status quo of quo vadis? - KCE

54 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76
4 ELEMENTS FOR A QUALITY DEVELOPMENT
FRAMEWORK FOR GENERAL PRACTICE IN
BELGIUM: STATUS QUO OR QUO VADIS?
Quality development in general practice is only emerging in Belgium. Successful
countries needed a long period (10 to 15 years) to achieve results. This work gives
directions to set up a system for quality development in general practice in Belgium. The
first section proposes a brief evaluation of the current quality development initiatives in
general practice described in chapter 1.4. The data from the review of the five countries
(chapter 2) and elements of the feasibility study of EPA (chapter 3) give additional
features for a quality development framework in Belgium.
4.1 EVALUATION OF CURRENT QUALITY DEVELOPMENT
INITIATIVES IN GENERAL PRACTICE IN BELGIUM
Few studies analyzed the impact on the current Belgian quality development strategies.
Most strategies focus on the individual GP whilst no strategy targets the GP practice.
‘Accreditation’ for GPs in Belgium requires GPs to fulfil criteria e.g., CME, peer review
and minimum number of patients. It is not mandatory: GPs may perform acts without
being ‘accredited’ but with a lower remuneration. However, most practicing GPs did
earn an ’accreditation’ that allows higher payments. Unfortunately, there are few data
on the effectiveness of this procedure i.e., on its effect on the quality of care provided
by ‘accredited’ GPs versus the GPs who are not ‘accredited’. More research is needed
to explore the effectiveness of this ’accreditation’ procedure and CME sessions. Among
others, the use of learning agendas and portfolios may be considered.
Peer Review groups (LOKs – GLEMs) also play a major role in the Belgian quality
landscape. Doctors believe they are important but firm evidence of their efficacy is
lacking. The trends towards group practices and large-scale after-hours care services in
Belgium will provide other means for GPs to build professional relationships. Peer
review might be successful but its role needs careful revision. Maybe the formal use of
the quality cycle, based on real, timely and trustable data could improve the value of the
GLEM/LOK meetings.
Finally, the effectiveness of feedback on prescription has not been demonstrated for
GPs. Only a small number of GPs, who are definitely outliers, see their behaviour
questioned. The double role of the RIZIV/INAMI, both payer and controller, creates
mistrust among the GPs: in the EPA field study (chapter 3), GPs frequently mentioned
they fear the handling of their data by any governmental agency.
The cost of the existing ‘accreditation’ procedure for GPs in Belgium can be estimated
using the RIZIV/INAMI statistics on reimbursed consultations and ‘forfait’ data. In 2005,
25 396 607 consultations have been done by 10 223 accredited GPs 139 . This represents
an extra budget of 68 316 873 euros when multiplying the extra fee of 2.69 euros (rate
2007) by the number of consultations. The global lump sum budget for GP accreditation
(‘forfaits’) was 5 474 398 euros in 2005. The sum of both budgets can be estimated at
least at 73 791 271 euros. A few other nomenclature codes are not considered in this
estimation e.g., technical acts and patient surveillance.
4.2 LESSONS FROM THE REVIEW OF FIVE COUNTRIES
The literature in the countries under study showed that a single intervention is not
likely to lead to any considerable increase in quality. The most successful countries
(Australia, the Netherlands and the UK) have a strong culture of quality but a long time
(10-15 years) was needed before any tangible impact. This triple experience also shows
that the introduction of quality development is a driving force for boosting up the role
of general practice in the health care system.
The most remarkable finding is that these countries apply quality development
strategies at multiple levels. They focus on the level of the practice that is the most
important and currently missing in Belgium.