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Cross Analysis | General Practice | Community Pharmacy

Karl Krajic  |  Petra Plunger  |  Ursula Reichenpfader  |  Jürgen M Pelikan
1. Status quo of Patient-/ User oriented health promotion in general practice and community pharmacy in Europe.
A Cross analysis of Country Reports on the status quo of health promotion in general practice and community pharmacy in Member States of the European Union participating in the project

A. Introduction
B. Country Reports: Cross-Analysis relating to General Practice
1. Material and Methods
1.1. Country Reports
1.2. Literature Search
1.3. Personal Communication
1. Health Promotion in Professional Role and Practice
1.1. Professional Organisations: Policy and Position
1.2. Role Concepts and Professional Practice
2. Health Promotion in Education and Training: Extent and Character
2.1. Undergraduate Level: Basic Medical Education (BME)
2.2. Postgraduate level: Vocational Training:
2.3. Continuing Professional Development
3. Health Promotion in General Practice Research
3.1. Research in General Practice/ Primary Health Care: Character and Infrastructure
3.2. Research on Health Promotion in General Practice/Primary Health Care: Issues in Literature
4. Health Promotion and General Practice Infrastructure
4.1. Reimbursement and Incentive Policies
4.2. Organisational Factors and Practice Pattern

C. Country Reports: Cross-Analysis relating to Community Pharmacy
1. Background
1.1 Methods and Sources:
1.1.1 information from national CR:
1.1.2 Literature search and other published material
1.1.3 Personal communication (project meetings, other conferences)
2. Results
2.1 How strong is the interest of community pharmacy in health promotion and to what extend is health promotion an element of everyday practice?
2.2 What are supporting factors and barriers for health promotion in community pharmacy?
2.3 Role definition (and self-understanding) and perception of professional role of community pharmacists by relevant actors with respect to health promotion
2.3.1 What is the position of professional bodies regarding health promotion in community pharmacy?
2.3.2 What is the professional understanding of health promotion in community pharmacy and how does it relate to the professional role?
2.3.3 What is the perspective of health policy regarding health promotion in community pharmacy?
2.3.4 What do patients expect regarding health promotion in community pharmacy?
2.3.5 What are future perspectives on the development of the professional role in health promotion
2.4 Community pharmacy infrastructure
2.4.1 Factors related to organisation of work in community pharmacy
2.4.2 Remuneration systems/ adequate resources
2.4.3 Co-operation
2.5 Education and training
2.5.1 What is the status quo on education and training related to health promotion?
2.5.2 What are future scenarios for education and training related to health promotion?
2.6 Research
2.6.1 What is the status quo of research related to health promotion in community pharmacy?
2.6.2 What are future perspectives for research in this area?

A. Introduction

When the European Commission decided to fund a project on Development of Health Promotion in General Practice and Community Pharmacy in Europe, one of the basic assumptions was that the two settings offered good opportunities for health promotion - but there also was very little information available as to the extent to which these opportunities were already being exploited in the member states of the European Union.
Given the comparably high political profile of health promotion in health policy in some Member States like the UK, there was awareness about ongoing practice initiatives in this part of Europe - but the project managers had little systematic information on what was going on in the other Member States.

The basic logic of rational/professional problem solving asks for a thorough diagnosis before solutions, "a therapy" are established - describing the status quo and identifying the main causal mechanisms that are responsible for the state of development reached so far - in other words: factors supporting further development and barriers in its way. So one part of the project supported by the European Union was the attempt to reach such a diagnosis in each of the participating Member States.

The questions that guided this information gathering process can be summarised in the words of the representative of the European Commission at the European Conference on Health Promotion in General Practice and Community Pharmacy in Brussels, November 10-11, 2000:

"How strong is the interest in the professions concerned - but also on the political level - in health promotion in health care? To what extent is health promotion an element of everyday practice?

What supportive factors and what environments do pharmacists and general practitioners encounter in these fields and what are the barriers which they experience?
What are the precise needs of the professions if they want to move forward with health promotion? Are there training needs, communication needs, possibly financial needs?
What lesson can one learn across Europe from the experience which is there in the field? Is there something which can be abstracted from the activities that are going on - is there something like best practice?

Could health promotion prove to be some common ground between general practitioners and pharmacists, is this in fact an area for co-operation between the professions?
Can health promotion contribute to communication between both professionals and the patients and clients?"
(Kamphausen 2000)

Given the broad concept of health promotion and the low level of systematic information available at the outset of the project, to answer these questions - if understood as a task for scientific research in a strict sense - would have led to several more extensive research projects, with surveys and other types of systematic research to be conducted in many member states, in collaboration with national health promotion and health care researchers.

But given limited resources in time and money and the central practical aim to make a difference in European Health Promotion Policy, determined by the fact that the framework has been the "Action Program for Health Promotion of the European Union" and not a scientific program, the Commission, together with the scientific project managers opted for a rather fast, pragmatic, action oriented strategy in the information gathering part of the project.

As one of the central aims of the project was to get the professional associations of General Practice and Community Pharmacy informed, interested and involved, it was decided to conduct Country Reports by the formal professional associations as project partners (or authorised by them) as the main source of information on the national situation (complemented to some extent by other information gathering strategies like literature searches, discussions with partners and experts, organisation of a European Conference).
There consequences of this decision were manifold: Professional associations have a lot of first-hand information on professional practice in their country - but this information of course privileges the professional perspective. Second, the difficult process of establishing co-operation with professional associations in some Member States (see Project Summary also had consequences for the amount and quality of information that could be included into this cross analysis. Finally, these difficulties also led to delays in the overall research, analysis and discussion process of the project.

So the outcome of these information gathering strategies provides rather tentative answers to the questions mentioned above - and also highlight the need for further research.

Country Reports: Cross-Analysis relating to General Practice
Ursula Reichenpfader


1. Material and Methods

1.1. Country Reports
Country Reports are the primary source of this paper. Documents have been provided by project partners from Austria, Belgium, Germany, Greece, Ireland, Luxembourg, and Spain. The authors have utilised the agreed upon "Framework for Country Reports" (see Appendix), and a series of personal contacts were made to complement this material (telephone, e-mail communication). However, given the limited number of available reports, only a segment of health promotion in European general practice can be pictured. Sections have been complemented by selected English-language literature.(1)

1.2. Literature Search
The above material was complemented by selected relevant literature. A search of MEDLINE (advanced) and EMBASE (selected journals) was performed utilising the following search history: {"health promotion" (MeSH topics/ all subheadings)} AND {"family practice" (MeSH topic/ all subheadings) (term associated with non -MEDLINE terms: "general practice"/ "family medicine") OR "family physicians" (MeSH topic/ all subheadings)}. A total of 370 abstracts was obtained out of which all English-language articles were included(2). Further relevant material from references in the retrieved articles were obtained (see for a more detailed description of the initial literature search Background Paper

1.3. Personal Communication
Previous drafts of working papers (draft "Concept Paper, Part General Practice", proposal "Working Definition of Health Promotion in General Practice, draft "Conclusions and Proposals") have been discussed at project meetings and at the project conference with the expert group, the trans-national partners of the project. Furthermore, bilateral communication with the members of the above mentioned groups were an important further input for the development of this paper.


1. Health Promotion in Professional Role and Practice

1.1. Professional Organisations: Policy and Position
Health promotion in general practice is recognised in several policy statements as an integral part of the professional role. Professional organisations have been addressing this issue both at a European and at a national level. These statements vary in character, depending both on the respective organisation's remit and specific health policy context. They range from rather general recognition of the health promotion role of the general practitioner (e.g. UEMO Policy Statement - see Background paper GP 6 part A 1) to specific scientific reports (U. K. Royal College of General Practitioners). Role responsibilities in these contexts refer to health promotion under a broader umbrella concept with an emphasis on individually and mostly disease-oriented interventions, and information transfer within the consultation (i.e. preventive services, specific patient education, including group health education and counselling).

The Medical Profession and Health Promotion: Example from Germany:
With respect to relevant policy statements of a representative professional organisation, only one such example has been identified from the Country Reports available. In the specific policy 1994 statement adopted by the German Medical Association(3), health promotion and prevention have been explicitly recognised as essential tasks of the medical profession. In this document, contributions both of the medical profession and of health policy to facilitate health promotion activities and live up to the principles as set out in the Ottawa Charter are being addressed. It follows up a statement previously issued by the organisation, where a 3-level strategy for health promotion has been proposed. This approach recognises a second level - beyond the main focus on individual patient education in the consultation - where physicians can use measures directed at informing and educating specific risk-groups and enhancing self-help. Yet even on a third level, they can be involved in activities directed at the community and the wider public in an advocacy role. The organisation has since developed a specific CME Curriculum Health Promotion and recently issued a statement(4) reiterating the willingness of German physicians to contribute to the government's health promotion programme, particularly with respect to co-operation in evaluation and quality assurance of health promotion services. No similar policy statement by other professional associations in the Member States was identified.

Other examples of positioning on health promotion by professional organisations from available Country Reports are less formal or explicit in character, such as support for health promotion and prevention at conferences (Greece) or contribution in planning of health promotion programmes (Belgium, French Community: Superior Committee Health Promotion; involvement in drawing up five-year health promotion programme). Also, the professional organisations or societies may implicitly adhere to relevant health promotion documents (particularly the Ottawa Charter -Ottawa Charter for Health Promotion. WHO, Geneva,1986 ) when being involved in programme planning. (e.g. Spain(5), Belgium French Community: health promotion projects have to be in line with the Ottawa Charter).

1.2. Role Concepts and Professional Practice
Material as available from national Country Reports provides limited information on documented current state and extent of health promotion practice in routine general practice/ family medicine in the respective Member States. The following information was obtained illustrating the range of health promotion and prevention activities from the available Country Reports:

Range of Health Promotion and Prevention in Professional Practice: Examples from Country Reports
- Prevention and Health Promotion are priorities for the primary care services in Spain. General practitioners have specific responsibility for preventive health and anticipatory care for adults and children. Since January 1989, the Spanish Society of Family and Community Medicine, the Spanish Society of Paediatricians and the Ministry of Health have been supporting the country-wide programme of Prevention and Health Promotion (PAPPS).Spanish general practitioners provide preventive activities such as cardiovascular risk factor detection, as well as lifestyle counselling in the area of smoking, alcohol consumption and medication use for hypertension within the PAPPS programme. Also, specific sub-programmes for mental health and child health have been implemented.

- Irish general practitioners already participate in national programmes such as the Methadone Treatment Protocol ("MTP") and will be involved in the National Breast Cancer Screening Programme in the nearest future. Also, they routinely provide health education in a number of different areas in individual consultations. Activities range from disease-oriented clinics (asthma, diabetes, hypertension), Well Woman Clinic (cervical smears, breast examination, hormone replacement therapy) and family planning clinics, to risk factor screening. Increasingly, general practitioners are trained to provide smoking cessation counselling and management of alcohol problems.

- In Germany, the main focus of health promotion is on individual health counselling and risk factor modification. In addition to general health advice and lifestyle counselling, many general practitioners offer special services to patients at risk applying behaviour modification and cognition therapy techniques for obese patients and smokers. Also, some provide lifestyle counselling to groups in the area of diabetes and hypertension. (Model projects of structured patient education in these areas have been initiated). Also, general practitioners routinely offer health checks and provide cancer screening, but are only marginally involved in providing women's health services.

- Similarly, general practitioners in Austria and Luxembourg routinely provide individual preventive services, such as adult and child health checks, cancer screening and specific disease-oriented clinics (diabetes, hypertension). To some extent, they are also involved in methadone treatment programmes, childhood immunisations and women's health services.

- A similar range is provided by Belgian general practitioners, in addition to recent initiatives of counselling for alcohol problems and palliative care.

- According to the author of the Greek report, "preventive medicine is not widely practised, particularly in rural and suburban areas…" although he states that "the concept [of health promotion] is understood by the professional organisations". However, he concludes that initiatives are run on a low scale presently, and that "it is somewhat an illusion to talk about health promotion in Greek general practice" at this moment.

While the above reflects and exemplifies current practice of health promotion and prevention activities according to the Country Reports, authors have also addressed factors underlying and shaping professional role and the relationship with other health professionals and clients/ patients.

Some of the general practitioners that were involved in the described model initiatives referred to perceived patient demand or acceptance relating to health promotion and prevention intervention. Project co-ordinators consider both patients and users' expectations as well as the general practitioners' perceived support by health policy as further relevant factors that may affect professional role and self-perception with respect to health promotion:

Overall, as material on models in the Country Reports suggests, patients and users did not have a contribution or input in the development of these initiatives (exceptions included below). Rather, some projects identified have evaluated degree of acceptance and satisfaction of users with provided services:

Patients' preferences and expectations with respect to health promotion: Information from available Country Reports
- Successful collaboration and community support have been demonstrated in a German model initiative: "Prevention of cardiovascular diseases in Wremen").

- Cancer care project "IMPROVE", (Austria)

- In the context of a national Mammography Programme in Luxembourg, women have been surveyed with respect to their attendance (indicating that they would attend if their general practitioners had advised them to do so), thus allowing some assessment of their expectations towards their general practitioners in that matter (Dr. Y. Wagener, "Health Promotion in Primary Health Care", Country Report).

- More general surveys of the public in Spain have assessed users' utilisation of health care services

- Also, users' and patients' perceived demand by health professionals can be relevant as is described by the author of the Greek report stating "people are reluctant [to] or ignorant of issues of preventive medicine".
Concluding, no systematic findings of patients' preferences for and expectations of health promotion in general practice have been described by the authors in available Country Reports.

With regard to literature on patient and service users involvement in health care, a variety of approaches and concepts ranging from shared information, shared evaluation, and shared decision making (in the consultation), to shared responsibilities have been discussed (Coulter 1999). Accountability, with patients being partners with professionals applies to involvement in planning and designing of services and involving of the general public. Approaches of consultations, patient panels, forums, focus groups, or representation on formal councils have been utilised (Taylor 2000) Patients' expectations and preferences is increasingly explored in healthcare, yet with presently limited conclusive knowledge in research about feasibility and validity of methods(Wensing, Grol 2000). Concepts of doctor-patient partnerships in clinical consultations are being further developed (Charles, Whelan et al. 1999).

However, none of the above issues have been explored in detail in the framework of the Country Reports. Summarising, information on patients' perspectives, their experiences and expectations with relevance for health promotion in general practice is available to a very limited extent only from the Country Reports. This indicates that there is a lack on systematic information in this particular respect.

With respect to the expectations from health policy, no systematic analysis of policy documents or reports, research or questioning of relevant health policy actors has been attempted in this project. However, some written documents concerning a health policy position on specific aspects relevant to medical practice have been collected and was complemented by selected examples on (easily) retrieved English-language statements:

Expectations from health policy and the role of the general practitioner in health promotion:
Country Report authors have referred to material evidencing expectations of health policy (government and health ministry, respectively) vis-à-vis health professionals with respect to health promotion:
- An Irish strategy document "Building Healthier Hearts" (Department of Health and Children, Ireland, 1999) explicitly addresses the role of the general practitioner in cardiovascular prevention.

- Elsewhere, authors state "support by health policy for health promotion" (Spain, Germany), or indicate collaborative action (Belgium)

- some scepticism was expressed also (Greece: "Health promotion has been, in theory, a priority […] but so little has been achieved so far.").

- The potential contribution of general practice for health for all, through the delivery of a wide range of integrated health care functions including health promotion, disease prevention, curative, rehabilitative and supportive care has been recognised in a document that addressed medical professionals and decision-makers at all levels of the health care system. (Framework for Professional and Administrative Development of General Practice/ Family Medicine in Europe; WHO Europe, 1998 (in Boerma, Fleming 1998)

Further to information from the Country Reports, English-language literature on general practitioner surveys reflecting their opinions, perceptions, expectations and perceived practice relating to health promotion has been analysed to reflect current relevant role concepts and professional practice. An overview, particularly of relevant conceptual and implementation research, can be found in the project's "Concept Paper, Part General Practice". An overview of the current prevention activities by European general practitioners, identified within the "European Survey of the Task Profiles of General Practitioners" has been published(6).

All the material above considered, it can be concluded that health promotion in general practice is both an important part of the professional understanding and an element in daily practice. From this material, it can be concluded that there is only little variation in character of health promotion practice. Generally, health promotion is understood as an umbrella concept and primarily carried out in individually oriented interventions within the consultation. Nevertheless, the extent to which individual general practitioners are involved in health promotion varies.

Further to this, according to the self-perception of the profession(7), many activities and strategies in daily practice are not explicitly labelled "health promotion practice" although they address principles of health promotion. These concepts and discussions have mainly evolved from within the discipline of general practice or have been further developed in this context. Thus, these concepts and strategies hold considerable acceptance within the profession and are well connected to the positioning of general practice/ family medicine as a person- and context-oriented specialty. Health promotion in this context is understood as an "integral" component carried out alongside other daily tasks, rather then "stand-alone" or campaign issues, ideally with a primary care team approach. These activities and strategies follow health promotion principles of empowering and enabling individuals and groups with approaches of patient-centeredness effective communication, holistic medicine, physician-patient partnerships and resource mobilisation. Nevertheless, both health promotion practice and integration of the above reform concepts into everyday practice in general practice are not well documented.

2. Health Promotion in Education and Training: Extent and Character

In literature, new concepts, contents and techniques to be incorporated in the medical curriculum have been defined (for more detail(8), also see Wade J, 1991; MacLeod S, 1996). They highlight issues of health promotion and disease prevention, population health, health services and applied research, interdisciplinary and multi-professional education, blending primary, secondary and tertiary care team approach, users' involvement in decisions, gender equality, and community orientation. Also, relevant professional organisations at the European level are involved in further developing general practice training.

Voices for a more appropriate general practice training and education: some examples:
- Organisations such as EURACT (European Academy of Teachers in General Practice) are actively engaged in developing proposals of basic medical education that integrates skills and knowledge relevant for health promotion, enhances techniques of developing relationship-building competencies, and communication and consulting skills. Still more support and alliance building are needed.

- As noted by the Group of Representatives of General Practitioners in the European Union: […] "Major efforts are needed to teach techniques that encourage lifestyle modifications and to increase general practitioners' awareness of the importance of primary prevention in cancer control. (Draft Strategy for General Practice 1997-2000, "Europe Against Cancer Programme"). Such actions are needed both in specific training and in continuing education programs for general practice. General practitioners' organisations can play an important role in promoting such activity."

- Furthermore, at the international level, the need for a reorientation of medical education and for strengthening the ability of the medical sector to address "preventive and promotive health strategies" by means of medical education has been explicitly articulated. (in World Health Assembly Resolution 48.8. 1995, in "Doctors for Health", 1996)

- Following up on this, a report by WHO and WONCA(9) stated […] "In seeking to provide more relevant learning experiences, medical schools should teach not only the main causes of morbidity in the population which they serve, but the cultural context in which illness and health is defined and the expectations of the people in the population. Growing recognition of general practice/ family medicine, both as an academic discipline and as speciality with its person and context orientation, has contributed considerably to a re-orientation towards a more person-centred approach in overall medical education.

While the above evidences the efforts to reform medical education and general practice training both by professional organisations and international health policy actors, information from available Country Reports did not focus on the overall developmental status of general practice education and training. Factors concerning specific training in structural aspects, such as design of training programmes, degree of direct involvement of general practitioners in controlling and directing programmes, status of general practice academic departments, or specific programme characteristics have been explored in detail elsewhere. (For more detail see Draft compilation "UEMO Questionnaire the Current Status of Specific Training in General Practice" [in Kennedy, T.E. (Ed.) 1999: European Union of General Practitioners Reference Book 1999/ 2000, pp 148-15]). All the above still vary to a considerable degree across the Member States. While these underlying factors will shape and affect integration of health promotion and prevention in training, their specific relationship with actual recognition of health promotion and prevention was not within the scope of this project. The following can be summarised:

2.1. Undergraduate Level: Basic Medical Education (BME)
Country Report authors all indicate that courses relevant for health promotion are integrated in basic medical education curricula to some extent. Yet knowledge and skills courses, particularly communication training, are reflected to a varying degree. Information has not focused on detailing extent or character of courses (i.e. elective vs. mandatory), thus only a rough estimation may be provided.

Elements relevant for health promotion in BME curricula: Information from available Country Reports
- Comparably prominent in current undergraduate medical training, BME in Ireland integrates courses of epidemiology, public health, clinical prevention and communication training in all medical schools. Early patient contact programmes in the first two years concentrate on the influence of social circumstances on health status. Also, after the inception of a national Methadone Treatment Protocol (MTP) in one of the five schools, a specific educational module has been developed to introduce students to the health and social problems experienced by drug misusers.

- BME in Spain integrates courses in preventive medicine, epidemiology and public health, yet with only optional communicational skills modules. Similarly, current BME in Austria also reflects the above topics, yet at a very late stage. Particularly communication skills courses do not figure prominently and mainly occur on an optional basis.

- According to the author, health promotion and prevention in German BME are only minor components. Greek curricula reflect health promotion courses to a small extent, though mainly on an optional basis.

Overall, integration of relevant health promotion courses in basic medical education shows some variation, with respect to both extent and character of courses. Courses are primarily taught by departments of Public Health, Social Medicine and Epidemiology, and very often - where in place - departments of General Practice. Communication skills courses appear to be offered rather on an optional base.

2.2. Postgraduate level: Vocational Training:
Some variety also exists with respect to integration of health promotion in current general practice/ family medicine specialty schemes.

Elements of health promotion in vocational training schemes: Information from available Country Reports
- No health promotion and prevention modules are currently integrated in vocational training in Greece

- Vocational training in Austria with little structured theoretical teaching, (even though training objectives emphasising health promotion, prevention and psycho-social health are clearly outlined for general practice training schemes) does not specifically integrate health promotion topics. Specific communication training, currently not part of the formal training scheme, can be obtained on a voluntary basis (in addition to formal training programme).

- Educational objectives for German general practice specialty training also address health education and prevention and its integration within the community, and provides for a mandatory 8-hours theoretical module on health promotion and prevention. No further structural training on health promotion is included within the 5-year training scheme.

- However, the programme for 3-year specialty training in "Family and Community Medicine" in Spain, with one required year spent in a primary health centre, includes specific prevention and health promotion components such as health education; epidemiology, primary health care and community medicine.

- Also, throughout the current 3-year training specialty scheme in Ireland, with 1 year required as a general practice registrar in a training practice, courses are taught covering consultation and communication skills, principles of health promotion, population screening and early detection of disease.

Overall, training schemes in Member States that are clearly centred in primary care/general practice and which have well-developed academic resources in general practice, seem somewhat more systematically provide structured and theoretical training including health promotion, population health, and communication training. Examples from Spain, and particularly Ireland, are promising, and the ongoing development of academic general practice in Germany and plans to foster general practice and quality training are also pointing in the right direction. Generally, communication skills modules are frequently offered on an optional base only.

2.3. Continuing Professional Development
Extensive information as been provided in the area of Continuing Professional Development(10), with a focus on Continuing Medical Education. Overall, some commonalities can be identified across the Member States with regard to content of current CME programmes. CME programmes, generally with voluntary attendance prevailing, are conducted and offer courses on risk factor screening and early detection of disease (cancer, cardiovascular disease) and patient education (e.g. diabetes, hypertension, weight reduction).

Structured programmes and planning initiatives in a coherent framework for general practice development exist in many of the reporting Member States. Generally, educational and training activities are under the leadership of scientific general practice organisations (also in co-operation with national medical associations or other scientific specialty organisation). Many initiatives have only been developed in the recent past. Lifestyle counselling techniques and specific patient education activities are predominantly covered. Specific disease related topics such as cancer screening, often within a framework of national programmes are of further relevance. The following activities were identified:

Current CME activities relating to health promotion and relevant preconditions: Information from available Country Reports
- Co-ordinated educational activities are increasingly developed in the French community in Belgium and range from training projects directed at general practitioners in the area of cardiovascular prevention, cancer screening, methadone treatment, management and detection of alcohol problems, and palliative care. In addition, joint local meetings for discussing medication and prescription together with community pharmacists are in place.

- Specific academic training programmes under active leadership of the general practice scientific society (Irish College of General Practice) have been initiated in Ireland, some with a collaborative approach involving relevant local actors in development and implementation of training in general practice. For example, skills courses and training workshops on smoking cessation set up in liaison with Local Health Promotion Units have been well received and are now operated according to a revised format. A national network for CME Infrastructure runs courses on consultation and communication skills as regular components. Specific topics such as adolescent gynaecology, immunisation, cervical smears, alcohol and six week baby check are covered. Further, in the context of the "Methadone Treatment Protocol" (MTP), specific training with regular update seminars and CME meetings have been implemented on a national scale and are well accepted. A research initiative is currently developing a programme on adolescent health, with the results illustrating the subsequent development of specific general practice training. As a model of "good practice", it shows a range of essential characteristics relevant for supporting health professionals in providing acceptable and high quality services in primary care. Specific training needs have been identified with respect to women's health services. A national survey of current service provision and attitudes recently identified " lack of skills" as most common reason given by surveyed general practitioners for not providing adequate family planning or women's health services. It was stated that a variety of formats should be available for interested general practitioners (e.g. meetings, study days, CME meetings, visits at specialty services) and be determined by local needs. This addresses important issues relevant for the usefulness and suitability of continuing education and training interventions in general practice: arrangements that allow and support general practitioners to attend are key. Such arrangements would take local or context-specific characteristics into account, such as barriers in infrastructure (e.g. working in solo practice, high workload, geographical considerations) and require adaptations. Shorter formats or distance learning have been used to enable interested general practitioners to attend. (see "Encouraging Smoking Cessation in General Practice").

- A further example of a collaborative initiative has been described in Spain. In the context of the in national health promotion and prevention programme ("Spanish Programme of Prevention and Health Promotion", PAPPS), a variety of actors concerned (all relevant health professionals at the primary care level, health authorities, scientific experts) have collaborated from the outset in developing and implementing a comprehensive prevention programme. In this context, a specific working group on Health Education has developed protocols and guidelines for specific counselling activities. This material is being used in educational modules of CME and was well accepted by general practitioners. For example, a research project has been commissioned within the framework of this programme (initiative "office-based physician's advice on adolescent exercise behaviour"), exploring effects of general practitioners exercise counselling for adolescents with training seminars in different areas of Spain(11). Also in the context of this programme, training seminars for alcohol- and problem drinking-related counselling have been introduced and have been well received. Further to this, smoking cessation training workshops are widely implemented. The possibility of local adaptations for protocols and favourable organisational arrangements enabling general practitioners taking time off for attending CME and educational activities are certainly relevant for wide acceptance.

- Indicative of the high level of interest of the medical profession for health promotion is the specific curriculum on health promotion which was developed and organised by the German Medical Association. As an accredited CME programme, a series of courses, both with a general introduction to the concepts and theory of health promotion and issue-specific modules, have been implemented. A 1995 general practice survey has identified specific educational needs for smoking cessation, nutritional counselling and infection control. But also less structured formats for skills building and competences have been described in Germany. Local project initiatives with specific research support have trained general practitioners in school health education ("School and Health", with teacher-general practitioner teams) or implemented case conferences in order to improve multi-professional knowledge transfer and shared care ("Project Ambulatory Gerontological Care"). Within the framework of a community-based study programme, a local study group of general practitioners interested in health promotion has been set up and has received brief structured training for exercise counselling ("Community-based Behavioural Medicine Östringen").

Increasingly, scientific inquiries are directed on content, structure, and function of physician-patient communication. Research has shown that effective communication is related to outcomes of patient satisfaction, physician satisfaction, compliance and improved perceived health status. However, clinicians have had little formal training in communication skills (for a more detailed discussion on different approaches to doctor-patient communication see article by (Epstein, Campbell et al. 1993)). Furthermore, research is increasingly focusing on demonstrating linkages between patient-centered care and "good communication" in health care (for example see (Bensing, Verhaak et al. 2000)). Thus, we specifically examined this issue in the framework of the Country Reports. The following was described:

Recognition of communication training: information from available Country Reports
- Regular courses and skills workshops have been implemented in Ireland and Spain.

- Recent initiatives have been piloted in the area of cancer care in Austria (project "Inter-professional Communication and Information Transfer - Improved Teamwork in the Multi-professional Home Care Team")(12), offering local training workshops for improving communication skills and co-operation. Still in Austria more extended course formats exist(13), leading to the awarding of a diploma in "Psychosocial Medicine" and "Psychosomatic Medicine". Focussing on aspects of physician-patient relationship, communication and psychosocial aspects, these courses offer both accompanying Balint- and psychosocial competence training groups and a series of theoretical modules (organised in co-operation between Austrian Medical Association and Department of Medical Psychology).

- In Belgium, there are specific training projects as part of an European initiative in palliative care/cancer care ("RAMPE" project).

- In Luxembourg, communication training is provided only for general practice trainers, whereas

- in Greece, no specific communication training opportunities currently exist throughout the entire medical and professional education and training.

Warranting closer inspection is a diversity with respect to specific structural resources and incentives supporting the CME activities. The following information was provided:

Relevant preconditions for CME activities: Issues of adequate funding, incentives and planning
- Need for funding, particularly for CME activities has been expressed in Luxembourg. The author(14) has pointed to the serious lack of funding for any educational and quality assurance initiatives.

- In some instances, where training initiatives are a component of a coherent overall strategy in a specified health promotion or prevention programme, specific government funding (by local or regional health authorities or relevant bodies involved in planning, organisation or implementation of healthcare, respectively) for training has been provided. For example, in Ireland funding for the national "Methadone Treatment Protocol" specifically provides for quality training measures.

- Need for more comprehensive support to increase the level of skills and knowledge relevant for health promotion has been indicated by the Greek Country Report author. He states that no financial or organisational backup are currently in place and activities to increase these competencies are dependent on the spirit and motivation of individual physicians or local bodies.

To some extent, incentives have been introduced linking reimbursement for specific procedures to completion of training or quality assurance activities.
- Contractual arrangements with specific schemes or contracts such as linking reimbursement fees with specific training requirements have been set up in Austria (methadone replacement) and in Germany (specific diabetes education and management).

- A similar recommendation has been made by the author of the Belgian Country Report, proposing linking increased reimbursement fees to the completion of accredited CME meetings that integrate health promotion topics. (see comments by Dr. André).

On yet another level, access or opportunity to attend training in the first place, is relevant too. How general practice is organised in primary health care will affect opportunities for attending training.
- Organisation of premises such as partnership and team approaches in health centres in Spain increase the likelihood of attending training sessions. General practitioners may take time off during the year.(15)

Concluding, detailed information was obtained on Continuing Medical Education where a variety of activities under active leadership by professional organisations have been initiated. Relevant topics in health promotion and prevention, predominantly focussing on lifestyle counselling, patient education, or specific screening interventions are covered and a diversity of formats are in place (ranging from quality circles, brief teaching sessions, skills workshops, seminars, to more extensive academic courses). Currently, as regards information from available Country Reports, specific training in communication skills is not offered systematically, but recent European and national initiatives are increasingly establishing training possibilities. Competing high workload and general lack of funding (financial incentives, respectively) have been identified as relevant barriers to participation in training activities.

All information from the available Country Reports considered, there is substantial interest and motivation of general practitioners to increase knowledge and skills in the area of health promotion. Particularly where support for continuing education is low (Greece, Luxembourg), authors have indicated the high motivation and interest of general practitioners for health promotion and health counselling.

Continue (Part 2)