Slovenia
is with its 20 000 square kilometres and 2 billions inhabitants
amongst smaller countries in Europe. As part of former Yugoslavia
health care system used to be a "parading horse"
of socialist philosophy. After the second world war health
service was nationalised and there were enormous investments
in building up primary health care network. Several laws implemented
Andrija Stampar's (Andrija Stampar was Croat and the first
president of WHO.) ideas on primary care in service to all
the people and using active approach in primary care in searching
for health problems among disadvantaged and risk groups (children,
women in generative period, workers, tubercolotic patients
etc.). The combination of his ideas and social orientation
of socialist government led to an extensive growth of primary
care facilities. Primary health care centre was built in every
community to create an environment for literal deployment
of the idea of integration of all primary care services. As
a result of this and under the influence of Soviet model of
policlinic system, supported with western trends toward subspecialised
health care services the role of GP became narrower and narrower.
Well baby clinics and immunisation in children period were
run by physicians with special interest in the topic. The
service gradually became a special primary care service. The
same was true with antenatal and preventive gynaecologic services.
The professionals in this so called dispensaries claimed for
the regulation that only specialist in the field i.e. paediatricians
or gynaecologists can run those services. The overall atmosphere
in the country and in the world was in favour to such decisions.
The assumptions were well supported by the tremendous improvement
in all quality indicators, too. Beside preventive services
these primary care specialists took over also curative part
of health care of younger generations. There was also an enormous
expansion of secondary services with pressures of different
specialists to take over the care for certain disease groups.
In this way diabetologists in late sixties organised a range
of diabetic dispensaries on secondary level. General practitioner
used to be seen as an inadequate source of care appropriate
mainly for emergency care, treating acute events and some
chronic conditions that had not yet raised enough interest
in one of the subspecialty. The fact is that many of the GPs
followed this orientation as well. This is true mainly for
the bigger centres and less for rural areas where GPs kept
broader task profile. This developments however good intended
were not in accordance neither with the official legislation
that claims the importance of strong primary care neither
with developments in general practice in the world.
Family
practice
After
1991 and declaration of independence Slovenia could adopt
new attitude to general practice. With new supportive legislation
the trends in more primary care orientation become part of
our reality. The gatekeeping role of 800 GPs become even stronger
with the introduction of personal lists of the patients. In
spite of this we are faced with traditional way of thinking
and even more important with no actual shift of resources
from secondary to primary care. The managers of primary health
care centres are faced with the problem how to contain costs
with the raising number of tasks GPs are willing to take for
their patients.
With
the politic, economic and organisational change in the society
public claims for quality health care, too. The national insurance
company demands more and more for the money that is paid for
health care. It tries to impose different quality control
mechanisms in the health care environment to reduce costs.
Public expectations has raised. People want more personal
care, shorter waiting times and the best possible care. The
physicians became aware of their power and after 50 years
Medical Chamber was re-established. The Chamber covers some
quality aspects: licensing, relicensing and peer review. Peer
review has long tradition but it used to be run on voluntary
basis. Nowadays it is part of obligatory assessment of health
care quality and periodically covers all providers. In the
nearest future some aspects of peer review should change towards
modern concepts of quality improvement: instead using implicit
criteria using explicit criteria, instead external evaluation
there should be an evaluation of internal QI activities, and
besides suggesting CME providers should be involved in QI
activities. Licensing and relicensing every seven years is
new procedure in health care in Slovenia. To relicense the
physician has to pass the relicensing exam or get certain
number of points from CME activities. This gave raise to traditional
CME courses and several new. Life long learning became a visible
way of practitioners life style. Quality improvement activities
will also credit for relicensing.
Policy
on quality improvement
The
draft on quality in health care was introduced at the WHO
DIABCARE liaisons meeting in Ljubljana in March 1996 and published
in medical journal. Aim of the policy on quality in health
care is to connect existing QI structures and activities and
add "missing links" create a framework for systematic
quality improvement in the country. We see it as a leverage
for the shifts in organisation and financing of health care,
allocating founds for quality improvement activities and structures.
Department
of family medicine
One
of important structural changes in our country in general
practice is new Department of family medicine. Besides undergraduate
education it is very much involved in Cupertino with Association
of general practitioner in postgraduate education, CME and
different quality improvement projects. The topics covered
by the projects are: Problem oriented medical record keeping,
Definition of GPs task profile, Quality of the communication
across the interface between primary care and National insurance
company, Workshops on primary prevention in GP for trainees
and tutors (smoking, alcohol), Prehospital emergency/accident
service, Secondary prevention of hypertension (locally developed
guidelines and interventions), TQM of hypertension management
in primary health care centre, Video seminars on communication
skills, Patient satisfaction survey, Guidelines on management
of acute low back pain, Antibiotic prescribing practices in
acute respiratory infections, Developing complaint system
and many others. Since there is no structure nor fond for
quality improvement at a hand all the projects are subject
to public concourses for grants that makes QI efforts not
easy.
Future
actions
The
survey on GPs task profiles showed willingness of the practising
physicians to adopt broader practice style including preventive
services, psychosocial aspects and effective communication
strategies. When we examined the attitude of GPs toward quality
and QI we found self-awareness and critical perspective towards
quality problems and redness for change. One of the main obstacles
is the predominant reliance on quality control aspects of
quality instead of empowering individual providers to improve
quality by mechanisms as self-control, endless learning, quality
circles, positive incentives and other QI strategies. In overall
QI becomes important part of our daily activities and moves
slowly but steadily in the desired direction.
Research
agenda
Several international projects are currently running in Slovenia.
