By Adrian Rohrbasser, Swiss delegate of the SAFM
October 2009
Switzerland is one of the richest countries in the world. It has one of the best health care systems, but also one of the most expensive. The country faces major problems in financing the increasing expenditure in health care. The split reimbursement of hospital care between the local government and the insurances favors hospital based health care. Reducing hospitals would imply less job facilities, which makes it impossible for any politician to close hospitals, apart from the emotional factors this would cause in the local population. In order to optimize the facilities, the ambulatories are extended. Ambulatory care at any hospital is entirely reimbursed by the insurances and not regulated. Hospital care and costs of ambulatory care units have therefore substantially increased.
Institutes for Primary Care/Family Medicine have been established at the University of Basel, Zürich, Bern and Lausanne, which is a milestone in the history of family medicine in Switzerland. However, primary care has decreasing appeal (1), especially among young physicians. Many reforms have been undertaken, such as a revision of the reimbursement of lab testing which led to a significant decrease in the income for GPs. The sale of drugs to the patients, which is allowed for GPs in many cantons (states), is also under criticism and the new regulations lead to another decrease in the income for GPs. Unfortunately, all these interventions and reforms in the health care system are politically motivated and lack any evidence. This is due to the fact that valid data about the health care system are not available, including studies assessing the role of the GP. Switzerland has previously focused – and still does so – on clinical research more than any other country. However, there is not any awareness that health service research is needed to enable evidence-based decisions for all stakeholders. The focus is still on what (new diagnostics and therapies for example) should be provided and underestimates the potential that lies in how the care is provided. OECD data, as well as other research data, have provided quite strong evidence that a better Primary Care orientation of a health care system is associated with lower costs and most probably with better care and higher quality of life for its patients. Unfortunately, Switzerland has never participated in these data collections and, consequently, politicians and other stakeholders are completely unaware of these facts. Not only politicians underestimate the importance of health service research but also GPs in Switzerland, who complain about the fading importance of their specialty.
There exist many potential threats to Swiss family medicine. Regulations given by the National Administration of Health continually decrease the attraction of the profession for young doctors. This dangerous approach of the government endangers the care of a growing number of chronically ill people. On the one hand, Swiss family doctors struggle with the shortage of young doctors like everywhere else; on the other they have to cope with absurd political guidelines increasingly restricting Family Medicine. As a response, the three formerly autonomous Swiss associations of primary health care (general practitioners SGAM, general internists SGIM and paediatricians SGP) have decided to unite for political issues in a corporate, professional association called “Swiss Family Doctors”. Therefore, a single and powerful contact can be established for all issues of Family Medicine in terms of “one voice – one structure”. The new association will represent all family doctors in all political and media related activities, whereas the pure specialist duties remain with the particular associations. Further, the association aims for a title in Family Medicine that is accredited throughout Europe.
Quality improvement is an ongoing issue because it is expressed in the federal regulations but not set into practice yet. A system that shows and monitors the quality of care given is mandatory according to the regulations. So far, the different groups of doctors have not managed to achieve consent as to which system they want to use. Different specialists have their own preferences as a result of which there is a vast amount of different systems used. EPA, apart from a variety of other indicator sets for organisational quality, is only used by few general practitioners. A project led by the Swiss Medical Association will provide an overview of what is in use at present.
1 Thomas Rosemann, Department of General Practice and Health Services Research, University of Zurich, Switzerland Wonca Europe and its input on the Family Medicine research in Zurich; Primary Care 15, p272
