The new indicator, average GP time availability per inhabitant per year is easy to calculate, provides new and meaningful information for assessing workforce availability and access, is sensitive to variations and provides a reliable indicator in comparative studies across countries
Meaning of the indicator
This new indicator provides a more precise estimate than medical density of the time that GPs have available for each citizen and brings some major nuances and potentially interesting advantages. First, by averaging the real time spent with patients, it describes better the true availability of GPs. Second, by providing a time duration instead of number concerning GPs, it has the capacity to capture the comprehensive content of consultations and the allocation of time resources to specific activities and thereby, a possibility to assess the appropriateness of care provided as described by Levesque et al.(2) Indeed, with this indicator data we can distinguish overall time from face-to-face time. This is interesting from a health policy-planning perspective. Last, the number of minutes per capita per year and is probably easier to understand for all health actors even if it remains a global description of the accessibility to PC.
Comparison between countries
In the comparative analysis, GPs from Sweden, the Netherlands, Germany and the United States had the lowest average time available per inhabitant per year for face-to-face contact (38.0 to 55.5 minutes). GPs from New Zealand, Norway, France and the United Kingdom had an intermediate average time available per inhabitant per year for face-to-face contact (63.0 to 75.5 minutes). GPs from Switzerland, Canada and Australia had the highest average time available per inhabitant per year for face-to-face contact (82.0 to 118 minutes). Of note, GP average time available per inhabitant per year for face-to-face contact and overall patient contact (face-to-face, emails and telephone) varied more than three-fold depending on the country (38 vs 127 minutes), even though all eleven countries in the survey are considered industrialized countries.
Compared to the current indicator, such as medical density, the ranking of the countries is similar with the new indicator for some countries such as Australia, Canada, Switzerland, the United Kingdom and New Zealand. However, for other countries, such as Sweden, the indicators differ substantially. Indeed, Sweden has an intermediate medical density (0.644 GP per 1000 population) but a low average time available per inhabitant per year for face-to-face or overall contact. Along with New Zealand GPs, Swedish GPs work the fewest number of hours per week and spend the highest percentage of their weekly work hours on administrative issues. However, it is important to note that depending on the mode of practice, many administrative tasks (e.g. accounting, medical record keeping, agenda management, establishing prescriptions, medical certificates or medical reports) may be included in the time spent on face-to-face contact. Definitions can also vary across GPs. As with GPs from Switzerland and Norway; GPs from Sweden have a smaller number of weeks of presence in their practices by year (44.5) than the other countries (45.0 to 47.0). Such differences illustrate that depending on the indicator used, the results concerning “apparent GP availability” for face-to-face contact may diverge greatly across countries. This is relevant as in fine, what matters the most is the time that physicians can spend doing their primary job, taking care of patients, and it may directly affect patient health outcome and satisfaction.
Using indicators that are useful for assessing health care system organization, we noted important differences between countries. However, we should mention that this is only poorly correlated with overall health status of the population. Indeed, Switzerland, Sweden or the Netherlands for example, are considered to have very high-performing health care systems in terms of their population’s health status, with longer life expectancy from birth, lower obesity rate and fewer “potential years of life lost” (See Appendix Exhibit A2). However, Switzerland has one of the highest average time available per inhabitant per year for face-to-face contact while Sweden and the Netherlands have much shorter times available for face-to-face contact (See Appendix Exhibit A2). Several hypotheses can explain this apparent paradox. First, it could indicate that the indicator is too specific to modify substantially macroscopic health. Second, it may question the ability of PC to address efficiently key health problems within a given time availability. Finally, it is plausible that a ceiling effect is at play. Indeed, with an overall high quantity of resources that we have in all Western countries (human, financial, etc.), the gain in health might be marginal or random when we add more GPs. This is well illustrated in a study on quality of access to health care systems(23) published in the Lancet. Indeed, despite similar spending, countries can achieve very different access to care services. For the present indicator, we can thus question the importance to have high GP’s time availability in terms of efficiency. But as we will discuss bellow, it is difficult to estimate an “ideal” GP time availability as it depends on different organizational variables.
Furthermore, comparing with other measures of access, we also found that the link between GP time availability and the general assessment of PC accessibility is only partially correlated. For example, in a recent study by the Commonwealth fund(24), countries such as Australia and Switzerland, which have longer GP time availability do not perform especially well in terms of access measured through patient skipping-care rates. On the other hand, countries such as the Netherlands, Sweden or Norway, with low GP time availability show good access levels with limited disparities. These are just some examples that might indicate that other factors, mostly organizational, play important roles in access to PC.
Factors influencing GP time availability per capita
As mentioned above, many factors might influence the time availability of GPs for their patients and for the population. This is the idea behind the new indicator, which may allow a finer time-related measure of a GP’s time availability for face-to-face per capita and a better characterization of what GPs do in this time, including primary care organizational activities. In terms of care provided and overall accessibility to health care system, GP time availability per capita captures only a fraction of all problems of access. For example, primary health care systems are uniquely funded and structured and the roles & tasks of GPs differ considerably across countries. One important factor that varies a lot between countries is the consultation’s duration. Indeed, for example in the Netherlands, a consultation last 11 minutes while in Switzerland it is 20 minutes and 24 in Sweden. We can easily postulate that the content of a 20 minutes long consultation is very different from an 11 minutes one. However, few studies have addressed the issue of the content of consultation. It is out of the scope of the present study to explore this aspect, but this new indicator might be useful to investigate the content of care.
Furthermore, other organizational factors at the practice level (consultation structure and collaboration between GPs and other primary care providers) vary from one practice to another. In the present study, Switzerland has one of the highest annual GP availability per capita compared to other countries. On the other hand, GPs collaborate the least with nurses and case managers and are the least likely to use electronic patient medical records (only 54.3 % of Swiss GPs are using electronic medical record comparing to 72.9 to 99.3 % for the other countries). Thus, despite higher annual average GP availability, Swiss GPs delegate less tasks to other primary health care providers. This may lead to inferior "effective" time for their patients compared to countries like Sweden with the lowest GP average time available per capita but with comparatively good collaboration with other PC providers including a strong nurse-led gate keeping system.(25) (26) Similarly, GPs from the Netherlands have a low average availability per inhabitant per year but almost all collaborate with nurses or case managers within or outside of their practices. Thus, a strong collaboration with other primary health care providers is likely a key element for a “productive” PC system(27) (28) as perhaps GPs with a high annual time availability per capita but who do everything themselves are not able to provide appropriate, effective and necessary care to the population.
In that perspective, it is interesting to note that Kringos et al(29) reported on the strength of PC in European countries, and that countries ranking the highest for accessibility are not necessarily those with the highest GP time availability. However, the advantage of the new indicator is to be able to guide the GP workforce and improve consultation content by taking into consideration other key organizational factors.
Estimating the shortage of GPs
Currently, health policies of several industrialized countries mention a somewhat subjective perception of on-going or future “medical shortage”. However, this notion becomes relative on comparing the different countries of the study with each other. Indeed, as we have seen several factors may explain the differences between the GPs’ available time.(6) (22) (30) (31) (32) (33) (34) (35) (36). In addition, it raises confusion and difficulty of assimilation of two concepts: downsizing and shortage.
For example, in Switzerland the future GP shortage is often voiced by professional associations, the media or in the country’s policies. (8) (37) (38) This perception is partly based on GP demographic changes (i.e. more than 60% of Swiss GPs were over 54 in 2015), sociological changes of the medical profession (part-time work, feminization) and the tendency for students to pursue specialty training on graduation from medical school. Further, the increasing needs of the population due to aging and multimorbidity may have a role.(39) Objectively, several reports acknowledge the growing difficulty of finding a GP or obtaining a prompt appointment.(37) Is the solution to bring in more GPs or to transform PC by more inter-professional collaboration? This question is raised rarely, due to strong medical society lobbyism to keep physicians as “lonely players”. In short, we need to be cautious about comparing and interpreting both medical density and GP time availability to conclude a “shortage”. A careful consideration of the overall PC organization is mandatory.
Limitations and Strengths
There are some limitations to this study. The differences in GP participation rates in the survey (from 8 to 46.5%) may have a repercussion on the collected data. However, the data were weighted to account for differential non-response concerning known geographic and demographic parameters, which may have reduced the selection bias. The mode of data recruitment/completion and incentives varied across the countries. Data were self-reported and were perhaps exposed to declaration biases. The number of GPs withheld for each country in our calculation may be imprecise. According to the OECD Health Care Resources Statistics(40), the density of GPs per 1000 population differs considerably between their sources and those used by the CWF. It is important to note that the density of GPs may also vary according to the particular statistical source due to the definition of PC Physicians. For example, the largest difference in medical density between our study and the OECD concerns the Netherlands, with about 2.7 times more GPs according to the OECD than estimated by our study.
A strength of the study is the sample size. A further strength is the standardized methodology of the questionnaire allowing international comparisons. The selected countries are all high-income countries with similar population health output, allowing comparison.