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At the heart of general practice since 1960

Why Britain wins on health care front

German-born Dr Jurgen Wygrala has experienced both the German and the British health care

systems and he says he prefers the British

n his recent piece 'How to save the NHS' (Pulse, October 7) Dr Phil Hammond said: 'If he (Winston Churchill) had not won the war, we would have a health service like the Germans.' Implied in this comment is admiration for the German system, a feeling it is better than the British one. I have worked in both, and believe me, this isn't the case.

The insurance-based German system costs the average German approximately 14 per cent of his gross salary, of which the employer pays 7 per cent. So it is not cheap. Nor is it primary care led. Generalists and specialists are equally accessible to patients, and when deciding which type of doctor to go to the patient often bases his choice on what his symptoms are, and is treated in the way each doctor thinks fit.

If the patient is not happy with the service, he goes to a different doctor. This fragmentation leaves big gaps in communication between doctors, and increases cost immensely through repeat investigations. It can also take an awfully long time to reach a correct diagnosis.

Each individual doctor is given a quarterly budget which he uses to prescribe drugs, order investigations and so on. Most doctors are singlehanded and run their practices like a small business, with employed staff. Taking over a practice is a huge investment for a singlehanded doctor, often costing several hundred thousand Euros.

An item-of-service culture in German medicine means that doctors of any specialty, including GPs, purchase a lot of equipment, and this needs to be used to get a return on the investment.

The consequence is that investigative activity is very high at the beginning of the quarter, even though it may not be clinically necessary. The more patients seen, the more points scored, the more the remuneration. Audit hardly exists, and clinical governance is very much in its infancy.

Investigative activity decreases during the quarter where the target budget is being reached, and a common practice is then to close the surgery for one or two weeks at the end of the quarter as no one sees the point in working for free. Not very satisfactory for the patient.

Being singlehanded, both generalists and specialists work very much in isolation. And as each patient contact brings with it remuneration, losing a patient through referral is done reluctantly as it means loss of income.

The patient in this system remains lonely. He is left very much to make his own health care decisions, and finds it difficult to thread his way through the decision-making jungle. Empowerment and informed decision is very difficult to achieve as the system forces the individual doctor to place as much emphasis on his own economic interests as he does on the patient's health.

The German health care system is currently in crisis. It is not cheap for patients, and it is not delivering ­ a critic has likened it to driving a VW Beetle (an old Beetle) with Porsche running costs. In fact it is no longer affordable.

Patients have grown used to a system full of the latest technology, and to hang on to these patients, doctors have to have this technology. To pay for it, they have to use it.

I would prefer to drive a car I can afford, and would rather keep my finger on my patient's pulse than on his purse.

I would rather keep my finger on the patient's pulse than on his purse~

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