Gp in Europe

Portugal
The healthcare system

Portugal has a National Health Service (NHS) following the principle of universal coverage, since 1979. The great majority of doctors are employees of the NHS. However, these doctors can also work in private practice. Half of the NHS doctors work also in private practice.Eighty-five per cent of people are registered with general practitioners (GD/family doctors in the community health centres of the NHS. There are 355 community health centres and 1,878 small primary care practice units spread all over the country. General practitioners/Family doctors have patient lists of 1,500 people, on average.Within the NHS, access to secondary and tertiary care is done by GP referrals. However, in emergency services, private practice and some sub-systems outside the NHS, patients go directly to the specialists.In 1990, a new General Healthcare Law was approved by Parliament, aimed to change the healthcare system to a more liberal model. Presently, several organisational reforms are being introduced within the NHS, but it is not yet clear what will be the final shape of the system.The NHS, financed by the State budget, is universal and provides comprehensive care, or assures that this care will be provided.

Total medical manpower: 29,000 doctors:

• 44 per cent female;

• 23 per cent are GPs/family doctors;

• 43 per cent are other specialists;

• 22 per cent are postgraduate residents (all specialities, including general practice/family medicine, eight per cent are doctors without any postgraduate qualification (basic doctors);

• 40 per cent are pre-registration residents (doctors after graduation from medical school, but who must attend a general common internship) Presumed number of unemployed doctors (1994 less than 500). Population/doctors ratio: 338. The official medical career (within the NHS) has three branches (Decree-Law 73/90):

• general practice;

• hospital doctors;

• public health;

• mean salaries per year (before taxes):

a) generalists/family doctors with specific diploma (in the NHS) — 30,000 ECU;

b) specialists (in the NHS) — 30,000 ECU;

c) in private practice and in sub-systems other than the NHS, some doctors — either GPs or specialists can have higher incomes.general practice/family medicine is recognised as a medical spe ciality with qualified professional status, as with any other med ical speciality within the NHS.

In the 1960s and early 1970s, Portuguese doctors were concentrate< mainly in large city, in hospitals. Only a small number of doctor remained working as GPs.After the revolution of 1974, healthcare came to be a priori!' for political and social transformation. Debates for a NHS preparec the establishment of this NHS in 1979.From 1975 to 1982 a provisional medical service (one year long was created to cover the country, specially in peripheral and dcprivec areas. This service was provided annually, on an obligatory basis by young doctors, as an indispensable condition for joining ;medical career within the NHS.In 1982 a law was passed establishing a career of general practia within the NHS. Thousands of young doctors who provided th( year long medical service in peripheral areas decided to follow thi;new career.Today, Portuguese general practice/family medicine can b< summarised as follows:

• 6,000 GPs/family doctors (average age 40 years) working ir multi-professional community health centres and paid on salary basis;

• each person can choose their personal family doctor withir the NHS. Family registration is suggested and most people dc this;

• there is a system or patient lists (average size is 1,500 patient' per list). Most of the lists are organised by families.

Eighty-five per cent of entrants in the new GP career between 1981 and 1986) were doctors without specific vocational training ir general practice. Only ten per cent accomplished a three yeai residency/vocational training programme. This training became obligatory for the new entrants in the GP profession after 1987 Special in-service specific training programmes were implementec for those GPs who had no vocational training and had been ir general practice for at least five years.In 1982 the College of General Pracf/ceofthe Ordem dos Medico;(the Portuguese Medical Association) was founded as the accreditatior board for specialisation in general practice/family medicine.In 1983, The Portuguese Association of General Practitioner'. (APMCG) was founded to respond to the problems and needs faced

After the basic medical course, which lasts for six years, there is a general internship (1 8 months in the areas of internal medicine surgery, paediatrics, gynaecology, obstetrics and in general practice/primary healthcare. This internship is obligatory for all doctors in order to allow them to practice independently.There is a national MCQ examination each year for those who want to enter postgraduate residencies/vocational training programmes (hospital specialities, four to six years; general practice/family medicine, three years; public health medicine three years).The option for the residency in general practice is made at the same stage as for any other medical speciality and it is, for the new doctors, the only way to get the diploma of specialist in general practice/family medicine. There is a Residency Booklet with aims, general contents, specific targets and evaluation guidelines which guides trainees and trainers along the training programme.

The training residency programme is based on the practice of family medicine in a health centre. Hospital stages or rotations and monographic courses are considered as additional learning inputs in the training process.However, in the first years, about 5,500 doctors were assigned to the general practice career in the NHS without having any vocational training. So, it was necessary to implement a special in-service training programme for those doctors. This programme lasts for 1 2 months.About 3,750 GPs have already finished their specific in-service training programmes, and about 1,400 will finish it in the next two to three years.The organisation and management of these programmes is done by the three Institutes of General Practice (north, centre, south).The main educational aims and contents are similar to those of the three year programme, taking into account that the trainees are doctors who have been working as family doctors for at least five years. 

There is also a Training Booklet for this in-service training programme.The trainers are also selected GP/family doctors with the specialist diploma.

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