psychological and social circumstances.

Training

At medical school, there is an obligation to undertake 6 years of training and pass a national multiple-choice question examination. The results determine the speciality to which the newly qualified doctors are allocated. This surprised me. Hospital specialities are preferred to family medicine, as these command greater public and professional respect and higher pay. The family medicine training program is very different from that in the UK. Trainees start their 4-year family medicine training straight out of medical school. The first 6 months of family medicine training are spent working at a GP practice, mostly shadowing and performing basic procedures. After this, 2 years are spent in hospital training posts, and the last 18 months in family medicine.

The role of the GP

There are an estimated 12 000 GPs in Romania, with an average list of 1500. Each GP usually rents a room, which may vary from an apartment to a single room. Romanian GPs must conduct a 5-hour clinic followed by 2 hours of home visits in each session. Appointments are 15 minutes long and a Romanian GP sees between one and twenty patients per session. We saw an average of 20 patients per clinic. Patients often know exactly what they want from the consultation. As there are no receptionists or administration staff, the consultation is usually interrupted many times by nurses, doctors and patients walking in and out of the consultation room. Knocking on the door before entering appeared to happen infrequently and the door was only locked for intimate examinations.

Each consultation is documented using the insurance card. Each prescription was issued for a maximum of 3 months and the cost depended on the medication. It is well recognised that a patient prescribed medication from the hospital should have this prescription continued by the hospital. However, if the hospital did not provide the medication (frequently the case) then the Romanian GP must provide it and foot the bill! Yes, really!

There are only two computer systems available to record patient data. These are monitored by the Ministry of Health and ultimately the Ministry of Finance. The health budget is allocated by the Ministry of Finance for dissemination by the Ministry of Health. Funding is allocated unequally to primary (the smaller portion) and secondary care with additional funding for specific health programs, including cancer care, diabetes care, organ transplantation and vaccinations. Each GP derives their funding based on the number of registered patients and the number of consultations.

Interestingly, the former dictator Nicolae Ceausescu had diabetes, and promoted diabetes as a speciality. All patients with diabetes are referred for specialist care. Romanian GPs cannot initiate orally prescribed medication for diabetes.

I was surprised to learn that there were no local or national antibiotic guidelines or any other disease-related guidance for GPs. Romanian GPs can only prescribe each patient seven medications through their health insurance. There are many medications that cannot be initiated and require prior approval by a secondary care doctor. If a patient needs additional medication, one has to be stopped first! I could not imagine such a constraint for my patients with complex co-morbidities.

Public expectation of primary care

Patient care was very much driven by the patient, and patients had responsibility for organising their own care. For example, if a patient needed referral, the GP gave the patient their referral letter and the patient had to identify an appropriate or preferred place to access the service. A large proportion of the patients we saw came in with the results of blood tests or scans done privately and wanting diagnosis and treatment.

Many patients attended for sick leave administration. GP can only sign a sick note for a maximum of 30 days per year. If a patient had needed more than 30 days off in the last 12 months, they had to be referred to a secondary care medical specialist to approve the sick note for up to 90 days. If a patient required more than 90 days off work, they were referred to a special commission to sign patients off for between 90 and 120 days. There were some exceptions. Patients diagnosed with myocardial infarction, stroke or tuberculosis are allowed a year of sick leave automatically, and patients with cancer two years.

Patients attended very frequently, often several times in the same week to update doctors on tests that had been performed. As a result, the GPs knew the patients and their families very well. This familiarity created a very good doctor–patient relationship, but a more paternalistic one than in the UK. Dr Effrim described this as integral to Romanian culture. Romanian GPs were also responsible for much of the antenatal care and routine child health checks.

Other services

There were no district nurses, no palliative care provision and no hospices. There was a limited homecare service. I asked Dr Efrim about palliative care, and she informed me that most people die in hospital, often, sadly, with poorly controlled pain. There was no equivalent of the 2-week wait service for suspected cancer referral.

Reflection on exchange

Observing primary care in Romania revealed an alternative way of organising primary care to that in the UK. It gave me new enthusiasm for the speciality and the opportunity to meet inspirational Romanian GPs working for positive change as advocates for their patients. I hope to bring the wonderful perspective of a uniquely patient-focused consultation to my own practice and to reduce bureaucracy. I now, more than ever, appreciate being part of a multi-disciplinary team.

Get involved

If you are interested in Romania or elsewhere then good news! From August 2018 further Erasmus funding is available to support Hippokrates Exchanges until May 2020. Forty-one successful applicants will be awarded a grant to cover the travel costs and living expenses for a 2-week exchange. Participants will also be asked to host a visitor from another European country. Exchanges without Erasmus funding are always available. For more information and application forms see the website at www.rcgp.org.uk/jic.

If you cannot leave your workplace, another way to get involved in global health is to host a visitor at your practice. Hosting provides an opportunity to share your passion for general practice with someone equally enthusiastic. Learning about healthcare in your visitor’s country offers the opportunity to reflect on your own clinical practice and healthcare system, to appreciate the facilities and system that we have and to think about new ways of improving clinical practice and patient care. Further information can be found at www.rcgp.org.uk/jic.