PRIMARY-CARE, FINANCING AND GATEKEEPING IN WESTERN-EUROPE

Primary care in western Europe is delivered by general practitioners ( GPs) but their role within the overall health system is poorly underst ood. The aim of this article is to present an overview of the characte ristics of general practice in the context of health systems and to de scribe their variability and interrelationships. Data were obtained fr om two main sources: publications of official organizations and EC res earch projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeepe r function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. A lthough all countries have universal health insurance, the mode of pay ment of GPs differs. In some countries, the gatekeeper function of gen eral practice is more highly developed and the use of specialist servi ces varies accordingly. Practice characteristics such as workload, len gth of consultation, ordering of tests and reappointments also vary wi th differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relation ships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not inco mpatible with high public satisfaction and are associated with lower v isit rates. However, strong gatekeeping is not characteristic of fee-f or-service arrangements. These findings suggest a need for more concer ted research that could inform policy decisions concerning primary car e in the USA as well as in Europe.