The most important competences in HP&DP
Both focus group and interview respondents expressed broad agreement that HP&DP is one of the most important competences and responsibilities of FP/GPs provided in everyday practice and one, which is also expected by patients. It was perceived as equally important as such activities undertaken in a practice as diagnosis and treatment. Words used by study participants to describe this perception were as follows:
"...important...", "...fundamental...", "...crucial...", "...basic...", "... pillar...", "...key...", "...main...".
Among 3 areas of competences (educational, clinical, organisational), participants acknowledged clinical competences as the most important.
" No one else can replace us (doctors) in delivering clinical work, whereas health education may be done by others... Others can organise our work too..." (PL,M,44 = Polish doctor, male, 44 years old).
"Patients come to me with complaints, so I think that taking medical histories and physical examination are important... and recognition of early signs of diseases" (LT,M,52).
Within clinical competences none of the discussed sub-areas (screening, chronic disease management, preventive interventions) was indicated to be more important than the others. Moreover, there were more essential competences perceived in the clinical area than in the educational or organisational areas. These competences are listed in table
4.
Table 4
Most important FP/GPs competences in specific areas of HP&DP.
Area I: Educational Task: Health promotion | 1. Child and maternal health | (1) providing continuous care in antenatal, perinatal, early and late childhood; (2) facilitating referrals and consultation to higher level services for complex pregnancies; (3) family planning; (4) running monitoring programmes |
| 2. Lifestyle | (1) planning and implementation of individual and group educational activities alone and in collaboration with practice team members and other specialized services |
| 3. Environment | (1) identifying abnormalities in the family structure and functioning; (2) cooperating with different entities with a stake in health care in maintaining and protecting a healthy environment |
Area II: Clinical Task: Disease prevention | 1. Screening | (1) organising effective screening in practice; (2) linking screening to treatments available in the health care system |
| 2. Chronic disease management | (1) identifying early stages of chronic diseases (history taking and physical examination); (2) developing and implementing evidence-based strategies in order to prevent complications in chronic diseases; (3) coordinating services provided to patients by specialists and other health care providers; (4) managing co-morbidity, multimorbidity and patient complexity |
| 3. Preventive interventions | (1) identifying individuals at high risk for communicable and non-communicable diseases; (2) providing short-term interventions in addictions; (3) maintaining adequate immunization coverage; (4) counselling for modifying lifestyle/health behaviour; (5) providing referrals to specialists and other services |
Area III: Organisational Task: Provision of services | 1. Information | (1) gathering and retrieving medical information from practice using IT |
| 2. Patient relationship | (1) communicating with individuals; (2) developing and maintaining good relationships with patients and their families; (3) engaging patients in health promotion and disease prevention programmes |
| 3. Local communities | (1) applying community care measures on a local level to prevent diseases; (2) cooperating with professions involved in providing community care |
During data analysis it became obvious that some physicians revealed a slight hesitation in distinguishing between cure of chronic diseases and tertiary prevention.
"Does anybody know the borderline between a regular treatment of disease or long-term problem, diabetes, coronary or so on and tertiary prevention...?" (PL,F,34). "It is not easy to separate common clinical skills that I need to diagnose and treat patients from specific preventive skills" (PL,M,43).
In the area of educational competences there was high awareness among physicians of the importance of child and maternal health. Although some of them mentioned the role of other health professionals, e.g. obstetricians and midwives, they generally indicated this sub-area as more crucial than the other two. Respondents indicated that educational activities (individual and group) connected to lifestyle are also important. Among various environmental competences, only those related to functioning of the family and cooperation with different entities with a stake in health care were agreed to be important (see table
4).
Organisational competences were considered by doctors to be less fundamental than clinical. Nevertheless, they were described and discussed with attention to details. In this area, respondents believed that communication with patients and building good relationships with them and with their families are very important. It was uniformly expressed that new technology might be helpful in the collection and retrieval of medical information. Other important competences in the sub-area of local communities are listed in table
4. Typical opinions about organisational competences in HP/DP are cited below.
"Communication is one of the most important GP competences, which is needed both for personal counselling and group sessions" (LT,M,45). "... the proper software can provide physicians with a tool to calculate a patient's health risk and to gather and retrieve information" (PL,M,37). "The most important organisational competence is to be able to collaborate with everyone who is useful in health promotion, I mean people involved in education, employment, environment, welfare, police, church. Hazardous factors are determined by broader social and community influences" (Pl,M,53).
During the interviews and focus groups some competences, which can be considered important in all areas and sub-areas of the HP&DP framework, were identified. These competences include the ability to: (1) develop professionally, (2) educate oneself in a continuous manner, (3) improve quality of care, (4) work in a team, (5) identify and solve problems, (6) set priorities in practice, and (7) provide holistic care.
Furthermore, apart from general or specific types of competences, the study participants recognized the most essential clinical problems and diseases that require preventive care. These conditions include: (1) cardiovascular diseases, (2) cancers, (3) infectious diseases, (4) pathological pregnancy, and (5) psychiatric disorders and addiction. Respondents believed that in relation to these problems each FP/GP should have a proper combination of knowledge, skills and attitudes that will enable them to provide preventive care in accordance with professional standards.
Areas with inadequate competences
According to study participants, Polish and Lithuanian FP/GPs may have inadequate HP&DP competences in the areas of organisation and education. A prevalent belief was expressed that the existing system of under- and post-graduate education guarantees development of sufficient competences in clinical areas.
In the area of organisation a large gap may exist in competences related to teamwork.
"There may be a lack of effective cooperation among the staff in practice" (LT,F,54). "More integrated teamwork, proper workload sharing with nurses and others is needed; efficient management, coordination, and mutual support rarely exist" (LT,F,35). "Teamwork is below a level that would assure quality and safety of care" (PL,M,44). "Doctors don't delegate tasks to others" (PL,F,44).
Also, competences necessary for proper cooperation with specialists from other disciplines or professionals from other sectors were perceived as possibly insufficient. Referring to this topic, study participants enumerated a large number of professionals FP/GPs should collaborate with.
"The most important organisational competences which are lacking are an ability to collaborate with anyone who can be useful in HP&DP" (PL,M,44). "FP/GPs don't know how to coordinate with other local services" (LT,F,42). "Networking with appropriate services doesn't exist" (LT,M,45). "Ability to conduct a constructive dialogue with policy and decision makers, although valuable, is not undertaken" (PL,M,43).
Respondents expressed opinions that in the area of educational competences existing skills in changing patient behaviour might be insufficient.
"Probably most of us (doctors) can give a patient information about lifestyle or something like that but the patient does what he wants" (PL,M,44). "I think that only modest changes in behaviour can be achieved in primary care and few patients follow advice; maybe multiple interventions are needed" (LT,F,54).
An additional issue to which participants of the study called attention was a possible lack of competence in physicians who, before implementation of family medicine in Poland and Lithuania, had practiced in primary care but had specialized in other medical disciplines, most often internal medicine or paediatrics. In the late 90s, these physicians completed specializations in family medicine after participation in short retraining programmes. In our study the opinion was often expressed that internists might provide inadequate preventive care for children, while paediatricians might do the same in caring for adult or elderly people.