Family Practice Advance Access originally published online on January 7, 2005
Family Practice 2005 22(1):20-27; doi:10.1093/fampra/cmh714
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Saying ‘goodbye’ to single-handed practices; what do patients and staff lose or gain?
Centre for Quality in Care Research (WOK), University Medical Centre Nijmegen, The Netherlands
Correspondence to P van den Hombergh; Email: p.vd.hombergh{at}lhv.nl
Received 12 July 2004; Accepted 27 September 2004.
van den Hombergh P, Engels Y, van den Hoogen H, van Doremalen J, van den Bosch W and Grol R. Saying ‘goodbye’ to single-handed practices; what do patients and staff lose or gain? Family Practice 2004; 22: 20–27.
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Abstract |
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Background. The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices.
Objective. The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices.
Methods. Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included ‘single-handed/group practice’, ‘rural/ urban’ ‘part-time/full-time’ and ‘male/female’.
Results. Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education.
Discussion and conclusion. The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.
Keywords. General practice management and organization, patient opinion, practice visit, quality assurance, single-handed practice.
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Introduction |
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The trend in Europe is from single-handed to larger group practices in general practice. The 10% single-handed practices in the UK are under siege and in The Netherlands the number of single-handed GPs—once a majority—is declining rapidly (47.6% in 1996 to 40.0% in 2002).1 The shift to part-time working along with a relative increase in female GPs contributes to the reduction of single-handed practices. However, it is unclear how this secular change relates to the quality of care in the absence of evidence to promote the scaling up of practices. Such evidence may be particularly relevant for the European countries where patients generally consult single-handed GPs. These GPs often work without a receptionist, practice assistant or nurse, e.g. France as rated as best in the year 2000 on the controversial WHO-list of quality of health care.2 Current evidence about the respective advantages of each type of practice is not conclusive, either on clinical outcome or on practice management. Single-handed GPs in the UK did not under-perform clinically after adjustment for practice characteristics (deprivation, percentage Asians, blacks, men over 75 years, rurality, presence of a female GP, and vocational training).3 In addition, another study found no association between practice size and the quality of care of patients with ischaemic heart disease.4 Assessment of differences in practice management between practices has been scarce and incomplete. In a study by Baker on accessibility and availability patients reported that single-handed practices scored better than group practices. Patients prefer smaller practices, non-training practices and practices where GPs have personal lists.6 Baker concluded that practice organisation should be reviewed in order to ensure that the trend towards group practices that provide a wider range of services, does not lead to a decline in patient satisfaction. He further recommends personal list systems and small personal teams within the practice.7
GPs in The Netherlands have until recently been predominantly single-handed, but increasingly prefer to work in group practices. Only 2% of the GP trainees opt for single-handed practices. Single-handed practices have less means to purchase equipment,8 to delegate medical and organizational tasks and to collaborate with other health care providers. Single-handed GPs refer more readily, do more home visits, have fewer trainees, are less well equipped and are computerized to a lesser extent.9
From both a policy perspective, as well as a quality improvement perspective it will be relevant to explore those aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. Of specific interest are aspects that have not previously been assessed, such as practice infrastructure, teamwork, communication with colleagues and other care providers as well as quality assurance activities. These and other aspects of practice management can be assessed with the practice visit method VIP (Visit Instrument to assess Practice management). The VIP is an assessment instrument developed, tested, validated and continuously revised since 1995 and used by over 2500 GPs to audit their practice management. The VIP involves patients as well as GPs and staff.10 It enables an analysis of strong and weak points of the practice management of distinctive practices to be made. An international version is currently being developed.11
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Methods |
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For our study data from 1874 GPs in 1055 practices were available, collected in practice visits between 1998 and 2003. GPs, practices and GP-groups applied for visits mainly because application for a practice nurse precluded an practice assessment, but also as part of a wider programme of professional education. In order to obtain a clear picture, we excluded two-partner practices (n = 289), which left 518 single-handed practices and 248 practices with more than two GPs. The VIP data12 were used to analyse 303 indicators divided over four areas. The data was collected both at practice and at GP level, but data on GP level was aggregated at practice level. After factor analysis we were able to construct 56 dimensions out of the 303 indicators. Answer categories of the indicators were yes/no, time or numbers.
The four areas covering the field of practice management are:
- Infrastructure (premises, equipment, service and organisation)
- Team (task division, workload and job stress of the GPs)
- Communication (with colleagues/care providers, meeting time, patient information, computerized patient records, IT)
- Quality assurance activities (CME, audit, QA-activities)
| BOX 1 The Visit Instrument to assess Practice management (VIP): development and procedure The content of the VIP was determined in a consensus procedure defining the domain of practice management and the indicators for its quality. Questionnaires were used to obtain information on both the practice organization and the management of the GP. The questionnaires were for each GP, one practice assistant, 30 patients per practice, and 30 patients per GP. The observer prepared a preliminary report with this data and completed the feedback report with a practice observation. The visit takes half a day. The GP invests one hour in answering the questionnaire and has a normal surgery during the visit. The time required to discuss the results is one hour or more depending on the GP and the practice. Practice visits by a non-physician observer instead of by a colleague proved to be more feasible and better accepted.20 In a follow-up after one year, GPs and practices had changed significantly in the majority of criteria. Peer visits differed from visits by non-physician observers in the aspects of practice management that changed. Comparing one's score in the feedback to the average score of other colleagues and practices can be considered a sophisticated means of peer review. The most important feature of the VIP is that the GP and the practice themselves are motivated to get feedback on their practice management. For more information see www.wokresearch.nl, www.nhg.artsennet.nl or www.pietervandenhombergh.nl
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Descriptive statistics were used to assess characteristics. Unpaired t-tests were used to analyse differences between single-handed and group practices (>2.0 GPs) comparing raw scores on dimensions of practice management. We used raw scores because some characteristics of single-handed practices are intrinsic to their nature, but we repeated the procedure correcting for rurality, working part-time and sex in a multivariate analysis (GLM, general linear model procedure).
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Results |
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In Table 1 we compare practice characteristics (rurality, staff) and GP characteristics (sex, full-/part-time, years in the practice) with data representative for the national GP population. In our research group we have fewer single-handed GPs and more GPs in group practices than nationally. Both groups were comparable for other characteristics. The results are summarised in Tables 2
–5 and will be described for each main area of practice management.
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Infrastructure of the practice (Table 2)
Group practices have on average better facilities (treatment room for the practice assistant, meeting room, draft sluice, headphones, paper shredder), but they more often miss relevant tools (ear thermometer, tissues, clock, better day light on desk, more reference books, etc.). The examination rooms in group practices are somewhat less hygienic and offer fewer services (sanitary pads, diapers, shoehorn, bucket for disposing used equipment, paper towels etc.), but their treatment rooms are somewhat more hygienic and they have slightly better facilities (sterility, but also hepatitis B vaccination of staff). Group practices have more sophisticated equipment and diagnostics (proctoscope, EKG, audiometer, spirometer, doptone, hyfrecator etc.) and their GPs also use this equipment more frequently. They also have more emergency and laboratory equipment and facilities (anaphylactic shock set, urinary catheter, epistaxis tampon, ring saw). Differences between both type of practices in the number of basic medical technical procedures (IUD, proctoscopy, removal of atheroma, lipoma, chalazion, pessaries, intra-articular injections, microscopic examination of mycosis) were not found. Yet GPs in group practices inserted more IUDs and GPs in single-handed practices taped a few more ankles and applied more pessaries. Group practices scored better on ‘general organization of the practice’ (practice routines, protocols, logistics of patient information, telephone management, etc.). The doctor's bag was slightly better equipped in single-handed practices (blood glucose and urine sticks, urinary catheters, thermometer, mayo tube, pocket breezer) and they had more patient information material (leaflets, demos) available in their surgery. Patients of single-handed GPs reported to have waited less time before a consultation and to be happier with the time they got in a consultation.
Lower scores on most infrastructural aspects of the single-handed practice organization contrasted with the higher appreciation of the accessibility and the organization of their surgeries. This higher appreciation also included the facilities and the privacy of single-handed practices, contrary to the more ‘objective’, lower score of these aspects by the visiting observer. ‘Services for preventive care’ (offering flu vaccination, PAP-smear, risk profiling of cardiovascular risk factors, special service for DM, Asthma/COPD) did not differ between single-handed practices and group practices.
Team (Table 3)
Single-handed practices had more fte practice assistants per 1000 patients than group practices. Their GPs delegated more organizational tasks to their practice assistant, but GPs in group practices delegated more medical technical tasks. Tasks such as monitoring patients with chronic diseases (diabetes, asthma/COPD, cardiovascular risk factor management) and preventive tasks were equally often delegated to the practice assistant. Collaboration in the local GP group (structuring of the meetings, discussing medical and organisational topics) did not differ between practices. Yet, group practices meet for longer with their colleagues as well as with their partners in primary care and consultants/specialists. Group practices also had more protocols on care and formal collaboration with the hospital (policy on referring to the hospital and back to the GP, on emergency patients, on bad news, acute psychiatry, etc.)
Workload and job stress of GPs. Full-time single-handed GPs spent on average one hour per week more (34.6 versus 33.5 hrs/wk) on direct contact with patients than full-timers in group practices. Total workload per week did not differ significantly (55.7 versus 54.8 hrs/wk). When asked, however, how many hours GPs in single-handed practices wanted to work per week, they preferred on average to work two hours less than GPs in group practices. Single-handed GPs experienced slightly more inappropriate demands, were a little less happy with the available time and less satisfied with the time they had to invest in their job. They did not differ in experienced job stress at the end of a working day.
Communication and patient records (Table 4)
Both types of practices reported an average of 35 minutes as the time taken for a formal meeting of GP and practice assistant to discuss practice matters. Group practices were computerized to a greater extent (problem list, medication, episode registration, agenda for appointments, coding), and the quality of their computerized records (use of SOAP-method) was on average a little higher as well as their use of the computer (to generate prescriptions, referral letters, letters to other care providers, surveys for flu vaccination, disease management and the registration drug intolerance and contraindications) than single-handed practices. Group practices scored less on the use of the internet and data transport to the hospital and pharmacy. Single-handed GPs had more patient information material in their surgery and also handed the information out more often according to their patients (receiving a leaflet, getting instruction with a demo, having information readily available in the practice).
Quality improvement (Table 5)
Group practices scored better on audit, assessment and other quality improvement activities in the GP-group, as well as on indicators for quality assurance in the practice (year report, needs assessment, protocols in the practice, appraisal of staff, education of staff, calibration/ maintenance of equipment). They participated in audit with feedback on outcomes more often (prescriptions, referrals, diagnostic tests) and in quality assurance activities. The staff in group practices got on average two hours more training per year.
The GLM procedure with ‘single-handed/group practice’, ‘rural/urban’, ‘full-/part-time’ and ‘male/female’ as independent variables hardly changed the results found with raw scores. The contribution of part-time working and male/female ratio to the differences is limited.
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Discussion |
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Group practices score more highly on infrastructure and team, but patients appreciated single-handed practices better in most aspects of practice management. This higher score reflects the tension between the needs of the patient and the interests and priorities of the professional and his/her estimate of what serves best the interest of the patient. Patients of single-handed GPs even appreciated the premises better in spite of the higher score of the direct observer on the practice facilities of group practices (treatment room, accessible for handicapped etc.). This better patient appreciation may partly be a halo effect (having a personal, continuous relationship with their GP). Yet, patients rated both types of practices equally when asked factual information about the GP being disturbed during the consultation and the GP being well informed by specialists.
The better appreciation cannot be explained by a difference in workload of the GP. Full-time GPs in both practices work approximately 55 hours a week. However, single-handed GPs experience higher job stress in particular on the scale for inappropriate demands and have a stronger wish to work fewer hours. This may be the price the GP pays for the better patient service.13 Larger practices probably afford some protection against high job stress. The better appreciation by patients of service, accessibility, availability and organization of the surgeries often amazes group practices, being better equipped with telephone equipment (emergency line) and having their focus on easy access.
Most indicators for infrastructure are based on guidelines produced by the Dutch College of GPs. A higher score on these indicators in group practices reflects an ambition to give evidence-based professional care based on the medical needs of patients rather than putting emphasis on service. The results reflect the tenuous relationship between patient demands and the medical needs as defined by the professionals.
Better equipment and infrastructure in group practices does not necessarily result in a wider range of medical services or preventive activities. This is unexpected. GPs in group practices benefit from aspects that come with the larger scale organization. Many tasks are already delegated, comprehensive equipment is present, preventive services are more routine as well as quality improvement activities.14 Yet, they do not perform significantly better on preventive services than single-handed GPs. The finding that patients in group practices receive less patient information, indicates that centralized organization of patient information does not live up to its promise of being more adequate.
GPs in group practices have to do their own practice management, for example their own surgery and examination room, supply of their doctor's bag, handling of patient education material, record keeping, quality improvement activities and time management. But widening the range of medical procedures beyond their own share in practice management may be more tedious in a group practice, because of the loss of autonomy. Single-handed GPs have more autonomy and are only restricted by the standards and guidelines of their profession. This may result in a different innovation and client centeredness, but also in the opposite: economizing on investment in infrastructure to raise income.
The size of the practice may not be the best indicator for the difference in service. Campbell found that the number of patients per GP is a better indicator for consultation length in group practices.5 Another important consideration is that things which are necessary for quality of care in group practices may not necessarily be the same in single-handed practices. For example the use of protocols, the importance of communication between team members and shared record systems etc. are key factors in a group practice environment but arguably less important in a single-handed practice.
The results have to be interpreted with some caution. We were able to include a high number of practices in this study and thus did not calculate the power of the study beforehand. A retrospective power analysis showed that for several indicators differences of 2% or 1 hour (standard deviation 12% and 5.8 hours, respectively) were already significant. Therefore a significant difference may not necessarily be ‘clinically’ relevant.
Furthermore, we assessed structural aspects of general practice along with patient outcome. A relation between structure and process—proxy's for quality of care—is tenuous and could not be demonstrated in general practice.15 This certainly applies to the relation of infrastructure and outcome.
Group practices employ more female doctors and part-time working professionals, but correcting for part-time working and male/female ratio would not do justice to the character of group practices. In the GLM procedure the contribution of part-time working and male/female ratio to the differences proved to be limited.
The sample size is large, but there may still be questions on its representativeness. The variety of reasons for practices to participate other than already being an advanced practice, probably resulted in some selection, but we think this selection does not seriously jeopardize the conclusions of this comparison or the representativeness of the sample.
The fewer fte assistants per 1000 patients in group practices may be due to delegation of jobs to auxiliary staff (cleaners, secretarial staff, administrator, manager) and poorly reflects the support of the GP in the practice.
Conclusion
Patients favour small practices and full-time GPs. This contradicts developments in general practice in many countries. Which type of practice offers a better service and higher quality care has until now been a matter of fierce debate rather than research, but it may be a better strategy to see what lessons can be learnt from research.
Working in isolation and lack of feedback by colleagues are known risks (alcoholism, suicide) for single-handed GPs. Due to high profile cases such as Harold Shipman, single-handed GPs are under siege in the UK.16 This threatens to discredit the quality of care delivered by single-handed practices as a group.17 The type of practice that serves best the interest of patients is per definition elusive because quality differs in the eye of the beholder be it i) the patient, ii) the GP and staff or iii) society.18 It is important to look for ways to diminish tension between patients' preferences and organizational developments.19 More accurate information on how single-handed practices differ in service and organization from other practices will be valuable information for all stakeholders.
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Declaration |
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Funding: no funding, data collection was intrinsic to the practice visit and paid by the participant.
Ethical approval: not applicable.
Conflicts of interest: none.
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1 NIVEL, http://www.nivel.nl
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