Task shifting to improve practice efficiency: A survey among general practitioners in non-urban Baden-Wuerttemberg, Germany

Abstract

Background

Germany is challenged by an increasing shortage in general practice services, especially in non-urban areas. Task shifting from general practitioners (GPs) to other health professionals may improve practice efficiency to address this mismatch.

Objectives

Exploring GPs’ motives and beliefs towards task shifting in non-urban Germany and identifying potential factors influencing these.

Methods

The cross-sectional survey was disseminated by mail in three waves between July 2021 and August 2022 among all GPs in non-urban Baden-Wuerttemberg, Germany. It included items on demographics and practice characteristics as well as 15 Likert-scale items addressing motives and beliefs towards task shifting, based on the Theoretical Domain Framework. Likert-scale items were analysed descriptively, influencing factors on motives and beliefs were identified using multiple linear regression.

Results

Response rate was 24.2% (281/1162), with respondents comparable in age and gender to all GPs in Baden-Wuerttemberg. GPs’ motives and beliefs towards task shifting are positive overall. The majority expects task shifting to reduce their workload (87.9%) and increase practice efficiency (74.7%). They are open to shift additional tasks to other professionals (69.1%), even in the currently prohibited form of substitution (51.2%). Motives and beliefs were significantly more positive among younger GPs and those participating in the GP-centred care programme.

Conclusion

This study describes GPs’ motives and beliefs towards task shifting in non-urban Germany. Identifying younger GPs and those participating in the GP-centred care programme as particularly endorsing may help design future interventions aiming to improve efficiency in general practice in non-urban Germany.

KEY MESSAGES

• The majority of participants, especially young GPs, hold positive motives and beliefs about task shifting in general practice.

• The GP-centred care programme, as an alternative to the regular remuneration system, influences motives and beliefs towards task shifting.

• Legal adjustments seem warranted, as GPs support task shifting in the more extensive form of substitution, currently prohibited by law.

Introduction

General practice is challenged by the rise of chronic diseases in an ageing population [1,2] as most health needs are treated in general practice [3,4]. In Germany, this is especially true in non-urban areas, where the relative amount of older people is higher [5] and general practitioners (GPs) spend more time performing home visits [6,7], resulting in a higher time exposure per patient compared to urban areas [8]. Concurrently, GPs are replaced at an insufficient rate, resulting in an ageing GP workforce, foreshadowing an imminent shortage in GP services [9,10]. One option to address this mismatch might be to improve efficiency in general practice. Recent reviews have shown that team-based approaches may improve efficiency and be beneficial for patients [11–13]; however, the amount to which these insights are transferable to the specific setting of German general practice is unclear.

In contrast to other European countries (e.g. Spain or the United Kingdom), most GPs work in solo practices comprising one or two GPs [14]. Medical tasks are performed by GPs or to a lesser extent by medical assistants (MAs) as the only other established profession [15] (German: Medizinische Fachangestellte). Attempts to introduce additional professions such as physician assistants remain limited to individual projects and are not common yet [16,17]. Thus, team-based approaches in German general practice remain limited to task shifting from GPs to MAs.

To promote task shifting, two major training programmes for MAs, ‘Healthcare assistants in general practice’ (German abbreviation: VerAH) and ‘Non-physician practice assistant’ (NaePA), have been implemented [18]. However, both programmes are not ubiquitously adopted [19] and MA responsibilities remain narrower compared to international examples (e.g. the United Kingdom or Denmark) [20,21].

This is partly due to legal restrictions. Specifically, task shifting is limited to performing tasks delegated by GPs. Therein, GPs remain responsible for any task performed and are obligated to ensure adequate qualification of MAs. Although performed in other countries, the more extensive form of substitution, where MAs perform tasks without supervision or outside the organisational structure of general practice, is prohibited by law. Currently, although task shifting has been shown to improve practice efficiency [22–25], GPs feel insecure about legal specifications [19,26,27] and perceive remuneration for tasks shifted to MAs as increasingly complicated [19].

This complexity has been addressed by implementation of the GP-centred care programme (German: hausarztzentrierte Versorgung). Opposed to the regular remuneration system, where remuneration is organised in small capitation fees accompanied by numerous fees for service, remuneration in the GP-centred care programme is delivered mainly in capitation fees. Although being voluntary for both patients and GPs, patients forfeit their right to consult any physician at any time and are obligated to consult their GP first. Thereby, it aims to improve care coordination by introducing a gatekeeping role, as in Belgium or the United Kingdom [14,28]. Patients profit from improved care coordination and consequent health benefits [29,30], while GPs profit from less bureaucratic remuneration. Finally, the programme specifically promotes task shifting by financially incentivising training programmes for MAs and simplifying remuneration of tasks shifted to MAs. Still, the resulting effect on task shifting remains unknown.

To expand task shifting in general practice, a behaviour change of decision-makers is necessary. As most practices are owned and operated by GPs, they decide who performs which task in their practice, making them the primary decision-makers in their practices. Thus, it seems natural to focus on GPs’ motives and beliefs using behaviour change theory.

Previous studies established a high ‘willingness to delegate’ among GPs [19,24,31–33] and facilitators such as a reduced workload [24,34] or barriers such as lacking financial incentives [24] or legal concerns [19]. However, underlying motives and beliefs [32] as well as reasons for the gap between ‘willingness to delegate’ and actual involvement of MAs [31] remain vague. Specifically, findings indicating women [24,35], young GPs [24,26,35] or GPs working in group practices [26,35] being more willing to delegate were not replicated in more recent studies [31]. Furthermore, no studies focused on non-urban areas, where motives and beliefs might differ, due to organisational specifics such as the higher number of home visits or lower accessibility of secondary care [6,7]. Ultimately, although some factors influencing delegation have been identified, underlying motives and beliefs remain elusive, leaving tangible ways to expand task shifting in German general practice undetermined.

Objectives

Therefore, this study aims to explore GPs’ motives and beliefs towards task shifting to MAs, to increase practice efficiency in non-urban general practice in Germany and to identify factors influencing these motives and beliefs.

Methods

Setting

Study design is a cross-sectional survey among all GPs currently active in non-urban areas in the state of Baden-Wuerttemberg, Germany. Baden-Wuerttemberg was selected as a convenience sample resulting from the conducting institute’s connections in the state.

The federal Office for Building and Regional Planning provides two county-level definitions of Non-Urbanity (population density and population reachable in a pre-defined travel time) [36]. 12 of the 44 counties in Baden-Wuerttemberg met one or both definitions. GPs working in either of the 12 counties represented our target sample. GPs were defined as all physicians currently active in general practice, as defined by German law (general internal medicine, general practice and paediatrics). As challenges such as the management of chronic diseases may impact paediatrics differently, we excluded paediatrics from our target sample.

To identify members of the target population, we used a database provided by commercial marketing agencies targeting physicians. After removal of doublets and invalid address sets (e.g. not currently active as a GP), 1,162 of 1,383 initially acquired address sets were identified as eligible, representing our study sample. According to data from the Association of Statutory Health Insurance Physicians, which registers all currently active physicians, approximately 1,250 GPs should qualify as eligible, indicating some non-inclusion of the study population. No public data specific to our sample were available to further check for representativeness of the study population (e.g. gender).

Survey

The survey was self-designed, as no validated survey assessing this topic exists. The Theoretical Domain Framework (TDF) was applied as the theoretical basis, as it is designed to explore factors influencing behaviour change and is well established in health services research. It comprises 14 domains potentially influencing behaviour change, 9 of which were represented in the survey in 15 five-point Likert-scale items (1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Strongly agree; Table 3). The items were designed using validated question stems [37] and pretested, as reported in detail in the study protocol [38].

Table 3.

Factors influencing general practitioners’ motives and beliefs towards task shifting.

			Gender	Age	Workload	Employment status	Practice-type	GP-centred care
			Male (Ref.) Female/diverse	(years)	(hours/week)	Self-employed (Ref.) Employee	Solo practice (Ref.) Group practice	Non-participant (Ref.) Participant
4.1	I work in a region where there is currently a shortage in primary care supply.	Estimate	−0.14	−0.01	0.02	0.11	0.04	0.39
4.2	I am one of the first to implement new models in health care or practice organisation.	Estimate	0.25	−0.01	0.02**	0.32	0.44*	0.91***
4.3	I am able to implement changes to the processes in my practice.	Estimate	−0.05	−0.02***	0.01	−0.23	0.45***	0.16
4.4	I am well-informed about the possibilities of delegation.	Estimate	0.08	−0.01	0.01	−0.05	0.22	0.30
4.5	When I think about efficiency in my practice, the use of delegation plays a role.	Estimate	−0.08	−0.02**	0.01	0.08	0.04	0.67***
4.6	My goal for this practice is to achieve the highest efficiency possible.	Estimate	−0.28	−0.02*	0.01	0.08	0.12	0.30
4.7	I will delegate as many tasks as possible to my non-physician medical staff in the future.	Estimate	0.04	−0.02	0.01	−0.15	0.04	0.41*
	I think that an increase in delegation of medical tasks to non-physician medical staff in my practice…
4.8	… increases patient satisfaction.	Estimate	−0.18	−0.02	0.01	0.37	−0.01	0.35
4.9	… impairs the treatment of my patients.	Estimate	0.00	0.01	0.00	−0.06	−0.03	−0.35*
4.10	… reduces my workload.	Estimate	0.07	−0.02***	0.00	−0.03	−0.11	0.29*
4.11	… increases efficiency in my practice.	Estimate	0.04	−0.03***	0.01	0.01	0.00	0.41**
4.12	… is financially worthwhile for my practice.	Estimate	−0.12	−0.03***	0.00	0.20	−0.15	0.25
4.13	I am open to delegating additional medical activities to my practice personnel.	Estimate	−0.20	−0.02	0.01	−0.06	0.06	0.84***
4.14	I am open to delegating additional medical activities to my practice personnel, if they obtained additional training.	Estimate	0.27	−0.02*	0.01	0.09	0.09	0.68***
4.15	I am open to transferring medical tasks to my practice personnel in the sense of substitution.	Estimate	0.08	−0.01	0.01	0.24	0.03	0.78***

N = 224; * p < 0.05; ** p < 0.01; *** p < 0.001.

Bold values signify the most relevant significance values.

The final survey (Supplement 1) included items addressing demographics, practice characteristics (e.g. participation in the GP-centred care programme) and 15 Likert-scale items addressing motives and beliefs towards task shifting to MAs.

Survey administration

We administered the survey by standard mail. Mailings included a personalised cover letter describing the purpose of the study, the survey, a response form, a free return envelope and a second envelope without identifier to contain the completed survey, ensuring respondents’ anonymity.

The survey was administered in three waves in July and August 2021 and August 2022. The third wave, initially planned for September 2021, was postponed due to the COVID-19 vaccine booster campaign starting in September 2021. We expected response rates to drop significantly, because of the growing workload. Thus, in consultation with associated GPs, we identified summer 2022 as most suitable to administer the final wave.

Analysis

Survey responses were scanned, digitally converted and uploaded into a database. Unreadable answers were censored. All data were checked for plausibility before analysis (e.g. identical responses across all items), incomplete survey data were included in the analysis if applicable, with missing items reported.

We performed descriptive data analysis without adjusting for potential statistical errors or non-representativeness and did not perform sensitivity analyses. Practice type was dichotomised into solo practice and group practice, disregarding further discrimination between medical care centre, group practice and joint practice. No other modification of items was performed.

Analysis to identify influencing factors on motives and beliefs was performed using a multiple linear regression model between demographics, practice characteristics and TDF items. Data analysis for multiple linear regression was conducted in R version 4.2.3.

Ethics approval and consent to participate

The study has been approved by the Ethics Committee II of Heidelberg University, Mannheim Medical Faculty in April 2021 (Approval no. 2021–530). Consent for participation in the survey was assumed when the survey was returned.

Results

Respondent characteristics

Of 1,162 surveys, 281 were returned, resulting in a response rate of 24.2%. Respondents’ characteristics are reported in Table 1.

Table 1.

Respondents’ characteristics.

	n	Mean SD
Age	280	56.8	9.8
	1
Working Hours per week	255	47.5	12.0
Missing	26
Gender	n	%
Male	169	60.6
Female	110	39.4
Non-binary	0	0.0
Missing	2
Employment Status	n	%
Self-employed	250	90.6
Employed	26	9.4
Missing	5
Practice Type	n	%
Solo practice	131	49.4
Group practice	134	50.6
Missing	16
GP-centred care	n	%
Participant	192	71.1
Non-participant	78	29.9
Missing	11

Motives and beliefs towards delegation

Table 2 shows GPs’ responses to Likert-scale items addressing motives and beliefs towards delegation. The majority of respondents aim to reach the highest efficiency possible in their practices (mean = 4.08, SD = 0.94) and delegation comes to mind when thinking about ways to achieve this goal (mean = 4.14, SD = 0.91). They feel able to implement changes to processes in their practices (mean = 4.06, SD = 0.85) and expect delegation to reduce their personal workload (mean = 4.27, SD = 0.83) and increase efficiency in their practice (mean = 3.98, SD = 0.92). Further, most do not fear an impairment of patient treatment when delegating tasks to MAs (mean = 2.30, SD = 1.00). Ultimately, the majority of GPs are open to delegate additional tasks to MAs in the future (mean = 3.70, SD = 1.19) and, to a lesser extent, most GPs are open to shifting tasks to MAs in the form of substitution (mean = 3.32, SD = 1.19).

Table 2.

General practitioners’ motives and beliefs towards task shifting.

	Item	n	Mean	SD	1. Strongly disagree	2. Disagree	3. Neither agree nor disagree	4. Agree	5. Strongly agree
4.1	I work in a region where there is currently a shortage in primary care supply.	281	3.96	±1.17	2.5%	14.6%	11.4%	27.4%	44.1%
4.2	I am one of the first to implement new models in health care or practice organisation.	277	2.99	±1.21	13.4%	22.4%	27.8%	25.3%	11.2%
4.3	I am able to implement changes to the processes in my practice.	281	4.06	±0.85	0.4%	7.5%	8.9%	52.7%	30.6%
4.4	I am well-informed about the possibilities of delegation.	281	3.84	±0.94	1.1%	10.3%	16.7%	47.7%	24.2%
4.5	When I think about efficiency in my practice, the use of delegation plays a role.	279	4.14	±0.91	0.7%	7.9%	7.2%	45.2%	39.1%
4.6	My goal for this practice is to achieve the highest efficiency possible.	280	4.08	±0.94	0.7%	7.5%	13.2%	40.0%	38.6%
4.7	I will delegate as many tasks as possible to my non-physician medical staff in the future.	279	3.73	±1.08	1.8%	15.4%	18.6%	36.6%	27.6%
	I think that an increase in delegation of medical tasks to non-physician medical staff in my practice…
4.8	… increases patient satisfaction.	281	3.19	±1.05	3.6%	26.7%	28.1%	31.0%	10.7%
4.9	… impairs the treatment of my patients.	280	2.30	±1.00	25.0%	33.6%	29.3%	10.7%	1.4%
4.10	… reduces my workload.	281	4.27	±0.83	0.4%	5.3%	6.4%	43.1%	44.8%
4.11	… increases efficiency in my practice.	281	3.98	±0.92	0.7%	7.1%	17.4%	42.7%	32.0%
4.12	… is financially worthwhile for my practice.	279	3.52	±1.04	2.2%	15.4%	30.8%	31.5%	20.1%
4.13	I am open to delegating additional medical activities to my practice personnel.	278	3.70	±1.10	4.7%	12.9%	12.6%	47.1%	22.7%
4.14	I am open to delegating additional medical activities to my practice personnel if they obtained additional training.	277	3.87	±1.03	3.2%	9.7%	12.3%	46.6%	28.2%
4.15	I am open to transferring medical tasks to my practice personnel in the sense of substitution.	277	3.32	±1.19	7.3%	21.1%	20.4%	34.5%	16.7%
	N = 281

Influencing factors on motives and beliefs towards delegation

Table 3 shows results of the multiple linear regression model correlating demographics and practice characteristics with TDF items. The model included N = 224 surveys, due to missing values in N = 57 responses. A more detailed table is provided in supplement 2.

We identified GPs’ age, average working hours, practice type and participation in the GP-centred care programme as influencing factors on GPs’ motives and beliefs. Older GPs described themselves significantly less often as being able to implement changes in their practices, less likely to aim for the highest efficiency possible and delegation comes to mind less often when thinking about increasing practice efficiency.

Participation in the GP-centred care programme significantly influences motives and beliefs towards delegation. Participants identify as first to implement new models in health care or practice organisation and delegation comes to mind more often as an option to increase practice efficiency. They are more open to delegate additional tasks to their personnel and subsequently intend to do so in the future. Fittingly, participants’ beliefs about consequences are more positive. They expect a reduced workload and increased practice efficiency, without expecting an impaired patient treatment. Finally, participants are more open to transfer tasks in the form of substitution.

Discussion

Summary

We explored GPs’ motives and beliefs towards task shifting to MAs to increase practice efficiency in non-urban GP in Germany. Motives and beliefs were positive, indicating fertile ground to advance team-based care and, more specifically, task shifting in the future.

For the first time, participation in the GP-centred care programme was identified as major influencing factor. To a lesser extent, we confirmed previously identified factors such as age, working hours and practice type to influence GPs’ motives and beliefs, whereas, opposed to previous findings, gender and employment status did not.

Comparison with existing literature

Young GPs having more positive beliefs about delegation has been shown before [23,39,40], although more recent studies did not find similar associations [31]. This seems unintuitive, as experience in delegation fosters positive beliefs [26] and younger, thus less experienced, GPs still show more positive beliefs than older, more experienced GPs. Although lacking an explanation, this raises hopes for more team-based care in the future, especially as the reduced workload and improved time management is strongly agreed upon once more [19,24–26,31,41].

Most significantly, we identified participation in the GP-centred care programme as a major influencing factor on motives and beliefs. Although being hinted at before [40], for the first time we describe its influence in detail. Although training of and delegating to MAs is financially incentivised, participants did not expect delegation to be financially worthwhile more often, hinting towards other specifications of the programme being responsible for its influence. Possibly, the programme addressing previously identified barriers, such as increasing bureaucracy and unclear legal conditions [19] when delegating to Mas, or benefits not addressed in this study, such as increased work satisfaction [26] or improved patient care, may encourage more positive motives and beliefs in participants.

Finally, we confirmed the openness of GPs to transfer tasks in the form of substitution [35], particularly in young GPs and participants of the GP-centred care programme. Although currently prohibited by law, international examples suggest that this may help further advancing efficiency in GP [11], warranting reconsideration of this policy.

Strengths and limitations

Several caveats must be considered. First, the response rate, although comparable to previous works in similar settings [26,31,40,42], and address data not obtained from registers might lead to selection or non-coverage bias. As no registry data identifying only GPs working in rural areas in Baden-Wuerttemberg were available (e.g. registry of the Association of Statutory Health Insurance Physicians), address data were acquired using commercial sources. These data did not include demographics, leaving us unable to test representativeness of our sample. However, aggregate data by the Association of Statutory Health Insurance Physicians suggest similar gender (female/male/diverse 46%/54%/0%) and age distribution (mean 55.4 years) [43,44] between our sample and all GPs working in Baden-Wuerttemberg, indicating representativeness to some extent. Still, factors such as the socioeconomic status of the population treated in each practice were not addressed in this study, potentially leaving other influencing factors on GPs’ motives and beliefs obscure.

Second, the application of the survey was spread over a longer period, as the third wave was postponed past the COVID-19 booster campaign. The huge number of vaccinations and the strain put on general practice during the booster campaign might have influenced responses. Due to the study design, we could not test for differences between waves, leaving its influence unclear.

Although survey items have not been psychometrically tested before conducting the study, we see the theory-guided approach as a strength. Thus, despite not all TDF domains being operationalised in the survey, this study provides valuable insights and raises questions for future research.

Finally, this study focuses solely on GPs, leaving the perspectives of MAs, patients and other stakeholders undetermined. Clearly, these must be considered when making organisational changes in general practice. Although previous research shone some light on this topic [32,45–50], further research focusing on these perspectives is necessary.

Implications for research and practice

Reasons for the influence of the GP-centred care programme remain unclear. Specifically, as we did not find financial incentives particularly relevant to participants, other specifications may foster positive motives and beliefs. Future research should focus on identifying specifics of the programme influencing task shifting, e.g. organisation rather than amount of remuneration, to help transfer its benefits into other healthcare systems. Furthermore, liberating legal restrictions, e.g. the permission of task shifting in the form of substitution, might help increasing efficiency in general practice, although undesired effects, such as the risk of lower remuneration for tasks substituted, must be considered.

Conclusion

Most GPs are willing to expand task shifting in non-urban general practice. This study provides a deeper understanding of underlying motives and beliefs and identifies younger GPs and those participating in the GP-centred care programme as particularly endorsing. This may inform future initiatives aiming to increase efficiency in general practice, ultimately mitigating the increasing shortage in GP services. For now, concepts on how to expand task shifting and ultimately advance team-based care in general practice need to be further explored and clarification of reimbursement as well as reconsideration of legal restrictions is necessary.

Notes

We use the term ‘general practice’ as translation for the term commonly used in Germany: ‘hausaerztliche Versorgung’. Other translations for the German term may include ‘family medicine’ or ‘primary care’, depending on the specific roles assumed by physicians in different healthcare systems.

Glossary

Abbreviations

GPs

General practitioners

MA

Medical assistant

TDF

Theoretical Domains Framework

SD

Standard deviation.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

HA (Principal Investigator) conceptualised the study as part of his dissertational project. JF advised on the study design. JR, RD and HA performed data analysis. HA, SS and JF conducted data interpretation. HA produced the first draft of the manuscript, which was revised by JR, SS and JF. All authors reviewed and approved the final version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data Availability statement

The data sets used and/or analysed during the current study are available from the corresponding author upon reasonable request.