Country and population

Luxembourg is a small country in western Europe. It covers an area of 2586 km² with a mean density of 194/km². Luxembourg has 502 100 inhabitants in total, of whom 285 700 are Luxembourgers, which means that 43.1% of the total population living in Luxembourg are foreigners (in 2010). On 1 January 2010, 14% of the population were 65 years or older, 68.3% were of working age (15–64 years), and 17.7% were children, aged 0–14 years.

Geographically the country is divided into two regions: the “Oesling” in the north with a lower density (32%) of population and the “good country” in the south, which is more industrial and contains the most populated (68%) municipalities. The administration of the country is divided between 3 districts, 12 cantons and 116 municipalities. The administrative languages are French, German and Luxembourgish (STATEC, 2010).

Development and economy

Luxembourg is a representative democracy in the form of a constitutional monarchy. The chief of state is HRH Grand Duke Henri. The government is represented by a Parliament headed by a Prime Minister.

Luxembourg has the highest GDP per capita of the EU; it is estimated at PPP$ 62 119 in the year 2008 (OECD, 2009). This is partly due to the elevated percentage of cross-border workers who contribute to the GDP but are not residents of Luxembourg (Eurostat, 2010). Luxembourg is ranked 24th on the Human Development Index with 0.852 (UNDP, 2010). The unemployment rate in 2009 was 5.9%, and by October 2010 it had grown to 6.1%.

Population’s health

The total life expectancy at birth was 81 years in 2008 (World Bank, 2010). Life expectancy in 2005–2007 was 77.6 years for males and 82.7 years for females. In 2009, there were 11.3 births per 1000 inhabitants (9.5 births per 1000 Luxembourgers and 13.7 births per 1000 foreigners). The total fertility rate was 1.59 in 2009 (STATEC, 2010). The infant mortality was 1.82 per 1000 live births in 2007; 3.82 children per 1000 were born dead in 2007 (STATEC, 2010).

In 2007, the most frequent causes of death were cardiac diseases, cerebrovascular diseases and cancers (digestive and respiratory system) (STATEC, 2010; Ministère de la Santé, 2007). Death from cancers was more frequent in males (570 males vs. 470 females), whereas diseases of the circulatory system were a predominant cause of death among females (781 females vs. 613 males) in 2007. These diseases are followed by chronic respiratory diseases (122) and external causes of death (270).

The primary cause of hospitalization for men is cancer whereas for women it is arthropathic diseases. Together with cardiovascular diseases these two represent 17.1% of all hospital admissions (IGSS, 2008).

Characteristics of the health care system

Table A18.1 shows that Luxembourg has the highest expenditure per capita on health care of all EU countries. Health care is funded by compulsory health care insurance, additional voluntary insurance and co-payments. Health insurance is compulsory for working people, their relatives and children, and therefore provides nearly full coverage of the whole population. A shortage of nurses is a relatively small problem in Luxembourg as the number of nurses relative to the population is around two-thirds higher than the average of EU15 countries (OECD, 2008). The picture is reversed with regard to physicians. In 2008, density of physicians (excluding dentists) was 3.1 per 1000 habitants with a proportion of two-thirds specialists and one-third GPs (STATEC, 2010). Patients have free access to every specialist and, as reimbursement of the costs is good, consumption is quite high.

Table A18.1

Development of health care resources and utilization.

Considering hospital stay, the mean duration of stay is diminishing in recent years due to ambulatory surgery. In 2008, 69.3% of the patients had a stay of four or fewer days in hospital and 81.5% stayed fewer than seven days.

Since 2003 costs for pharmaceutical prescriptions have risen constantly at a rate of about 4.4% a year. In 2008 pharmaceutical costs were €154.5 million and were 5.9% higher than in 2007 (IGSS, 2008).

2.1. Primary care governance

Primary care in Luxembourg has not been defined with explicit goals. No policy documents have been issued by government or important stakeholders that reflect a clear vision on current and future primary care. As a result, for example, no policy measures have been implemented to regulate and assure an equal distribution of primary care providers and facilities. This lack of focus on primary care is also reflected in the absence of a primary care unit within the Ministry of Health and within the body for the state inspection of health care, as well as in the lack of a specific budget for primary care that can be distinguished from other sectors.

The medical association, the Association des Médecins et Médecins Dentistes (AMMD) defends the interests of the medical and dental professions in relation to the sickness funds and the government. As this organization represents the doctors working in primary care as well, it also defends pay and conditions and promotes the development of concrete projects in primary care. In addition, the professional association for GPs, the Cercle des Médecins Généralistes (CMG) is an important promoter of any professional projects in general practice.

On a more scientific level, the Société Scientifique Luxembourgeoise de Médecine Générale (SSLMG) is the association that initiates, promotes and sustains scientific projects, research in general practice, and postgraduate training. Most of its members are teachers in the vocational training of general practice at the University of Luxembourg. The Association Luxembourgeoise pour la Formation Médicale Continue (ALFORMEC) is the organization responsible for continuing medical education in general practice. It is funded by pharmaceutical industry, the Ministry of Health and by the fees of its members.

Physicians can work in primary care after they have completed postgraduate training, either in Luxembourg or in another member state of the EU. Continuing medical education is only a deontological obligation, and not mandatory for other primary care providers such as GPs (Ministère de la Santé, 2004). There are no formal requirements for starting and running a primary care facility or practice.

As a voluntary mechanism to maintain and improve the quality of care, the independent scientific organization called the Conseil Scientifique was created by a governmental regulation in 2005. It aims to elaborate and communicate recommendations concerning good medical practice in health care (not specifically for primary care). The Conseil Scientifique has developed guidelines for the prescription of antibiotics, medical imaging and laboratory tests, primary prevention of cardiovascular diseases, and guidelines for oncology. The guidelines specifically produced for use by GPs were either adapted from foreign guidelines or developed by medical specialists.

Another important measure to maintain and improve quality of care is provided by ALFORMEC, which offers continuing medical education training specifically aimed at GPs (ALFORMEC, 2010; Conseil Scientifique, 2010).

Informed consent by patients has not been regulated by law. Other patient rights, such as patient access to their own medical files, confidential use of medical records, and the availability of complaint procedures in primary care facilities have been secured by law.

2.2. Economic conditions of primary care

There are no official statistics available for the total expenditure on primary care. It is only known that 1.1% of the total health expenditure is spent on prevention and public health (OECD, 2009).

Health insurance is compulsory for those who are working, retired, receiving alternative payment or minimal revenue or those being paid as unemployed people. As a result it is estimated that 97.9% of the population is covered for medical expenditures (including primary care), either directly (68.3%) or via a family member (Caisse Nationale de Santé, 2009; IGSS, 2009).

Health insurance reimburses 90% of the costs of patient visits to a GP or medical specialist. The reimbursement for home visits is 80%. The co-payment for medicines prescribed in primary care varies greatly, depending on the type of medication. Medicines for chronic diseases are often fully reimbursed (Caisse Nationale de Santé, 2010: Arts 34–38).

Almost all GPs (90%) are self-employed with a contract to health insurance fund(s) or health authority, receiving a fee-for-service payment. Only 10% are salaried employed, working either for a health insurance company, the Ministry of Health or a community-driven hospital. Salaried employed GPs receive a flat salary. In 2006, the average annual income of a self-employed GP was PPP$ 128 875 (€115 987), and of a salaried GP PPP$ 107 558 (€96 802). Fig. A18.1 shows big differences in the average income between a mid-career GP and medical specialists, who have much higher incomes. All allied health care and nursing professions have lower incomes than GPs.

Fig. A18.1

How does the average income of mid-career health professionals relate to that of a mid-career GP.

2.3. Primary care workforce development

Patients can directly access a GP, or any medical specialist, for primary care or specialized services. Therefore primary care is provided by GPs, dentists, gynaecologists/obstetricians, paediatricians, specialists of internal medicine, ophthalmologists, ENT specialists, cardiologists, neurologists and surgeons. Patients do need a referral to access nurses and midwives. Fig. A18.2 shows a small increase in supply over a five-year time period for GPs, gynaecologists/obstetricians, paediatricians, ENT specialists, neurologists, and surgeons. The biggest increase in supply occurred among dentists. The development of supply of internists, ophthalmologists and cardiologists shows a negative trend (Eurostat, 2009; OECD, 2009).

Fig. A18.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period.

According to national statistics, in 2008 30% of active physicians were GPs, and 70% medical specialists (IGSS, 2009). There are no recent public data available on primary care workforce capacity needs and development in the future.

The age distribution of GPs shows that 8% are younger than 35 years, 22% between 35 and 45 years, 38% between 45 and 55 years, and 32% older than 55 years.

There is no medical faculty with a complete basic medical training in Luxembourg or with an undergraduate training in general practice. The University of Luxembourg offers a postgraduate training in general practice which was first introduced in 2004. The number of participants has increased from 14 in 2005–2006 to 37 in 2007–2008. After completion of the three-year training (including theory and practice training) students obtain a certified EU training diploma in general practice (Ministère de la Santé, 2004). The tasks and duties of GPs have formally been described in the Code de Déontologie Médicale (Ordre National des Médecins, 2005).

A professional training specifically for district or community nurses, or primary care nurses, does not exist. Most of the GPs in Luxembourg do not employ a nurse in their practice.

There is no journal on general practice published in Luxembourg.

3.1. Access to primary care services

Although the density of GPs is a bit lower in the rural region in the north of the country, it is estimated that GPs are well distributed among cities and villages. However, there are no official statistics on the variation in supply between cantons. National norms of targeted density of GPs do not exist, nor are there standardized procedures of workforce capacity planning. A major concern is that more than a third of the GPs will reach the retirement age within the next 10 years, which will put the accessibility of care under pressure.

In 2008, there were in total 89 pharmacies distributed through the country. A fixed number of inhabitants is required in a given area in order to allow a new pharmacy to be established (IGSS, 2009).

A survey in 2007 showed that overall, 89% of patients find it easy to reach and gain access to GPs (European Commission, 2007). Primary care practices are not legally bound to a minimum number of opening hours. They usually use an appointment system and offer special clinical sessions (see Fig. A18.3). Practices rarely use e-mail consultations (2.7% of GPs in 2007), or consult patients over the phone. Primary care practices occasionally have a practice web site (Dobrev et al., 2008).

Fig. A18.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

An average work week of a GP is around 60 hours. An average consultation with a GP takes 15–20 minutes. The number of home visits differs quite a lot between GPs. Younger GPs provide fewer home visits than older colleagues. Between urban and rural areas, the number of home visits performed by GPs can vary between 1 and 20 visits per week.

After-hours care provision is organized mainly around two modes. Hospital emergency departments provide primary care by taking care of health problems after office hours. Second, since December 2008 walk-in centres have been available for face-to-face contact with a GP after office hours. These centres are open every evening from 8.00 p.m. to midnight, and on Saturdays, Sundays and holidays. Between midnight and 7.00 a.m. GPs are on duty for phone services and house visits (Government of Luxembourg, 2008).

Given the minor co-payments, the affordability of primary care for patients is not a real issue. A survey in 2007 showed that only 4% of the population in 2007 rated general practice care not affordable (European Commission, 2007).

3.2. Continuity of primary care services

GPs do not have a patient list system. Patients have a free choice of doctor, and can change their GP any time they want. There is no official data available about the stability of doctor–patient relations and patient satisfaction about the quality of their relation with primary care providers. Generally, patients consider a certain GP as their primary medical care consultant, except for very specific diseases for which they directly visit a specialist. It is estimated that a GP is responsible for about 500 patients per month.

GPs are obliged by law to keep medical records for all patient contacts (Ordre National des Médecins, 2005). They usually (72% in 2007) have a computer at their disposal in their office which they use for their financial administration, prescription of medicines and for keeping medical records. GPs do not commonly use their computer to interact with other care providers or pharmacies, to book appointments or to search for medical information on the internet (Dobrev et al., 2008). The functionalities of the computer (for instance being able to generate lists of patients) depend on the software that is used.

Referral letters are usually used by GPs to refer a patient to a medical specialist. After an episode of treatment, medical specialists usually write a brief medical assessment and treatment discharge letter; these are often brought by patients to GPs.

There is no direct procedure for informing GPs within 24 hours about contacts that patients have with out-of-hours services. Normally, a GP receives the information at the next visit of their patient, or earlier by letter if the patient has been hospitalized. Direct transfer of information is possible but not very common.

3.3. Coordination of primary care services

There is no gatekeeping system in Luxembourg. Patients can visit any GP or medical specialist directly for their health problems. Patients can also directly receive home care from a nurse, in which case they pay the costs out of pocket. Referrals from a GP or a medical specialist are only normally required for a visit to a paramedical therapist (e.g. physiotherapist, occupational therapist), specialized nurse, midwife or dentist.

The majority of general practices are single-handed practices (see Fig. A18.4). Shared practices are however becoming more and more common: 30% are group practices of two or more GPs.

Fig. A18.4

Shared practice.

Partly as a result of the predominance of single-handed general practices, GPs only occasionally have face-to-face meetings with their GP colleagues, and only seldom collaborate with practice nurses, midwives or community mental health workers. They more frequently meet with home care nurses, social workers and primary care physiotherapists, and cooperate with pharmacies mostly by phone. Task substitution does not exist in primary care. For example, nurse-led clinics within primary care, for example for patients with diabetes, or to provide health education, do not take place. Health education for patients is mostly provided by patient associations.

Among group practices it is more usual to organize monthly meetings to discuss clinical cases with specialists and other providers, and to provide continuing medical education. Joint consultation among specialists and GPs however does not occur. The habit of asking advice from medical specialists is very individual and depends on the skills of the GP, his or her habits of working and the geographical situation of the office. Generally it is not uncommon to ask advice from a specialist.

3.3. Comprehensiveness of primary care services

Primary care is provided by a range of medical specialists in addition to GPs. This limited role of GPs is clearly shown by Table A18.2. As a result, GPs are not necessarily always the point of first-contact care for all new health problems. For most new health problems patients usually or occasionally visit a GP. This is also the case for treatment and follow-up care of diseases, and the provision of medical technical procedures. There are no official statistics available of the percentage of total patient contacts handled solely by GPs without referrals to other providers. GPs are often involved in the provision of preventive care (not for children) and less so in health promotion activities.

Table A18.2

GPs’ involvement in delivery of various primary care services.

4.1. Quality of primary care

In 2008, 12.9% of the total expenditures on health care are spent on medicines prescribed within primary care. This percentage increased by 5.8% over one year. Of the prescribed medicines, 69% are fully reimbursed, 26% are reimbursed up to 80%, and 5% are reimbursed up to 40% (IGSS, 2009). About 27.3 DDD/1000 inhabitants/ day of antibiotics were prescribed by ambulatory physicians in 2007 (ESAC, 2009).

Very little information is available that provides an indication of the quality of care provided for common primary care conditions. Concerning diabetes care, it is known that, in 2008, 48% of the diabetic population had an HbA1C level higher than 7.0% (Cebolla & Bjornberg, 2008).

In 1999, 2135 per 100 000 inhabitants were hospitalized because of a disease of the respiratory system (Ministère de la Santé, 2006).

Infant vaccination rates within primary care are generally around 96% (Ministère de la Santé, 2009). Nevertheless, the provision of preventive care can clearly be improved, as influenza vaccinations of the population aged 60 or older are relatively low, at 42% in 2001, and up to 55% in 2007. Even though Luxembourg has had a national breast cancer screening programme since 1992, in which women aged 50–69 years receive biannual invitations, in 2008 only 64.5% of the target population received a mammography (OECD, 2009; Schopper & De Wolf, 2007; Von Karsa et al., 2007). The screening rates for cervical cancer are even lower: 49.3% of women aged 20–69 years received a Pap smear test in 2008 (Linos & Riza, 2000; OECD, 2009).

4.2. Efficiency of primary care

There are no official statistics available that give an indication of the efficiency of primary care.