The UEMO statement on quality issue in general practice

UEMO Quality Assurance Working Group

The paper aims to describe the context quality issue in European general practice / family medicine. UEMO Working group on Quality Assurance decided to adapt the actual UEMO Statement, adopted in May 1994, because of the changes in the discipline at the beginning of new century and following new definitions of the speciality.

General practice is an academic and scientific discipline with its own educational content, research, evidence base and clinical activity, which is oriented to primary care. The discipline is generally the point of patient’s first contact with the health care system, therefore it provides unlimited access and deals with all kinds of health problems, regardless of age, sex or any other characteristic of the person concerned.

General practice is oriented to the individual, his/her family and community; it is providing continuity of care (longitudinal or episodic), simultaneously managing both acute and chronic health problems. In general practice common health problems are prevalent, illnesses are presented in an undifferentiated way, often at their early stage, influenced by cultural, social, psychological, existential and physical dimensions. The speciality has a unique consultation process, its basic value is interpersonal relation.

Core competences of modern general practitioner/family physician (GP/FP) can be grouped within six central characteristics, fundamental to the discipline:

  1. patient centred care
  2. primary contact
  3. problem solving
  4. comprehensive approach
  5. health care service utilisation
  6. academic professionalism

The family doctors/ general practitioners are specialist physicians, specifically trained in the principles of the discipline. Working as personal doctors in their primary health care systems they provide comprehensive and continuing care to their patients, irrespective of age, sex or illness.

GP/FP respects patients as autonomous individuals, in context of their family, their community and their culture. Building partnership in managing patient’s health problems in health promotion, disease prevention, diagnose, cure, care or palliation, he (she) engages physical, psychological and social factors, utilising his (her) best knowledge, skills and patient’s trust engendered by repeated contacts.

GP/FP uses and engages resources available within the community they serve for the best of his (her) patients, using and integrating the sciences of biomedicine, medical psychology and medical sociology.

Why are changes necessary?

Over the past 30 years general practice became the cornerstone of most national healthcare systems in Europe. It is now also an academic discipline, having its own curriculum, research base and peer reviewed journals. The intellectual framework, within which general practitioners operate, is different from, even complementary to, but never less demanding than that of specialists.

It is no doubt now that several reasons emerged, creating new philosophy of good general practice. New types of evidence are being generated, creating many major changes in health care systems all over the globe. The general practitioner of the new millennium needs the evidence at his everyday work, since knowledge and clinical performance deteriorate with time; trying to overcome this clinical entropy through continuous medical education programs, having different approach to clinical learning which has been shown to keep general practitioners up to date.

In last twenty years two important changes occurred in general practice/family medicine in most European countries: more and more women practice as GPs/FDs, more and more physicians choose to work only part time.

Also in this context quality development must be considered an important tool in modern general practice. If research produces new knowledge and health technology assessment discusses, whether knowledge should be used, then quality addresses the question whether we work appropriately.

Quality issue in European general practice

In last years the objectives in European general practice changed a lot. Quality development became a tool in good practice work.

This issue can be addressed in several dimensions. The terminus quality in general practice can be used:

  1. to stress the core content of the given medical services
  2. to describe the patient - GP communication during the practice consultation
  3. to describe the continuity of care process (in episodes of care), involving different health care providers
  4. to describe good general practice and primary health care organisation as quality.

The task of general practitioners and family physicians is to provide health care for all health problems their patients might have, making the best use of available resources. In order to achieve that they use clinical audit, scientific evidence and guidelines, they are also compelled to analyse the cost effectiveness of their work.

What is quality in general practice?

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. In general practice one encounters so many cases, where scientific, evidence based approach is actually feasible: health promotion and disease prevention, continuity of care, communication skills, patient's health education, management of chronic diseases, etc.

Since quality in GP is a broad field, UEMO QA Working group states, that it implies not only good clinical care, but also appropriate medical record keeping, accessibility of general practitioner, emergency and out -of- hours services, team work, professional relationship with colleagues and patients, cost – efficiency, teaching and research.

Good medical practice nowadays means appropriate use of effective health care procedures in individual patients in specific situations. In order to be efficient and effective, GP has to base his decisions and actions on the best possible evidence. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. It is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights and preferences in making clinical decisions about their care.

By best available external clinical evidence we mean clinically relevant research. It often comes from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.

UEMO acknowledges that an enormous step forward is done in general practice in all European countries. General practitioners have to realise that they are trying to reach the same goal. There are of course considerable differences between countries, due to the stage of development and not to difference in philosophy of general practice. Some countries have already overcome the difficulties in implementing QA process, some are nearly there and some have just begun the process.

The basis for good work in general practice are general practitioner's core competences, applied within the areas of clinical tasks, communication with patients and practice management. General practice/family medicine is patient centred and scientific discipline, including three domains:

  1. contextual: using bio-psycho-social approach in every encounter
  2. attitudinal: maintaining GP’s professional capacities, vales and ethics
  3. scientific: adopting a critical and research based approach to practice.

Quality in modern general practice / family medicine is based on:

  1. solid basic medical education
  2. mandatory specific training in general practice/family medicine (planned by peers-GPs, performed at least half in general practice setting)
  3. practice evidence based medicine
  4. continuous medical education and continuous professional development
  5. participation in quality assurance activities, using QA instruments
    • clinical audit in each health care setting, quality circles,
    • individual work assessment using quality indicators of good clinical practice, following their changes over time and comparing indicators between different settings
    • groups in GP
  6. involving patients and considering patient satisfaction
  7. analysis of cost-effectiveness and sensible distribution of health care resources
  8. research
  9. teaching
  10. incentives for good practice.

At last but not at least: for the good work in general practice UEMO strongly recommends never to forget that both, patient and his GP are humans with many physical, psychical and social determinants, needing and deserving personal approach. In doctor - patient relationship, personal touch, trust and respect should always be preserved. It should, above all the professional quality, which is definitely prerequisite, contribute to the success and might lead to better results in the process of care.

Appendix

CHARTER on QUALITY in general practice / family medicine

1. QUALITY ISSUE in general practice

1.1 GP should be committed to good practice in his/her daily work.
1.2
GP should audit his/her own performance on a regular basis.
1.3
General practice should be organized in such a way that outcome review is possible.
1.4
Data on examinations, diagnoses, treatment and follow-up should be collected in a structured manner and be open for quality assurance projects, both internal and external, subject to patient confidentiality.
1.5
GP should keep record of his/her CME/CPD (continuing medical education/continuing professional development) activities.
1.6
In the group practice criteria or guidelines for diagnosis and therapy should be established for the whole group.
1.7
In the group practice data should be acquired and recorded in such a way that they can be used for assessment of the performance of the group practice utilizing the established criteria, subject to patient confidentiality.
1.8
Quality assurance projects at the level of the group practice should be conducted.

2. NATIONAL (REGIONAL) PROFESSIONAL SCIENTIFIC ORGANIZATIONS

Professional scientific organizations are supposed to develop quality criteria in the specialty that can be used by individual GPs and in group practices.

3. NATIONAL (REGIONAL) ORGANIZATION of QUALITY ASSURANCE

3.1. Quality assurance at the national/regional level requires a national/regional institution established by the profession, developing and encouraging the quality assurance projects. It is responsible to professional bodies and independent from external political and economical influences.
3.2. These professional bodies have the responsibility to develop general criteria of good medical practice, in the field of examination, diagnosis, therapy and follow-up.
3.3. Professional bodies should have the opportunity and expertise to perform external quality assurance by peer review.

4. FUNDING

4.1. Quality Assurance in medical practice is an essential element of state of the art. Therefore the necessary expenditure on quality assurance must constitute a natural and mandatory element in the general expenditure on health care taking into account the socio-economic context.
4.2. The system of remuneration for medical services, both salaried and in private practice, should contain provisions to support expenditures on quality assurance.

Literature

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