'Meet a doc' in Vienna
At the recent Wonca Europe Vienna conference participants were able to meet an Austrian GP in their practice. The WONCA editor was privileged to meet Dr Erich Lemberger, a solo GP, and his practice manager, his wife Elizabeth, in their practice not far from the centre of Vienna. The practice premises were situated on the first floor of a rather inauspicious looking residential apartment block. Inside however, the well equipped premises are thoroughly modern and welcoming. The waiting room has a pleasant ambience with beautiful modern décor including, artistic posters, leather ‘tub’ chairs for patients, a trendy and colourful coat rack, matching the colourful kids’ toys all neatly stashed on a shelf. The consulting room had a professional air, being attractive, well equipped and orderly - the lovely desk in rich tones of wood had a noticeable absence of messy piles of paper as records and most needs are dealt with by electronic means. There is a smaller spare consulting room for students.
The Austrian GP in the health system
Before the event, participants and many other conference attendees who hoped to be granted a late booking visit, were given background information about the Austrian health system by Dr Wolfgang Spiegel (pictured).
Austria has a social health insurance system “Sozialversicherung” with almost universal coverage. The insurance is paid for by employers and employees and the funds are administered by numerous different health insurance agencies. This enables all patients to attend a family doctor free of charge, unless they choose to attend a private GP – or a specialist.Spiegel, who is the president of the Viennese Society of General Practice and a senior researcher at Medical University of Vienna, pointed out that, in general, consumer satisfaction with the health care system in Austria is, generally, high. Access to all levels of care is easy, waiting times for in-patient procedures (eg for hip arthroplasty) are short and there is usually no payment at the point of care delivery. Therefore, Austria ranked highest in a European health systems quality rating (European Health Consumer Index 2007).
With regard to efficiency and coordination of care things look different: the patient’s point of contact to the medical system is not well defined. The Austrian system has an overemphasis on specialist and hospital care, with patients able to self refer to specialists. There is a two-fold coverage with medical specialists – self-employed specialists who have contracts with the social insurance agencies as well as hospital based specialist doctors. The GP does not have a ‘gatekeeping’ role. A system which does not use the well established advantages of a structured and primary care-oriented system, is bound to result in excess use of secondary and tertiary care, and so it is unsurprising, that according to Spiegel, Austria has an extremely high number of hospital beds per capita and that it ranks first in Europe with regard to in-patient stays (27.9 per 100 inhabitants in year 2007).
Austrian consumers rate their health system higher than those from any other European country. No doubt the freedom to go to a GP, or to a self-employed specialist or to consult in the out-patient department of hospitals for any complaint, makes for good satisfaction for patients. "A popular system, but does it do well with regard to coordination of care?", asks Spiegel. Without the GP as the cornerstone of a system, can there be continuity of care, good preventative health measures and cost effective care? There also is an ongoing increase in the number of specialists in the system, as compared to GPs.
Doctors in Austria are comparatively well trained in high quality medical schools. Currently, to be licensed as a GP necessitates a three year vocational training period, which is mainly hospital-based, and the passing of a final licensing exam. The three years should contain a six month training period in GP offices but the government allows that this time is substituted with training in acute care outpatient departments which, according to Spiegel, has nothing to do with primary care. GPs take students and doctors-in-training at their own expense, as there is no compensation for teaching and mentorship, and no possible increase in income from the presence of trainees. Thus, both the duration and discipline-specific content of vocational training for general practice is low.
GPs in Austria struggle for recognition of our discipline as a speciality.
Dr Lemberger’s working life
The core hours were given by Dr Spiegel as 15-20 hours per week, but in Dr Erich Lemberger’s clinic, we found that each working day is more like 10 hours long. Dr Lemberger is a solo GP – there is no scope in the Austrian system for GPs to join together in a group practice. He services a population (patient list) of 8000 people, and as such, will see a minimum of 50 patients per day. In busy times this number may rise to as many as 120 per day, with added home visits to the elderly, frail and emergency cases. New patients account for 5-10% of attendees each week.
Paperwork is onerous. GPs are contracted by the insurance companies and paid a basic fee of 19 Euros per patient per three months, to provide as many or as few consultations as each patient requires. Extra services, such as ECGs, do attract a further fee for the GP. Office overhead costs run as high as 60%.
The relief for the Viennese GP is that at 7pm the phones can be switched through to an after hours telephone service and that service will take the calls, visit the patients and provide care from 7pm to 7am and on weekends. So Dr Lemberger can finally relax when he and his wife return home at night. Luckily for them they have only an adult-aged daughter.
Dr Erich Lemberger and his wife Elizabeth (right) with (from l to r) visitors Christophe Simonett, Suzanne Gagnon, Andreas, Dr Blais and Prof David Moores
Dr Lemberger and his wife welcomed a mixed group of WONCA doctors - from Canada, Sweden, Switzerland and Australia - with cool drinks (on a very hot day), snacks and the famous Mozart chocolates. About ten patients were eagerly and probably impatiently waiting downstairs for their evening consultations and we appreciated the precious time we were given by Dr Lemberger as an insight to his daily life.
At the end of the visit, we all agreed: Dr Lemberger is a very dedicated and enthusiastic GP who works very hard for his money!
The WONCA editor would like to thank Dr Erich and Mrs Lemberger for their kind hospitality on this visit, and congratulate Dr Spiegel for organising such a high interest activity.
Dr Karen Flegg