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17 May 2023 | Country Update
Reorganization of emergency and GP care as part of a larger healthcare reform -
20 January 2023 | Country Update
Reorganization of out-of-hours services in primary care -
01 July 2021 | Policy Analysis
New incentives introduced to encourage primary care group practices -
01 July 2021 | Country Update
Measures to encourage the establishment of primary care group practices -
30 April 2020 | Country Update
New regulation on telemedicine -
18 May 2019 | Country Update
19 points from the GP’s Online Organization -
09 March 2019 | Country Update
New housing accommodations for GPs -
08 February 2018 | Country Update
Shrinking coverage of children by family pediatrician practices -
13 August 2015 | Country Update
National Assembly passes new law on primary care -
19 October 2013 | Country Update
Swiss-Hungarian model project to improve primary health care services in disadvantaged regions
5.3. Primary / ambulatory care
In Hungary, municipalities are responsible for ensuring the provision of primary care to the local population (1990/3), including family doctor services (through family physicians and family paediatricians), dental care, out-of-hours services, MCH nurse services and school health services (1997/20).
Family doctor services, at least in larger municipalities, are provided to adults by family physicians and to children by family paediatricians. In smaller municipalities, family physicians care both for adults and children in so-called mixed practices. Family doctors are required to have a qualification in the specialization of family medicine, which was introduced in 1992.
Local governments are responsible for ensuring that family doctor services are available to their population. They have the right to designate the primary care districts for family doctor services within their territory. To be eligible for HIF financing, family physician practices must care for at least 1200 residents over the age of 14 years and family paediatrician practices must care for at least 600 children aged 14 year or younger (1999/1). Primary care districts, which must cover the entire territory within the local government’s jurisdiction (for example, a municipality), serve as the basis of the territorial supply obligation. People do not have to register with a provider in their primary care district. Since 1992 people have been allowed to choose their family doctor freely, but may only switch to a new family doctor once a year. Family doctors are not allowed to refuse patients who live in their primary care district, but may refuse applicants from other districts (1992/3). Municipalities can decide whether to deliver family doctor services themselves (by hiring family doctors as public employees) or to contract with family doctors working as private entrepreneurs. The latter is the most common arrangement in primary care and is known as “functional privatization”. In these cases, the practice itself owned and equipped by the local government, but family doctors receive capitation payments directly from the NHIFA.
To work in a primary care district with a territorial supply obligation, family doctors must purchase a special licence (known as a “practice right”, or praxisjog), which was introduced in 2000 and was granted to all family doctors working in primary care districts with a territorial supply obligation (2000/1). According to this system, if a municipality advertises a family doctor post, the applicant has to buy this licence from the retiring family doctor or the doctor’s relatives to become eligible for the post. In this way, the central government intended to ensure that practices are bought and sold, while at the same time allowing local governments to remain responsible for ensuring the provision of primary care. Local governments retain discretion to decide in what form and by whom primary care will be provided. New entrants therefore still require the approval of the local government, as well as the capital to purchase a licence.
Family doctors are meant to act as gatekeepers in the Hungarian health care system. With the exception of certain specialist services, physician referrals are mandatory for obtaining higher-level care (1992/3), and patients are generally obliged to pay user charges if they bypass the referral system. Patients have direct access, however, to specialists in dermatology, ear, nose and throat diseases, obstetrics and gynaecology, general surgery, traumatology, ophthalmology, oncology, urology and psychiatry.
In 2009 there were 4971 family physicians and 1548 family paediatricians practising in Hungary, and the average number of inhabitants per practice was 1738 and 938, respectively (HCSO, 2010f). Looking at referrals made by family physicians, it is clear that they have not been effective gatekeepers. Between 1990 and 2008, the number of non-diagnostic referrals to providers of outpatient specialist care increased more than four times, and the number of patients per family physician referred to inpatient care increased by 78% (HCSO, 2010f). One of the reasons for these large increases may be that there is no incentive in the current, capitation-based payment system for family doctor services to provide definitive care and avoid unnecessary referrals. On the other hand, family physicians regularly complain about their overloaded schedules, excessively complicated regulations, onerous administrative requirements, and the overutilization of health services by patients.
The annual number of consultations per family physician increased by 31% from 1990 to 2006 (HCSO, 2010f). This was one of the government’s arguments for introducing user charges in February 2007 (2006/9). At the same time, given that a substantial part of patient–doctor encounters in primary care take place for the purpose of obtaining a referral, the government rationalized prescribing regulations in order to reduce family doctors’ workload. Moreover, the requirement that family doctors prescribe only one month’s worth of medication at a time for patients with chronic disease was changed so that three months’ worth of medication could be prescribed. As a result of these measures, the number of consultations decreased by 15% from 2006 to 2007. After user charges were eliminated in April 2008 (see section 6.1.1), the number of consultations increased by 5% that year and by more than 8% in 2009 (HCSO, 2010f).
In addition to family doctor services, municipalities are also obliged to provide MCH and school health services. The District MCH Service is staffed by highly qualified nurses, trained at higher education level. They provide preventive care and health education to pregnant women, women in childbed and children under the age of 6 in geographic areas that are determined by the local government and cover no more than 250 persons in need of care (2004/6). MCH nurses are employed by the local government and work autonomously in the facilities provided by it, or they make on-site visits to families and schools. The work of district MCH nurses is coordinated and supervised by senior MCH nurse officers at the county level and by the chief MCH nurse at the national level (see section 5.1). MCH nurses also provide school health services together with physicians as a preventive service for children between 3 and 18 years of age. Based on the number of pupils to be cared for, school health services can be provided on a part-time or full-time basis. Finally, as their name implies, school MCH nurses and physicians are employed directly by a given school (1995/11).
Emergency care (out-of-hours services) and primary dental care services are also provided in the primary care setting (see sections 5.5 and 5.12).
As part of a larger restructuring of the Hungarian health system (see the update from 7 December 2022), primary care is being transformed. Two main aspects are
- reorganizing the emergency out-of-hours services and
- creating new adult and pediatric general practice (GP) districts.
Reorganization of emergency out-of-hours care (see the update from 20 January 2023) takes place on a county-by-county basis. By 1 May 2023, it was adopted by six counties.
Primary care transformation is also related to the creation of new GP practice districts.
Authors
In February, the government will gradually start the reorganization of new emergency out-of-hours services. First in one Eastern county (Hajdú-Bihar), followed by another, Western county (Győr-Sopron) in March.
According to the measure adopted in December 2022, the responsibility for the provision of out-of-hours services is taken away from local governments and given to the National Emergency Ambulance Service (OMSz). The new system divides the out-of-hours period into two:
- Between 4 pm to 10 pm, there will be family doctors available in the districts of a county.
- Between 10 pm to 8 am and during the weekend, there will be district emergency centres staffed with highly qualified paramedical workers, managed by the OMSz. Patients can either call a new four-digit telephone number, where a trained health worker from the OMSz performs a telephone triage, or directly call the dedicated OMSz number in case of life-threatening emergencies.
The number of out-of-hours service points in the country will be reduced to 108. The new system is gradually implemented, since family doctors and the Hungarian Medical Chamber show significant resistance on the grounds of patient safety.
Authors
In 2021, the government introduced new measures to encourage the establishment of primary care group practices and to enhance the role of general practitioners. Primary care group practices involve the cooperation of several family doctors, family paediatricians and primary care dentists. In more and more cases, this is complemented by the provision of specialist care and prevention services aimed at improving the health of the population, increasing the number of healthy years spent and reducing the burden of disease. Additional services in primary health care are provided by the involvement of other professionals such as dietitians, physiotherapists, health visitors and psychologists. Among the new services provided to the public, the following have a prominent role: care of chronic patients, prevention activity, lifestyle counselling, organized and personalized screening, and community-level health promotion activities.
The government also introduced additional funding for wages for GPs who established group practices. Group practices can be organized based on different levels of cooperation. With the loose (so-called collegial) cooperation, providers receive additional funding when they provide a minimum of four hours of prevention and 20 hours of weekly surgery. In addition, in close cooperations, consisting of between 5 and 12 providers, primary care doctors receive additional funding in exchange for the provision of planning information on local capacities, competencies, and the provision of extra services (selected from a list of currently 48 items).
In primary care, solo-practicing family doctors and primary care dentists are encouraged to form group practices with the aim to raise the standard of local care, improve the health of the population, and improve their health awareness. As part of the reforms initiated by the government during the COVID-19 pandemic, the establishment of group practices among GPs is encouraged with substantial additional funding to increase wages, which makes fixed budgetary transfers the dominant component of the payment for family doctor services. Accordingly, the legal and organizational framework, the types of group practices (either close cooperation or loose cooperation), and the related membership requirements have been set out in Government Decree No 53/2021 and No 277/2021.
References:
https://egeszsegvonal.gov.hu/ellatorendszer/praxiskozossegek.html
On 29 April 2020, new telehealth regulations were introduced to maintain care continuity throughout the COVID-19 pandemic. The government issued a decree allowing doctors to provide health care services online (Government Decree No 157/2020) with the necessary financing changes. In addition, doctors are allowed to administer electronic prescriptions in the frame of telemedicine consultations.
On the World Day of Family Doctors, the GP’s Online Organisation, which represents approximately one sixth of GPs in Hungary, published a proposal with 19 points which would conceptually transform primary care. This document was published last year as well, however no changes were implemented so the Organisation published the same proposal again. The 19 points includes recommendations such as rethinking the entrepreneur status, practice rights, and payment system of the GPs, as well as creating a new, professional indicator system and standardising contracts with the municipalities.
However, there seems to be no commitment from the government yet to fulfil these expectations, as they plan the draft budget for next year only with a 6 percent increase for the Health Insurance Fund.
Authors
New accommodations dedicated for GPs serving the local population will be built within the Hungarian Village Program in small settlements where positions have remained vacant for a longer period. Alpár Gyopáros, the government commissioner responsible for the development of modern settlements emphasized that the purchase of GP practices is also supported by the government. He said, that there are 250 vacant GP position in small municipalities, where there are no family doctors for over a half year, and the service is only sustainable by permanent replacement. Besides, hundreds of practices operate with GPs over retirement age, or with GPs, who will soon reach it.
The aim of these measures is to make the positions more attractive for young professionals. From September 2019, other application will open with 11 billion HUF for renovating the old accommodations, beside the modernisation of the doctor’s offices.
Authors
Although, 30 family pediatrician practices are currently registered as vacant, this does not capture the full picture. Estimates say that at least 7–8 thousand practices were closed because of staffing difficulties. The reason can be found in the regulations: municipalities are expected to keep vacancies open for a half year only. After this period, they are allowed to redirect patients to GPs instead. According to data of the National Insurance Fund (NEAK), in 2016, 19 percent of children under 14 years and 38 percent of the 15- to 18-year-old children are not treated by pediatricians. The Association of Pediatricians suggested prolonging the regulation up to five years.
According to the Hungarian Central Statistical Office, in 2016, 1500 pediatric practices had to deal with more than 10 million cases. As the Association of Pediatricians pointed out, this number could be enormously decreased by extending the parental entitlement to certify school attendance. Parents are allowed to give the certification only three times a year, and every other case has to be taken to a pediatrician.
Authors
The National Assembly has passed a new act on primary care to pave the way for its organizational reform and create a framework for enhancing the roles and responsibilities of family doctors in the Hungarian health care system. Previously, there was no separate act on primary care; this highlights the high priority the current government has given to the development of family doctor services and the political importance of GPs. Family doctor services are still predominantly provided by individual practices managed by entrepreneur family doctors. Although the provision of primary care remains the responsibility of municipalities, family doctors are incentivized by the act to establish group practices. The act assigns the responsibility for better coordination and integration of services to the National Institute for Primary Care.
Authors
On 3 July 2013 a Swiss-Hungarian model project was launched to improve and expand primary health care services in Hungary’s underdeveloped regions. HUF 3.7 billion (USD 16.3 million) will be made available over three years to four towns in the
north and east of the country. Switzerland’s Ambassador to Hungary, Jean-Francois Paroz, called the project “vitally important in the context of Hungary’s healthcare reform”. Miklós Szócska, Minister of State for Healthcare, said that the project would cover all primary care services, thereby also yielding public health data to help professionals assess the health situation in Hungary’s underdeveloped regions.
http://www.kormany.hu