Apologies for the radio silence! As some of you know, I have started a Masters in Medical Anthropology in October last year and I had three assignments to hand in in the space of two weeks in January! I’ll definitely write up a blog post on how this is going and about how much the content is blowing my mind but you’ll just have to wait!!
This week, I have a post from the lovely Dr Natascha Burgert, a member of the Exchange Team on the RCGP JIC. Here, she describes her funded trip to Italy under the Erasmus scheme to observe primary care in a different setting. Having just been to the Vasco da Gama (VdGM) Forum in Torino last September, I can really see the attraction of Italy with its mouthwatering cuisine and innate sense of design and style. Two major cultural lessons that I learnt from my Italian colleagues back then was that cappuccino is a morning drink only and pineapple is not ok on pizza. Lesson learnt. Anyway, over to you Natascha!
Erasmus exchange in Italy
I did a two-week funded Erasmus Plus exchange to Tolentino in the Marche region of Italy. A small rural hill town in central Italy with a population of about 20,000, it has a beautiful old centre, which boasts a number of churches and old palaces. It also lies close to the epicentre of the 2016 earthquake, which sadly damaged a large proportion of the old buildings.
Whilst there, I shadowed Dr Paola Mutani, a single-handed GP with 1500 registered patients (the maximum allowed by the Italian healthcare system), who has worked in the area since 2004. She works in the same building as three other family doctors as well as a nutritionist and a psychologist. As is common practice in Italy, she is able to choose her own hours depending on demand and list size. On a standard day, she spends half her day seeing patients in surgery and the other half of the day is used for home visits (usually about two a day), visits to the local nursing home and admin.
One of the first things that struck me when I arrived was the structure of each surgery session: there were usually about seven pre-booked patients with 30-minute appointments and then further patients just slotted in with anything urgent if required. The patients could talk about as many problems as they wanted and they fully led the agenda of the consultation. They often brought in test results from investigations done by specialists at the hospital for the GP to explain to them. Patients also regularly asked about their relatives’ health, commonly wanting tests organising or results explaining for their family members. It often felt like you were dealing with a whole family’s problems rather than just the patient in front of you. As the GP did not have a receptionist, she received numerous phone calls from other patients during the consultations asking for an appointment or to discuss clinical matters, creating a degree of constant interruption. The secretary and other patients also often walked into the room in the middle of consultations.
I felt the longer appointments worked very well allowing doctors to fully deal with a patient’s concerns. Although there was a rough time frame for appointments, the time taken very much depended on the patient’s needs and no one seemed to mind waiting a bit longer knowing that their own problem would be dealt with thoroughly. Of course, this relaxed attitude to time keeping may also be at least partially explained by the Italian culture. It contrasts significantly with the British system of rigid 10 or 15-minute appointments, which is not conducive to a patient-centred approach and does not make it easy to build up the doctor-patient relationship.
What initially shocked me was the limited or often complete absence of documentation about each consultation. The only record of the patient having seen the GP was the scanned in test results that they had brought in. Very occasionally, the GP might also write down a couple of words to indicate the reason for the consultation eg chronic cough. Dr Mutani asked me why we had to make notes and I explained that it would help other GPs, who saw the patient at a later date, and that the written notes were also sometimes used as proof of what had been done if the patient sent in a formal complaint. In Italy, however, most doctors work single-handedly, so there is no need to ‘hand over’ to colleagues and every GP therefore knows their patients and their previous history very well. I love the idea of having your own list of patients and feel that we have definitely lost some of that continuity of care in the British system with its large health centres and super-partnerships. According to Dr Mutani, the number of complaints received is very low; this may be because the GP, at least in rural Italy, seemed to be like an extended family member that patients trusted nearly unconditionally. It may also have something to do with the fact that the system is a lot more risk averse – patients were able to request specialist opinions, even if not necessarily needed, in contrast to the UK where the GP is the gatekeeper to secondary care.
Another big difference was the amount of antibiotics prescribed. I witnessed numerous consultations, where the patient came in with a fever or a cough and was then given a course of antibiotics, despite there being little to no evidence of an underlying bacterial infection on examination. Both the GPs I spoke to suggested the reason for this was that the patients were felt to be high risk, for example due to having diabetes or other pre-existing health conditions. The types of antibiotics given also varied significantly to the ones prescribed in the UK. For example, amoxicillin was rarely used, as the resistance rate in Italy is much higher; instead the GPs often prescribed cephalosporins and fluoroquinolones.
All drugs are prescribed by brand name rather than as generic preparations, so drug reps were regular visitors to the practice. They would often speak to the GP between patients, telling them about their latest product and giving out free samples; even the GP teaching session I attended was run by a drug rep. Not having to prescribe generic drugs in line with national or local guidelines meant that the patient had more options available to them (eg combination treatments), but it made me nervous seeing how much influence the drug reps had on what was prescribed.
Have you changed your practice in the UK?
Although there are disadvantages about having your own set of patients, especially when you run a single-handed practice and want to take some time off or go on holiday, it was refreshing to see true continuity of care. This made me think about how you can keep continuity of care in our modern world with doctors wanting a better work-life balance and busier much larger surgeries. I realised that we had to find a middle ground, where the continuity of care was provided only to those most in need and there had to be a back up plan if the patient’s usual doctor was away. I am planning to do a QI project looking at how to best identify patients, who, at that stage of their healthcare journey, would benefit from seeing the same doctor (eg those in mental health crises, newly diagnosed cancers, vulnerable adults). This list would have to be fluid, so that, for example when a patient had recovered from a bad bout of depression, they would again go back to seeing any doctor.
I have for a long time felt that 10-minute consultations do not serve our patients well and that we should be more flexible with how long an appointment we offer. However, at the moment, consultation times are decided by the system and the practice you work in, so I don’t think this is very easy to change. Maybe we need to start listening more to our patients and ask them how much time they think they will need, as research suggests that they are surprisingly good at predicting this.
Has it changed your opinion of the NHS?
Although there are some areas that the NHS definitely has to work on (working hours and work intensity in particular), I think my exchange has actually made me appreciate the NHS more. I have realised how good we are at ensuring that medicine is evidence-based and that we are not over-investigating or over-treating patients. Drug companies have very little influence on the prescribing of medications, which means we tend to prescribe those with the best cost-effectiveness. We are also trained to give care in a full range of different areas including gynaecology and paediatrics, which I feel makes being a GP more interesting and varied. We have a structured training programme with well-validated exams and assessments. In Italy, on the other hand, GP training was only established in 2004 and there is no standardization across the country. Trainees do not have to sit any exams and there is no portfolio to assess the trainee’s competencies.
Final thoughts from Sonia
Observing healthcare abroad is a hugely enriching experience and not only do we learn about a different culture but it gives us the opportunity to reflect on our own healthcare system. Sometimes, when you’re knee-deep working in the NHS, it’s very difficult to appreciate what is so good about it and this time to compare and contrast often leaves our exchangees more appreciative and reinvigorated. More than this, we know that this reflection can also stimulate discussions around what can be improved and can lead to system change. I really recommend that you do at least one exchange in your life as it is a fascinating experience seeing your day job in a parallel universe. Click here and scroll down to the ‘Exchanges’ section to find out the different ways of getting involved and for contact details for our National Exchange Co-ordinator (NEC). These exchange programmes are powered through the Vasco da Gama Movement and all countries who are members to WONCA Europe are eligible to apply. If you are applying from outside the UK, click here to find out who your local NEC is and ping them an email to get the details!!!