Greek rural GPs' opinions on how financial crisis influences health, quality of care and health equity

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Dear Editor

During the last 4 years Greece has experienced an austerity period that has severely affected spending on healthcare services and populations health, referred to in the literature as 'the Greek tragedy'¹. Although data are limited, the first impact of this crisis has been on access to healthcare services and the use of medications^2-5. Current health policy discussions are focused on the re-organisation of primary-care services and a restricted budget for medicines and emergency healthcare provision, as was outlined in the Memorandum of Understanding between the European Commission and Greece⁶.

Within this framework and as part of a WONCA initiative to promote Family Medicine and establish a World Family Doctor Day (www.globalfamilydoctor.com), on 19 May 2012 members of the Cretan Practice Based Research Network (CPBRN) in General Practice were invited to participate in an electronic exchange of opinions and views. The main topics which were formulated to stimulate discussion included: 'The challenges and problems faced by rural-serving Greek General Practitioners (GPs) on Crete, in the context of the current financial recession and austerity period'. The theme selected for this electronic debate was: 'To what extent does the financial crisis impact on health, quality of care and health equity'.

Nine GPs out of the 16 active members of the CPBRN participated in the forum and the main concerns raised are presented in this letter. All participating GPs agreed that the financial restrictions in the national healthcare system have affected the quality of patient care in their area of responsibility. Content analysis of all written responses revealed several topics, and participants' responses were categorized into themes. The main statements are summarized:

• The malfunction of the newly established electronic prescription application, and the increasing drug and medical equipment supplies shortages in addition to the demands of the bureaucracy are already affecting everyday clinical practice leading to frustration for both doctors and patients. (Impact on time and resources availability)
• Already burdened national healthcare services are striving under an increasing number of patients who now seek public rather than private healthcare services due to the economic crisis. (Impact on healthcare usage)
• The economic instability has had an impact on mental-health disorders and may increase depression, somatization and anxiety, as well as further escalating potential healthcare costs due to making such diagnoses with safety on a large scale. (Impact on morbidity traits)
• There appears to be a trend towards patients no longer seeking preventive care, resulting in a greater risk of morbidity and premature mortality. (Impact on preventive services usage)
• Concerns were raised that resources should be allocated to address immigrants' healthcare needs. Transmissible diseases associated with poverty and loss of individual control have been recognized as a real threat in a period where limited resources are available for their management. (Impact on health of vulnerable population groups)
• The monitoring of multi-morbidity using inexpensive diagnostics and technology should be introduced centrally in primary care, based on a balance of cost and effectiveness. (Impact on use of inexpensive technology)
• In a field that has received limited financial and institutional research support for decades, the current austerity has further reduced research capacity in family practice and primary care. (Impact on research capacity)
• Alcohol overuse and domestic violence are common problems in primary care and are associated with an individual's significant loss of income. (Impact on 'micro-social' cohesion).

Not surprisingly, the rural GPs involved expressed an urgent need for guidance on how to manage the issues they struggle to cope with every day due to reduced quality and equity in health care in this period of significant financial deceleration (Impact on quality and equity). In Australia, for instance, rural GPs procedurally can provide safe, high quality colonoscopies, overcoming the rural inequity in access to screening initiatives⁷. Given the well-known association between mental health disorders and poverty, it is challenging for rural GPs in Crete to have to support their patients with limited pharmaceutical therapies due to financial restrictions. In this instance, the iterature suggests that primary-care, clinician-driven internet cognitve behavioural therapy (accessed via a computer) is effective for patients with mild and moderate symptoms of depression and anxiety as an alternative to or in conjunction with pharmacological treatment⁸. The GPs also need support in dealing with new regulations regarding the prescription of medicines, for instance in educating patients who still do not trust generics and fear that using them may place their health at risk. Associated with this issue, it is of interest that recently published research reported underutilization of prescribed medicines in a rural communitry, with 8.5 (± 5.8) medicines boxes found stored for 'future use' in 40 households, at a total cost of approximately 9,000 euros⁹.

In this letter, many rural GPs from differing backgrounds express their unmet professional expectations and their concern and great uncertainty about the future quality of primary-care services available, and their role as providers of care in Greece during this unprecedented austerity period. The urgent adoption of a tested health reform model¹⁰, by both patients as health service users and professionals as health providers must be a priority.

Recently, the Greek Prime Minister expressed a wish for Greece to become the 'success story' of Europe. The CPBRN members wish for Family Medicine to become the 'success story' of the national healthcare system, while also challenging policy-makers to avoid further faulty health policies that might shrink the already meagre healthcare expenditure.

In conclusion, the Greek GPs, particularly those in rural areas, have been 'invited' to cope with certain challenges during the years of austerity ahead. One of the greatest challenges will be to ensure that the whole population has equal access to the provision of health care when resources are severely limited. Such equality of access must be independent of socioeconomical status, race or ethnicity¹¹.

Tsiligianni I, Anastasiou F, Antonopoulou M, Chliveros C, Dimitrakopoulos S, Duijker G, Kounalakis D, Makri K, Petraki C,
Prokopiadou D, Stefanaki I, Symvoulakis E,Tsakountakis N, Vasilopoulos T, Vittorakis C, Lionis C,
on behalf of the Cretan Practice-based Primary Care Research Network 'G. Lambrakis'
& Clinic of Social and Family Medicine, School of Medicine, University of Crete,
Heraklion, Crete, Greece

References

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2. Sbarouni V, Tsimtsiou Z, Symvoulakis E, Kamekis A, Petelos E, Saridaki A et al. Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural and Remote Health 12(4): 2156. (Online) 2012. Available: www.rrh.org.au (Accessed 6 March 2013).

3. Karatzanis AD, Symvoulakis EK, Nikolaou V, Velegrakis GA. Potential impact of the financial crisis on outpatient hospital visits due to otorhinolaryngologic disorders in Crete, Greece. International Journal of Medical Science 2012; 9(2): 126-128.

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6. European Commission. Memorandum of Understanding between the European Commission acting on behalf on the Euro Area Member States and the Hellenic Republic. (Online) 2012. Available: http://ec.europa.eu/economy_finance/eu_borrower/mou/2012-03-01-greece-mou_en.pdf (Accessed 10 January 2013).

7. Azzopardi J, DeWitt DE. Quality and safety issues in procedural rural practice: a prospective evaluation of current quality and safety guidelines in 3000 colonoscopies. Rural and Remote Health 12: 1949. (Online) 2012. Available: www.rrh.org.au (Accessed 6 March 2013).

8. Hoifodt RS, Strøm C, Kolstrup N, Eisemann M, Waterloo K. Effectiveness of cognitive behavioural therapy in primary health care: a review. Family Practice 2011; 28(5): 489-504.

9. Tsiligianni IG, Delgatty C, Alegakis A, Lionis C. A household survey on the extent of home medication storage. A cross-sectional study from rural Crete, Greece. European Journal of General Practice 2012; 18(1): 3-8.

10. Kousoulis AA, Symvoulakis EK, Lionis C. What Greece can learn from UK primary care experience and empirical research. British Journal of General Practice 2012; 62(603): 543.

11. World Health Organization. Health and Freedom from Discrimination. (Online) 2001. http://www.who.int/hhr/activities/q_and_a/en/Health_and_Freedom_from_Discrimination_English_699KB.pdf (Accessed 10 January 2013).