Effect of the new contract on GPs' working lives and perceptions of quality of care: a longitudinal survey

Job satisfaction criteria to improve general practitioner recruitment: a Delphi consensus

BACKGROUND

The clinical general practitioner (GP) workforce is decreasing. Many studies have analysed the negative aspects of the profession but, few examine the positive aspects and job satisfaction. A European collaborative group including 8 participating countries recently conducted a qualitative study to analyse the positive factors and found 31 job satisfaction factors.

OBJECTIVES

To determine which of these 31 factors are important and applicable to future policies to improve family medicine attractiveness, recruitment, and retention in France.

METHOD

The Delphi consensus method was chosen. Two Delphi rounds were conducted in March-April 2017 and retained satisfaction factors with at least 70% of scores ≥7. The Nominal Group Technique (NGT) was used to rank these retained factors. Participants assigned 5 points to the factor they considered most important, 3 points to the second, and 1 point to the third. Factors receiving at least 5% (10 points) of the total points (198 points) were included in the final list. The expert panel included GPs and non-GPs.

RESULTS

Twenty-nine experts began the procedure and 22 completed it. Thirty factors were retained after the 2 Delphi rounds. The NGT resulted in 8 factors: (i) Engage in family medicine to take care of the patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration.

CONCLUSION

These 8 job satisfaction factors are important to consider and apply to future policy development.

Medically underserved areas: are primary care teams efficient at attracting and retaining general practitioners?

The geographical imbalances of General Practitioners (GPs) may affect their accessibility for populations, especially in medically underserved areas. We investigate the effect of the dramatic and recent diffusion of Primary Care Teams (PCTs), especially in medically underserved areas, in order to attract and retain GPs through an improvement of their working conditions. We analyze the evolution of GPs and young GPs density between 2004 and 2017 according to a spatial taxonomy of French living areas in 6 clusters. Based on a quasi-experimental design comparing living areas, depending on the clusters, with PCTs (treated) and without PCTs (control), we used difference-in-differences models to estimate the impact of PCT new settlements on the evolution of both attraction and retention of GPs. Our results show that PCT settlements are efficient to attract young GPs and that the magnitude of the effects depends on the living area clusters. Results call for specific policies to address geographical inequalities of GPs that consider the type of place and also, in France, for new measures to attract and retain GPs in rural fringes.

Effect of interventions for the well-being, satisfaction and flourishing of general practitioners-a systematic review

OBJECTIVES

Clinician well-being has been recognised as an important pillar of healthcare. However, research mainly addresses mitigating the negative aspects of stress or burnout, rather than enabling positive aspects. With the added strain of a pandemic, identifying how best to maintain and support the well-being, satisfaction and flourishing of general practitioners (GPs) is now more important than ever.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, PsycINFO, Embase, CINAHL and Scopus from 2000 to 2020.

STUDY SELECTION

Intervention studies with more than 50% GPs in the sample evaluating self-reported well-being, satisfaction and related positive outcomes were included. The Cochrane Risk of Bias 2 tool was applied.

RESULTS

We retrieved 14 792 records, 94 studies underwent full-text review. We included 19 studies in total. Six randomised controlled trials, three non-randomised, controlled trials, eight non-controlled studies of individual or organisational interventions with a total of 1141 participants. There were two quasi-experimental articles evaluating health system policy change. Quantitative and qualitative positive outcomes were extracted and analysed. Individual mindfulness interventions were the most common (k=9) with medium to large within-group (0.37-1.05) and between-group (0.5-1.5) effect sizes for mindfulness outcomes, and small-to-medium effect sizes for other positive outcomes including resilience, compassion and empathy. Studies assessing other intervention foci or other positive outcomes (including well-being, satisfaction) were of limited size and quality.

CONCLUSIONS

There is remarkably little evidence on how to improve GPs well-being beyond using mindfulness interventions, particularly for interventions addressing organisational or system factors. This was further undermined by inconsistent reporting, and overall high risk of bias. We need to conduct research in this space with the same rigour with which we approach clinical intervention studies in patients.

PROSPERO REGISTRATION NUMBER

CRD42020164699.

FUNDING SOURCE

Dr Diana Naehrig is funded through the Raymond Seidler PhD scholarship.

Impact of rural workforce incentives on access to GP services in underserved areas: Evidence from a natural experiment

Financial incentives are often used to improve recruitment and retention of physicians in rural and remote areas. In 2010, the General Practice Rural Incentive Program (GPRIP) was introduced in Australia, causing an exogenous change in the eligibility for rural incentives for some geographical areas. This study investigates the effect of this policy reform on waiting times for a non-urgent GP appointment using panel data (2008-2014) on 2058 GPs. Using difference-in-difference methodology, results show that the number of GPs in practices in newly eligible areas increased. However, no evidence is found that this reduces waiting times for existing patients, and only weak evidence is found that waiting times for new patients fell, by around 16%. Our results suggest that financial incentives may only play a limited role in improving access to primary care and should not be the only solution to address medical workforce shortages in underserved areas.

Working lives of GPs in Scotland and England: cross-sectional analysis of national surveys

OBJECTIVES

The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced.

DESIGN AND SETTING

Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation.

PARTICIPANTS

2048 GPs in Scotland and 879 GPs in England.

MAIN OUTCOME MEASURES

Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree').

RESULTS

Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes.

CONCLUSION

Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.

Substantial Differences in Turnover Intention Between Direct Care Workers in Chinese Hospitals and Long-Term Care Facilities

OBJECTIVES

High retention rates among direct care workers (DCWs) affect the quality of aged care. However, limited research has explored factors associated with retention in China's aged care industry. This study compared turnover intention among DCWs in Chinese hospitals and long-term care facilities (LTCFs).

DESIGN

A cross-sectional survey with the stratified-random sampling method.

SETTING AND PARTICIPANTS

A total of 370 DCWs from 7 hospitals and 311 DCWs from 7 LTCFs located in Fujian Province, China, were surveyed.

MEASURES

Turnover intention, contractual status, income, sociodemographic characteristics, and other work-related factors were self-reported by surveyed DCWs.

RESULTS

Approximately 80% of DCWs in hospitals had employment contracts, whereas only 9% of DCWs were contractual in LTCFs. DCWs from hospitals reported lower turnover intention (20.5% vs. 37.0%) than did DCWs from LTCFs. Contracted DCWs from hospitals had the lowest turnover intention (14.8%). Contracted and noncontracted DCWs in LTCFs were more likely to report turnover intention than hospital contracted DCWs (odds ratio [OR] 3.68, P = .008 and OR = 3.17, P < .001, respectively).

CONCLUSIONS AND IMPLICATIONS

Contractual status and facility type were jointly associated with turnover intention of DCWs in China. DCWs in LTCFs were likely to report much higher turnover intention than contracted DCWs in hospitals. The expanded use of employment contracts may lower turnover intention in long-term care DCWs by improving their job stability and security. The labor market of DCWs needs to be regulated by the Chinese Labor Law.

The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries

BACKGROUND

The workload of general practitioners (GPs) and dissatisfaction with work have been increasing in various Western countries over the past decades. In this study, we evaluate the relation between the workload of GPs and patients' experiences with care.

METHODS

We collected data through a cross-sectional survey among 7031 GPs and 67,873 patients in 33 countries. Dependent variables are the patient experiences on doctor-patient communication, accessibility, continuity, and comprehensiveness of care. Independent variables concern the workload measured as the GP-reported work hours per week, average consultation times, job satisfaction (an indicator of subjective workload), and the difference between the workload measures of every GP and the average in their own country. Finally, we evaluated interaction effects between workload measures and what patients find important in a country and the presence of a patient-list system. Relationships were determined through multilevel regression models.

RESULTS

Patients of GPs who are happier with their work were found to experience better communication, continuity, access, and comprehensiveness. When GPs are more satisfied compared to others in their country, patients also experience better quality. When GPs work more hours per week, patients also experience better quality of care, but not in the area of accessibility. A longer consultation time, also when compared to the national average, is only related to more comprehensive care. There are no differences in the relationships between countries with and without a patient list system and in countries where patients find the different quality aspects more important.

CONCLUSIONS

Patients experience better care when their GP has more work hours, longer consultation times, and especially, a higher job satisfaction.

Does accreditation affect the job satisfaction of general practitioners? A combined panel data survey and cluster randomised field experiment

A critical question for policy makers in health care is whether external interventions have unintended consequences such as lowering professionals' job satisfaction. We investigate whether a non-monetary incentive, in the form of mandatory accreditation, affects the job satisfaction of Danish GPs. Accreditation of general practice in Denmark was introduced as a cluster randomised stepwise implementation from 2016 to 2018. We measure job satisfaction at three time points: before the randomisation took place, one year into the accreditation process and two years into the accreditation process. We use a balanced panel of GPs who have completed all three waves of the survey (n = 846) and estimate a series of random and mixed effects ordered logit models. Despite many GPs having negative attitudes towards accreditation, we find no evidence of accreditation affecting GP job satisfaction. However, there are negative associations between job satisfaction and perceiving accreditation as a tool for external control. Policy makers are therefore encouraged to carefully inform about new interventions and identify barriers to diminish pre-existing negative perceptions about the incentive.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Canadian family physician job satisfaction - is it changing in an evolving practice environment? An analysis of the 2013 National Physician Survey database

Background

To explore the determinants of job satisfaction and work-life balance satisfaction of family physicians in Canada.

Methods

This is a secondary analysis of the Canadian 2013 National Physician’s Survey using descriptive statistics and binomial logistic regression. An estimated 34,753 family physicians practicing in Canada at the time of survey administration in 2013 were eligible for the survey. The main outcome measures were respondent satisfaction with professional life and satisfaction with work-life balance.

Results

The survey had a response rate of 17%. Seventy-two percent of respondents were satisfied with their professional lives, and 49% were satisfied with their work-life balance. Male family physicians had lower odds of satisfaction with their work-life balance than their female counterparts (OR = 0.86, 95% CI 0.82–0.92). Family physicians using an electronic medical record had higher odds of dissatisfaction with their professional lives (OR = 1.13, 95% CI 1.05–1.22) and work-life balance (OR = 1.22, 95% CI 1.15–1.30) than those not using an EMR. Family physicians not in a focused practice had greater odds of dissatisfaction (OR = 1.61, 95% CI 1.50–1.72) with both their professional lives and work-life balance (OR = 1.29, 95% CI 1.22–1.37) compared to their colleagues who have one or more areas of clinical focus.

Conclusions

Canadian family physicians are more satisfied with their professional lives than with their work-life balance. Novel findings that family physicians with one or more clinical areas of focus are more satisfied with their work and work-life balance satisfaction, and that family physicians using electronic health records are less satisfied with their work and their work-life balance merit further inquiry.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0786-6) contains supplementary material, which is available to authorized users.

Impact of pay for performance on behavior of primary care physicians and patient outcomes

BACKGROUND AND OBJECTIVES

Pay-for-performance is a financial incentive which links physicians' income to the quality of their services. Although pay-for-performance is suggested to be an effective payment method in many pilot countries (ie the UK) and enjoys a wide application in primary health care, researches on it are yet to reach an agreement. Thus, a systematic review was conducted on the evidence of impact of pay-for-performance on behavior of primary care physicians and patient outcomes aiming to provide a comprehensive and objective evaluation of pay-for-performance for decision-makers.

METHODS

Studies were identified by searching PubMed, EMbase, and The Cochrane Library. Electronic search was conducted in the fourth week of January 2013. As the included studies had significant clinical heterogeneity, a descriptive analysis was conducted. Quality Index was adopted for quality assessment of evidences.

RESULTS

Database searches yielded 651 candidate articles, of which 44 studies fulfilled the inclusion criteria. An overall positive effect was found on the management of disease, which varied in accordance with the baseline medical quality and the practice size. Meanwhile, it could bring about new problems regarding the inequity, patients' dissatisfaction and increasing medical cost.

CONCLUSIONS

Decision-makers should consider the baseline conditions of medical quality and the practice size before new medical policies are enacted. Furthermore, most studies are retrospective and observational with high level of heterogeneity though, the descriptive analysis is still of significance.

Financial incentive schemes in primary care

Pay-for-performance (P4P) schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals' behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost-benefit emerges.

The influence of a market-oriented primary care reform on family physicians' working conditions: A qualitative study in Turkey

BACKGROUND

Turkey has undergone a 'Health transformation programme' putting emphasis on the reorganization of primary care (PC) services towards a more market-oriented system.

OBJECTIVES

To obtain a deep understanding of how family physicians (FPs) experienced the process of the reforms by focusing on working conditions.

METHODS

This phenomenological and qualitative research used maximum variation sampling and 51 FPs were interviewed in 36 in-depth and four focus-group interviews.

RESULTS

Thematic analysis of interviews provided seven themes: (1) change in the professional identity of PC physicians (physician as businessperson); (2) transformation of the physician-patient relationship in PC (into a provider-customer relationship); (3) job description and workload; (4) interpersonal relationships; (5) remuneration of FPs, (6) uncertainty about the future and (7) exhaustion. Most FPs felt that the Family medicine model (FMM) placed more emphasis on the business function of family practice and this conflicted with their professional characteristics as physicians. FPs complained that some of their patients behaved as extremely demanding consumers. Continuously increasing responsibilities and extremely high workload were commonly reported problems. Most participants described the negative incentives in the performance scheme as a degrading method of punishment. The main factor was job insecurity caused by contract-based employment. FPs described the point at which they are with terms such as exhaustion.

CONCLUSION

By increasing workload and creating uncertainty about the future and about income, the PC reforms have led to working conditions, which has led to changes in the professional attitudes of physicians and their practice of medicine.

The role of GP's compensation schemes in diabetes care: evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners

Background

Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks.

Methods

In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs’ preferences for time spent on preventive health care activities and age, gender and practice characteristics.

Results

Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs’ preferences for time spent on preventive health care services.

Conclusions

The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.

Motives for early retirement of self-employed GPs in the Netherlands: a comparison of two time periods

BACKGROUND

The high cost of training and the relatively long period of training for physicians make it beneficial to stimulate physicians to retire later. Therefore, a better understanding of the link between the factors influencing the decision to retire and actual turnover would benefit policies designed to encourage later retirement. This study focuses on actual GP turnover and the determining factors for this in the Netherlands. The period 2003-2007 saw fewer GPs retiring from general practice than the period 1998-2002. In addition, GPs' retirement age was higher in 2003-2007. For these two periods, we analysed work perception, objective workload and reasons for leaving, and related these with the probability that GPs would leave general practice at an early age.

METHODS

In 2003, a first retrospective survey was sent to 520 self-employed GPs who had retired between 1998 and 2002. In 2008, the same survey was sent to 405 GPs who had retired between 2003 and 2007. The response rates were 60% and 54%, respectively. Analyses were done to compare work perception, objective workload, external factors and personal reasons for retiring.

RESULTS

For both male and female GPs, work perception was different in the periods under scrutiny: both groups reported greater job satisfaction and a lower degree of emotional exhaustion in the later period, although there was no notable difference in subjective workload. The objective workload was lower in the second period. Moreover, most external factors and personal reasons that may contribute to the decision to retire were reported as less important in the second period. There was a stronger decrease in the probability that female GPs leave general practice within one year than for male GPs. This underscores the gender differences and the need for disaggregated data collection.

CONCLUSIONS

The results of this study suggest that the decrease in the probability of GPs leaving general practice within one year and the increasing retirement age are caused by a decrease in the objective workload, a change in GPs' work perception, external factors and personal reasons. Based on the results of this study, we consider workload reduction policies are the most useful instruments to control retention and retirement.

Experience of contractual change in UK general practice: a qualitative study of salaried GPs

BACKGROUND

General practice in the UK underwent major change in 2004, with the introduction of new contracts and a significant element of pay for performance. Although salaried GPs form an increasing proportion of the general practice workforce, little is known of their experiences.

AIM

To explore the views and experiences of salaried GPs working in English general practice.

DESIGN AND SETTING

Qualitative study using semi-structured interviews in 17 practices across England, between July 2007 and September 2009.

METHOD

Interviews were conducted with 23 salaried GPs. A topic guide included questions on motivations for a career in general practice, descriptions of their daily working environment and duties, practice relationships, and future aspirations.

RESULTS

The new ability to opt out of out-of-hours responsibilities was deemed positive for the profession but not a major driver for choosing medical speciality. Views regarding the impact of the Quality and Outcomes Framework were ambivalent. Differences in pay were regarded as largely reflective of differences in responsibility between salaried GPs and principals. Most participants reported conducting varied work in collaborative practices. Participants held varying career aspirations.

CONCLUSION

Salaried GPs' working experiences were dependent upon personal aspirations and local context. Most salaried GPs were reportedly content with their current position but many also had aspirations of eventually attaining GP principal status. The current lack of available partnerships threatens to undo recent positive workforce progress and may lead to deep dissatisfaction within the profession and a future workforce crisis. Further large-scale quantitative work is required to assess the satisfaction and future expectations of those in salaried posts.

Multi-tasking, quality and pay for performance

We present a model of optimal contracting between a purchaser and a provider of health services when quality has two dimensions. We assume that: (i) the provider is (at least to some extent) altruistic; (ii) one dimension of quality is verifiable (dimension 1) and one dimension is not verifiable (dimension 2); (iii) the two quality dimensions can be either substitutes or complements. Our main result is that setting the price equal to the marginal benefit of the verifiable quality dimension can be optimal even if the two quality dimensions are substitutes.

What doctors think about the impact of managed care tools on quality of care, costs, autonomy, and relations with patients

Background

How doctors perceive managed care tools and incentives is not well known. We assessed doctors' opinions about the expected impact of eight managed care tools on quality of care, control of health care costs, professional autonomy and relations with patients.

Methods

Mail survey of doctors (N = 1546) in Geneva, Switzerland. Respondents were asked to rate the impact of 8 managed care tools on 4 aspects of care on a 5-level scale (1 very negative, 2 rather negative, 3 neutral, 4 rather positive, 5 very positive). For each tool, we obtained a mean score from the 4 separate impacts.

Results

Doctors had predominantly negative opinions of the impact of managed care tools: use of guidelines (mean score 3.18), gate-keeping (2.76), managed care networks (2.77), second opinion requirement (2.65), pay for performance (1.90), pay by salary (2.24), selective contracting (1.56), and pre-approval of expensive treatments (1.77). Estimated impacts on cost control were positive or neutral for most tools, but impacts on professional autonomy were predominantly negative. Primary care doctors held more positive opinions than doctors in other specialties, and psychiatrists were in general the most critical. Older doctors had more negative opinions, as well as those in private practice.

Conclusions

Doctors perceived most managed care tools to have a positive impact on the control of health care costs but a negative impact on medical practice. Tools that are controlled by the profession were better accepted than those that are imposed by payers.

'Oh God, not a palliative': out-of-hours general practitioners within the domain of palliative care

To date, the experiences of out-of-hours general practitioners with regard to palliative care patients and their management are yet to be evaluated, since the new General Medical Services contract came into force. In 2007 the National Institute for Health Research highlighted the need to identify factors that improve and hinder the delivery of optimum palliative out-of-hours care. By interviewing general practitioners who work out-of-hours shifts, this project explored factors influencing confidence in dealing with symptom control and palliative care provision outside regular working hours. Face-to-face semi-structured interviews were conducted with nine out-of-hours general practitioners employed by Serco. Interviews were conducted by a specialist doctor in palliative care who had in the past worked as an out-of-hours general practitioner. Interviews were analysed using Interpretative Phenomenological Analysis. General practitioners expressed concerns relating to constraints within the system provided by the private company-owned out-of-hours provider. Data from interviews was thematically very rich and brought out many different subject areas, some similar to previous interviews, some different. Sub-themes related to the process-driven aspects of working in out-of-hours: * Motivation, * Time-pressure constraints and continuity, * The out-of-hours doctor within the domain of palliative care, * Isolation within system. General practitioners stated that their motivation was mainly financial. There was clear concern about the lack of continuity, and inadequacy of notes and follow-up, and there was a demonstrated need for more learning on the topic of palliative care. Pressure from the out-of-hours provider to see more patients was felt to be oppositional with the need to spend adequate time with this vulnerable patient group. General practitioners felt as unwanted strangers who were viewed with suspicion by patients and carers in palliative care situations. It was clear that most of the doctors interviewed felt a strong sense of isolation when working out-of-hours shifts, and some felt less inclined to contact specialist palliative care services.

Overcoming the barriers to chlamydia screening in general practice--a qualitative study

BACKGROUND

There is low uptake of chlamydia screening in general practices registered with the English National Chlamydia Screening Programme (NCSP). Aims. To explore staff's attitudes and behaviour around chlamydia screening and how screening could be optimized in general practice.

METHODS

A qualitative study with focus groups and interviews, in general practices in seven NCSP areas. Twenty-five focus groups and 12 interviews undertaken with a purposively selected diverse group of high and low chlamydia-screening practices in 2006-08. Data were collected and analysed using a framework analytical approach.

RESULTS

Higher screening practices had more staff with greater belief in patient and population benefits of screening and, as screening was a subjective norm, it was part of every day practice. Many staff in the majority of other practices were uncomfortable raising chlamydia opportunistically and time pressures meant that any extra public health issues covered within a consultation were determined by Quality Outcomes Framework (QOF) targets. All practices would value more training and feedback about their screening rates and results. Practices suggested that use of computer prompts, simplified request forms and more accessible kits could increase screening.

CONCLUSION

Practice staff need more evidence of the value of opportunistic chlamydia screening in men and women; staff development to reduce the barriers to broaching sexual health; simpler request forms and easily accessible kits to increase their ability to offer it within the time pressures of general practice. Increased awareness of chlamydia could be attained through practice meetings, computer templates and reminders, targets and incentives or QOF points with feedback.

Work stress of primary care physicians in the US, UK and German health care systems

Work-related stress among physicians has been an issue of growing concern in recent years. How and why this may vary between different health care systems remains poorly understood. Using an established theoretical model (effort-reward imbalance), this study analyses levels of work stress among primary care physicians (PCPs) in three different health care systems, the United States, the United Kingdom and Germany. Whether professional autonomy and specific features of the work environment are associated with work stress and account for possible country differences are examined. Data are derived from self-administered questionnaires obtained from 640 randomly sampled physicians recruited for an international comparative study of medical decision making conducted from 2005 to 2007. Results demonstrate country-specific differences in work stress with the highest level in Germany, intermediate level in the US and lowest level among UK physicians. A negative correlation between professional autonomy and work stress is observed in all three countries, but neither this association nor features of the work environment account for the observed country differences. Whether there will be adequate numbers of PCPs, or even a field of primary care in the future, is of increasing concern in several countries. To the extent that work-related stress contributes to this, identification of its organizational correlates in different health care systems may offer opportunities for remedial interventions.

Relationships between work satisfaction, emotional exhaustion and mental health among Swiss primary care physicians

BACKGROUND

Work-related satisfaction is an important determinant of quality of care. However, its relationship with doctors' mental health is poorly understood. It could have an independent beneficial effect on mental health (direct association) or simply reduce the impact of work stress on mental health (moderating or 'buffering' role).

METHODS

One thousand seven hundred and thirty-two Swiss primary care physicians (824 board-certified generalists, 436 general internists, 162 paediatricians, 147 internal medicine specialists and 163 physicians without specialty qualification) completed a mailed questionnaire. Previously, validated instruments were used to measure mental health (SF-12), emotional exhaustion [Maslach Burnout Inventory (MBI)] and work-related satisfaction. Linear regression models with mental health as dependant variable were used to study the relationships between these variables. Differences in mental health scores were standardized to represent a one standard deviation (SD) difference in the other scales [standardized beta coefficients (SBC)].

RESULTS

In multivariate analyses, higher levels of mental health were found in respondents with higher work-related satisfaction with current income and social prestige (SBC 1.04) and professional relations (SBC 0.57), and in respondents with lower emotional exhaustion (SBC -4.98) and higher personal accomplishment scores (SBC 1.72). Interaction terms between these dimensions of work-related satisfaction and emotional exhaustion were significant, supporting a 'buffering' role of these dimensions.

CONCLUSION

Work-satisfaction with current income, social prestige and professional relations are important correlates of mental health among primary care physicians, as well as emotional exhaustion. Higher levels of these dimensions of work-related satisfaction seems to mitigate the relationship between emotional exhaustion and physicians' mental health.

Economic influences on GPs' decisions to provide out-of-hours care

BACKGROUND

Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work-life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs.

AIM

To analyse which factors influence an individual GP's decision to re-provide OOH care when their practice has opted out.

DESIGN OF STUDY

Cross-sectional questionnaire survey.

SETTING

Rural and urban general practices in Scotland, UK.

METHOD

A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation.

RESULTS

Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services.

CONCLUSION

The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.