Abstract
Background: Out-of-hours primary care has been provided by general practitioner (GP) cooperatives since the year 2000 in the Netherlands. Early studies in countries with similar organizational structures showed positive GP experiences. However, nowadays it is said that GPs experience a high workload at the cooperative and that they outsource a considerable part of their shifts.
Objectives: To examine positive and negative experiences of GPs providing out-of-hours primary care, and the frequency and reasons for outsourcing shifts.
Methods: A cross-sectional observational survey among 688 GPs connected to six GP cooperatives in the Netherlands, using a web-based questionnaire.
Results: The response was 55% (n = 378). The main reasons for working in GP cooperatives were to retain registration as GP (79%) and remain experienced in acute care (74%). GPs considered the peak hours (81%) and the high number of patients (73%) as the most negative aspects. Most GPs chose to provide the out-of-hours shifts themselves: 85% outsourced maximally 25% of their shifts. The percentage of outsourced shifts increased with age. Main reasons for outsourcing were the desire to have more private time (76%); the high workload in daytime practice (71%); and less the workload during out-of-hours (46%).
Conclusion: GPs are motivated to work in out-of-hours GP cooperatives, and they outsource few shifts. GPs consider the peak load and the large number of (non-urgent) help requests as the most negative aspects. To motivate and involve GPs for 7 × 24-h primary care, it is important to set limits on their workload.
KEY MESSAGE:
GPs are motivated to work in GP cooperatives and they outsource few shifts.
GPs consider the workload during peak hours and the large number of (non-urgent) help requests as negative aspects.
To consolidate commitment of GPs to provide out-of-hours care, limits should be set on their workload.
INTRODUCTION
The last decades several countries changed the organization of out-of-hours primary care, mostly into large-scale settings. Reasons for the reform included the low personal commitment of general practitioners (GPs) to be on call, the increasing workload, and the shortage of GPs in some countries (Citation1–3,Citation5,Citation6). In the Netherlands, large-scale GP cooperatives were set up around the year 2000 to replace the small rotation groups (Key features of GP cooperatives are described in Box 1). This reorganization was initiated by the GPs themselves, following examples in other countries such as the UK and Denmark (Citation3,Citation4). In 2006, the member council of the Dutch College of GPs stated to be willing to stay responsible for primary care for patients around the clock. Almost all GPs participate in a cooperative (Citation1).
50 to 250 GPs connected.
Population includes 100 000 to 500 000 patients.
Distances to GP cooperative are not more than 30 km.
GP cooperatives are mostly situated next to or in collaboration with hospital.
Accident and Emergency Departments.
Access through a single, regional telephone number.
Telephone triage is conducted by nurses who are supervised by GPs.
GPs have different roles: home visits, centre consultations, and telephone triage supervision.
GPs handle on average four-to-five consultations per hour, varying for peak hours and type of shifts.
A GP's shift is six-to-eight hours, with a mean of four hours on call duties per week.
Salary of about €65 per hour.
A minimum of 50 hours of out-of-hours shifts per year is a criterion for re-registration as a GP (25 hour for GPs with a GP registration > 25 years).
GPs can exchange or sell shifts (i.e. other GPs, often young locum GPs are paid to take over shifts).
Home visits with drivers in identifiable GP cars that are fully equipped (e.g. oxygen, intravenous drip equipment, automated external defibrillator, medication).
Information and communication technology support, including electronic patient files, online connection to the GP car, and sometimes connection with the electronic medical record in the GP daily practice.
Information and communication technology support, including electronic patient files, online connection to the GP car, and sometimes connection with the electronic medical record in the GP daily practice.
GP cooperatives are intended for urgent help requests that cannot wait until the next day. However, in reality, most requests are medically non-urgent, made by the ‘worried well.’ In the Netherlands, 80% of contacts with a GP cooperative are medically non-urgent (Citation7). Moreover, the demand for health care is ever increasing, also out-of-office hours (Citation8). The subsequent increasing workload might have a negative influence on the commitment of GPs and their motivation to work in a GP cooperative. It is said that nowadays Dutch GPs quite regularly outsource a considerable part of their out- of-hours care shifts, particularly night shifts, to locum doctors (mostly young GPs) or other GPs connected with the cooperative, although there is no evidence for this. Experiences in the UK show that rejecting out-of-hours shifts can result in fragmentation of care, and an increase of different care providers and brings forth a risk of quality loss (Citation9,Citation10).
Insight into positive and negatives aspects of working in a GP cooperative can provide input to consolidate commitment of GPs to provide out-of-hours care. Several studies investigated GP satisfaction with GP cooperatives shortly after the reforms. English GPs showed to be generally satisfied with the cooperative, with an increased satisfaction compared to the former situation while Dutch and Irish GPs also had positive experiences (Citation6,Citation11–14). These positive results of studies performed shortly after the reforms may reflect ‘honeymoon enthusiasm’ for the cooperative, which is not necessarily sustainable (Citation6). To our knowledge, the subject has not been studied recently; thus it is not known whether the positive results still hold today and whether there are negative factors that should be addressed to maintain GP commitment. The study aim was to examine positive and negative experiences of GPs providing out-of-hours primary care and the quantity of and reasons for outsourcing shifts.
METHODS
Study design and setting
A cross-sectional observational survey study was conducted into GP experiences with GP cooperatives, which provide out-of-hours primary care. The study was performed in a convenience sample of six GP cooperatives, located in the east, south, and west of the Netherlands. The cooperatives contacted us to perform a work experience survey among their GPs as a part of their quality policy. All 688 GPs who had daily practices and who were connected to these cooperatives (range: 66–189 GPs per GP cooperative) were invited to participate in the web-based questionnaire. Nearly all GP's working in a GP cooperative have daily practices.
Questionnaire
A previously developed and pilot tested questionnaire was used to measure GP experiences (Citation12). The questionnaire consists of background items (e.g. age, sex, practice organization) and items on GP experiences. In this study, we examined predefined items on motivating and burdensome aspects of working in a GP cooperative and items on outsourcing of shifts. GPs were asked to rate each item on a five-point scale (‘not important at all’ to ‘very important’ or ‘not burdensome at all’ to ‘very burdensome’). During the data collection period, the item ‘Responsibility to deliver healthcare 24-h a day’ was added to the motivational aspects in the questionnaire on request of the second participating GP cooperative. Therefore, this item was answered by GPs in five out of six GP cooperatives.
Data collection procedure
The management of each GP cooperative announced the study via e-mail, during a GP meeting, and/or via a newsletter. Next, the researchers sent an e-mail with a link to the web-based questionnaire to all GPs working in the cooperative. GPs who did not respond after 14 and 28 days received a reminder. The study was performed during a two-month period per GP cooperative in the years 2008–2011.
Statistical analysis
The analyses are mainly descriptive: results are expressed in percentages. To improve the clarity of the tables, we reduced the five-point scales to three categories. For example, the categories ‘not important at all,’ ‘not important,’ ‘neutral,’ ‘important,’ and ‘very important’ are combined into ‘not important,’ ‘neutral,’ and ‘important.’ To examine if sex and age were related to the percentage of outsourcing of shifts, a Chi-square test and Pearson correlation analysis was performed, respectively, using the data on the original five-point scales. Data was analysed using SPSS 20.
RESULTS
Characteristics of the respondents
The response rate was 54.9% (n = 378). Most respondents were male (65.9%). The mean age was 48.0 years. Of all GPs, 20.9% worked at a single-handed practice during daytime, 34.1% in a duo-practice, and 43.9% in a group or health centre.
Motivating aspects
Main reasons for working in a GP cooperative were to retain registration as a GP (78.9%) (see Box 1 for further details) and experience in acute care (73.8%). In addition, feeling responsible to deliver care 24-h a day (65.9%) and wanting to contribute to effective and high-quality care (57.1%) were important motivational aspects for most GPs. The opportunity to work out-of-hours (4.0%) and financial motives (24.4%) were considered least important ().
Table 1. Importance of motives for working in GP cooperatives.
Burdensome aspects
Many aspects of working in a GP cooperative were considered burdensome by more than half of the GPs: the peak hours with a high rate of patient contacts (80.7%), the total number of patient contacts (73.1%), arranging an admission outside the hospital (69.9%), demanding and aggressive patients (66% and 61.5% respectively), and the low threshold to contact to the cooperative (63.3%). Moreover, unnecessary centre consultations or home visits (57.2%), unplanned care for self-referring patients (56.9%), multitasking (51.9%), and the risk of adverse events (51.3%) were considered burdensome by most GPs. Alternatively, the least inconvenient aspects were having little diagnostic facilities (17.2%) and restricted autonomy (19.5%) ().
Table 2. Burdensome aspects of working in GP cooperatives.
Outsourcing shifts
Most GPs did their out-of-hours shifts themselves, although GPs can pay colleagues to take over shifts: 84.8% of the GPs sold maximally 25% of their shifts to other GPs (, see also Box 1). The percentage of outsourced shifts significantly increased with age (correlation coefficient: 0.11). There was no relation between sex and the percentage of outsourced shifts.
Figure 1. Percentage of GPs who outsource a part of their shifts in GP cooperatives to other GPs (x-axis: percentage of shifts outsourced; y-axis: percentage of GPs) (n = 378 GPs).
GPs mainly outsourced night shifts (56.0%). Weekend day shifts (16.0%) and evening shifts (2.0%) were less often outsourced. The main reason for outsourcing was the desire to have more private time (77.5%). Most GPs (71.2%) considered the workload in their day practices an important reason for outsourcing and, to a lesser extent, the workload during the out-of-hours shift at the GP cooperative (45.5%). Other reasons for outsourcing were pregnancy or care for children and housekeeping (32.7%), education or other work (22.5%), and age (21.9%). Reasons for outsourcing related to the content of the work in the GP cooperative were considered less important: job satisfaction (20.0%), unknown patients (14.8%), and the working climate (5.3%).
DISCUSSION
Main findings
The main incentives for GPs to do their shifts in GP cooperatives are to retain registration as a GP and remain experienced in acute care. In addition, GPs are motivated by their feeling of responsibility to deliver continuity of care and by their wish to contribute to effective and high-quality care. Important negative aspects, however, are the large numbers of patients during peak hours and the large numbers of (non-urgent) help requests, resulting in a high experienced workload. Still, the vast majority of GPs choose to provide the out-of-hours services themselves: 85% of the GPs do not sell their shifts or they sell maximally one quarter of their shifts to other GPs (mostly young GP's without a day practice). The percentage of outsourced shifts increases with age. Reasons for outsourcing are not directly related to the content of work, but are the wish for more private time and the high workload in GPs’ day practices. Remarkably, the workload in their day practices is a more important reason for outsourcing than the workload in the GP cooperative.
Comparison with existing literature
There are only a few studies into GP experiences with out-of-hours GP cooperatives and all were performed relatively soon after the introduction of the cooperatives. English studies reported satisfaction scores of 62% and 92% (Citation6,Citation11). A more recent study in Ireland showed that for 82% of the GPs, the GP cooperative had a positive effect on their lives, but still half of the GPs felt overburdened by the out-of-hours’ work (Citation14).
Earlier research among GPs in the Netherlands, just after the onset of GP cooperatives, demonstrated a lower workload this study (Citation12). This is not surprising, because the number of contacts with GP cooperatives in the Netherlands has increased over the years (Citation10).
Finally, it is notable that more than 60% of the GPs in our study experience rude and aggressive patient behaviour as burdensome, while an earlier study showed that in most contacts (98%), there is no or only verbal aggression (Citation15). Perhaps the experience of rude or aggressive behaviour has a strong effect on GPs, influencing their motivation and evaluation, even if the frequency of these encounters is limited.
Limitations
The response rate was rather low compared to other survey studies among GPs (Citation6,Citation11,Citation14). The low response rate and convenience sampling method make it difficult to ascertain to what degree the results can be generalized to the overall population of Dutch GPs. We did not perform a formal non-response bias analysis, but the background characteristics of the respondents (i.e. sex, age, practice type) correspond well with national figures of GP characteristics (Citation16). In addition, the six participating GP cooperatives varied in size and were spread across the Netherlands. We found little variety in results between GP cooperatives; which contributes to the representativeness of the results for the Netherlands.
For some questions, it is possible that socially desirable answers are given, especially for altruistic themes such as wanting to retain responsibility for healthcare 24-h a day and contributing to effective and high quality health care.
This survey only examined experiences about ten years after the implementation of the cooperative structure. A baseline measurement would have allowed us to provide information about changes in GP experiences.
Implications for clinical practice and future research
Several of the burdensome aspects of working in a GP cooperative are out of control of the GP cooperative, such as patient behaviour and the workload in GPs’ day practices.
There are some strategies that could be examined for their effectiveness to reduce the workload at the cooperative. First, telephone triage could be improved to reduce the number of ‘unnecessary’ consultations. In the Netherlands, telephone triage is performed by triage nurses. Placing a telephone GP, who can be consulted by the triage nurses at the call centre continuously; can reduce the number of home visits and consultations (Citation17). Moreover, quality differences between triage nurses could be reduced by more training. Another solution is to introduce nurse practitioners as doctor substitutes to assist during peak hours. Nurse practitioners have proven to provide equally safe and efficient care during daytime primary care (Citation18,Citation19). However, the effects on the quality and safety of substitution of care from general practitioners to nurse practitioners in out-of-hours care should be examined (Citation20).
In the Netherlands, the main reason for working in a GP cooperative is that this is required to retain registration as a GP. However, this is not a mandatory requirement in other European countries where GPs who choose to work out-of-hours may have different motivations. Similarly, working hours mandated by the GP contract in the UK are longer (8.00 a.m.–6.30 p.m.), which may also lead to differences in experience of working in a GP cooperative. These contextual differences may lead to interesting differences in responses, which could be examined in future international research.
Finally, as GP cooperatives exist for over a decade, qualitative research might provide new insight or experiences, which could be relevant to include in a future survey.
Conclusion
GPs are motivated to work in out-of-hours GP cooperatives, and they outsource few shifts. GPs consider the peak hours and large number of (non-urgent) help requests as the most burdensome aspects. GP cooperatives can introduce several measures to reduce the workload. This can contribute to the involvement of GPs in primary care 24-h a day.
ACKNOWLEDGEMENTS
This article was based on Smits M, Keizer E, Huibers L, Giesen P. Ervaringen van huisartsen op de huisartsenpost. Huisarts Wet 2012;55:102–105. Additional data was included and the information in the manuscript was adjusted for international readers.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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