Table 3 The impact of governance in primary health care delivery: a systems thinking approach with a European panel
Statement examples | Correlation between agreement /disagreement and panel PHC background | Thematic analysis (aspect of structure-process-outcome referred in the statement) |
|---|---|---|
1. Setting up and managing PHC practices constitute additional workload for self-employed PHC physicians, compared with public employee physicians. A: 91% N: 5% D: 4% | A: SHI financing mechanism, self-employed physicians, compulsory training. | Structure: PHC financing; Process: Job satisfaction; Outcomes: Quality |
Comment example: “Practice management is a job. In France, new practices trying to put preventive care forward struggle because of the additional workload (e.g., asking for funds, meeting representatives, motivating other practitioners toward new health .care practices, etc)” (agree) | ||
Comment example: “Public PHC centres have administrative staff and director, in private PHC there is none and one GP makes this part of the job (or it is externalised, which increases costs)” (agree) | ||
2. Private patients' expectations for diagnostic and treatment activities can be high as they feel they are contributing more to the care they receive, and this may lead to unnecessary interventions or treatments. A: 75% N: 13% D: 12% | A: Private ownership, lack of NHS contracts. | Structure: Patients’ entitlements (employment status, payments); Process: Access; Outcome: Costs |
Level of agreement: OOP (no significant differences between subgroups) | ||
Comment example: "When patients go to doctors privately, it is almost as if the doctor has to give the patients their "money's worth" (agree) | ||
Comment example: “It depends on the degree of patient’s relationship with their physician and their educational level” (disagree) | ||
3. When physicians are monitored on their clinical practice, the same organisation that monitors them should provide clinical guidelines to support them (in order to ensure some consistency between the guidelines and the clinical practice monitored!). A: 71% N:10% D: 19% | A: PHI or OOP coverage, competence regulated, physicians’ competences regulated by central or regional. | Structure: PHC regulation; Process: Accountability, Compliance; Outcomes: Quality |
D: General taxation entitlements, lack of OOP or PHI entitlements, lack of competences regulation | ||
Comment example: “However, the guidelines must be done with physicians’ approval or it will lead to a direct conflict…” (agree) | ||
Comment example: “They should count on national guidelines” (disagree) | ||
4. Public planning of the distribution of PHC services can help decrease the inequalities in access to PHC in a country. A: 89% N: 9% D: 2% | A: Civil servants, lack of FFS payments, type of institution conferring the license to practice. | Structure: PHC regulation; Process: Access; Outcomes: Equality |
Comment example: “Self-organisation leads to less and less GPs working in deprived and poor area. Public health centres allowed to increase the number of GPs in those areas” (agree) | ||
Comment example: “We must pay attention to freedom of exercise in case of public planning” (disagree) | ||
5. The coordination of PHC physicians with other specialists/hospital services can be difficult. Health authorities should establish clear links and pathways to make this coordination easier. A: 87% N: 5% D: 8% | A: Contracted to NHS or NHI, capitation and performance payment mixed. | Structure: PHC regulation; Process: Coordination; Outcomes: Quality |
D: SHI several funds financing, FFS payments | ||
Comment example: “Clear and easy to follow” (agree) | ||
Comment example: “This will generally increase the bureaucratic workload” (disagree) | ||