Family Practice Vol. 16, No. 1, 12-17
© Oxford University Press 1999
The effects of shifts in the balance of care on general practice workload
Health Economics Research Unit, Department of Public Health, University of Aberdeen, Foresterhill, AB25 2ZD, UK.
Scott A and Wordsworth S. The effects of shifts in the balance of care on general practice workload. Family Practice 1998; 16: 12–17.
Received 12 January 1998; Revised 16 July 1998; Accepted 7 October 1998.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
Background. The consequences of the move towards a primary-care-led NHS are shifts in activity from secondary care to primary care and more involvement of GPs in purchasing decisions. Although there are many anecdotal reports of an increasing primary care workload, there is little empirical evidence on the extent of such shifts. This paper reports the results of a survey of GPs in Grampian, in the north-east of Scotland, in which we attempted to gather information on the effects of shifts in the balance of care on general practice.
Objective. We aimed to examine GPs perceptions of the extent to which general practice workload has changed due to planned and unplanned shifts in the balance of care.
Methods. The design of the study was a self-reported questionnaire, which was administered in general practices in the Grampian Health Board, Scotland. The subjects were senior partners of all general practices and the main outcome measures were the types of changes which have taken place in general practice, their source, their effect on practice workload and how practices have reacted.
Results. A 60% response rate was achieved (52/86); 85% (44/52) of GPs claimed that their workload had increased due to shifts in the balance of care and that 72% of the shifts were initiated outside the practice. Geriatric care, early discharge and psychiatric and psychology services, as well as nursing home care, were reported to have had the greatest impact on workload. The main aspects of practice workload which had increased included the number of GP consultations, general stress at work and number of home visits, whereas the net income of the practice and health outcome of patients were reported to have decreased. Practices have dealt with the increase in workload by shifting tasks from GPs to nurses and absorbing the workload into existing practices/ patterns. Responders reported that ideally more nursing and GP staffing would be required. Overall, GPs welcomed the shifts in the balance of care, were more concerned about poor communication rather than actual increases in workload and claimed that morale had fallen.
Conclusion. GPs perceive that the move towards a primary-care-led NHS is increasing the workload in general practice. If the shift in the balance of care away from secondary care is to be successful, then more information is required about such shifts to support practices as change continues.
Keywords. General practice workload, primary-care-led NHS, shifts in the balance of care..
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
As the idea of a primary-care-led NHS becomes reality and with the potential for GPs to negotiate extra payments for increases in workload, it becomes important for health authorities and health boards to gather information about such increases. The consequences of the move towards a primary-care-led NHS are shifts in activity from secondary care to primary care and more involvement of GPs in purchasing decisions. Although there are many anecdotal reports of an increasing primary care workload, there is surprisingly little empirical evidence on the extent of such shifts.1–4 Such information is necessary to enable health boards/authorities to transfer resources from secondary to primary care and provide information on how best to support general practices as shifts continue. This paper reports the results of a survey of GPs in Grampian, in the north-east of Scotland, which attempted to gather such information. The survey was a self-reported questionnaire and as such the results should be interpreted as an indication of the types of work that have shifted. Obtaining GPs' perceptions of how workload has changed is important, since it is these perceptions than can influence GPs' stress, job satisfaction, morale and their responses to increased workload.
|
Subjects and methods |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
A questionnaire was sent to all 86 practices in the Grampian Health Board area. It was addressed to the senior partner who was asked to complete the questionnaire from the perspective of the practice as a whole, and in terms of shifts in the balance of care that had occurred in the preceding 12-month period. The questionnaire was piloted on six GPs to test their interpretation of its layout and questions (face validity). After confirming this measure of validity, the main survey was posted in June 1996, with a reminder being sent to those who had not replied after 4 weeks.
The aim of the survey was to collect information about: which care groups/disease groups/patients/services are influencing practice workload as a result of shifts in the balance of care, which of these had the greatest impact on workload and whether the shift was initiated by the practice or outside the practice. They were then presented with a list of 17 attributes of work and asked to indicate which attributes of workload were being affected and their relative importance in relation to job satisfaction. The attributes were defined from a review of the literature on sources of job satisfaction and stress.1,5 Further questions related to how the practice had dealt with the increase in workload and GPs' attitudes towards such shifts.
The questionnaire had 10 main questions with subsections. Some of the sections required open-ended responses, while others required ‘agree/disagree’ and ‘yes/no’-type responses. Several questions checked the internal consistency of the questionnaire. That is, if a responder answered a question in a way that did not contradict their answer to an earlier related question, then the responder had understood the questionnaire and answered consistently.
The results for each question were analysed using simple descriptive statistics, summarizing the results across the whole sample of those who responded. For any particular question, the summary we have used is the mean of those responding to that question. The answers to the open-ended questions were grouped into similar categories and coded accordingly. The answer to every question was cross-tabulated with a range of practice characteristics to assess whether there were any patterns of shifts or in attitudes to these shifts, by different types of practice. To test for such associations, the Likelihood Ratio test (chi-square2 test) for 2 x n tables was used.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
A response rate of 60% (52/86) was achieved after a reminder was sent out. Our checks for face validity show that GPs did not have problems interpreting the questionnaire. While 85% of responders claimed that there had been an increase in workload, 15% of responders claimed that the practice workload had not been affected. Table 1
shows the main types of patients/services or care groups that were reported to have influenced practice workload as a result of shifts in the balance of care. The top four types were anticoagulation, early discharge, geriatric care and psychiatric/psychology services. For the 44 practices who claimed that workload had increased, there was an average of four areas that had shifted per practice. Of the 180 shifts in total, 28% were initiated by practices and 72% were initiated outside practices. For each type of care, for those shifts initiated outside the practice, 38% were initiated by the local trust and 44% specifically mentioned general medical specialities. Of those shifts reported to have been initiated by the practice, 20% used GMS and 80% used fund savings to enable the shift to occur. For all shifts, 33% were initiated because of ‘increased amount of care offered by the practice’, 17% were to ‘reduce cost’, 33% due to ‘government policy’ and 17% due to ‘good practice’. Of the shifts mentioned by each GP, they were asked to identify one which had the largest impact on workload. These are shown in Table 2. The top four were geriatric care, early discharge, psychiatric/psychology services and nursing home care. The remainder of the questionnaire referred specifically to this shift. For the shift mentioned by each GP in Table 2, responders were then asked which specific aspects of practice workload had increased or decreased and were asked to rank each attribute in relation to overall job satisfaction. For Table 3, the columns labelled ‘increase’ and ‘decrease’ show the frequency with which responders indicated an increase or a decrease. The column labelled ‘average rank’ shows the mean ranking and that labelled ‘rank order’ shows the order of importance as implied by the mean rank. Both of these columns indicate how important the attribute is in relation to job satisfaction.
|
|
|
The number of GP consultations seems to have been affected the most and is also rated as the most important. Although general stress at work is the next attribute to have been affected the most, it is less important than other attributes. Similarly, although continuity of care was less likely to have been reported to have increased, it was ranked as the second most important attribute of workload. Thus, even though an attribute has been affected significantly, this does not always mean it is particularly important to GPs.
With respect to how practices had dealt with the increase in workload, GPs were asked to tick one or more of a predetermined set of factors. Table 4 shows that the most frequent responses were ‘by shifting tasks from GPs to nurses’ (63% of responders) and ‘absorbing the extra work into existing practice’ (58% of responders). In response to the open-ended question of what the GPs ideally required in order to deal with the increase in workload, the most frequent suggestions were more nursing input followed by more GP input (Table 5). Attitudes towards shifts in the balance of care are summarized in Table 6. The majority of GPs seemed to welcome the shift in the balance of care; were concerned that poor communication and the involvement of the practice in the shifts were more important than the actual increase in workload; agreed that job satisfaction has fallen; disagreed that quality of care for patients has fallen; and agreed that morale amongst partners and staff has fallen. The differences between responders and non-responders are shown in Table 7 below. The table shows that there are no significant differences between responders and non-responders in terms of practice characteristics and ‘objective’ measures of workload, such as patients per WTE GP.
|
|
|
|
Although practice characteristics were examined in relation to the GPs' responses, many of the questions had too few responses to gain meaningful associations. However, there were some interesting findings. Practices with fewer WTE partners were more likely to have reported an increase in workload, although this was a weak association (P = 0.09). Those practices who initiated shifts were more likely to be fundholders, compared with practices who did not initiate shifts (P = 0.001). Training practices were less likely to have experienced an increase in stress (P = 0.09) compared with non-training practices and fundholders were more likely than non-fundholders to have re-organized duties amongst GPs and to have sought assistance from the health board. Finally, there were no associations between the attitudes towards shifts in the balance of care and practice characteristics.
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
As the emphasis on attaining a primary-care-led NHS seems set to continue, questions are raised as how to best facilitate any resulting shifts in the balance of care away from secondary care and into primary care. At the local level health boards and health authorities require detailed information on how general practice workload is being affected if they are to support practices as both planned and unplanned shifts continue.
The results of the survey should be interpreted as an indication of the types of work that have been affected, and present an initial idea of the relative importance of these attributes in relation to GPs' job satisfaction, stress, morale and their responses to increased workload. It would have been difficult to examine changes in workload using actual data, unless a comparative study had been conducted.
There are several issues concerning the design of the questionnaire which may influence the results. First, although responders were asked to complete the questionnaire from the perspective of the practice, it is likely that the results are biased towards responders' (that is senior partners) own personal views of the shifts, rather than the views of the practice as a whole. For example, the extent to which responders consulted with other partners or other practice staff is unclear. Secondly, the results are self-reported and therefore may not correspond to what is actually happening. It is possible that some GPs may have used the questionnaire to ‘protest’ at the increase in workload. If this was the case then there would have been little variation in some of the answers provided. However, there was sufficient variation in the answers to indicate that, on the whole, this was not the case (although it cannot be ruled out). The fourth issue was that many responders did not answer each and every question, resulting in missing values. In particular, for question two, most responders appeared to have little or no difficulty in suggesting the types of patients/ services/care groups which were affecting practice workload as a result of shifts in the balance of care. Yet when asked to identify whether the shift was initiated from within or outwith the practice, or the reason for the shift, the subsequent columns were often left blank. Also, for question three, on the shift outside the practice which had the biggest impact, some responders wrote about a shift which had not been specified in question two. In question four, many GPs did not attempt to complete the ranking section, while others did so only partially. Blank responses may have been due to there being insufficient time for the GP to fill in the questionnaire, or that the GP did not know the answer, or did not fully understand the question being asked.
Question ten, which was an open-ended invitation for the responders to make any comments about the questionnaire or other issues it had raised but had not been covered, was left mainly blank, while some responders made more general comments not specifically related to workload. A further issue was the coding in question 2, specifying which types of care had shifted. Little re-coding was undertaken by the authors, apart from where two or more types of patients or care were obviously related (e.g. ‘warfarin’ and ‘INR monitoring’). Given that the question was open-ended, it was difficult to interpret what exact type of care had shifted. For example, ‘geriatric’ may include a range of different types of patients and may overlap with some other categories such as ‘nursing home’ and ‘psychiatric/psychology’. However, the results do give a general impression of the main areas of care that have shifted.
|
Conclusion |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
With the current shift in the balance of care from a secondary to a primary-care-led NHS the role of the GP is changing, with consequent increases in workload. The transfer of resources to primary care should be evidence-based, both in terms of evidence of cost-effectiveness, and in terms of data on how workload is actually being affected. Currently, there is little information on how GP workload is being affected, even though general practices require support in their move to the fore-front of health care. Such information is essential if the transfer of resources and the prospect of local pay in the primary care white paper are to be evidence-based.
|
Acknowledgments |
|---|
This project was funded by Grampian Health Board. Thanks go to Dr Karen Foster, Professor Lewis Ritchie and Professor Cam Donaldson. HERU is funded by the Chief Scientist Office of the Scottish Office Department of Health (SODoH). The views in this paper are those of the authors and not SODoH.
|
References |
|---|
|
TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionReferences |
|---|
1 Institute for Health Policy Studies. Changing Work Practices and Workload in Secondary and Primary Care. Report of a multi-agency working group in Southampton and South West Hampshire Health Commission, Faculty of Social Sciences, University of Southampton, 1995.
2 Godber E, Robinson R, Steiner A. Economic evaluation and shifting the balance towards primary care: definitions, evidence and methodological issues. Health Economics 1997; 6: 275–294.[Web of Science][Medline]
3
Pedersen LL, Leese B. What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base. Br Med J 1997; 314: 1337–1341.
4 Scott A, Vale L. The effect of shifts in the balance of care on the workload of GPs. A systematic review of the literature. Br J Gen Pract 1998; 48: 1085–1088.[Medline]
5 Scott A. Designing incentives for GPs. A review of the literature on their preferences for pecuniary and non-pecuniary job characteristics. Discussion paper 01/97, Health Economics Research Unit, University of Aberdeen, 1997.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  E. M Zantinge, P. F. Verhaak, and J. M Bensing The workload of GPs: patients with psychological and somatic problems compared Fam. Pract., June 1, 2005; 22(3): 293 - 297. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Shipman, J. Addington-Hall, S. Barclay, J. Briggs, I. Cox, L. Daniels, and D. Millar Educational opportunities in palliative care: what do general practitioners want? Palliative Medicine, April 1, 2001; 15(3): 191 - 196. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||