How Can You Do a Primary Care Exchange in the Midst of Global Pandemic?

Earlier this year, I was selected to attend the 2020 WONCA Europe Pre-conference Exchange in Berlin. Conference exchanges are one of the activities offered by the Vasco da Gama Movement – they usually involve spending a couple of days shadowing a GP from another country before attending a conference in that country. They are a fantastic opportunity to gain an insight into another healthcare system  and  a way to share knowledge and create friendships with international colleagues. I was really excited: having had my first experience of a pre-conference exchange in Croatia last year, I knew that a few days in Berlin seeing their system of primary care first-hand and meeting new colleagues was an opportunity I couldn’t pass up. I’ve had the pleasure of visiting Berlin a couple of times in the past (looking for a photo for this blog post made me realise that the last time was 10 years ago, which means I’m well overdue a return trip) and have always enjoyed myself there. Then of course, COVID hit and everything was postponed from June until December. Still optimistic at this point that we might still get our exchange, the thought of Berlin in December was conjuring up images of Christmas markets, glühwein, lebkuchen… but sadly, it was not to be. With the inevitable second wave of COVID, the conference and pre-conference went virtual. Whilst conferences and meetings have a somewhat easier time with the transition to online platforms (putting the difficulties with ‘Zoom-fatigue’ aside) I didn’t really see how an online exchange would work.

I had clearly underestimated Rocío, our new exchange coordinator, and the German host team (including Christian, who is also on the VdGM executive board and who was interviewed previously by Sonia here), who were determined not to let the small matter of a global pandemic stand in the way of an exchange. And so, the day before the VdGM pre-conference, and on the eve of Germany’s second lockdown and London’s transition to Tier 3 restrictions, I took part in the first ever virtual European primary care exchange. From the comfort of our own homes, 29 participants from 14 different countries were able to meet and visit 3 different German GP practices (located in Jena in Thuringia, Tübingen and Boxberg in Baden-Wuerttemberg) – these are marked on the map below to give you an idea.

The locations of the 3 practices where the exchange was held

We spent some time getting to know each other, and also working each where we were geographically – by plotting our locations on a map, we could see that we were spread all over Europe, with Germany right in the centre. We kicked off with an overview of the German healthcare system – this is a world-renowned service and I was keen to learn more about how this was organized.

Germany’s healthcare system is a mix of public and private: family doctors are self-employed, and there are both state and private health insurance providers. Those who are self-employed, or earning above a threshold of salary can choose between the public and private insurers, but employees earning below the threshold are automatically enrolled in the public insurance system and pay a proportion of their salary towards this (having health insurance has been mandatory in Germany since 2007). Those who are unemployed will have their health insurance costs covered by the state, but in general, healthcare is not state-funded (this is known as the Bismarck Model). Although this is a contrast to the NHS system I’m used to (based on the Beveridge Model where the service is funded from tax payments), practically, the principles and ethos of the German healthcare system seemed to me to be similar: since medical bills go directly to the insurer, patients are not left to fund their medical bills so their should be no financial barrier to access, and everyone has access to same level of care no matter what their earnings are. This is referred to as the ‘principle of solidarity’. For me, this is one of the most fundamental aspects of any healthcare system – I believe no-one should be denied access to basic healthcare simply because they cannot afford it. Another of the main principles of the German system is that of self-governance, where decisions around financing and other aspects are made by bodies of representatives of healthcare professionals and the insured public, effectively meaning that the system is run both by and for the people.

German family physicians are not gate-keepers to secondary care, patients can also choose to access specialists without the need for a referral (although this is usually preferred), and similarly, they have free choice over their GP. They don’t need to be registered with a particular GP or practice, so can change around as much as they like. I wonder how this impacts on continuity of care – without transferable electronic patient records, I imagine that patients with more chaotic lifestyles or those who move around a lot might get a lost in the system, but overall, it seems that patients do generally stick with their GP and they definitely have their ‘regulars’, particularly in the more rural practices where seeing your local GP is far more convenient. Given that even with the freedom to go directly to a specialist most patients see their GP first, I see this is a sign of the strength of primary care, and the combination of free choice and universal health coverage seems almost idyllic!

Being able to have a look around the clinics was a bonus: all three were really bright and looked very modern, and we were soon all discussing how jealous we were! Some had facilities that I’m not used to in my practice: it’s quite common for German GPs to carry out ultrasounds so they had dedicated rooms for this, and some had access to point of care blood tests (troponins for example), which is not so common in my experience in the UK. Hannah’s surgery in Tübingen also ran a methadone dispensing scheme (complete with an automated machine that would calculate and dispense the correct dose!). It’s a busy service, seeing around 70 patients per day, and this necessary service has continued throughout the pandemic – it may have become even busier as drug supply chains have been cut and drug dealing cannot occur as openly, driving up the need for methadone replacement.

In terms of COVID, Germany had a relatively low rate in the first wave with localised outbreaks and an early lockdown but like much of Europe is now being hit harder during this second wave, which has triggered this stricter Christmas lockdown. While there were clear signs of the impact of the pandemic (the addition of some steps to a window for patients who only needed to collect a prescription to avoid them coming in, a shelter in case of rain for patients who would need to queue socially-distantly outside, spaced out seating in the waiting room) it’s clear that most patients are still being seen face to face as default, albeit with PPE. This seems so unusual to me, having spent the last nine months consulting remotely by phone and video with the majority of my patients (but let’s be clear: still seeing patients in person when clinically indicated), and many of us commented on how there was almost an air of normality. Partly this is influenced by available technology: in the UK we were well-placed to quickly convert to remote consulting in many areas. Also, in Germany, GPs are responsible for carrying out the COVID testing as well, so perhaps seeing large numbers of patients in person since the start has influenced this as well. Reflecting on this with colleagues afterwards, we debated whether the UK had ‘got it right’ in terms of our rapid conversion to remote consulting – although we are protecting our patients and many issues can be easily and efficiently dealt with remotely, are we also missing out on those non-verbal cues and rapport-building with patients? Going forwards, I think that some degree of remote consulting will remain after the pandemic has settled, but we will certainly need to consider lowering our threshold for face to face consultations whilst ensuring safety and considering patient choice in this, and I think this is something we can learn from our German colleagues.

So, although it’s not the same as being there in person (we obviously couldn’t meet in person or sit in and observe consultations with patients) in the context of the current situation it is vital that we maintain these connections and create opportunities such as this in whatever way we can. The virtual format had some real advantages – with 29 participants, more of us were able to get involved and this allowed for a wider comparison and discussion of each of our experiences, and I can imagine that eliminating the travel time and costs would make it much easier for those from lower and middle income countries to attend. This was a really innovative way to get some experience of the German healthcare system, and I’m really grateful to our German hosts and organisers for making this happen – danke schön to you all (and also muchas gracias a Rocío)! Now I’m off to enjoy the rest of the virtual WONCA conference with a slice of stollen, the best I can do until I can visit Berlin (properly) again.

Previous (pre-COVID) visit to Berlin – yes that is 10 years ago!

Since I wrote this blog, two new virtual exchanges have been announced (and both sound amazing): a joint VdGM-Waynakay exchange with Brasil, Mexico and Peru on 14th March and a Madrid Conference Exchange on 24th and 25th March – contact your National Exchange Coordinator by10th March to find out more and apply (find their contact details here).

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