Translation of “For years we have been begging for a GP, but no one has come” appearing in the February 4th edition of liberal print weekly Magyar Narancs.
We have investigated at close range one of the serious problems affecting the Hungarian health-care system. Why are there no general practitioners in the villages? And why would being a village doctor still be wonderful?
“Honestly, who would want to come here?” The mayor of the Ibafa in Baranya County, population 240, spreads his hands wide. As the leader of a small settlement, László Benes knows what to say about perhaps the greatest problem with the system of GP provision. “According to some calculations, 1500 to 2000 is the minimum number of national insurance cards – this is what is needed for running a practice to be worthwhile under the current norms. In the four settlements in our area there are 700 to 750, and they won’t even talk to us. After the death of our last doctor, his son inherited the practice, but he couldn’t sell it, so it was returned to the local council. This was in 2003. Since then, we have been using substitutes to provide care – a doctor from Szigetvár comes for a few hours each week. We’ve been doing all we can for a long time to get a new doctor of our own: we moved the surgery into the local government building and renovated it, we provided a service residence in the neighbouring village, and we decided to hand over the practice free of charge. But there were no applicants, as though it were no longer an honourable thing to be a village doctor.”
This is not only a problem Ibafa faces. The figures showing the extent of the lack of professionals in Hungarian health-care grow ever more alarming, including those for the GP system. Data from the Healthcare Registry and Training Centre (ENKK) show that this applies in particular to the emigration of doctors and nurses under the age of 40, who can earn abroad six times what they can at home. They choose to work elsewhere because of this – not to mention the better standard of living, environment, professional development and opportunities for advancement. This has led to a situation where in some areas it is impossible even to give away a general practice for free. In villages it is practically impossible, while in cities the situation is “merely” difficult. While mainly material concerns lie behind all this, that is only one aspect of a complex problem.
The responsibility of local councils?
Currently 277 posts are permanently vacant, which is 39 more than at the same time last year. We asked the office of the national Chief Medical Officer about possible reasons for this, where we were told there could be numerous reasons, including the ageing of GPs. They added that the unfilled posts often affect such small numbers of local residents that it is not viable to maintain a post. “Moreover, there are some local councils that do not even want to fill the posts, and prefer to use a system of substitution,” they said. The National Public Health and Medical Officer Service (ÁNTSZ) asserts that local councils and the current rules are also responsible for the situation. “Unfortunately the current rules do not oblige local authorities to cooperate with one another… although a different structure of postings and division of labour would in many cases allow us to solve the provision of GP services,” it added.
However, in reality it appears that some settlements are “sweating blood” to get their own GP – but to no avail. A good example of this is the case of two villages in Baranya, Ibafa and Meneske, where the GP posts have been vacant for over a decade despite the local council offering pretty much everything.
There is a house, but no network
Back to Ibafa, where the job of GP has been vacant for years.
According to the community’s leader, the village had everything in the past: a respected teacher, a priest, a doctor, services. They even opened a building society that was the pride of the village, and which operated from 1958 until just recently. “They couldn’t cover the cost of meeting the conditions laid down by the law in the building, and closed up instead. The same goes for the post office and the kindergarten. There is a school in the neighbouring village, Almamellék, and the kids travel there. The shop is still open, and the pub, but that could easily be just a matter of time, too. Four mobile shops come to Ibafa, the competition is too strong,” László Benes explained. “Despite our negotiating for years with the service providers, there is no mobile phone antenna in the village, and so no coverage either. And besides phone coverage, internet access is also restricted, very slow, and only suitable for doing the most basic tasks. We hope we’ll get broadband internet in the near future, and we’re doing everything we can to make it happen. We may have lost heart when it comes to the doctor, but we still haven’t buried ourselves yet.”
Villagers also live in hope in the similarly sized Nemeske, about the same distance from Szigetvár. We spoke to the mayor, Mrs Péter Tóth, on the telephone as she was distributing firewood in the village. “We’d like to renovate the service apartment, because it was built in 1971 and really needs it,” she said when we asked her about her plans. “There was even a couple who showed an interest. They approached us because their kid was going to Pécs university, but in the end nothing came of it. Substitutes have been providing the service for over ten years – they even do ECGs and take blood samples from the patients. It’s important that they don’t have to travel to Szigetvár or Pécs for this, so we’ve spent a lot on the service. But the young ones, the freshly graduated doctors would sooner go abroad. Just like any other young person who can do so.”
Cities are different
Although an empty practice caused concern in Pécs, they did succeed in finding a doctor in the end. According to records at the department of primary health-care provision at the Chief Medical Officer’s bureau, the 5th paediatric care area has been without a doctor since 2015. The practice is on Hősök tere, not far from a sign marking the edge of town where, malign gossip has it, the bus is reluctant to venture. There is a substitute service and, as HR department manager Dr Csilla Tóth Maulné puts it, thanks to Pécs’s clinics and doctor training, the issue of vacant practices has never been a serious problem in the city. The 5th paediatric care area is an exception (there have been three attempts to recruit to the area, but no applicants even though a local council service apartment was offered), but now a solution has been found: doctors and care providers posted at practices in the four neighbouring paediatric care areas have undertaken to assume responsibility for providing care to the child population in the affected area. It starts in two months.
The countryside is not attractive
If the government only had the will, it would mean a complete change to the whole situation, said Dr Kamill Selmeczi, president of the FAKOOSZ National Association of Primary Care Doctors. “Despite the signals, warnings, recommended pre-emptive and treatment strategies, the relevant decision makers remain silent, especially when it comes to any significant rise in the ratio of health-care funding to GDP. The state continuously owes significant sums to the health-care sector, for work done by all the workers who are still in the system, and overtime to cover for those who left!”, she stressed.
In an interview given to Magyar Nemzet, the organisation’s president also recommended that, beyond just the settlement of wages, modernisation should be carried out. In many places, 1960s-type conditions await young doctors, which they understandably do not find particularly appealing. “Such practices could be made attractive if, for example, the local council provided a car for GPs who have to serve several settlements, so they could travel more easily between them, or they could provide housing subsidies.”
More than a doctor
“A GP’s monthly income comes from many sources: a fixed salary and the so-called ‘card money’,” explained a doctor practising in Budapest, who requested anonymity. “A GP receives a supplement depending on how many people live in their area. It is difficult to give a precise figure, because more money comes from old people and children, and one can take on other tasks, too. I don’t even count what is worth how much, I only look at the sum the state transfers at the end of the month.”
All this has to be covered in the practice: the doctor’s own salary, those of the assistants, bills, medicines, equipment and substitutions if one takes a holiday. The situation in the capital is still better than that in the countryside. “I worked for a year in the country and I would not go back. It is a 24-hour job, and one is not just a doctor when on duty but all the time. In a village, you are The Doctor, and they count on you even outside working hours. This was a burden that I could not bear. I can understand that after several years of sparkling university life, a newly qualified doctor is not drawn to the countryside. One can only live in a village, and leave behind the bustle of the city, if one really desires it. Otherwise you only suffer,” she said.
These comments appear to be supported by the fact that, although a significant proportion of doctors have reached retirement age, they are forced to work because there are no replacements.
From the surgery straight to the grave
“If every GP in Baranya who works during retirement were to down tools tomorrow, the entire system of health-care provision would collapse,” said a doctor living on the border of the county, who also did not wish to be named, to indicate the seriousness of the situation. “I have been practising for more than 40 years, and my son also became a doctor but does not want to follow the career, so I don’t know who I can leave my practice to. I used to have 1,400 in my area but now it is 1,100. The population is dwindling in villages, especially areas made up of lots of tiny villages, so the stipend that they bring in is reduced.”
It is difficult to cover all costs from the monthly stipend, and if things continue like this, it will only get worse. Fundamental changes need to be made, and much higher state support, the female doctor said. “General practice in the city is totally different from the village. There the patients go to the relevant medical centre if they have a specific problem. However, in the village – although the situation has changed a lot – they turn to their GP first in all cases. In mixed areas, moreover, children come as well as the parents, so the doctor knows everybody, and that is real family doctoring. When substituting, this is more difficult to do, since in addition to providing health-care in your own area (which can comprise several villages) you also have to go to another one, which can mean there is not enough time for the patients. I’ve been in my village since 1975, and I live here amongst my patients, about whom I know everything. Since the centralised duty roster, they don’t call me up out of surgery hours, but they still know they can count on me if there is a problem. Anyone who wants to be a doctor, especially a village doctor, has to be committed. There is no half-a-million forints a month salary, and you can forget about ‘gratuity money’. There is a romantic picture of the countryside that many people still cling to, but in reality no longer exists. They don’t keep animals, and patients don’t bring chickens or half a pig in lieu of payment. In any case I would not accept them: the people are poor, and if I followed my heart, I would sooner give to them. Overall, I can say that change is needed in all areas, because this way the surgery is heading for the grave. I’m already retired, but since this has been my whole life, I still work. Two generations have grown up under my care, and now the children of my former children come to me. That brings me joy in spite of the workload and the low pay. If anything, this is what makes it worthwhile.”
The state support is not enough in itself
A statement on the OEP [national healthcare fund] website says the average performance-related pay for providing general practice services is between 600,000 and 750,000 forints. Since last year, general practitioners required to provide district health care are also entitled to 130,000 forints per practice to cover bills and accommodation. OEP’s calculations suggest that the total average monthly income for a GP’s practice is about 1.2 million forints. From this, the doctor must cover costs, his assistants’ payroll, bills, equipment, medicines and substitutes.
The state – beyond the aforementioned funding from the OEP – gives further support to those who choose an area that has been persistently vacant. According to the 2016 tender documents, a doctor who takes on a practice that has been empty for a year or more receives a relocation allowance of 6 million forints. Seven million forints go to anyone who wins a post in an area that has been vacant for more than two years, eight million if it has been vacant for three years, and nine million if it has been vacant for at least four years. A doctor who takes on a practice that has been vacant for five years or more receives 10 million forints. Among the conditions for this support, however, is a provision requiring the doctor to spend at least four years in his new posting, and the number of patients to receive GP provision must exceed 1,000 in the case of adults, and 500 in the case of children. It is this latter provision which means Ibafa and the villages around it have slipped through the net.
It would be worth rethinking the payment system for this reason alone, but also because there has been no year where the relocation allowance set aside for GPs was successfully distributed in full. In 2015, only 471 million of 750 million forints was used up, because there were not enough applicants. In 2014, when 500 million was available, 41 GPs practices were filled. The winning doctors received a total of 273 million forints, so more than 40% of the available funds went unused. How much has been set aside for this year (in 2016 it was 500 million) has not yet been made public. All we know from ÁNTSZ is that the imminent tender “will provide millions of forints in support to popularise long-time vacant areas and promote the switching of practices”.