Family doctors, the reform comes to a halt. But how does it work in other European countries?
From Spain, which focuses on dependency, to France, which is more similar to us with the freelance model. In other countries there is often no clear alternative but mixed models prevail
Key points
There is increasing tension between the Ministry of Health, the Regions, and general practitioners. The unions of the general practitioners do not like the proposal to introduce, alongside the current convention relationship, an employment relationship dependent on the National Health Service to guarantee their presence in community homes, and many of them are in a state of agitation, even ready to go on strike. And also opposed to the initiative are the majority parties - Forza Italia and Fratelli d'Italia in the lead - who consider the idea a 'bungled and bureaucratic solution' and are against transforming the family doctor into an employee of the NHS. With the reform now therefore likely to end up definitively in the drawers. But how does it work in other European countries?
Europe and the specific model in Italia
The recourse to dependency is not new and in Europe there are already those who envisage it, although in ways that are often more articulated than the simple convention/dependency alternative. Thus, while in Spain and Portugal the general practitioner is dependent, in France, Germany, Belgium and the United Kingdom there are also forms of dependency, but the GP still retains above all his freelance characteristic. And in the Netherlands the GP is independent of the public service, but "dependent" on insurance companies. In comparison with the major European partners, therefore, the Italian GP retains a particular physiognomy: he is not an employee of the National Health Service, but a 'pure' contracted professional, chosen by the citizen and linked to a personal fiduciary relationship, which remains the most typical feature of the Italia model.
French model close to ours, in Spain there is dependence
France is the country that most resembles it: there, too, the GP is predominantly a freelancer, but his role is more embedded in a coordinated care pathway that also affects reimbursement. In Germany, on the other hand, the family doctor moves within a territorial network that is more open and less centred on an exclusive personal relationship. The clearest difference is with Spain, where the family doctor is a public service doctor, embedded in primary care structures and teams. The United Kingdom presents an even different model: the GP is the gateway to the NHS system, but works mainly in practices contracted with the health service, not as a simple civil servant. Belgium and the Netherlands, finally, maintain a strong free-professional imprint, but in the Netherlands the filtering role towards the rest of the system is much more structured than in Italia. Italia therefore has neither the dependent doctor typical of the more public models, nor the strong gatekeeper of other European systems. It maintains above all a contracted, personal and fiduciary figure, closer to tradition than to full integration in the public health machine.
Roles, Functions and Salaries in Different Countries
More in detail, for the major partners, in France the Assurance Maladie distinguishes between libéral, salarié or mixte practice; for primary care medicine, however, the prevailing form remains self-employed/liberal. The monitoring of the European Observatory indicates that the majority of primary care physicians are self-employed and historically paid primarily on a per-performance basis, albeit with increasing shares of lump sums and incentives. In Germany, territorial care is still centred on doctors niedergelassen, i.e. established in practice and contracted for outpatient care. However, the system also admits angestellte doctors, i.e. employees, in practices and especially in Medizinische Versorgungszentren (MVZ). So the German model remains predominantly freelance, but less 'pure' than it once was.
For Spain the picture is almost the opposite: family doctors in primary care work largely as salary/statutory staff in the health services of the Autonomous Communities. The European Observatory's Summary 2024 speaks explicitly of salaries for family doctors, with a capitated component and a small performance-related part. The United Kingdom is often perceived as the most 'public' model of care, but in general practice the historical pillar is another: independent GP practices working under contract with the NHS, not a network composed mainly of state-employed doctors. It is a distinction that makes the British model closer in some respects to the contracted systems of continental Europe than to the Spanish model.
