The first association one gets when thinking about independence in is that independence is good. We all want to be independent and free. For me, coming form Slovenia, this feeling is perhaps even deeper. Slovenia regained its independence after a thousand years of being ruled by Germans, Austrians, Italians, Hungarians and Serbs. Nevertheless, we have always cherished the fact that we are different and have tried hard to maintain our independence as much as possible. What is interesting is that even though it took us a thousand years to reach independence, we are now trying very hard to join the European union. We are trading our independence for a value of belonging to EU. And the feelings of pride that we are achieving its standards are comparable to the feelings of pride when we became independent from Yugoslavia. This is a strange contradiction. When I lecture about independence to medical students, I do that in a context of family as a unit of care. I try to describe family as a system and how it develops over time and the problems it faces during various stages. I can not do that without addressing the systems theory, which is very useful in describing complex systems.peer-reviewe

Svab, Igor

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• PROFESSIONAL INDEPENDENCE IN GENERAL PRACTICE I. SVAB FAMILY PHYSICIAN, SLOVENIA (KEYNOTE LECTURE AT THE 1 8TH ICGP NATIONAL SCIENTIFIC MEETING) INTRODUCTION The first association one gets when thinking about independence in is that independence is good. We all want to be independent and free. For me, coming form Slovenia, this feeling is perhaps even deeper. Slovenia regained its independence after a thousand years of being ruled by Germans, Austrians, Italians, Hungarians and Serbs. Nevertheless, we have always cherished the fact that we are different and have tried hard to maintain our independence as much as possible. What is interesting is that even though it took us a thousand years to reach independence, we are now trying very hard to join the European union. We are trading our independence for a value of belonging to EU. And the feelings of pride that we are achieving its standards are comparable to the feelings of pride when we became independent from Yugoslavia. This is a strange contradiction. When I lecture about independence to medical students, I do that in a context of family as a unit of care. I try to describe family as a system and how it develops over time and the problems it faces during various stages. I can not do that without addressing the systems theory, which is very useful in describing complex systems. Systems Theory - A Short Overview The general systems theory is a response to the limitations of the nineteenth century science and its reductionistic approach. The theory approaches prob-lems from another point of view: not by reducing problems, but by including all the relations and describing them. Nature is, according to this theory, Slide] . DECEMBER 2001 15 ordered in a hierarchy of systems, both living and non-living. Each level in the hierarchy is both a whole in itself and also a part of a greater whole. Each system has features that are unique to that level and can only be explained by criteria that are appropriate at that level. The reason why the elements of the systems form a system is because by joining they also get an added value, as they can perform certain functions that they could not as separate entities. Because of this higher systems, like families, can not be explained using the methods for the explanation of the subsystems. The person can not be explained in terms of biology and biochemistry, for instance. The reason why two individuals join together is because they gain love, as I explain poetically in my lecture to medical students. The reason why professionals join together and form scientific societies is because they are much better represented in politics and can influence political decisions. But the creation of a system comes with a price. There are two main prices to pay. The first is that the system in itself needs some energy to maintain its function. The more complex the system, the more power it takes to maintain itself. Additional energy is needed for its coordination. If doctors want to join together in a society, they need additional resources, for instance. The second is that by joining in a system the individual elements of the system lose some of its autonomy. As I explain to my students , the price of love is relinquishing a bit of one's own independence. If physicians join together, they must decide to obey some common rules, which are imposed on their individual freedom. Some ofthem may have problems with that and would prefer not to belong to an organisation at all. The balance between independence and gained values of love or acceptance is difficult to maintain, but it is necessary. Survival is impossible on either of the extremes: to be entirely independent means to be entirely alone and forgotten, to be totally accepted means that one loses one's values and ceases to exist as a person. To make things even worse, the balance is also changing all the time. We all belong to societies, the family Physician / it-tabib tal-familja families, cultures that change constantly and in a changing system we need to adapt to the changes. It is also important to say that the balance is highly individualised. Europe, for instance, has a tradition of culture, where people work together in a society and share a responsibility for weaker vulnerable groups of the population. The balance in America which cherishes independence and individual responsibility at the expense of social security is a different one. The socialist system that has prevailed in the countries of central and eastern Europe has tried and failed to maintain a different balance with much less individual freedom. Because of this individual balance it is very difficult to pass judgements from one situation to another, from one health care system to another. Application to the Health Care System If we look at the health care system from the systems theory point of view, we can see that the health care system is a complex one and that it has in itself the following main elements: • the profession, • the users of health care • the payer. Each of them consists of different elements. There-fore in addressing the issue of autonomy, I can con-sider the autonomy of the medical profession within the health care system and the autonomy of the individual doctor within the medical profession. Slide 2. The Autonomy of Medical Profession and General Practice Because of the issue of the conference I will spend most of my time talking about the relation betweeen the medical profession and the payer (=government) and the power struggle between the two. DECEMBER 2001 16 The medical profession has a special role in a society which is a result of its importance. If general practice would not be important, government would not spend time and efforts to deal with it. We would be totally independent and allowed much more freedom that we are experiencing now. The privileged role of the medical profession and general practice within it is changing constantly. Although health has always been one of the key values in human life, the relative autonomy of medicine within the society has decreased. The development of modern technical medicine has created a very complex health care system, where general practice was regarded as anachronism in terms which would soon become extinct. There were some serious critics of modern medicine. The two most famous critiques have been delivered by Ivan IIIich and lan Kennedy who claimed that medicine is counter productive and that medical interventions produce more harm than good. The critics that were attacking the technically developed medicine have pointed to the difficulties modern medicine has encountered because medicine was forced to change from a paternalistic approach towards patients to a partnership orientated role where the doctor and the patient are considered as partners deciding about care. There has also been an important change in the relative importance of general practice over the past decades. Because ofthe problems of modern medicine, the public needed someone to talk to, someone who would guide them through the maze of medical experts. This was the period of the renaissance of general practice throughout the world, which has started in the early seventies with the creation of the old Leeuwenhorst group and the EGPRW (Eurpean Gen-eral Practice Research Workshop). Some countries had to create a new name for general practice and they called it family medicine. This has occured in many European countries and in the USA. The politicians have also recognized the importance ofthe newly developing discipline. General practice is now clearly seen as probably the only profession that can help in maintaining the health care system in a manageable state. Without the contribution and cooperation from general practice no health ministry can hope to manage the health care system. The managers of the health care system were trying to seek partnership with general practice and the way to influence the profession. This recognition of the importance of general practice has also meant a threat to its autonomy. The most effective mechanism through which the government ties to influence general practice is through a payment system. the family physiCian / it-tabib tal-famiija :" In general practice in principle the following ways of payment exist: salary a contract with the payer individually A lot of research in public health has been done looking at the effects of the payment system on physician performance. If I would be allowed to make a simplification, it is fair to say that the main problem of the salaried system is the motivation of physicians . This is especially a problem when the salaries are low. In countries of central and Eastern Europe, all the physicians were salaried public employees. Not only that: their wages were quite often very low and sometimes lower than the wages of taxi drivers, for instance. The result ofthat was corruption and quality of care which was very low. The independence of general practice was low and professional indepen-dence within the practice was the only freedom they have got. On the other hand, some other countries also have salaried physicians (Spain , Portugal) with quite good results. But generally, the contractual agreement where the payer pays the provider directly is a better solution. The problem are the terms of the contract, which is usually a combination of a fee for service and capitation. If a fee for service is the main item for billing, the problems of high number of unnecessary tests, examinations and procedures quickly emerge. The system based almost entirely on capitation is an equally problematic one, having similar problems like the salaried system. Increasingly, more innovative approaches are tried throughout the world, a lot of them without any scientific evidence and without testing the schemes in advance. This results in constant health care experiments which is perhaps interesting reading but also an illustration how difficult it is to organise health care in a modern changing society from the point of view of the payer. Table 1: Indicators of professional independence FUNCTION The ability to reach a dialogue with policymakers through a body that is representing the profession. The ability to guarantee quality of professionals that start working in practice The ability to guarantee quality of everyday care The ability to perform research and to implement research findings in practice The ability to educate its own members and to contribute with its educational potential to education of other professionals. DECEMBER 2001 17 The Price of Professional Independence The partnership between the policymakers should be based on trust if it is to be effective. One of the important reasons why we feel so strongly when we believe that professional autonomy has been challenged is due to the fact that we believe that the trust has gone. Ideally, the policymakers trust that the profession is able to perform some of the important tasks and this is why they delegate some of their authorities to the profession. General practice then tries to demonstrate that it is capable of responding to these needs . In countries where general practice is well developed, a lot of the functions are performed by organisations of general practice. In countries where the autonomy of general practice as a profession is low (which also means a low standard of general practice), these functions are performed by other agencies. This is the second reason why we feel so strongly when the autonomy of the profession is challenged: because we believe that lower professional independence is an indicator of a low level of the profession we belong to. The functions that can be delegated to the profession usually include the following: 1. The ability to reach a dialogue with policymakers through a body that is representing the profession. 2 . The ability to guarantee quality of professionals that start working in practice 3 . The ability to guarantee quality of everyday care 4. The ability to perform research and to implement research findings in practice 5 . The ability to educate its own members and to contribute with its educational potential to education of other professionals. Bearing that in mind it is possible to make a list of questions that address professional autonomy in a country . This is very useful when one tries to assess the position of the profession in a country (see Table 1). INDICATOR Is there a college of general practice? What are its functions? Is vocational training obligatory for independent practice? How is peer review organised? Who recertifies the practitioners? Is there a scientific journal of general practice? Is there a department of family medicine at the univerSity? Is it independent? the family physiCian / it-tabib tal-Jamilja Individual Independence Individual doctors also need and want their independence within the profession. The professional independence of an individual is stronger in general practice than anywhere in medicine. General practitioners are used to work often alone , sometimes in their relative isolation and with little contacts between themselves. The changing society has meant a drastic change for this somehow idealised description of the GP's work. Because of the pressure from society to prove that we are able to perform according to the standards of quality , the mechanisms of control are increasing . Professional independence in clinical care without any control is rapidly leaving general practice . The issue now is not whether we are · going to assess our performance but who is going to do the assessment and how, who decides on standards of good practice and how. The development in some countries of central and Eastern Europe is perhaps an interesting illustration of this trend. Before the collapse of the socialist empire, general practice was not important. Organisations of general practice were, at best, voluntary organisations within the medical socioety which was a voluntary organisation without any real power. General practi -tioners were independently working in their offices with absolute clinical freedom within the boundaries of the health care system. They were often providing bad health care for low wages. Their self-esteem was low and the only expression of their freedom was their professional idependence in practice. The result of this was low quality of health care and a low esteem of the profession by the public. After the breakup, the profession has tried very hard to maintain and to regain its professional independence. Professional organisations were created or were given a greater authority (e.g. to give licenses to physicians, to control quality of care). Vocational training became obligatory, so that the average GP now is less independent in his practice than before. But the position of the profession is clearly better. D ECEMBER 2001 18 Nevertheless, some general practitioners want to protect their independence against the community and against their own medical societies. In that way, professional independence is a barrier to higher quality of health care . I have seen clear examples of that in Croatia , where independent GPs do not want to get involved in any kind of quality assurance programmes. CONCLUSION My research in the field of professional independence of general practitioners has led me to the following conclusions: 1. There is no total professional independence. We always work in an environment to which we are responsible . This is one of the core elements of general practice, which can never exist in a vacuum. The responsibility of general practice is not just to our conscience, but also to the society. Because of its importance, general practice will never be totally independent. 2. The way the balance is maintained is individual (country specific) There are many different examples of the countries how this is organised and it is very difficult to make general conclusions. Each country must decide according to its system of values and its own tradition . 3. Professional autonomy is given by society and is based on trust As long as society, represented by policymakers, believes we can provide some of the very important professional functions, we will maintain our autonomy. We will, nevertheless, be constantly challenged also because the policymakers are being challenged by the changing society. The way to minimise the problems is to base our relations on trust and communication. the family physician / it-tabib tal-famiija 

Professional independence in general practice

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Professional independence in general practice

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