Objective: [corrected] To detect factors that more directly restrict effectiveness and efficiency of the family physician's work in the health center. Made proposals for change which will contribute to increase this efficiency and effectiveness.
Method and participants: Consensus method by Delphi technique. Thirty experts, from different settings of the National Health System at the province of Alicante, were requested for participate in this study: 15 health center co-ordinators, 7 directors of district primary care services and 8 chairmen of internal medicine hospital services. Twenty-four experts maintained their participation in all phases of the project, that means 80% of participation.
Results: The factors identified with a larger consensus (supported by at least 83% of the participants) were: difficulties in the relationship and communication between primary and secondary care levels; lack of incentives or motivation in manpower policy; vertical health programs not realistic and not well co-ordinated; a society each time more medicalized; deficiencies in the makeup of the general practitioners patients listś; political influences in management; excessive bureaucracy on consultations; deficiencies in continuing medical education; lack of prefixed aims and previously set criteria of standards; different training and involvement levels among professionals; limited access to diagnostic tests and a limited health education level among the population. The solutions proposed with a larger consensus (supported by at least 92% of the participants) were: to improve and increase communication between primary and secondary care levels; to makeup the patient list of every general practitioner and to adjust the staff of the health centers according to sociodemographic population variables and professional duties (practice, management, teaching, research,.); to design programs of continuing medical education with obligatory attendance for professionals; to incentive and to motivate professionals; to professionalize and depoliticize management; reduction of unnecessary bureaucracy on consultations by computing some tasks; to establish guidelines in practice; to introduce the Individual Health Card; self-management in health centers; to increase the primary care capacity in solving health problems; freedom of choice of the specialist consultant by the general practitioner; to release the access for the general practitioners to certain diagnostic tests; to improve certain social services and to increase the time that health center co-ordinators devote to managerial tasks.
Conclusions: Most of the problems identified and the solutions proposed were linked either with organisational or managerial factors or with human resources management. The essences of the new primary care model are not questioned. Other Spanish publications which investigated the opinion of health professional as well, have identified similar problems and proposed similar solutions. This coincidence and the high degree of agreement reached by the participants in designing problems and in proposing solutions, may indicate that factors that most restrict the effectiveness and the efficiency of the family physicians work in health centers are clearly explained and it is necessary to deal with the solutions resolutely.