WHO report scrutinises role of personal doctors in Gesy

Around 35 per cent of all visits to a GP end with referral to a specialistThe role of personal doctors has come under scrutiny as part of a recent World Health Organisation (WHO) report on our national health system (Gesy). The report, titled ‘Strengthening primary health care and reducing overprovision of low-value specialist care: policy options for Cyprus’, was prepared by four experts – including academics from LSE and Brown University – for the WHO and the European Observatory on Health Systems and Policies. It’s wide-ranging, and quick to note the benefits that Gesy – introduced in 2019 – has brought to the island. “The share of the population reporting unmet health care needs has declined,” it points out, “dropping from 1.4 per cent in 2018… to 0.1 per cent in 2022, well below the EU27 average of 2.2 per cent.” When it comes to primary care, however – the lynchpin of the whole system – the function of personal doctors (GPs) isn’t working out as intended. The approximately 800 GPs in Cyprus, each with a panel of patients (capped at 2,500), are supposed to act as a filter, streamlining services – but too often act as mere middlemen, funnelling patients to specialist doctors which is what many patients seem to want anyway. “Patients who are used to direct access to OSs [specialists] often prefer to bypass personal doctors,” says the report, “perceiving them as bureaucratic gatekeepers rather than trusted providers of care… “Additionally, cultural factors and perceptions of OSs as more capable or accessible than personal doctors further drive a preference for outpatient specialist service.” At the moment, figures from the Cyprus Health Insurance Organisation (HIO) show that around 35 per cent of all visits to a personal doctor end with referral to a specialist. The equivalent figure for the NHS in Britain, for instance, is 8-12 per cent. Clearly – though the report doesn’t say so – any system with such an imbalance at its core is heading for trouble, and potential collapse. It remains to be seen if the report will lead to anything. Disy – which takes credit for making Gesy happen – said the WHO “affirms the success of Gesy, and exposes the government’s inertia with regard to next-day challenges”. The HIO, which runs the service, hailed the report, saying its recommendations are in line with the HIO’s own policies. The report doesn’t just identify problems, it also proposes solutions. Some are long-term, like promoting multi-doctor practices instead of solo GPs. Others are short-term, representing “foundational reforms” which should happen before anything else does. One big change being proposed has to do with how personal doctors are paid. “Their remuneration, largely comprised of capitation fees, is paid primarily based on patient numbers, irrespective of the quality or quantity of care,” says the report – and proposes a blended model which would also include ‘fee for service’ (the actual care provided) and performance-based pay. Personal doctors in Cyprus get 80 per cent of their income from capitation fees. The equivalent figure in Estonia – another small country – is about 50 per cent. “In the legislation creating Gesy, the figure was 70-30,” Dr Mary Avraamidou, president of the Cyprus Association of Personal Doctors, told the Cyprus Mail. Once the service was up and running, initially it was 100 per cent capitation, and now, for the past few years, it’s been 80-20 – “but we’re not at all satisfied”. The problem, she says, is that the HIO “are still unable to use real quality indicators” to calculate the performance-based part, the only exception being perhaps vaccination coverage (for the flu vaccine). Instead, they’ve done things like setting a cap on how many patients should be referred for X-rays and lab tests – a crude metric that also tends to penalise conscientious GPs. The criterion should be “health outcomes,” says Avraamidou. “HIO should come and see, for instance – how many of my diabetics have A1C [average blood sugar] levels under seven?” How many patients had cholesterol levels successfully lowered? How many have been checked for atrial fibrillation, and prescribed coagulants to lower the risk of a stroke? In short, doctors should be rewarded for being doctors. Yet, it seems, the infrastructure is still not in place, seven years later, to do the job properly. When the health ministry sent her to Portugal, notes Avraamidou, to see how their version of Gesy works, their system was putting out automatic daily alerts “that this or that patient is diabetic, and six months have passed since their last check-up”. Here, on the other hand, “right now the HIO software can’t even let me find, with a single click, who my diabetics are”, let alone what their needs are. As for referrals, Avraamidou doesn’t dispute the 35 per cent figure, but notes that many of those referrals – actually, she claims, most of them – aren’t initiated by GPs themselves. Instead, what often happens is that a patient – often a chronic patient, someone with myasthenia or rheumatoid arthritis – makes an appointment with their specialist, who then directs the patient to their GP to issue a referral. The GP never even gets to see the patient. Her own proposal, she says, is for such referrals to be marked down to the specialist (as long-term referrals), not ascribed to the personal doctor. The report isn’t just about personal doctors. It also recommends, for instance, scrapping the so-called global budget for specialists (basically a lump sum, incentivising them to provide as many services as possible) and instead setting volume caps based on the population’s health needs – though, again, we’d first need to have better data, so as to calculate the population’s health needs. Other proposals seem more minor. Tightening the criteria to become a personal doctor has already happened, more or less, after the initial free-for-all to make up the numbers. Making it harder to change one’s personal doctor would be useful (as things stand, patients can threaten to leave if a GP is slow to provide referrals) but not too radical – though it does indicate that patients, not just doctors, need a change of mindset if Gesy is to survive. In the end, the most important bit of the report may be ‘Policy option 7: Incorporating patient decision aids into personal doctor consultations’ – not for what it is, but for what it represents. The proposal is simple, to incorporate special tools (often AI) that illustrate to patients what their options are, with the GP guiding them through the process – what Avraamidou calls “shared decision-making”. This, in a nutshell, is the relationship of trust – putting the ‘personal’ in personal doctor – that Gesy is based on. Unless and until people start seeing their GPs as trusted partners, as opposed to bureaucratic appendages whose role is to sign bits of paper, it’s unlikely the system will change for the better.