What is secondary and tertiary care

Primary doctor system - what are the consequences of downsizing in Germany?

Summary: The principles of primary care work and the advantages of a primary care system for patients, society but also for generalists and specialists are presented. Since the structural and organizational framework conditions for a primary doctor system have been destroyed in Germany for years, there are negative consequences.

Institute for General Medicine, University of Düsseldorf DOI 10.3238 / zfa.2018.0291-0295

Preliminary remark:In no western European country except Germany would this text be necessary, because there what is presented is available as self-evident knowledge and experience.

The term primary doctor system refers to a three-part structure of health care worldwide. There are those in it Primary care by general practitioners or general practitioners (generalists). There's one about that Secondary care by specialists who are based in most of the systems at the hospital and who also work there on an outpatient basis. Finally there is an inpatient Tertiary care in hospitals. The tertiary care itself is often divided again into “basic care” and “special care” (or with similar terms).

Behind these terms there is both a supplyconception as well as a structural-organizational supplyframe. The first corresponds to the substantive justification for the mentioned division and the second contains the organizational and legal framework created for the work in this three-part structure.

Care conception of the primary doctor system

The substantive justification for the division between primary and secondary medical care has two aspects:

  • The substantive justification for a Division of labor between these two areas and
  • the related differences in the Way of working by primary and secondary doctors.

Division of labor

The basis for a division of labor is the insight that in the outpatient area only a small proportion of patients require specialist treatment in secondary or even tertiary care. However, in order to decide which of the patients needs them, “someone” has to be responsible: In developed care systems, this is the primary doctor. This usually takes care of 80–95% of health problems themselves, depending on the country [1, 2]; for the other part, he arranges a transfer to secondary or tertiary care.

To ensure that this “selection” of the patient is more or less accurate, the doctor at the primary level needs a different way of working than the doctor at the secondary level. He must be medically broadly trained and also have the ability to justifiably and accurately integrate all information for a "work diagnosis" that becomes the basis for further action. The specialist, on the other hand, needs far more detailed medical knowledge, which, however, goes far deeper than that of the primary doctor.

With the task of filtering out the patients who need to be treated by the specialist, the doctor of primary care becomes gatekeeper for the other levels of care [1, 3, 4]. But of course he has duties that go beyond that gate-keeping go far beyond: He is the provider for the majority of patients with illnesses and complaints that, in his opinion, do not require secondary or tertiary care. And he is the provider for the majority of patients with chronic diseases as well as for the vast majority of prevention. In addition, the primary doctor is also the one who has to provide follow-up and often predominantly long-term care for patients with diseases that “come back” to him from secondary or tertiary care.

In addition to this, the specialists need in-depth, specialized training and knowledge and skills that enable them to deal with “special health problems”. Since the number of patients with special health problems is much smaller than the number of patients with any health problem at all, outpatient care also requires a significantly lower number of specialists than generalists, i.e. general practitioners.

This conceptual division of labor between primary physicians and specialists is generally viewed as inexpensive - which has also been shown in numerous studies [literature compilation in 5; also: 1, 6, 7, 8]. However, it has not yet been deduced whether this alone also achieves the intended optimal care, i.e. one with little under, over and incorrect care, although this has also been answered positively in many studies [1, 5–8]. There is also a study from Germany with a similar result [9] and one that suggests no cost savings but an improvement in quality [10].

However, in order to explain how this positive effect on the quality of care can come about in such a structured system, further conditions need to be explained, which will now be discussed.

Way of working

People see a doctor when they are sick, or at least feel that way. Or they go to the doctor because they want to do something preventive for their health. People - even with identical illnesses and complaints - are almost always “sick” or worried differently. This can be explained both by the course, the stage of the disease, the existence or non-existence of additional diseases (multimorbidity), but also by the way people deal with their disease or with their complaints. It is primarily important for the doctor to find out what is the basis of the complaints presented or what needs to be done diagnostically or therapeutically.

A doctor can best perform this task if he has an overview of the breadth of medicine at least in such a way that he can classify the complaints and, if necessary, findings using differential diagnostics across (almost) all medical subjects. In addition, however, he also needs the ability to bring his medical considerations together with what he has known about the patient so far. These are in particular the patient's previous appearance (e.g. safe vs. insecure) as well as his previous handling of symptoms, fears and illnesses (e.g. whether he is more of an “exaggerator” or an “under driver”). In addition, the doctor should be able to know the living conditions of the patient as a trigger or intensifier in order to gain a more complex understanding of the currently presented treatment cause.

From the overall view of these three areas - medical findings, how the patient deals with his illnesses / complaints, the patient's psycho-social environment - the primary doctor must come to a work diagnosis, which he then - often "on probationary period" in the sense of the so-called . “Waiting and waiting open” - can act [11]. The primary doctor therefore very often has to think integrally in order to come to decisions. Only in order to think and weigh up integrally - that is, to be able to go far beyond the medical field, he must know the patient as well as possible and have developed a sustaining doctor-patient relationship. Only in this way can he assume that he knows a lot about the patient and that he also recognizes nuances in his behavior (communication, facial expressions, etc.) as messages and that the patient communicates "everything" to him. In addition, one must consider that people usually do not open up to another person with all their problems, worries and vices, with whom they have not yet had a real relationship.

A generalist almost always interprets not only on a medical level, but also on a personal level; one speaks here of complex decision-making processes or of a hermeneutic case understanding [11]. But this is necessary because it is rather the exception to react to a finding or a complaint directly and only in a predefined manner, i.e. identically for each case, i.e. without weighting and thus without interpretation [12].

If, however, there is no good knowledge of the patient and no supporting doctor-patient relationship (usually developing together), the primary doctor cannot act with his generalist way of working. He would often act irresponsibly, as he has no basis for the necessary integrating and thus interpretive thinking. So he has to act in the interests of a specialist without a good knowledge of the patient's person. He then always has to do everything that comes into question, diagnostically and therapeutically. So he has to focus on the pure Medical level go. In many cases, however, the primary doctor cannot do this because he has received broad, but not in-depth, training. So he will - to protect himself - increasingly refer to specialists.

The working method of the generalist, who has got to know his patients and their complaints / illnesses over time and across the board, is also of considerable importance for the work of the specialist: The preselection of the patients who are referred to specialists makes their work easier more accurate. For the most part, only those people who are more likely to have a “specialist” problem get to the specialist. Therefore, if only these patients are subjected to specialist examinations, then the percentage of true-positive findings (and thus also treatments) will outweigh the percentage of false-positive findings [13]. The accuracy of specialist medical care is therefore considerably increased by the preselection of the primary doctor.

However, if the specialist sees "unselected" patients - with free patient access or because of very frequent referrals - then there is a clear predominance of false-positive results [13]. In the long run, the specialist is demotivated with regard to the experience of his own abilities - after all, the result of his work is often “nothing” or “false positive”. Because the lower the proportion of patients without the disease they are looking for, the more false-positive findings are made [13] - which may even have to be clarified using more extensive and intervening diagnostics.

But what about the "knowing well" and the "grown doctor-patient relationship", which are so important both for the primary doctor in his decisions and of so great importance when consulting a specialist on the basis of the primary doctor's decisions, anyway come about? This can only come about through an "undisturbed" activity as a primary doctor himself: Because the broad responsibility (comprehensiveness) of the primary physician as well as his continuous care (continuity) in all health and illness situations of the patient allows “good knowledge” and a “sustainable relationship” to be built [14, 15]. But there is no guarantee for comprehensiveness and continuity of care as the basis of a primary doctor system, the health care system as a whole is also massively threatened [1].

Structural-organizational supply framework

The work at the primary doctor level can only succeed in its cost-limiting and incorrect or over-treatment-reducing manner if the structural-organizational side of a primary doctor system is also guaranteed: insured persons / patients must therefore always - apart from exceptions - first visit the primary doctor and should as a rule, stay “enrolled” for as long as possible, ie do not change at short notice.

Situation in Germany

But if it happens that patients can visit the secondary care system directly - and can even do this in parallel with different doctors in a specialty - then the experience of the primary doctor with regard to "his" patient must inevitably decrease: His knowledge of the patient decreases and the doctor-patient relationship becomes less binding. According to a current representative survey, two-thirds of the insured persons seek specialists without prior contact with their general practitioner [16]. However, this means that the generalist's "ability to interpret" with regard to a patient, their complaints and how they deal with illness becomes increasingly less - and with it the use of their special abilities as a generalist.

In the western world there are two general social developments that are important here:

  • The more special, the better.

This is also so effective because general medicine has largely avoided explaining to the public how it works and thus its special additional ability.

  • The patient's autonomy needs to be strengthened.

He should decide for himself which care he needs and whether he would like to use several doctors. These orientations are not only favored in Germany. In Germany, however, there is also the structural and organizational support to achieve these “goals”: ​​on the one hand, because there are about the same number of specialists in the outpatient area as general practitioners (with an increasing proportion of specialists). On the other hand, about the fact that patients can also visit specialists directly - without consulting a primary doctor

Because over the past 35 years, the need for a referral slip issued by the family doctor to visit a specialist has been gradually abolished: until the 1980s, patients only had one or - depending on the health insurance company - two referral slips / quarter in their health insurance booklet. Then, in the 1990s, more and more health insurance companies sent entire booklets with transfer forms to the insured person; however, a referral was only valid with the signature of a doctor. Eventually the doctors and no longer the patients were given these forms to fill out for the individual patients. At the beginning of the 2000s, the health insurance card could finally be used by the insured as access to the specialist even without a referral, if the latter was willing to accept an additional payment of 10 euros. And finally, today we have achieved the “freedom” that every insured person can visit almost every specialist at their own discretion.

As this cultural change is accelerating, there have only been a few “direct visits” in recent years without a referral slip; but today it is almost the rule [16]. The result is not only the threat of the loss of general practitioner skills (see above), but also the rapidly increasing waiting times for specialists - and this in a country with an incomparably high number of specialists in the outpatient sector!

In the long run, this system will no longer be affordable. Solutions will then have to be sought: one would be to increase the patient's own contribution. Those who pay for it can then continue to use everything as they want. However, this could only "solve" the problem of the rush of specialists. However, this does not restore the quality that the primary doctor system is able to deliver, namely to reduce over-supply and incorrect supply.

The other possibility would be to (re) introduce the primary doctor system - as in all Western European countries - in its structural-organizational form; as also formulated by members of the Expert Council [17]. But these seem to be the only ones addressing this problem and suggesting solutions; Even DEGAM is not brave enough here to do it with the necessary clarity [18, 2].

Effects of the dismantling of the primary care system

If a (re) introduction of the structural and organizational framework conditions of a primary doctor system - i.e. a predetermined one gate-keeping or the implementation of a registration model with a family doctor [18] - does not take place, this will result in numerous deteriorations in care that are already visible today.

Quality of care at the family doctor

The family doctor, who can no longer know his patient as he used to, increasingly has to forego "interpretation" in the sense of complex decision-making. Because he no longer has a basis for it. Rather, he has to focus almost exclusively on the "medical" - and thus act like a specialist (see above). This then results in an increase in referrals to the specialists (if referrals are still being written for them). The presentations to the specialist then no longer take place on the basis of a preselection - as in a structurally and organizationally regulated primary doctor system. But with this one of the most important functions of the family doctor is slowly dying out.

Quality of care between primary and secondary care

If the patients visit different specialists and different general practitioners directly, then the general practitioner often does not know about the co-practitioners and cannot classify their working methods. And this is of great importance when recommending specialists to a family doctor: Because there are specialist colleagues who tend to weigh carefully and those who always suggest doing everything, regardless of whether they consider it to be medically advisable themselves. This reduces the communication - as far as it still takes place at all - to the pure "communicated information" on the findings, because the family doctor often does not have a partner who is really known to him. This often leads to further oversupply, as the family doctor now has to investigate all minor deviations in the findings - as a specialist suggested as possible.

Attractiveness of outpatient work

However, if the work of the family doctor is reduced to writing referrals, taking care of the mundane illnesses and accompanying chronically ill and psychologically problematic patients that no psychiatrist "takes", then the subject loses its appeal because there is no real task for him Doctor.

But also for the specialists there is a dequalification of their work and their experience. Because - unlike years ago - they are standing in front of a mass of patients for whom it is obvious that 80–90% of them ended up with them unnecessarily. This means that they experience that the majority of their specialist work ends “without any findings”, i.e. is in vain. Or they get frustrated by the high number of false positives.

Social costs

In addition to the economic damage caused by over-treatment and incorrect treatment as well as the increase in false-positive findings, there is also economic damage to the specialists providing care: They have to care for more and more patients than before, but they work in a budgeted area, i.e. the “Household pot” is also limited for them. And so the following applies: The more you work, the less the individual medical service is worth (monetarily): The point value is falling (total budget of the specialists divided by the number of all credit points provided). There is less fee per service. In the long run this could lead to the specialists (legitimately!) Trying to reduce the budget of the family doctors so that theirs can be increased.

Promote addiction

Even if only for a smaller, but not unimportant group of patients, the system of free access to all doctors leads to further damage: If you want to get drugs that have previously only been prescribed by one doctor or through their further prescriptions by other doctors coordinating family doctor knew, it is now possible that you can get any number of drugs (including BTM substances) - from different doctors who do not know about each other.

Further training to become a general practitioner

Since the content, breadth and specifics of the primary doctor's activity are becoming increasingly less important due to the lack of structural and organizational safeguards for the primary doctor system, the subject is emptied and thus unattractive. At best, it can only be “exciting” and demanding at the beginning of his work, because everything is still new.

After that, however, it becomes "boring" to take sick leave, to write referrals and prescriptions, to deal mainly with colds, coughs, hoarseness and back pain, and at best to devote oneself to the "mentally suspicious" who no specialist wants to look after. And if the development of the dismantling of the primary doctor system continues, then the question of the next generation of primary care physicians will be even more difficult than it is now: Since 2008 there has not been an increase, but a decrease, or in the years from 2013 onwards there has only been a constant one Number of specialist approvals for general medicine [19].

Due to the problems with the offspring as well as the reduction in serious work tasks of the family doctor outside of a structurally and organizationally secured primary doctor system, one must also ask whether further training of five years is necessary for this activity. Isn't it enough for a few years? At least one would be able to increase the number of junior doctors - mostly women - in the field of general medicine for a few years [20]. However, it is obvious that a general practitioner who has been trained for a shorter period of time will be even more insecure than he is already experiencing today. And so the transfer of money will increase and the work in the subject will become even more emptied. The trend towards turning away from the subject would be accelerated further.

The downfall of the primary doctor in Germany is unlikely to be stopped by shortened further training times and even by funding programs for general medicine. This could only be done through a structural and organizational safeguarding of a primary doctor system, i.e. an enrollment system with gate-keeping.

Conflicts of Interest: none specified.

Correspondence address

Prof. Dr. med. Heinz-Harald Abholz

Emeritus, University of Düsseldorf

Institute for General Medicine

Werdener Strasse 4, 40227 Düsseldorf

[email protected]


1. van Weel C, Kidd MR. Why strengthening primary health care is essential to achieving universal health coverage. CMAJ 2018; 90: E463-466

2. Popert UW, Egidi G, Eras J, Kühlein T, Baum E. Why we need a primary care system - background for a DEGAM position paper. Z Allg Med 2018; 94: 250-254

3. Deforestation H-H. Why is general medicine necessary and what does it need? Z Allg Med 2015; 91: 160-165

4th Expert Council for the Assessment of Developments in Healthcare - Report 2009. www.svr-gesundheit.de/index.php?id=6 (last accessed on June 20, 2018)

5. Albertadoctors. www.topalbertadoctors. org / file / top - evidence-summary - value- of-continuity.pdf (last accessed on June 20, 2018)

6. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457-502. www.ncbi.nlm.nih.gov/pmc/articles/pmid/ 16202000 / (last accessed on June 20, 2018)

7. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003; 38: 831-865

8. Garrido MV, Zentner A, Busse R. The effects of gatekeeping: a systematic review of the literature. Scand J Prim Health Care 2011; 29: 28-38

9. Schneider A, Donnachie E, Tauscher M, et al. Comparison of outpatient care costs for patients with and without general practitioner control - results of a routine data analysis from Bavaria. Z Allg Med 2017; 93: 297-304

10. Klora M, Zeidler J, May M, Raabe N, Graf von der Schulenburg J-M. Evaluation of family doctor-centered care in Germany based on GKV routine data from AOK Rhineland / Hamburg. ZEFQ 2017; 120: 21-30

11. Abholz H-H, Wilm S. Decision making in general medicine. In: Cooking MM (Ed). General medicine and family medicine, 5th edition Stuttgart: Georg Thieme Verlag, 2017: 645–655

12. Log H-H. The focus is on people - via the sought-after path between medical expertise and EbM guidelines. Z Allg Med 2017; 93: 445-449

13. Donner-Banzhoff N, Abholz H-H. Epidemiological and biostatic aspects of general medicine. In Cooking MM (Ed). General medicine and family medicine, 5th edition Stuttgart: Georg Thieme Verlag, 2017: 558–574

14. Freeman G, Hughes J. Continuity of care and the patient experience. London: The Kings Fund, 2010

15. Reeve J. Interpretive medicine - supporting generalism in a changing primary care world. Royal College of General Practitioners, Occasional Paper 88, London 2010

16th KBV. Survey of insured persons by the National Association of Statutory Health Insurance Physicians 2017. www.kbv.de/media/sp/Berichtband_ KBV_Versicherbefragung_2017.pdf (last accessed on June 20, 2018)

17. Friedrich Ebert Foundation. Position paper PATIENT FIRST! For patient-friendly, cross-sector care in the German healthcare system. http://library.fes.de/pdf-files/wiso/13280.pdf (last accessed on June 20, 2018)

18. Position paper of the German Society for General Medicine and Family Medicine (DEGAM). We need a primary care system. https://www.degam.de/files/Inhalte/Degam-Inhalte/Ueber_uns/Positionspapiere/DEGAM_ Positionspapier_Prim% C3% A4rarzt versorgung_final_NEU.pdf (last accessed on June 20th, 2018)

19. German Medical Association. Physician statistics as of December 31, 2016. there: Fig. 8: www.bundesaerztekammer.de/fileadmin/user_ upload / downloads / pdf folder / Statis tik2016 / Stat16AbbTab.pdf (last accessed on June 20, 2018)

20. Birck S, Bussche Hvd, Jünger J, et al. Does the contract doctor's goal of general practitioner or specialist internist change in the course of the further training? Z Allg Med 2014; 90: 508-16

Prof. Dr. med. Heinz-Harald Abholz ...

... specialist in internal medicine and specialist in general medicine. 1984–1998 family doctor in Berlin; 1998–2011 Head of the Department of General Medicine, University Hospital Düsseldorf. After retiring in 2012, she returned to a family doctor's practice near Cologne. DEGAM President or Vice President for nine years. Lecturer for public health (epidemiology, prevention) first in Berlin, then in Düsseldorf.


Primary doctor system - what are the consequences of downsizing in Germany?

Primary Health Care - Consequences of its Destruction in Germany?


Primary doctor system - what are the consequences of downsizing in Germany?

Primary Health Care - Consequences of its Destruction in Germany?


Primary doctor system - what are the consequences of downsizing in Germany?

Primary Health Care - Consequences of its Destruction in Germany?


Primary doctor system - what are the consequences of downsizing in Germany?

Primary Health Care - Consequences of its Destruction in Germany?

(Status: July 16, 2018)