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124 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 delegation of some tasks (mainly administrative tasks). Their opinion about the GP role relative to other health actors, such as the second line and the multidisciplinary coordination (mainly for frail elderly and chronic patients) was, however, less clear-cut. The stakeholders as well as both groups of students supported the idea to discourage the excessive use of the 2nd line (known as soft gate keeping) and they supported an increased role in the management of the multidisciplinary team. Such enhanced role would pave the way for more delegation of clinical tasks, which also seems to be supported. However, the stakeholders fell short of recognizing that this would require a new health professional role such as the advanced-nurse practitioner. Two radical policies such as scrapping the numerus clausus (resulting in higher influx of doctors in general) and the creation of regional resource agencies improving local working conditions for GPs (inspired by the Alberta Rural Physician Action Plan) were clearly discarded by the stakeholders. 7.6 PUTTING ALL TOGETHER Improving the GP career will not work just by adding up policies. A pinch of capitation, with a “soupçon” of early GP teaching and a bit of group practice will not necessarily make the good meal GPs and Belgian patients are waiting for. The coherence between policies is as much important as their individual excellence. How to get this coherence? 7.6.1 Tackling the issue over the whole life cycle: attraction, recruitment and retention. Attraction, recruitment and retention strategies are all important. As stated in the literature review, attraction and recruitment strategies are important because low recruitment is generally the reason why shortages arise. Retention strategies are also important because a strong retention can offset poor recruitment. Attraction occurs all over the 7 years medical curriculum: that should lead to teaching strategies focusing on the whole master and not only at the end of the curriculum. Strategies should focus on a better integration of GP and other specialties’ teaching. As suggested by Geyman 153 , a "pipeline education continuum" strategy may be more relevant: starting with high school, and progressing into medical school until after graduation. This has two important consequences. First, because attraction and recruitment strategies are community-level policies whereas retention strategies are much more linked to federal responsibilities, it could be necessary to improve the coherence between the Community-level and the federal decisions to avoid a lack of coordination between the policies. A gap is already visible in manpower planning: between 2004 and 2006, 230 GP training posts remained unfilled and were replaced by specialist posts. The issue of GP clerkship is another domain in which such coordination could be useful. Second, strategies should focus on the whole curriculum. Strategies leading to an increased division of GP training from specialist training should probably be avoided, and, instead, better integration of these teaching should be searched. As suggested by Geyman 153 , a "pipeline education continuum" strategy may be more relevant: starting with high school, and progressing into medical school until after graduation. 7.6.2 Taking a reform perspective This study has shown that it will be impossible to resolve the issues GPs are facing without taking a broader perspective on the health care system. The different policies reviewed and chosen must be thus integrated. Team-working and the improved role of the GP in the health system are two instruments allowing for care coordination. Many types of GP networks and collaborations are powerful instruments to enhance the role of the GP. For example, encouraging the GPs to work in group will allow them to get a bigger say in a multidisciplinary team, to get funding for supporting staff; but that would require the delegation of some tasks in order to focus on their core-business. The redefinition of the GPs’ role within and outside the primary care line is the key reform
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 125 issue that needs to be addressed. In Europe, reforms of the primary care sector have followed one of the following models 226 : • Increase the power of primary care as purchaser or coordinator and gatekeeper; • Broaden the service portfolio of primary care; • Provide supportive conditions in order to promote a stronger role for primary care; The stakeholders’ analysis suggests that most GPs in Belgium would be ready for the least radical reform (the 3rd one) but the readiness for the second one is unclear. On the one hand the multidisciplinary team was considered as valuable, but on the other hand the delegation of clinical tasks and the nurse-assistant practitioner did not get high support. This ambiguity is not unique and parallels the difficulties the improved role of primary care as coordinator has faced in countries (like France and Germany) with health insurance scheme 226 . The main reason why pro-coordination policies have failed in the health insurance countries (like France and Belgium) is the weakness of the primary care professionals and the blocking of powerful professional associations 226 . As a result, pro-coordination policies have tended to emerge as hospital-centered (or sickness funds centered) instead of primary care-centered. Local GP groups such as the GP "kringen/cercles" could come out as significant long term partner to broaden and integrate the services primary care provide at the local level. The Interdisciplinary primary care organisation -SISD/SIT) is an opportunity for GPs to catch-up with this coordinator role, which was, in March 2008, considered as key health policy in the Belgian Government declaration. As suggested elsewhere 226 , current developments in care coordination may risk opening an avenue to coordination without the primary care in the driver’s seat. That would be reduced still further attraction, recruitment and retention of general practitioners into the profession. 7.6.3 Getting the message through The GPs have many institutions and levers to make their case: academic centers of general practice for teaching, GP professional associations (e.g. FAG, Domus Medica), Scientific GP societies (as the SSMG) and Unions. They also have local associations dealing mainly with on-call services; they sit along governmental bodies in the INAMI/RIZIV funding bodies (medicomut), through medical unions. The question is whether these bodies can unite to reach a coherent and overall strategy. The Interuniversity ICHO in Flanders and Domus Medica are illustrations of attempts to group GP institutions in order to promote such coherent strategy. This report brings to light that general practice is in need of ambassadors and leaders to propose a radical, constructive agenda and to negotiate the implementation of this reform with the public authorities.
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