Family practice in Turkey: Observations from a pilot implementation.

OBJECTIVE: Turkey has implemented family practice on a pilot basis as part of the reform in health care, since 2005. This paper aims to understand and describe the prevalent practice patterns and clinic characteristics during the transition period.
DESIGN: A cross-sectional descriptive study design was used.
SUBJECTS: An online survey was conducted among Turkish GPs working as primary care doctors (without vocational training) during the reform period. Clinic and GP characteristics are analysed with descriptive statistics.
RESULTS: List size is an important factor; larger lists lead to shorter consultation time and a longer wait for patients. GPs are generally satisfied with the reform.
CONCLUSION: During the transition to family practice access of patients to health care has improved and GPs are satisfied with their job. KEY POINTS: Patients in Turkey have adequate access to primary health care services. The waiting time for consultation is relatively short. Basic prevention activities occupy the majority of the GPs' time. Reducing the panel size and introducing appointment systems may be useful.

Introduction

Primary health care in Turkey has been transformed in recent years (2005–2010),[1] involving the introduction of family practice as the primary system of delivering care.[2] According to the new reform, medical practitioners (doctors without specialization in family practice) serve as family doctors (general practitioners [GPs]) and are responsible for patients in their family health centre (FHC). Remuneration is calculated on the basis of a fixed salary, capitation-based contracts, and premiums for preventive services (e.g. rural visits).

This paper provides a descriptive analysis of primary care practices during the pilot implementation of the reform in Turkey. Furthermore, we aim to elucidate and describe the prevalent practice patterns and FHC characteristics during the transition period.

Materials and methods

In 2008, family practice was implemented in 11 cities in Turkey. GPs involved in family practice were invited to participate in a survey via e-mail lists and web pages with the support of provincial health officers. A total of 394 GPs responded (response rate = 14.9%) and completed the survey consisting of 14 questions in four main sections pertaining to the following aspects: practice, FHC and population characteristics, workload-related measures, time allocation patterns, GP characteristics, and job satisfaction. The survey data were subjected to descriptive analyses.

Results

The GP characteristics were as follows: the mean age was 36.27 years (SD = 6.25; min–max = 24–55), experience in the reform was 18.01 months (SD = 7.36; min–max = 1–66), 25% of the respondents were female, the probability of quitting within five years was 26.8% (SD = 31.8; min–max = 0–100), and the mean level of job satisfaction was 3.83 (SD = 0.88; min–max = 1–5). The FHC characteristics were as follows: the list size was 3584 individuals (SD = 493; min–max = 1887–5673), the number of office hours per week was 37.63 h (SD = 8.57; min–max = 15–90), and the total number of employees (including a nurse, medical secretary, or technician) was 1.22 (SD = 0.59; min–max = 0–4). Only 6% of the FHCs reported having appointment systems. Workload-related measures were as follows: the number of patient consultations per day was 57 (SD = 21.19; min–max = 10–135), the consultation time per patient was 10.7 min (SD = 4.64; min–max = 3–30), the in-FHC waiting time per patient was 18.14 min (SD = 15.76; min–max = 1–120), and the referral rate was 4% (SD = 3.88; min–max = 0–30). Time allocation was as follows: treatment and diagnosis, 51.5%; immunization, 20%; screening and other preventive measures, 10%; chronic care, 6.6%; administration, 7.7%; training, 2.9%; and other, 1.3%.

Discussion

The survey results show that the citizens of Turkey have adequate access to primary health care services following the pilot implementation of family practice. A large majority of GPs see their patients without appointments, which is similar to the advanced access paradigm that is becoming increasingly popular in other countries.[3] In addition, the in-FHC waiting times for consultations are relatively short. Previous studies have shown that GP referral behaviour is very complex and difficult to explain. Specifically, it has been found that less than 10% of the variation in referral rates can be explained by the GP and practice characteristics.[4] The pilot implementation experience in Turkey demonstrates that basic prevention activities, such as immunization, as well as the screening of mothers and children, occupy the majority of the time of GPs after regular consultations. This means that GPs do not have much time left for other health-promotion activities; they reported that such activities account for only an average of 10% of their time. Reducing the panel size and introducing appointment systems can help increase the time allocated for prevention activities. An interesting observation is the large difference between the percentage of time allocated for vaccination as well as mother and child care (19.8%) and the time allocated for other prevention and health-promotion activities (9.9%). Explanations for this discrepancy may be that immunization and mother and child care services are considered to be more critical and important than other prevention activities. Moreover, the percentage of target immunizations completed is a performance criterion, which is closely monitored by the Ministry of Health.

This study has some limitations. The response rate of this survey was low. Because this study involved a survey, approval from an ethics committee was not obtained. However, the study was approved by a panel of scientists from the Turkish National Science Foundation.

Despite the low response rate, the findings of this study provide valuable insights into the changes to the Turkish health care system and have the ability to influence future health policies or reforms. Further studies with larger samples should be initiated to address the working conditions of GPs in Turkey.