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Kringos DS, Boerma WGW, Hutchinson A, et al., editors. Building primary care in a changing Europe [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2015. (Observatory Studies Series, No. 38.)
This chapter will be devoted to the dimensions which have been grouped in the framework as “process” and that focus on essential features of service delivery in primary care. In addition to the breadth of services delivered, a comparative overview will be provided of variation in access to services, and continuity and coordination of care. In addition to the volume and type of primary care services, accessibility is determined by the remoteness of services and the practice organization (e.g. appointment system, after-hours care arrangements, home visits). Financial barriers, such as co-payments, determine the financial accessibility of primary care. The extent to which access to primary care services is provided on the basis of health needs, without systematic differences on the basis of individual or social characteristics, indicates the level of equality in access that is achieved. Continuity of care comprises relationship and management continuity. The coordination function reflects the ability of primary care providers to coordinate use of services within primary care and in other levels of health care. It is determined by the presence of a gatekeeping system, practice structure and teamwork, diversification and substitution of primary care providers, and integration and collaboration of primary care with secondary care and the public health sector. This chapter will conclude with a mapping exercise of the breadth of services delivered, accessibility, continuity and coordination of care in countries across Europe, showing also the interrelations across dimensions.
3.1. Access to primary care
An essential feature of primary care is providing access to services for all who need them, irrespective of personal characteristics, socioeconomic status or health status. Accessibility to primary care services is determined by several factors. The volume and types of services should be in good proportion relative to the needs of the population. The remoteness of services in terms of travel distance for patients determines the geographic accessibility of primary care. At practice level, resources should be organized in such a way as to accommodate access (e.g. appointment system, after-hours care arrangements, home visits). Any financial barriers that patients may experience in receiving primary care services, such as co-payments and cost-sharing arrangements, determine the affordability, and thus the financial accessibility of primary care. The extent to which access to primary care services is provided on the basis of health needs, without systematic differences on the basis of individual or social characteristics, indicates the level of equity in access that is achieved. The next section will discuss these features of access to primary care in each of the countries analysed (see Appendix I for a complete overview of all access to primary care features and indicators).
Table 3.1 provides an overview of results of the accessibility of primary care by country.
Table 3.1
Accessibility of primary care services, overview of selection of results by country.
Provision and distribution of primary care services
A necessary pre-condition for access to primary care is an adequate supply of practitioners, both per head of population nationally, and in their distribution within the country, to ensure there is a match between need for care and its availability. This has long been recognized as a challenge for all health systems (Hart, 1971).
International comparisons of the number of GPs per head of population need to be interpreted cautiously as there is variation in the extent to which primary care is also provided by other medical and nursing disciplines. However, in all countries, the main provider of primary care is the GP. The density of GPs (per 100 000 population), ranges more than sevenfold between European countries.
There are also differences in the distribution of GPs within countries. The largest interregional differences exist in Switzerland, Sweden, Belgium, Bulgaria and the United Kingdom. Least interregional inequality in availability of GPs exists in Portugal, Germany, Slovakia, Hungary and Denmark. There is a lack of quantitative data on urban–rural differences in supply, but several countries have particular difficulties in providing general practice services to rural and deprived urban areas.
In all countries except Austria, Iceland and Spain, shortages of GPs exist according to national norms, either in some regions, or nationwide, as in Cyprus, Finland, Malta, Slovenia, Sweden and Turkey. In Spain, steps have been taken to ensure equitable provision, based on age, rural area and disease prevalence. Norms on the distribution of GPs are absent in Ireland and Luxembourg. Several countries reported concerns that the supply of GPs would become more difficult in the near future because of the ageing workforce; for example in Luxembourg a third of GPs will reach the retirement age in the next 10 years.
Availability of primary care services
In addition to the provision of services, access relies on primary care services being available at times that suit the population, and for emergencies outside normal working hours. Primary care centres are obliged to have a minimum number of opening hours in all countries except Belgium, Finland, France, Germany, Ireland, Luxembourg, Slovakia, Sweden and Switzerland. However, there is marked variation in the minimum number of hours required per week, from 20 in Austria to 52.5 in the United Kingdom. In several countries (e.g. Norway), minimum opening hours are determined locally, and in others (e.g. Italy) they vary according to the number of registered patients.
There is a diversity of models for out-of-hours care (Huibers et al., 2009). Several countries report multiple systems, but the most common models are non-practice-based provision (including cooperatives, primary care centres and deputizing services) followed by practice-based services (based around one or more practices). Out-of-hours care supplied by emergency departments has been recognized as having weaknesses in terms of continuity, cost, coordination and accessibility (Huibers et al., 2009). The extent to which these departments contribute to out-of-hours care varies across Europe, but it is notable that in Cyprus, Estonia, Latvia and Lithuania emergency departments have the sole responsibility for after-hours primary care service delivery.
Types of contact
Appointment systems can facilitate access or make access more difficult, depending on their flexibility and responsiveness (Pascoe, Neal & Allgar, 2004). The extent to which appointment systems are used varies between countries; they are not frequently used in Austria, Bulgaria, Cyprus, the Czech Republic, Germany, Greece, Hungary, Italy, Romania, Slovakia and Turkey.
The extent of home visiting differs largely across Europe. The five countries with the highest average number of home visits per week by GPs are Belgium (37), Malta (28), Germany (25), Austria (15) and France (13); and the lowest are Portugal and Norway (both less than 1), Iceland and Turkey (both 1), and Cyprus, where no home visits are made. Although some of this variation is because of cultural or demographic reasons, it is likely that access to usual primary care is a problem for housebound and severely ill patients in countries such as Cyprus, where GPs do not offer any visits at all, and in countries with very low rates of home visits.
Access to primary care can be enhanced by the provision of a range of options beyond the traditional face-to-face consultation. Telephone consultations are usually offered, except in Cyprus, Estonia, Greece, Lithuania, Luxembourg, Poland, Romania, Slovakia and Turkey. E-mail consultations are frequently offered only in Denmark, and occasionally in Iceland, Ireland, Italy, Lithuania, Norway, Portugal, Slovenia, Spain and the United Kingdom.
In 2007, patient satisfaction with ease in reaching and gaining access to GPs was lowest in Turkey, Sweden, Portugal (60–69%), Latvia, Romania, Greece (70–79%), Lithuania, Bulgaria, Denmark, Italy and Slovakia (80–85%), with rates of 90% or higher in Austria, Belgium, Cyprus, Finland, Germany, Ireland, Malta, the Netherlands, Poland and Spain.
Financial barriers to access
In addition to geographical and organizational access, it is essential that financial barriers do not impede access to primary care services. In the majority of countries (16) there is no payment for a visit to a GP, while in 15 there are co-payments. Payment for a home visit by a GP is more common; there is no charge in only 12 countries, with co-payments in 14 and full payments in four (Cyprus, France, Ireland and Latvia). Payments for prescribed drugs are a lot more common; there is no charge in only four countries (Cyprus, Portugal, Romania and Slovenia).
Most countries apply one or more of the following criteria for exemptions for co-payments on primary care services: disadvantaged groups (income, employment status, legal status), pregnant women, children, young people in full-time education, blood donors, pensioners, war veterans, groups of patients with specific diseases (often chronic conditions), being registered in a health centre (only in Belgium) or preventive visits. Some countries have a ceiling for co-payments specifically for primary care services, medicines, or all medical care.
The level of co-payments often depends on the insurance status of patients, and the employment status of primary care providers. The highest (formal) payments in the public system exist in Ireland, where patients without a medical card (over 60% of the population) pay €45–60 for each general practice visit, with no reimbursement. In Switzerland no exemptions are made for primary care services, as patients have a deductible of CHF 300–2500 (€225–1875), depending on the insurance contract, and pay 10% of the physician fee up to CHF 700 (€525) a year after this limit is reached. As a result, 66% of the primary care physicians’ costs are paid out of pocket by patients in Switzerland. Patients who cannot afford health care services depend on social services. In a decentralized country like Sweden, medical care fees differ across the countries. For example, co-payments for visits to GPs range from SEK 150–300 (€14.69–29.38). Higher fees apply for out-of-hours consultations. In France, there is a general tendency for increasing out-of-pocket payments, even with a complementary insurance, and especially for primary care. In Hungary and Romania physicians use a tipping system, expecting an extra (unofficial) out-of-pocket payment from their patients. This means that the official system can be very different from the unofficial system. Out-of pocket payments in the private sector can also be very high across Europe. For example, when a patient insured via an SHI fund in Greece visits a private (not contracted) physician he or she has to pay market prices and will receive a fixed reimbursement of €20, which is often at least €50 lower than the price paid.
The following countries had the lowest levels of patient satisfaction with the costs of general practice care in 2007: Greece (57%), Cyprus (61%), Portugal (63%), Ireland (67%), Turkey (71%), Romania (76%), Finland (83%), Italy (84%) and Belgium (86%).
Overall accessibility of primary care
Fig. 3.1 shows the total access to primary care score by country, considering the performance of each country on all access indicators (see Appendix II for the applied scoring system).
Fig. 3.1
Total access to primary care score by country (scale 1 (low) – 3 (high)).
Many countries had difficulties reporting inequalities in geographical density of GPs. Of the 21 countries with available data, only six had relatively low inequalities in geographical availability of primary care services, and many reported shortages in supply. Another important aspect requiring improvement is the accommodation of access through home visits, e-mail consultations or use of appointment systems, which vary greatly across Europe. The perceived affordability of primary care by patients seemed to be an important aspect limiting access to primary care in several countries.
When considering all features of access to care, Slovenia, Denmark, Spain, the United Kingdom, the Netherlands, Poland, the Czech Republic, Portugal, Hungary and Lithuania have a relatively high accessibility of primary care. Access is relatively low in Ireland, Luxembourg, Turkey, France, Greece, Cyprus, Belgium, Bulgaria, Latvia, Malta and Switzerland. All other countries have a medium level of access to primary care. The difference between the highest and lowest performing countries is relatively high.
3.2. Continuity of primary care
Continuity of care consists of relationship continuity and management continuity (Hill & Freeman, 2011). Relationship continuity implies that patients benefit from having a long-term relationship with a primary care provider that goes beyond specific episodes of illness or disease. Some definitions also speak of personal or family continuity, where the continuity of care between a single provider or a family is stressed. The quality of the longitudinal relationship between primary care providers and patients, in terms of accommodation of patients’ needs and preferences, such as communication and respect for patients, determine relationship continuity. Management continuity involves coordination and teamwork between caregivers and across organizational boundaries. It includes an organized collection of each patient’s medical information readily available to any health care provider caring for the patient. This can be reached through medical record-keeping, clinical support and referral systems. The next section will discuss these features of continuity of primary care in each of the countries analysed (see Appendix I for an overview of the Continuity of Care features, indicators and additional information items).
Table 3.2 provides an overview of results of the continuity of primary care by country.
Table 3.2
Continuity of primary care services, overview of selection of results by country.
Continuity of care over time
Continuity of primary care is facilitated in primary care by GPs having a list of patients for whose medical care they are responsible, either personally or as a group. Such lists of registered patients are the norm in most countries of Europe, and mandatory in all countries except Austria, Belgium, Cyprus, France, Germany, Ireland, Luxembourg, Malta, Sweden and Switzerland. In some of these countries, registration with a GP is compulsory for some patients (e.g. those who are state funded in Ireland) or incentivized (e.g. by a reduction of co-payments in Belgium).
The average population size served by GPs is 1687 patients. GPs have the largest average list size in Turkey (3687), Malta (2500), the Netherlands (2322) and the Slovakia (2163); and the smallest in Luxembourg (500), Belgium (718), France (800), Italy (1094) and Norway (1219).
There is potentially a trade-off between choice and continuity. Patients are free to register with any primary care centre and GP in their locality in all countries except Finland, Greece and Sweden, where patients are assigned to a primary care centre, and Slovenia, where patients are assigned to a GP. Continuity is best achieved by patients visiting their usual primary care provider for their common health problems rather than attending multiple primary care providers or medical specialists. Interpretation of results regarding this aspect is difficult as some national data sets define the usual provider as an individual clinician, whereas in others it is defined as an organization. The extent to which other professionals (e.g. pharmacists and nurses) are used for common health problems also varies between countries. In all 23 counties where data were available, it was found to be “usually the case” that patients consulted the same provider for their common health problems, although this varied from a high of over 90% in the Czech Republic and Slovakia to lows of below 70% in Austria and Portugal.
Management continuity
Management continuity relies on good information systems, both within primary care and between primary and secondary care. GPs’ offices in all countries (except Latvia, Lithuania and Malta) are usually equipped with a computer for keeping medical records, financial administration and prescription of medicines. In only a minority of countries computers are also used for researching expert information on the Internet, booking appointments, and for communication with medical specialists or pharmacists. Finland and Denmark have the highest use of computers in general practice. Referral letters are usually used by all GPs in Europe, except in Austria, Greece, Italy and Turkey (no data available for Cyprus and Malta). In most (18) countries it takes more than 24 hours to receive information about out-of-hours contacts for patients.
Relationship continuity
On average 85% of patients in Europe are satisfied with their relationship with their primary care physician and trust their primary care physician. Satisfaction with the patient–primary care physician relationship is lowest in Sweden (55%), Lithuania (70%) and the Netherlands (70%); and patients least trust their primary care physician in Turkey (59%), Lithuania (60%), Bulgaria (70%) and Latvia (72%). On average, only 79% of patients in Europe were satisfied with the explanation given by their primary care providers of problems, procedures and treatments. This is lowest in Slovenia (49%), Hungary (60%), Lithuania (60%) and Romania (60%).
Overall continuity of primary care by country
Fig. 3.2 shows the total score of continuity of primary care by country (see Appendix II for the applied scoring system). Variation between countries appears to be very small. Only Turkey, Malta and Austria have lower scores. The difference between the other countries is negligible.
Fig. 3.2
Total continuity of primary care score by country (scale 1 (low) – 3 (high)).
In countries where GPs have a high patient load, relationship continuity can be improved by limiting the average population size per GP. This would reduce the work load and increase possibilities for building a high-quality relationship with patients. Patient satisfaction with several aspects of their relationship with their GP (e.g. consultation duration) could be improved in many countries.
3.3. Coordination of primary care
Primary care physicians can have an important role in coordinating the health care of their patients, including coordination within primary care, coordination of input from medical specialists, and coordination with public health to address broader public health issues. Lack of coordination of specialist care can lead to unnecessary costs, duplication of services and higher risk of medical errors. The next section will discuss the important features of coordination of primary care in each of the countries analysed (see Appendix I for an overview of the coordination of care features and indicators).
Table 3.3 provides an overview of a selection of results of the coordination of primary care by country.
Table 3.3
Coordination of primary care services, overview of selection of results by country.
Gatekeeping
One method of achieving coordinated care is for access to a specialist to be available only by referral from the patient’s GP, the so-called “gatekeeper” function. Between a full gatekeeping role for GPs and no gatekeeping, two other models can be distinguished. So the following four variants can be identified among countries in Europe:
- No gatekeeping system in place. Patients, with a few possible exceptions, have direct access to most physicians (Austria, Belgium, Cyprus, Germany, Luxembourg, Switzerland, Turkey);
- No formal gatekeeping system in place, but there are incentives. Direct access to most physicians is possible if costs of the visit are paid privately (the Czech Republic, Denmark, Finland, France, Iceland, Ireland, Malta, Slovakia);
- Partial gatekeeping system in place. Patients need a referral for only a selection of physicians (Hungary, Latvia, Poland, Sweden);
- Full gatekeeping system in place. A referral is normally required to access most specialist physicians (Bulgaria, Estonia, Italy, Lithuania, the Netherlands, Norway, Portugal, Romania, Slovenia, Spain, the United Kingdom).
Skill-mix of primary care providers
The organization of primary care can facilitate or hinder coordination, both within primary care and between primary and secondary care. Primary care may be organized around single-handed or group practices, or broader groupings including primary care and secondary care specialists. Countries with centralized responsibilities for primary care have more solo practices than decentralized primary care systems. In Austria, Bulgaria, the Czech Republic, Hungary, Latvia and Slovakia large majorities of general practices are single-handed. In almost half of the countries primary care is dominated by solo practices. The opposite is true for Finland, Lithuania, Poland, Portugal, Spain, Sweden and Turkey, where almost all GPs are working in group or mixed practices. Mixed practices with GPs and medical specialists are seen in Cyprus (20%), Germany (9%), Greece (20%), Latvia (8%), Lithuania (80%), Malta (20%), Romania (7%) and Slovenia (20%). They occur in 1% or fewer cases in the Czech Republic, Finland, Hungary, Spain and the United Kingdom. GPs working in group or mixed practices have more face-to-face meetings with other primary care providers, and offer more special sessions or clinics for specific patient groups, than single-handed general practices, thereby facilitating coordination of care.
The role of nurses in primary care is limited in most countries. Only in 12 countries do nurses provide health education in primary care, and the provision of nurse-led diabetes clinics is even less common (occurring in only five countries). Only in Denmark, the Netherlands, the United Kingdom, Sweden and Turkey are both types of nurse-led service offered.
Cooperation of primary and secondary care and public health
Cooperation between primary care providers and medical specialists is very limited in Austria, Bulgaria, Cyprus, Germany, Hungary, Iceland, Ireland, Norway, Portugal, Romania, Slovakia and Turkey. This may result from mutual competition when, as in Germany, medical specialists also work in primary care. In other countries, the most common model of cooperation is the provision of clinical lessons by medical specialists for GPs. The most extensive forms of cooperation exist in Sweden (including relocated specialist care, joint consultations and clinical lessons). GPs in the majority of countries do not regularly ask telephone advice from medical specialists (only in 13 countries).
Coordination between primary care and public health is underdeveloped in most countries. Only in 10 countries is primary care data routinely used to identify health policy priorities. However, community health surveys to improve the quality of primary care are conducted in all countries except Luxembourg, and regular nationwide surveys are undertaken in Belgium, Estonia, the Netherlands, Romania, Spain, Sweden, Switzerland and the United Kingdom.
Overall coordination of primary care by country
Fig. 3.3 summarizes all indicators on coordination by country (see Appendix II for the applied scoring system). Compared to the other aspects of service delivery, scores on coordination are generally low. Furthermore the variation between countries is considerably higher than the other aspects. What especially contributed to the low scores is the collaboration between primary care and secondary care and the scale and skill-mix of primary care practices. Currently, the dominant mode of general practice continues to be the single-handed practice, although in many countries group practices are increasing. Solo practice has limited possibilities for delivering integrated care.
Fig. 3.3
Total coordination of primary care score by country (scale 1 (low) – 3 (high)).
Combining all measures of coordination, Fig. 3.3 shows that Sweden, the Netherlands, Lithuania, Denmark, Greece, Poland, the United Kingdom, Slovenia, Spain and Malta have the highest level of coordination of care. This is lowest in Austria, Germany, Slovakia, Bulgaria, Hungary, Cyprus, Romania, Norway, Ireland, Iceland and Turkey. All other countries have a medium level of coordination of care.
3.4. Comprehensiveness of services provided in primary care
The broader the range of services that are offered to patients in primary care, the smaller the dependency on secondary care services, and the stronger primary care is. Possibilities to provide services are related to the availability of medical equipment in primary care practices.
The range of services offered includes the following domains of care: first-contact care and triage; diagnostic services, treatment and follow-up care; medical technical procedures; prevention and health promotion; and mother, child and reproductive health care.
This section deals with the important features of comprehensiveness of primary care in each of the countries analysed (see Appendix I for an overview of features and indicators).
Table 3.4 provides an overview of results of the comprehensiveness of primary care by country.
Table 3.4
Comprehensiveness of primary care services, overview of selection of results by country.
Primary care facilities are generally well equipped across Europe, although in Austria, Hungary, Italy, Luxembourg, Malta, Poland, Romania, Slovakia and Slovenia items such as gynaecological speculums, peak flow meters, ECG recorders, urine strips, instruments for stitching wounds or infant scales are not always in place. The diversity of problems for which patients can be helped in primary care (such as a severely coughing child, contraception problems, alcohol addiction) is highest in Bulgaria, Denmark, Finland, France, Hungary, Norway, Poland, Portugal and Sweden.
GPs often provide treatment and follow-up care for a broader scope of conditions in countries with more solo practices, although this may be a function of demographics; for example, in remote areas, GPs are more likely to work solo and offer a fuller range of services. Other frequently visited specialist providers for treatment and follow-up care are cardiologists, rheumatologists, gastroenterologists, psychiatrists, pulmonologists, oncologists, internists, endocrinologists, diabetologists and geriatricians. Overall, GPs handle more than 90% of their total patient contacts without referral in Denmark, Estonia, Finland, Iceland, the Netherlands, Norway, Portugal, Spain and Switzerland.
Medical technical procedures are most frequently carried out by GPs and primary care nurses in Belgium, Finland, the Netherlands, Norway and Sweden. Other providers who often perform typically primary care medical technical procedures are surgeons, ophthalmologists, gynaecologists, dermatologists, orthopaedists, rheumatologists, emergency room specialists, internists and nurses.
Preventive activities are provided by a large variety of providers in the majority of countries. Preventive care is frequently provided by gynaecologists, paediatricians, allergists, internists, cardiologists, dermatologists, midwives, emergency room specialists, infection specialists, obstetricians and special clinics, in addition to GPs.
Overall comprehensiveness of services by country
A summary of all comprehensiveness scores by country is presented in Fig. 3.4. With all measures combined there are only small differences between countries. Primary care services are most comprehensive in Lithuania, Norway, Bulgaria, Belgium, the United Kingdom, Spain, Finland, Sweden, Portugal and France. A more narrow profile was found in Slovakia, Italy, Greece, Cyprus, Romania, Hungary, Poland, the Netherlands, Slovenia, the Czech Republic and Austria. The other countries are in an intermediate position regarding comprehensiveness of primary care services.
Fig. 3.4
Total comprehensiveness of primary care score by country (scale 1 (low) – 3 (high)).
3.5. Overall service delivery in primary care
In Fig. 3.5 the countries’ positions on all dimensions of the primary care services delivery process have been taken together. Denmark, Spain and the United Kingdom have a high accessibility of primary care, provide a relatively high level of continuity and coordination of primary care, and provide the most comprehensive scope of primary care services. Countries where accessibility, continuity, coordination and comprehensiveness of primary care are somewhat less consistent are Estonia, Lithuania, Portugal and to a lesser degree (medium level) the Czech Republic, Finland and Poland. Austria and Cyprus have a relatively weak primary care services delivery process (considering all four dimensions). Consistency is even lower (weak/medium) in Bulgaria, Italy, Luxembourg, Romania and Turkey, and to a lesser degree (medium level) in Greece, Ireland, Malta and Switzerland. The least consistency among the dimensions of service delivery was found in the remaining 11 countries.
Overall, the scores of the four dimensions of the primary care services delivery process show no associations with each other. Each of the primary care structure dimensions is positively associated with primary care accessibility (Spearman’s correlation values range from 0.37 [p-value 0.04] for access – economic conditions to 0.54 [p-value 0.00] for access – governance). In addition, coordination of primary care is positively associated with primary care governance and primary care workforce development. The Spearman’s correlation values are 0.38 (p-value 0.03) and 0.41 (p-value 0.02) respectively.
3.6. Conclusions
This chapter has characterized the delivery of services in primary care by the breadth and comprehensiveness of the package of services delivered, how services are accessed by patients and the functions of continuity and coordination of care.
- Obstacles to access were related to shortage of GPs which were usually more perceptible in rural areas than in towns and cities.
- Geographical equality is not optimal in most countries. In general, access outside normal office hours is differently organized and in most countries typically non-practice-based, which may be unfavourable for continuity of care.
- Home-bound patients in countries where GPs rarely make home visits may experience difficulties in receiving the care they need. Although most countries had no financial barriers for visiting a GP, home visits and prescriptions were more often subject to private payments.
- Major conditions for continuity of care are well-kept medical records for patients and GPs being responsible (and accountable) for care provided to a defined practice population. Such “patients’ lists” were mandatory for all patients in two-thirds of the countries. In general, differences between countries on continuity were modest.
- On coordination, differences were larger and countries performed less well. A gatekeeping system was operational in only a quarter of the countries, although in others a partial gatekeeping system was in place, or at least there were incentives for patients to achieve the same effect. Solo practice, which is less favourable for coordination, was still the dominant mode of practice in almost half of the countries. Collaboration between GPs and medical specialists was an area for improvement in many countries, and the links between primary care and public health were poorly developed.
- In the countries where GPs had a strong role as the doctor of first contact they treated more than 90% of all patient contacts without referral. Regarding the provision of medical procedures and prevention the variation was large; these task domains were less developed.
- No association was found between the four dimensions of service delivery explained in this chapter. But dimensions of structure (governance, economic conditions and workforce; dealt with in the previous chapter) were associated with access and coordination.
References
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- Hill AP, Freeman GK. Promoting continuity of care in general practice. London: Royal College of General Practitioners; 2011.
- Huibers L, et al. Out-of-hours care in western countries: assessment of different organizational models. BMC Health Service Research. 2009;9:105. [PMC free article: PMC2717955] [PubMed: 19549325]
- Pascoe SW, Neal RD, Allgar VL. Open-access versus bookable appointment systems: survey of patients attending appointments with general practitioners. British Journal of General Practice. 2004;1(54):367–369. [PMC free article: PMC1266172] [PubMed: 15113521]
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