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Erasmus+ funded Hippokrates Exchange Program Project no.: 2014-1-UK01-KA102-000412 Participant report Seema Pattni– Germany – 1- 10 July 2015 When I received news that I had been awarded a place on the exchange scheme I was delighted. I was excited to visit a new country and experience their healthcare system. I believe that there is a lot to be gained from working abroad, not only for personal experience but also to encourage reflection on one’s native healthcare system. I visited Weimar and Jena, in Thuringia, Germany. I had been to Berlin before but had no idea what to expect about this part of Germany or what the healthcare system would be like. It was a bit of a manic rush trying to organise a placement within the time constraints of my job and the hosts’ capacities in Germany. However, the NEC, Solvieg was very dedicated to it being possible and before I knew it, I was on the departure flight. My first presumption about Germany was contradicted as soon as i arrived: my expectations of impeccable German efficiency were not qualified and instead, I was met with several, severe train delays (a combination of train driver strikes, hot weather and defunct train air conditioning systems). However, with my basic German linguistics and the friendliness of a fellow female passenger, I eventually made it onto a (moving) train and arrived in Weimar at 2am! The next morning, I was greeted by Dr Seidel, a GP based in Weimar. He also runs Infectious Disease clinics having trained and worked in this field for several years. I felt lucky with this exchange already, I have an interest in Sexual Health and Infectious Diseases, as I have worked in these departments and taken the Diploma in Tropical Medicine. I spent a few days sitting in with Dr Seidel in both his General Practice and HIV clinics. On the first day, I soon realised that not only would I need to speak German, but also Russian! Many of the patients in this area were from Ukraine, Siberia, Kazakhstan and Russia - I had not expected to meet a patient from Omsk! That day we saw patients with Kaposi’s sarcoma, Parkinsons Plus, cerebral toxoplasmosis, and some more generic conditions: Cushings, pilonidal cysts, gout and tonsilitis. A lot of what the UK would consider secondary or tertiary level work was done by Dr Seidel as part of his HIV work, however, I think this was a unique set up given his academic background. Over the weekend, I took time to explore the beautiful city of Weimar, famous for personalities such as Goethe and Schiller, as well as it’s quirky houses, painted in an array of pastel colours, almost every house is the colour of cupcake icing! There was also a heat wave, with temperatures of up to 38 degrees celsius, which made a visit to the refreshing outdoor lido obligatory! I then took a train to Jena and met my second host, Dr Stengler, a GP who has worked in Leeds, England, for several years before moving back to Germany. She very kindly hosted me in her apartment, which had a pretty good view of forests from the roof garden. This project is funded by the European Union. Dr Stengler’s working hours were, at minimum, from 7.30am to 7.30pm almost every day. She works as a single partner but shares the practice building (but not patients) with another GP, they cover each other only when one is away on holiday. Similarly, to Dr Seidel’s practice, Dr Stengler's did not have a practice manager (finances were managed by the GP) and the receptionists also did the work of health-care assistants and practice nurses. Clinics are a mix of pre booked and walk in patients. The consultations are not time restricted per say but vary from a few minutes to half an hour. Multiple problems per consultation seemed to be the norm! I observed less practice of the ‘Ideas, Concerns, Expectations’ consultation model. Other differences that I noticed early on in the second week were that there is no QOF system, although there are targets set for chronic disease patients. Practice lists are compiled differently, patients are counted per visit rather than per registered patient. GPs are paid per visit and according to the complexity of the work done for each patient on each visit, however there is a ceiling on payments for chronic patients who will likely have multiple visits. A separate budget is issued to each GP for medications, lab tests and physiotherapy referrals. GPs are expected to keep within budget. There is no cost for referral to secondary care. Each GP has to buy an existing 'seat' which serves a local community. Patients can attend any GP practice but most affiliate with one practice. Whilst in Jena, I took up the opportunity to join academic GPs at the Primary Care Centre at the University of Jena, where I gave a talk on CCGs and Commissioning, I had not expected the Professor of Health Economics to be in the audience! After visiting the University and speaking to other trainees, I decided to read more about the German healthcare set up. It is the oldest national social health care system in the world, founded by Bismark in 1889. The funding is through a multipayer healthcare system - 7% from the patients salary and equal amount from the employer. This is paid into Statutory Health Insurance. This is coordinated by not for profit organisations which apply common rates for all members and entitle all patients (who are issued with a personal insurance card) with the same access to care. Aside to the statutory health insurance, if you earn over €50 000 per year you can buy additional private health care insurance, 90% of the population is covered by the statutory system. Hospitals can be private, state or NGO led. Long term care in Germany is a notable feature. It works almost like a health pension. In addition to the statutory fund, all patients contribute 2% of their salary, a contribution matched by their employer, to save and provide long term care for when they are elderly. Upon reaching a certain age, approximately 65-70 years, people receive a lump some which can either be commissioned by their family for medical care or it can be used it for a care home. Children are also means tested and expected to help fund their parents health care needs. Accident insurance is another feature of the German healthcare system. Accident insurance is covered by the employer who will need to cover any risks, illness or injury incurred commuting to work or whilst at work. From a clinical perspective, another difference is that GPs in Germany do not cover as much paediatrics, gynaecology or family planning, as in the UK. This is because there are specialists working in the community who patients can consult directly or via a GP referral; less outpatient work is carried in the hospitals because of these This project is funded by the European Union. clinics. Specialists also provide out of hours care too, even psychiatrists. This lifts a huge workload off GPs who manage more chronic diseases and elderly patients. Acute home visits come in each day and GPs also organise planned home visits for nursing home/elderly patients. Often the visits were to farm houses or quaint village residences, the visits often ended with patients reminiscing about life in war time Germany, during the Berlin Wall, or changes since reunification; as wells as gifted box of home grown cherries or eggs from home reared chickens! I speak basic German on a basic level and could understand most of the consultation before the GPs offered translations. However, I think much of my understanding was actually harnessed from non verbal communication: it was easy to register the patient’s presenting complaint and their concerns was before any translation took place. Having my fluency in verbal communication removed, I was left to rely on other forms of communication and this was actually a very good test to see how much I could find out without discussing the problem with a patient. This experience was truly demonstrative, for me, that so much of a patient's mood, anxieties and overall well being can be drawn from their non-verbal cues, body language and behaviour. It was always apparent when a patient was suffering from depression or anxiety, it was even obvious when some patients were seeking a sick note! I learnt a lot from this exchange and will take my learning forward with me in future practice. It was also a great way to experience a different community and country and provided an insight into working abroad. I fully recommend others to take up this opportunity and look forward to more exchange opportunities and international conferences. This project is funded by the European Union.