HERU is funded by the Chief Scientist Office of the Scottish Executive Health Department

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The Future of General Practice in Europe. A
Health Economics Perspective
Anthony Scott Senior Research Fellow Health
Economics Research Unit University of
Aberdeen Scotland, UK
HERU is funded by the Chief Scientist Office of
the Scottish Executive Health Department
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Outline

• What is health economics?
• General Practice in Europe
• Highlight main economic issues and evidence

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Definition of Economics
The study of how men and society end up
CHOOSING, with or without the use of money, to
employ SCARCE productive RESOURCES that could
have ALTERNATIVE uses, to produce various
commodities and DISTRIBUTE them for consumption,
now or in the future, among various people and
groups in society. It analyses the costs and
benefits of improving patterns of resource
allocation Paul Samuelson
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Central concept of economics

• Resources are scarce.
• Every time we use them we give up the
  opportunity to use them in many other ways.
• The benefit or satisfaction given up in the best
  alternative use of the resources is the
• OPPORTUNITY COST
• Every time you hear the word COST think
• BENEFITS GIVEN UP

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Example How much should we spend on General
Practice?
Health status
Flat of the curve
Resources ()
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Real expenditure on Primary Care Physician
Services ( change compared to 1990)
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Expenditure on Primary Care Physician Services as
of Total Health Care Expenditure
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Main economic issues and trends

• Doctor-patient relationship
• Gatekeeping role of GPs
• Medical practice variations and evidence-based
  medicine
• Integration in primary care
• Paying GPs

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Doctor-patient relationship

• Imbalance of information between doctor and
  patient
• Doctors are in a powerful position
• regulation of medical profession
• financial incentives
• Reduce the imbalance of information
• long term relationships and continuity of care
• involve patients in decision making
• provide patient with more information about
  treatment options
• improve doctors communication skills

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Gatekeeping

• General practice is the main point of contact for
  non-emergency medical conditions
• Controls access to more expensive
  specialist/hospital care
• Leads to lower health care costs
• Evidence?

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Gatekeeping - evidence
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Reducing variations in medical practice
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Practice variations and evidence-based medicine
(EBM)

• Lack of information on what is best practice
• Need information on cost-effectiveness of
  interventions
• Large investments in gathering, summarising and
  implementing such information
• Cochrane Collaboration
• Role of guidelines
• Is clinical practice changing as a result?

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Integration in Primary Care (Managed Care)

• Horizontal integration
• GPs in group practice
• HMOs, GP fundholding, Primary Care Groups, out of
  hours care
• Vertical integration
• Changes in the balance of care between primary
  and secondary care
• minor surgery, diagnostic testing, outreach
  clinics

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Evidence on integration

• Horizontal integration
• higher quality of care and economies of scale
• provision of wider range of services
• increases in management costs
• no evidence about effects on patients health
  status and other outcomes
• Vertical integration
• evidence mixed

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Paying GPs

• Method of paying doctors influences costs and
  quality of care
• The end of fee-for-service?
• related to increasing health care costs
• less chance of long term doctor-patient
  relationships
• more chance of unnecessary care
• lower rate of patient visits
• Move towards mixed systems of prospective
  payment
• Effect of payment systems on GP recruitment

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Conclusion

• Role of Health Economics
• Strengthening of Primary Care in Europe
• belief that primary care is less costly than
  secondary care
• improves access for patients
• more resources
• increased GP workload
• increased accountability
• patient expectations
• explicit rationing / priority setting

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Conclusion

• Strengthening of primary care depends on
• geography
• epidemiology
• cultural differences
• attitude of GPs
• differences in payment and financing
• Much more evidence is needed about what type of
  primary care system provides the greatest health
  status from the resources available