Gérvas J, Pérez Fernández M, Starfield B H
Equipo CESCA, Madrid, Spain.
Fam Pract. 1994 Sep;11(3):307-17. doi: 10.1093/fampra/11.3.307.
Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.
在西欧，初级医疗由全科医生（GPs）提供，但他们在整个卫生系统中的作用却鲜为人知。本文旨在概述卫生系统背景下全科医疗的特点，并描述其变异性和相互关系。数据主要来自两个来源：官方组织的出版物和欧盟研究项目。从支付方式、守门人功能、执业机构和工作量这三个特征方面对全科医疗的特点进行了描述和分析。尽管西欧国家将全科医疗视为卫生系统的基石，但各国在初级医疗的主要特征方面存在很大差异。全科医生与人口的比例以及患者与个体医生的关联程度存在差异。虽然所有国家都有全民医疗保险，但全科医生的支付方式各不相同。在一些国家，全科医疗的守门人功能更为发达，专科服务的使用也相应有所不同。诸如工作量、会诊时长、检查医嘱和复诊预约等执业特征也因支付和守门安排的差异而有所不同。特别是，按服务收费与医患关系较弱、全科医疗吸引力降低、更多家访和更长会诊时间相关。强有力的守门安排与高公众满意度并不矛盾，且与较低的就诊率相关。然而，强有力的守门并非按服务收费安排的特征。这些发现表明需要开展更协调一致的研究，为美国和欧洲有关初级医疗的政策决策提供参考。
