ForUm has had an interview with the head of the department on medical assistance development and reform Kostyantyn Nadutyi to learn about why there is a necessity to introduce family medicine practice in Ukraine, what the population should expect and how it will influence the employment situation.
-What is the necessity to introduce the practice of family medicine in Ukraine?
- The level of population's health in Ukraine is worse comparing with European countries. We have higher cardiovascular and oncology mortality rate (60% against 50% in Europe) and lower life expectancy (62 years against 75-85 years in Europe). These rates partially depend on the work of the healthcare system.
Prescribing pills and treatment, we can control only 10% of health, while 90% do not depend on medicine, but other factors, including lifestyle - 40%. And here a family doctor comes. This family specialist is a general practice doctor, who treats whole families, not separate individuals and separate diseases. This is a doctor, who knows the family, knows what they eat and how they live.
We have different times now, when infectious diseases are no longer the biggest problem, thus the system of mass preventive care, which does not take into account individual differences, is no longer needed. Now we have to deal with hypertensive disease, ischemic heart disease, diabetes, asthma, phthisis, etc. Such diseases cannot be treated with mass preventive measures.
- The situation is clear from viewpoint of the very system, but how will it influence the patients?
- In this case, we have to understand whether the right to visit a subject matter expert at will is good or evil. As a professional, I am telling you it is evil.
A patient cannot establish a diagnosis by himself, and a subject matter expert sees the problem from one side only. Thus, we need a general practice doctor, who treats the patient as an integral organism and understands interrelation of different systems. The general practice doctor must be the first to examine the patient and define the need.
I will give an example. A 60-year-old man has five or six chronic illnesses. This is a fact. This man goes to specialists on each problem and every specialist prescribes four or five medicines. As a result, the patient gets a whole chemical plant in one bag. To take or not to take? Who can decide on the priority? None of the subject matter experts can do this, as they do not know other disciplines, but theirs. For this, we need a general practitioner, who will define priorities among pathologies and who will send the patient to right specialists. The general practice doctor can even cooperate with subject matter specialists to know how to control further treatment.
We have launched pilot projects in several regions, and there is an order, according to which a patient can go only to a general practitioner first. This family doctor will examine the patient and will decide on whether to send him to a subject matter specialist. The family doctor practice will be introduced all over Ukraine by 2020.
- Is Ukraine ready to overcome the old system and start practicing the new format? What are the main obstacles in the process?
- Many medical workers, unfortunately, are used to the current system and do not want changes. And if a 50-year-old physician, who has been working with adult population only, is told to become a general practitioner and take responsibility for children, it is understandable that he is not convinced. The reformation process takes time, and we give eight years for this. Moreover, the requalification is free of charge.
- What is the system of requalification?
- For today, we have two ways - to teach and to retrain. Students graduating medical universities can chose general practice for internship, and doctors of specific specializations can study at the postgraduate department t o become general practitioners. Before 2020, the requalification is free of charge. There are educational plans, already made until 2015. The requalification term is half a year. There is a list of diseases for every general practitioner to know. It includes 30 the most common diseases and 170 common enough. Thus, there are 200 diseases and conditions a general practice doctor must know in details. It does not mean he must be a gynecologist or a surgeon, but he must know how to take a splinter out... Six months for requalification is enough.
- But you know that the society already has an opinion about the quality of such requalification, and not a good one, as theory is one thing and practice is another...
- Yes, we do know, but I want to add that such rumors are spread by certain categories of subject matter specialists, who do not want changes or fear fall in demand. However, we must focus on the interests of patients, and if the world practice proves the new system is more effective, we have no right to risk people's health.
What we have now is irresponsible line, when a patient visits one doctor after another but leaves the hospital sick as before. Every doctor looks into his keyhole, but nobody assesses the general condition of the patient.
- Do you think the new system will strengthen doctor's responsibility?
- I want to point out that we modify the payment system as well. For example, if a doctor misses visual signs of cancer or tuberculoses, his payment will be reduced. Thus, apart from disciplinary responsibility, the general practitioner will bear financial responsibility as well. We introduce the model of capitation, and in this case for doctors it will be more profitable to render high-quality medical services and have healthy population. The system is still under development, as it is not perfect yet. For us it is the first and difficult experience, as financial specialists not fully understand it yet.
- You were speaking about fall in demand. How big will be the staff cuts, and where will doctors go?
- Well, if the family medicine starts working in full mode, the demand for subject matter specialists will indeed fall, by 30-40%. But on the other hand, we have about 100 thousand working pensioners, both doctors and nurses. The older the person, the more complicated the process of requalification for him. Within the time, doctors lose qualification, and if this or that pensioner will not be able to prove his skills, then, we are sorry, but he will have to retire. These 100 thousand pensioners are some kind of a buffer to prevent social disaster and mass cuts.
At the same time, we need local incentive to keep young specialists. We need a special program to motivate young doctors to stay on one place. And this is the task for local authorities, as the Healthcare Ministry cannot solve everything.
The key principle of family medicine is long-term contact between a doctor and a family. Now imagine, if the general practitioner becomes a family doctor at 60 years old, what long-term contact we are talking about. Thus, we have to motivate young specialists to stay on one place and work with the same families for 30-40 years. Europe has been practicing this system for 20 years already, and thanks to President's program, we can do the same now.
- The reform has been launched. Do we have any visible results already?
- Countrywide, every third patient is followed by a general practitioner, but unfortunately, not all general practice doctors follow the procedure of general practitioners. Every general practitioner must have an exam room and a medical treatment room. If you see in a hospital 10 offices of the so-called general practice doctors, but there is no room for medical procedures to make an injection or take a blood test, then this is not the general practice, but ordinary physician with a different name.
Fortunately, many administrations understand this, and in Kyiv we already have 76 similar clinics in operation. By the yearend the number will increase to 103, meaning every fifth patient is treated properly and according to the new system. I don't state that everything is perfect there. We receive certain complains and claims, but still we are on the right track. Family medicine is not only a general practice doctor, but also adequate equipment and environment. We are working on this, and in the pilot regions (Donetsk, Dnipropetrovsk, Vinnitsa regions and the city of Kyiv), the proper level will be reached within the next year or two. As for other regions, the situation will depend on resource provision, state and local budgets' support.
- How costly is this 'affair'?
- Creation of one center of primary assistance requires two million hryvnias. We have built 179 clinics already. But these are preliminary calculations. I believe it will cost more, as we have satisfied only 80-90% of needs. Moreover, we have certain difficulties with financing. We know that minimum 5% of GDP must go for financing of healthcare for the system to live and develop. Less than 5% means the system does not develop and less than 3%means the system is dying. We have 3.3% now.
- No, we are not dying, but we are not developing either. In the regions where the local authorities pay attention to the healthcare sector, the development is pretty good, but there are regions where local governments are engaged into politics and populism only, thus the problems appear. Medicine is a science, and if its development is not scientifically-based, it will never come to anything in the end.
And of course, we need money. Medicine is a resource-intensive system, and centers of primary medical assistance require obligatory investments to work properly.
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