Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias

KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 115
6.8.1.2 Financing policies
Financing policies did not get very high scores in comparison with the other topics. A
cross-topic comparison clearly shows that they were dominated by teaching and
organizational policies (figure 1). How to explain that result? As mentioned in the
European Observatory review, the payment mechanism cannot be separated from the
institutional context of the health care system 222 . The implementation of a new
payment mechanism disregarding the other aspects of the health care system may not
work very well 222 . Indeed, a capitation payment system usually restricts the free choice
of the patient and the GPs often become gatekeepers to specialized care, with a
stronger role in the evaluation of the patient’s needs. However, the highest scored
policy was incentives for practicing in underserved areas and the most-preferred policy
in the financing field was the capitation in addition to other fee-for-service. There was
much less convergence for the other financing policies.
The criteria analysis shows that some policies were good at improving the attractionretention
of GPs and the accessibility of care but they were not as good in terms of
cost-benefit and acceptance by other health professionals.
The policy relating to the capitation was more accepted by GP stakeholders than by the
other stakeholders groups. The policy improving the incentives to start a practice in
underserved areas was less supported by GP stakeholders than the other groups and by
Dutch-speaking stakeholders than by French-speaking stakeholders. This means that a
measure like Impulseo I does not seem to be supported much by the GPs themselves.
Most countries from the European Union have mixed system of payment, combining
fee-for-service with capitation and, in some cases, with target payment 2 . Belgium is
among the very few countries relying almost entirely on fee-for-service to pay GPs.
The most discarded policy in this topic is the combination of wage-earning and fee for
service. The term “wage-earning” is indeed against the conception of a “liberal”
profession for most stakeholders: they do not understand how this could be
implemented in practice. For a few of them it is far too expensive for the society.
Others think it is a current tendency because it will offer economic comfort to the GP
and allow him to practice a better medicine. Discarding salaried payment is not
consistent with the literature study showing that salaried contracts offer positive
incentives to GPs’ recruitment 171 , particularly for working in deprived areas. It is
consistent with the European situation where salaried payment are not frequent 222 . A
system relying on salary payments should be applied in very specific contexts, such as
areas with a very low population density: that statement from the literature is
consistent with the stakeholders’ results supporting incentives for practicing in
underserved areas.
6.8.1.3 Work-life balance policies
We faced a very interesting paradox for work-life balance policies. On one hand all
stakeholders agreed that, from a GP’s perspective, quality-of-life was the most
important criterion to choose policies improving GPs’ attraction and recruitment. On
the other hand, work-life balance polices got rather modest scores (4.7 for evolving
career and 4.5 for scrapping the individual compulsory emergency duty). The criteria
analysis explains the reasons: those policies would be good for the attraction but not
for the accessibility and cost-benefit. Thus, although these two policies are good for the
GPs themselves, the stakeholders worried about their negative effects on health care
access or on cost for the society.
However, two policies stand out among the work-life balance policies:
• the support of an “evolving” career: to increase the quality of medicine
by the diversification of the work, by meeting specialists, by a better
knowledge of the practice for the teachers, and by the possibility of
taking a break and thus preventing the burn-out;
• to scrap individual duty obligation: to decrease the pressure linked to a
continuous availability, especially at difficult times like evenings, nights,