FAMILY MEDICINE AND ITS VALUE IN THE SYSTEM OF POPULATION MEDICARE. TABLE OF CONTENTS AND ORGANIZATION OF FAMILY DOCTOR WORK (GENERAL PRACTICE)
The leading role of the out-patient care in medical service of the population is oblige heads of corresponding medical establishments and all medical personnel constantly to improve of its multi-sided activity.
Changes of ideology and economic conditions at transition to the market relation have caused necessity of development and an embodiment during a life of the actions directed on reduction of system of health protection organization in conformity to inquiries of a society.
Heads have begun reforming system of public health services, one of which directions is transition to giving the service on the basis of medical insurance. This work will last certain time, its rates in different regions can be different, that is caused by is the following objective reasons:
• State of economy;
• Development of all infrastructure of medical service;
• Change of structure of the population;
• Character of a pathology;
• A level of management and development of a certain areas, cities, areas.
The psychological factor play significant role in the state of training of heads of various levels of management, consciousness of necessity of reforming of certain areas of national economy (including public health services) by workers of this or that area, readiness of managers and subordinates for introduction of new bases, forms and methods of work in to practical activity . It is necessary also to take into account the necessity of training of the population to changes in usual for them system of public health services.
Reforming demands training and retraining of medical workers to work iew conditions, redistribution’s of the medical service between medical establishments of corresponding levels. It will lead to delimitation of fields of activity between structures of primary, secondary or tertiary medical service. Thus the role of primary health care (PHC) will considerably increase.
In world practice from the beginning of 60th years the concepts of primary care (PC) were introduced. In 70- th years other term appeared- primary medical care (PMC) and primary health ( medical sanitary) care (PHC) .
The committee of Institute of medicine in the USA (1995) has offered is the following determination: primary health care (PHC) is provision of the integrated accessible service concerning public health services by clinical physicians who are responsible for the significant majority of needs of public health services of a person, promote development of long –term partnership with patients and practice it at the family level and the community.
The European regional bureau by WHO has given is the following determination: primary health care (PHC) includes consultation and first care which is given an individual ly or by group of experts on public health services and related trades with it with the preventive and medical purpose.
Formulated in bases of the legislation of
(1992) the concept about the primary health care coincides with other determination of the WHO, namely: PHC is the basic medical and preventive service, simple diagnostics and a direction in difficult cases on consultation of higher level and the basic sanitary – educational actions.
It is a little narrower in comparison with determination of the
PHC is not only treatment of the widespread diseases and traumas by the basic means, but also assistance in the organization of a balanced diet, provision with good-quality water, carrying out of sanitary – improving actions, public health services of mother and the child, immunization against the basic infectious diseases, prophylaxis of endemical diseases and struggle against them, sanitary education of the population.
Reforming of public health services in
Functions of PHC are not limited only to medical service. A priority of its developments is connected also with the need to provide:
The guaranteed volume of the medical, psychological and social service;
Availability of corresponding medical and social services to all population;
Continuity of supervision over patients.
High-grade functioning of PHC needs the solution of some problems:
Carrying out organisation of actions;
Determination sources of financing;
Improvement and reorganization of infrastructure of PHC;
The coordination of its interaction with other kinds of medical service;
Trainings and retraining of medical and other staff;
Carrying out of corresponding sanitary – educational measures among the population .
PHC is a link providing the solution of the majority of problems of health of the population. PHC service possible with observance of the main principles, determined by WHO (the Alma-Aty conference, 1978):
Belonging to national system of public health services;
The maximal proximity to a residence and work of a person;
The maximal availability according to a level, volume, technologies and term of medical service giving;
Conformity of vocational training of experts and material base;
Service of provision of impressionable groups of the population (women, children) and persons who work in harmful conditions;
Regulation of activity of PHC by corresponding normative documents.
The decision of is the following problems is put on the PHC:
Diagnostics and treatment ill recovery or complete indemnity patients on the most widespread diseases, including not therapeutic type;
An after-care after reception of other kinds of the service;
A target direction for reception of medical care in cases which are outside the competence of the doctor of the common practice;
Carrying out of a complex of preventive actions;
Prophylactic medical examination of patients with orientation to pre-medical diagnostics and medical-social preventive provision ; Emergency service.
PHC is based on the fundamental of family medicine which introduction is determined by a number of preconditions.
First of all, it deal with economy state and a patient money.
The family doctor, working for a long time with a constant contingent, can take into account influence of various factors on their health , in particular their way of life .
He studies a person in details , his family and social environments, taking into account medical, psychological and social aspects of his state of health.
The family doctor, caring patients at disease, solves also the certain problems of the social plan, becomes the authoritative person and his advice are listened to , he can influence the different sides of life of the population.
So historically happened , that family clinical school, unlike a foreign one , was always marked by its skill to treat the patient, not his disease. District doctors in many respects play a role of family doctors.
Organizational forms of family medicine in the different countries of the world are different, never the less their principles do not differ in there essence.
The principles of family medicine recommended by the decisions of the International symposium on public health services (Saint Petersburg, October 1995 p.), are the following:
Supervision over rather stable contingent of the population taking into account medical -social problems of family;
Providing a family with a free-of-charge, available, continuous and constant PHC;
A free choice of the patient of the family doctor;
Central figure of PHC is a family doctor ( general practitioner);
the basic form of the organization of work – group practice of doctors, nurses and other workers.
At different stages of PHC activity and also in different countries PHC are represented by different experts : family doctors, doctors – therapists, pediatrists, obstetrics-gynecologists. Practicing medical sisters and assistants to the doctor after corresponding training, social workers involve in PHC activity.
The main person in PHC is a family doctor (the doctor of the general practice).
Tasks of the family doctor are determined by the European union of doctors in 1984.
Family doctor is a graduated medical worker who personally gives the primary medical sanitary and continuous service to separate patients, to families and the population of a site, irrespective of age, a sex and a kind of disease.
He services patients in rooming a place of residence, sometimes in hospitals. He possesses a priority in the decision of all problems of patients.
A family doctor constantly looks after patients with chronic, relapsing and incurable diseases. Long contact to them allows to trace a situation, to adjust good relations based on trust. The responsibility for health of the population is based on cooperation with colleagues of medical and non medical spheres. Models of work of family doctors can be very different.
An individual practice in
Group practice prevails in
The centers of health are distributed in the Scandinavian countries.
And these models can coexist.
Medical service of family doctors on the basis of polyclinics is most popular to some countries of the East Europe and the countries of former
In Czech in PHC, except for doctors of the general practice, pediatrists also take part . Doctors of the general practice have the certain business hours, if necessary, patients go to the centers of first care of a primary link of public health services.
The doctor can advise them concerning diseases and methods of treatment, to direct to specialists, to provide the continuous service at chronic conditions. It is very important as for the way of the control over cost of treatment, over use and rational distribution of resources.
The average number of visits on one inhabitant depends on age and sex and makes 5,0 during one year.
The experience of system of family practice in
The population of the country has the right to a free choice of the doctor and is in overwhelming majority is satisfied with him (85 %).
Family doctors provide with treatment almost 90 % of patients and only 10 % are directed to narrow specialists.
All day and night they observe a state of health of 1800 patients (on the average) during all their lives. At his disposal a family doctors has means at a the rate per on one patient .
Several workers are subordinate to each doctor:
nurses;
a secretary;
a computer operator ;
a manager;
a bookkeeper.
They are employed in brigade PHC, taking into account expediency and financial opportunities.
Besides doctors can cooperate with the midwife, the physiatrist, the psychologist, diet nurse, the logopedist, the worker of service of public trusteeship which are financed from other sources.
Except for the doctor»s visiting , if necessary, patients can call him to there places in case of significant worsening of a state of health.
Average of visits during one year – 3-4, about 10 % from them are medical care at home as in Britain it is not done to visit patients with fever and infectious patients. The advanced network of roads, high security of the population with motor transport, culture of mutual relations influences this process. Besides the significant part of contacts is correspondence and is connected with repeated prescriptions.
The doctor spends approximately 9 minutes for one visiting (on the average 7 visits in one hour).
In
In the
In
It is necessary to note, that according to the British doctors of family practice – at beginning symptoms of disease quite a big part of patients (up to 75 %) start in self-treatment and only 25 % see a doctor. It concerns mainly acute short-term diseases and which do not result in significant worsening of a state of health.
Family doctors in the
prefer group practice. It enables to organize mutual substitution, to advise patients Total, to get and use the complex and expensive equipment.
The system of family medicine in Great Britain have been functioning almost half of century, is estimated as effective, taking into account its popularity among the population and profitability.
Nevertheless it has also unresolved problems. For example, hospitalization turn . They are connected, in opinion of workers, with increase of requirements of patients to quality of the service. To service this, the British doctors try to reduce terms of treatment in a hospital, having improved medical – diagnostic process at pre-hospital and hospital stages.
The similar problem demands the solution in many countries.
Essential influence on reduction of terms of treatment in a hospital can have expansion of medical service at the patient”s place .
From this point of view rather interesting there is working experience of agencies giving medical service at the patient»s place which have appeared in the USA in 50years and have eventually been widely spread.
Their work is directed in satisfaction of needs of the patient in his own health services and in the situations dealing with to influence of different socially psychological factors.
The interrelation of hospital and agency is of great value .The later, first of all, should take part in the process of patients discharge from hospital.
Planning of the discharge can start during patient”s stay in a hospital, and sometimes before it and allows to give the most expedient medical service, to provide all needs for services with the least expenses.
The general rounds with participation doctor, the senior nurse , one of executives of a social service and the head of the agency fixed behind a certain department of a hospital also care to plan a patient’ s discharge .
They make a decision on health services of the patient after his discharge.
At active participation of agency in planning an extract of patients the problem of continuity of medical service is solved. In addition, the staff of agency further passes doctors of a hospital the information of a state of health discharged patients.
At a direction on home treatment the worker of agency Total with the doctor determines all its methods and procedures, checks necessity of the certain services and finds out opportunities of family concerning corresponding support of the patient. It is necessary to determined a personnel for providing the care, to receive necessary equipment and different means from auxiliary services.
Medical service is provided in-home with the coordinator. To this post usually appoint the medical sister. She is responsible for the decision of all problems during treatment, a correct initial and current estimation of a state of health of the patient.
Accordingly the plan of the treatment developed by the doctor and the coordinator, the brigade from personnel of agency and a doctor working according to the schedule, made by the coordinator.
The coordinator is responsible for realization of the program of treatment, consultations of the patient by the certain specialists.
Before the end of the course of treatment provided with agency, the coordinator makes out the file the form inquiry – the information of a state of health and results of treatment, the list of medical recommendations concerning the further treatment and improvement.
The need for health services at home can arise not only after hospital treatment , but also to family doctors, patients or their relatives can go the certain agencies.
The working experience of agencies on giving medical service in conditions demands detailed studying with the purpose of the further improvement of system PHC in our country.
The experience of
Today the majority of doctors of the general practice (family) work in the state medical institutions, their insignificant part is engaged in private practice or works in official bodies.
Both an individual and group practice take place except for family doctors, the stomatologist, the pediatrist, the obstetrics-gynecologist, and also medium-level medical staff – nurses of procedural and dressing rooms the younger nurses are involved in group practice.
Family doctors conduct reception of therapeutical, neurological, ophthalmological patients and etc.
According to the expert estimation, in a transition period family doctors can provide from 36 % up to 46 % of visiting of the ophthalmologist, the otolaryngologist, the neuropathologist and about 23 % of the surgeon.
Working in a polyclinic, they use its medical – diagnostic base.
In independent medical ambulance stations, far from a polyclinic, the volume of researches is being reduced.
One doctor serves approximately 1600-2500 person. During a year on consultation to other experts about 20 % of patients, are directed on examination to other establishments – 14 %.
It is offered to plaot less than 4 visits in a year for 1 inhabitant, the probable level of hospitalization is about15 %.
Providing of interaction of family doctors with other services and establishments, including polyclinics, hospitals, clinics, the advisory – diagnostic centers is of great importance .
Thus there is a task concerning reorientation of work polyclinics to giving mainly specialized care , to performance of improving programs, carrying out of regenerative treatment with necessary use of additional medical subdivision.
Reforming the primary medico-sanitary service on the basis of family medicine,
Actually numerous medical establishments take part in giving PHC: independent polyclinics and ambulance stations (including ambulance stations of rural district hospitals), polyclinic branches of city, central regional, regional hospitals, children’s polyclinics, female consultations, medico-sanitary parts, and also establishments of the pre-medical service (PMS). Establishments of emergency join them also.
The primary medico-sanitary care in modern conditions is provided by district therapists and pediatrics, nevertheless its volume is far from the desirable one in connection with doctors of other specialties.
The first stage, preparatory, began in 90th years and includes development of normative – legal documentation, training and creation of material, organizational base, approbation of different models.
At the second stage the reform aimed at introduction of the general medical practice in to out-patient – polyclinic network.
First it is recommended to join district therapists, pediatrists and obstetrics -gynecologists. In modern conditions they, as a rule, work in different medical establishment. Therefore the basic problem is providing the coordination of their actions. Further district therapists and pediatrics will be responsible for the care at diseases of not therapeutic type.
Day time and family hospitals will be widely used, organizational associations of therapeutic and pediatric department will pened, in one establishment family brigades will be created.
Studying of world experience of giving PHC on the basis of family medicine and experience of its development in our state has allowed employees of the Ukrainian institute of public health to offer three organizational models of reforming of district -territorial system:
• Group practice of medical care in the form complex of brigades
(therapists, pediatrists , obstetrics-gynaecologists);
General practitioner who gives medical care to the population allot to him (adult or children’s);
A family doctor who serves all family realization of gradual transition to practice of the family doctor (the doctor of the general practice) demands significant time expenses. Transfer of children on service to the family doctor will be carried out in the certain sequence. First children older 12 years will pass to him, then – 7, 3 years and 1 year, and at last – all others. The end of this stage will finish transition to a family principle with the right of a free choice of the doctor.
A family doctor in
He can work an individual ly or with other doctors (group practice) in:
Official institution (a polyclinic, city or rural medical station , a medico-sanitary station), not state medical institution (the small, joint-stock, collective enterprise, cooperative society).
• A private (an individual ) medical ambulance station.
Taking into account economic profitability an individual practice is reasonable in settlements with a small population, iew districts of cities without the advanced infrastructure, at straggling districts.
Development of family medicine requires the solution of a complex of legal, economic, organizational tasks with regard for the psychological factor – readiness for recognition of is the following system of the medical service by medical workers and patients.
The free choice of the doctor can be realized on is the following terms:
Opportunities of this or that doctor to provide medical care to optimum number of patients;
Distance from a patient’s to a place of work of the family doctor;
Opportunities or convenience of reception of medical service from doctors of separate specialties.
The solution of this task, as well as other problems concerning the doctor – patient – medical establishment -city administration ” demands determination of administrative – legal bases of activity of family medicine as a whole, its place and mutual relations in the system of the medical service and etc.
Task of the family doctor in the certain measure are identical with problems of the district therapist as in both cases the question is service of a concrete contingent and performance not only especially medical actions. Nevertheless ,there are also the differences connected first of all with the fact that that the family doctor gives the service not only concerning diseases of
a therapeutic type .
A doctor of the general practice (family) independently starts and finishes treatment of a great number of patients, if necessary send them to advisers or directs the patient on hospitalization in the scheduled or emergency order.
Practical actions of the family doctor concerning :
Diagnostics;
Emergency call services;
Emergency hospitalization;
Consultations of other doctors;
Self treatment and treatment on consultations of advisers;
Scheduled of hospitalization.
Duties, rights, the responsibility of the family doctor and his relations doctors are determined by corresponding .
A family doctor provides:
-Outpatient reception hours and home visit;
-Carrying out of preventive, medical, diagnostic and rehabilitation actions
in the cases stipulated by qualifying characteristics;
-Giving emergency call service if necessary ;
-The organization of day time and family hospitals;
-The help in the solution of medical-social problems of family;
-Carrying out anti-epidemic actions in the centers of an infectious disease;
-Informing about cases of infectious diseases doctor of room of infectious
diseases and sanitary -epidemiological station.
A family doctor guarantees to the population:
-early diagnostics;
-complete value timely out-patient and family treatment ;
– a timely direction to the specialist ;
– organization of hospitalization of scheduled and emergency patients.
The family doctor, according to the agreement, may have some beds in a hospital for treatment his patients.
Abilities and practical skills of the family doctor should include :
– be able to use a technique of previous diagnosing;
-definition of necessity and sequence of application paraclinical methods
of diagnostics, a skill of their correct to estimation ;
-definition of the clinical diagnosis;
-definition of tactics of patient treatment (the emergency call service, emergency hospitalization, scheduled hospitalization, necessity of consultations of other experts, out-patient treatment);
Giving emergency call service at extreme condition (all kinds of a shock, acute heart and vascular insufficiency, etc.);
Carrying out of the most widespread manipulations;
Making of plans of prophylactic medical examination and rehabilitation patients and participation in their realization;
The solution of tasks of disablement of invalidity
Carrying out of prophylactic work with the population.
Mutual relations of doctors of family practice and specialists , including those of stationary establishments, are determined by corresponding contracts.
Depending on forms of the organization family doctors in some countries can cooperate not only with family medical sisters, but also doctor’s assistants .
Duties of the family medical sister are rather varied. She actively participates in carrying out preventive, anti-epidemic and sanitary – educational work, pre-delivery and postnatal home nursing of pregnant women and lying-in women, provides of a material for laboratory researches, gives emergency medical service, services the doctor at surgical operations, carries out the control over patient’s performance of medical and improving recommendations.
Medical workers of system of family medicine actively cooperate with services of social security.
Social worker can be a subordinated to a family doctor under the agreement with states of social security.
A family doctor has the right to charge to the middle-level medical staff and social workers some kinds of activity which do not demand medical knowledge.
