Clocks, watches, mountains, and trains. Clean Swiss efficiency. So, I was fascinated to learn about Swiss primary care when speaking at a recent conference in Lausanne; mostly single handed, still predominantly male, and with limited use of electronic records. Joining me from the UK was Stephen Campbell from Manchester, one of the architects of the quality and outcomes framework, and together we described both the theory and reality; from an overall perspective to day to day practice. Accepting that there are imperfections, it was a privilege to acknowledge the achievements of UK primary care. Concepts of quality and performance, which we now take for granted in the UK, were new and a little threatening for our audience. As in many countries, GPs are concerned about government motivation and worried about control.
It didn’t happen overnight in the UK. One might see its origins in the RCGP initiative “What sort of doctor” in the 1980s and the principles promoted in this document evolved over many years to become the quality and outcomes framework. Yes, critics point out that it focuses on easily measured criteria at the expense of other less objective but equally important aspects of care, how it creates a tick box culture, and the potential (although with little objective evidence) for gaming. Overall it’s a system that supports good practice. It was unfair, therefore, for the media to criticise GPs because they did so well. The rewards for good practice were generous and reflected an unexpected overachievement of targets, but this could only be good for patients. It is frustrating when hospital colleagues refer to them as a form of bonus payment (a bit rich when you consider the nature of merit awards), and it worries me when continuous quality improvement gurus suggest constantly raising the bar. My major concern is, however, that future government interference might force the introduction of politically driven rather than evidence based criteria.
How would I advise Swiss colleagues? First, it is difficult to argue against good practice. We all want to do our best for patients. So, grasp this opportunity. There is a general move towards performance improvement, both in Europe and the US, so it is going to come sooner or later. But, do ensure the profession takes control—your main focus is on your patients and not political expediency. Emphasise that it is about patient care and not a professional cartel. But, you need resources to support computer records systems, support staff, buildings, and infrastructure so you must work closely with local and federal government.
Different countries and cultures have their own individual challenges and, while the Swiss values of excellence and efficiency will undoubtedly facilitate change, there will be hurdles. My colleagues identified some particular complications; cross cultural differences in the approach to medical care reflected in the three languages—French, German, and Italian, a religious heritage (reflecting Catholic/Protestant traditions) and mountain (rural)-urban differences.
Sometimes initiatives in one country don’t travel as well as we might expect. As if to illustrate how we take some aspects of healthy living for granted, the hospital canteen had an outdoor terrace where we enjoyed our lunch in the mid day sunshine. But, staff were allowed to smoke. So strange to see nurses and doctors in uniform smoking. And, I’d forgotten the smell of smoke while you are eating.
Domhnall MacAuley is primary care editor, BMJ