Descriptive statistics
The key characteristics of the twelve interviewed GPs are displayed in Table 1. The qualitative analysis, clustering, and weighting of categories revealed 42 factors from 175 categories, 175 subcategories and 1003 codes. Using the cut-off level of one third, as mentioned above, this results in 36 factors, 93 categories and 25 subcategories from 979 codes. We classified 18 factors as facilitators and 18 as barriers. Table 2 shows the factors structured among the macro-, meso-, micro-, and individual levels.
Table 1 Key characteristics of the study population
Sex
|
Age
|
Female
|
7
|
Range
|
31-41 years
|
Male
|
5
|
Median
|
40
|
Children
|
Family status
|
Yes
|
6
|
Unmarried
|
6
|
No
|
6
|
Married
|
5
|
Federal state (living)
|
Federal state (working) (multiple answers)
|
Burgenland
|
1
|
Burgenland
|
3
|
Salzburg
|
2
|
Salzburg
|
2
|
Styria
|
6
|
Styria
|
5
|
Vienna
|
3
|
Vienna
|
3
|
Final year of vocational training
|
Vocational training in a GP practice
|
Range
|
2012-2019
|
Yes
|
6
|
Median
|
2016
|
No
|
6
|
Current vocation (multiple answers)
|
Diploma
|
Hospital doctor
|
6
|
Emergency physician
|
9
|
Locum GP
|
4
|
Manual medicine
|
2
|
Private practice
|
5
|
School physician
|
2
|
School doctor
|
3
|
Occupational medicine
|
2
|
Occupational medicine
|
1
|
Traditional Chinese Medicine
|
1
|
Public health officer
|
1
|
Acupuncture
|
1
|
University lecturer
|
1
|
Sports medicine
|
1
|
Preventive medicine
|
1
|
Sexual medicine
|
1
|
Employment status (multiple answers)
|
Opioid replacement therapy
|
1
|
Employed
|
10
|
Wound management
|
1
|
Self employed
|
9
|
Others (e.g. Botox, environmental medicine)
|
5
|
Table 2: Facilitators and barriers to work in a primary care unit as perceived by non-contracted GPs, mapped to the four levels adapted from Caldwell and Mays (36), Mulvale, Embrett (43), Smith, McNeil (57)
Facilitators
|
Level
|
Factor
|
Total¹
|
Interviews²
|
Macro
|
Awareness for reform implementation
|
21
|
9
|
Generational change among GPs
|
17
|
7
|
Meso
|
-
|
|
|
Micro
|
Benefits for patients
|
49
|
12
|
Organizational culture in a multi-professional team
|
73
|
12
|
Attractive conditions for professional medical work
|
89
|
12
|
Flexibility of working time
|
35
|
11
|
Professional interaction between GPs
|
20
|
9
|
Sharing of medical responsibility
|
11
|
8
|
Sharing a comprehensive infrastructure
|
14
|
7
|
Quality and research
|
21
|
5
|
Administration of the organization
|
17
|
7
|
Sharing of responsibility in business management and finance with associates
|
7
|
4
|
Flexibility of total weekly working hours
|
9
|
4
|
Individual
|
Work-life balance and flexibility in working time
|
36
|
10
|
Employment status
|
13
|
9
|
Strong doctor-patient relationships
|
15
|
7
|
Training practice: Preparation and motivation for primary care
|
12
|
7
|
Compatibility of family and work
|
0
|
0
|
|
|
|
|
Barriers
|
Level
|
Factor
|
Total¹
|
Interviews²
|
Macro
|
Strategy
|
54
|
12
|
Remuneration
|
75
|
11
|
Contract-system with social health insurance system
|
14
|
5
|
Little available information on PCUs
|
54
|
10
|
Insufficient training for primary care (university and postgraduate)
|
27
|
10
|
regulations concerning PCUs
|
26
|
8
|
Low perceived status of GPs
|
19
|
7
|
Lack of clear role definition
|
11
|
5
|
Meso
|
Resistance among medical community and tendency to keep up established structures
|
22
|
7
|
Population
|
18
|
6
|
Missing exchange of experiences (national/international)
|
8
|
5
|
Micro
|
High workload
|
43
|
11
|
Too little time for individual patient
|
25
|
9
|
group and team dynamics
|
9
|
4
|
Individual
|
Concerns regarding running an enterprise
|
60
|
11
|
Concerns regarding starting an enterprise
|
14
|
7
|
Flexibility and autonomy
|
28
|
8
|
Satisfaction with individual working arrangements
|
12
|
6
|
|
|
|
|
¹ Total number of occurrences over all interviews
|
|
|
² Number of interviews in which each category occurred at least once
|
|
|
Macro-facilitators
The interviewees perceived a positive mindset and will to develop new models in primary care in general. The GPs praised conductive regulatory conditions in the last years like the amendment of medical practice legislation, which allows employment of doctors by public doctors on the one hand, as well as general growing open mindset for multiprofessional work models in primary care on the other hand (n = 9). According to the interviewees, the new generation of GPs is interested in teamwork and uses motivation and creativity in the implementation of innovative PCUs. The demand for a good work-life balance requires shared working conditions by contrast with single practices (n = 7).
“And the open mindset, really working as a multiprofessional team. Really as partners on equal terms – doctors, nurses, physiotherapists, psychotherapists, social worker working as a team, really together, so to say with the patient in the centre, this would be fascinating. And I have a sense, that our generation is able to do that.” (A01)
Macro-barriers
All GPs (n = 12) missed elements of a policy strategy comprising rigid structures within the primary health care system and its stakeholders. The GPs were aware of the potential benefits resulting from an increasing number of multiprofessional PCUs, especially considering the growing GP workforce shortage and increased demand for secondary and tertiary care structures. Slow adaptation of the legal, economic, and political framework for the development of PCUs as well as of the professional mindset were seen as major problems, leading to the fact that further promotion of PCUs depends mostly on political will and individual champions. This led to the perception of an unclear vision and missing strategy.
"That was eleven years ago now. And since then NOTHING at all has happened. Eleven years. I'm young, but I've already experienced this long-lasting period. So, I'm a bit sceptical. [...] People from the field must be involved in the decision-making process and tell them - listen, it doesn't work like that. I don't understand, why does this work in other countries. What is the problem in Austria?" (A01)
Most GPs (n = 10) report little available information for the general public but also for themselves and did not feel addressed as a target group.
“At the moment, in my position, where I am now, I don’t get anything at all. So, I don’t get any information actively from somewhere else that someone would approach me.” (D04)
Further categories that arose are insufficient vocational training (n = 10), a low perceived status of GPs (n = 7), and lack of a clear role definition (n = 5).
The remuneration system in primary care (n = 11) was mentioned as the main barrier to choosing the job. The GPs complained about insufficient remuneration in comparison to the huge workload. The current fee-for-service system does not cover the broad spectrum of services needed for the demands of the patients. Some federal states even limit selected services. There was the perception that this system supports high frequency in daily curative care instead of an orientation towards patient-centeredness and a holistic care approach.
“I was interested in offering a diverse spectrum of services in general practice. But also, to take enough consultation time and accordingly to get the money for this time. […] It must be financially interesting, and it must become more flexible. […] It has to be possible, to really do it together as a team. And we also need a new form of remuneration. Because I can’t continue with the same billing system. […]” (A01)
The GPs noted that there are more comprehensive and complex requirements for PCUs as much bigger multiprofessional organizations compared to the existing regulations for single practices. Consequently, they requested support (n = 8) in business management (accounting, regulations, law) as well as financial funding.
“Economically, as a business leader, from an entrepreneurship view. I see myself as being able to do that, so to speak. But I lack the real expertise or experience in business management or in founding a company. So, I would like to have some support, maybe even guidance in the first few months, both in the start-up phase and in the operating phase. […] In principle, it would be more pleasant to have a consulting institution or an authority that you can turn to, there will probably also be people on the free market who can advise you in this regard.” (C03)
Five interviewees complained about the contract system within the public health insurance system (n = 5) because of its perceived complexity.
“Well, I would have decided to work as GP straight away. But I just knew that the bureaucratic effort and the current system regarding the accounting of services with the social health insurance group […] means either 70 hours a week or nothing at all. […] And that’s why it wasn’t an issue for me to take this step. Although from a thematic point of view I would do it immediately. [..] It gets stressful when I need an approval of the chief physician […] Then they make a call. Then they write the fax. They spend an hour there and get zero money for it.” (A01)
Meso-barriers
The GPs reported resistance within their medical profession (n = 7), with the majority of senior GPs adhering to traditional primary care structures and thereby impeding the spread of innovation.
“The main reason for this, I think, is surely because so many GPs are now close to retirement age. And those who are just not creative and young enough, they say, I won’t do it now in the last five years or, yep, five years, to change my way of working so much.” (B02)
Six GPs complained about increasing demands of the population (n = 6), like 24/7 availability or using GPs as “self-service shops”. GPs feel that lack of health literacy leads to over-utilization of primary care as well as the general health system. Five GPs mentioned the lack of exchange of experiences on both the national and international levels (n = 5).
Micro-facilitators
All interviewees mentioned benefits for patients of PCUs as a positive factor (n = 12). Providing comprehensive primary health care by a multiprofessional team with expanded opening hours fosters their intrinsic motivation. The interviewees liked the idea of referring patients easily to other professions within their organization.
“You can offer longer opening hours, you can also offer off-peak hours. […] For the patient, this is really a low-threshold, qualitative and also scientifically sound care. […] And I think that is the attractive thing. Because I am not isolated somewhere, but I am immediately in a system where I have several possibilities at my disposal.” (A01)
“So, I definitely believe that we can care for the patients more than we do at the moment. In terms of guidance on nutrition, exercise, proper exercise for the underlying diseases. […] Well, I think that we can improve the quality of health care with it.” (C03)
Beside the short ways of referrals, all GPs highlighted the low threshold for easy interaction between the team members. The GPs anticipated that the organizational culture in a multiprofessional team of a PCU effects general job enjoyment because of teamwork within flat hierarchical structures and cohesion between the team members in contrast to lone fighters in single practices (n = 12).
“I think that working with colleagues and several contact persons [professionals] is more attractive because you can also exchange ideas.” (E05)
“Also, the community [in the team] and so on. […] That is really one of the most important things, I have to say, in this, in the whole thing [PCU].” (F06)
The expectation of attractive conditions for professional medical work (n = 12) was a main facilitator for working in a PCU. Interviewees highlighted the opportunity for GPs to engage in diverse activities because of the broad spectrum of services provided in a multiprofessional PCU. Another factor relating to attractiveness is the interaction with different health and social professionals. These conditions allow GPs to focus on their core competences and medical care. Task sharing with assistants also relieves the burden of day-to-day care.
“That we always have immediate options if we are not totally sure on a concern, regarding legal, care matters or care facilities, the social work expertise. Yes, well. I say that if we enter into the discussion with respect for the other professional groups, we can certainly learn and benefit from it ourselves.” (C03)
“I think a good chance is that the other professionals are working there, […] can take a lot of work from the doctor. Services that don’t have to be performed by a medical doctor.” (L12)
Alongside multiprofessional exchange, the interviewees highlighted the professional interaction between the GPs within PCUs (n = 8). This allows them to share responsibility both in medical professional demands (n = 9) and in aspects of business management and finance (accounting, management) (n = 4).
“And also to have the feeling that you are not solely responsible for it yourself. That might sound a bit strange. […] He comes with his worries, with his pain, with his illnesses, with everything around him. You don’t carry that alone as a doctor. You can split it up a bit. That’s something that would calm me down inside. It would simply take the stress away.” (D04)
“The inhibition threshold may also be lower to ask questions in case of uncertainty, which I, as a young doctor, still have to say, that I am not one hundred percent sure that some decisions should or must be made in exactly the same way. So, I would rather need more check-up or diagnostics in form of a safeguard medicine. And if, for example, an experienced colleague could dispel certain uncertainties.” (C03)
“[…] I am still a bit afraid of self-employment, because I am not yet ready for it myself, but that is also a bit the reason why I have not yet done it, […] I would really prefer to work in a practice with shared responsibilities.” (F06)
Sharing a comprehensive infrastructure (n = 7) containing rooms and equipment as well as the documentation system, knowledge and information was another facilitator of PCUs’ attractiveness.
“So that synergy effects are used, such as therapy facilities, rooms, laboratory equipment and more. […] It is the availability of additional capacities, be it dietary or physiotherapeutic or psychological. That we have direct contact with the professional group. In part, we can actually make a consultation without delay.” (C03)
High quality of care because of the potential of performing health service research in primary care (n = 5) as well as well-organized structures and care processes within the workflow (n = 7) met the expectations of some interviewees in primary care and increased the attractiveness of PCUs.
“The exchange with colleagues, which you can’t do in a single practice. The fact that you can discuss cases […] I would say that everything is in one place and they don’t have to go somewhere else. […] of course, I get more feedback and can refer more sensibly if I am in exchange with the colleagues, so it would already have an advantage for me.” (K11)
The flexibility of working time (n = 11) played an integral role in the interviews regarding the occupation as a general practitioner. GPs expect flexibility in schedule of their working hours for private issues and praise having a substitute. Flexibility in working hours – more specifically reduction – (n = 4) also functions as a facilitating factor for PCUs.
“I was in Sweden and Norway for a longer period of time and also in England, […] I was able to experience it in general practice. And there were ten general practitioners and I found it great when you work in a large team. Flexibility of working hours. I can have children and reduce my hours. I can still accompany my patients longitudinally and of course I have a much higher quality when I have to work together with other colleagues in a team. […] That is not given at all at the moment. And that is why it is very uninteresting.” (A01)
“I would like it to be flexible, as I said. That it’s possible to make arrangements with colleagues in case of postponements, if something spontaneously comes up. That you can take care leave without any problems.” (E05)
Micro-barriers
The most dominant discouraging factor on micro-level was the high workload (n = 11) in primary care. The reasons for this are seen in a combination of increased needs originating from demographic change, overutilization, the service-driven remuneration system and the lack of coordination of care, resulting in high patient turnover.
“In Austria, it’s [primary care] marked because it’s very stressful. Very, very overloaded. Mostly in general medicine, it is simply a job that really runs at the limit. And that’s not necessary. Because the job is at the limit. Because you must deal with very seriously ill people. Because you must delve very deep into the psychosocial structures and that is very stressful. Thematically, it’s consistent. But not also because of the number of patients and the whole workload. It becomes too much and often you [GPs] are not able to bear this with a normal physical and mental state. And I think that is simply unattractive. Why should I expose myself to that if I have a nicer working option?” (A01)
Consequently, this cumulation of factors leads to the impression that there are insufficient time resources for individual patient care (n = 9).
“And I think everyone deserves the respect to get the time he or she needs. Because in crowded practices it is not possible to do things the way I would like to do them myself.” (C03)
“But I think you should still take enough time, if you can, to treat the patients well. But of course that is difficult with a full waiting room and with a limited office […] and you still have so many house visits […] Of course, you also have to make sure that you get patients through. But I still think that’s not the kind of medicine I want to do. I think every patient needs enough time.” (F06)
Four GPs voiced concerns regarding a higher risk of potential dissonances within the associates and the team (n = 4) in a PCU compared to a single practice.
Individual facilitators
A good work-life-balance associated with flexible working time was the most frequently postulated facilitator (n = 10) for the job option of being a GP in a PCU. The GPs partially mentioned flexible working time and hours combined with the compatibility of family and work (n = 4).
“What put me off was the workload and the little flexibility you have, because you’re just out there on your own. If I say my daughter is seven months old and I have to work less now, it just doesn’t work. And that’s a huge drawback. I find it very difficult to reconcile this with my family. If I had the option of a PCU in [place], five, six GPs who share this working load. Where […] I can work 20 hours in a PCU. I would jump right in there.” (A01)
“If you are self-employed and take on a health insurance contract, you have obligations that are harder to avoid when you have a child. […] But as I said, a single practice is no option for me because of the family situation. […] That’s too much for me now. I wouldn’t have any more time for the family.” (B02)
Seven interviewees assessed the option working as an employee in a PCU as more attractive (n = 7). The personal positive experience during training practice in a primary care practice was also mentioned as an important motivating factor for working as a GP (n = 7). The strong relationship with patients in primary care, based on free choice of the doctor and trust, as well as the gratitude received from them was also a possible facilitator for PCUs as a job option (n = 7).
“Such an employment relationship, working in a team. This is more attractive for me than being a lone fighter or a sole trader.” (L12)
“I certainly didn’t want to do general practice before the practical vocational training in general practice. She [GP trainer] was a very good doctor with a lot of experience. And it really helped me, I think it certainly helped me more than the internship in the hospital. So, I can only rate it positively. […] Well, simply because the way of working is completely different in general practice than in a hospital. You are not prepared for working as a GP through work in a hospital. […] So, I took a certain experience with me and also that I like working like that. With the patients and with the contact, with long-term contact.” (K11)
Individual barriers
Eleven interviewees mentioned concerns regarding business management (n = 11). These comprised employer costs and employee rights, organization of a PCU, and leadership of the team as well as budgeting and other economic functions as entrepreneurs (e.g. data protection). They voiced fears about the responsibility and insecurity including cases of their own absence. Continued remuneration during sickness or parental leave were considerable counterarguments. Entrepreneurial spirit – also mentioned as “braveness” – combined with economic knowledge and having the start-up capital also unsettled (n = 7) the GPs.
“Because I don’t want to carry this enormous economic risk. So, I would prefer to work in a PCU, so you are not alone, and you remain flexible. […] Well, in any case, that you are employed and in any case that you don’t have all the responsibility, economically and also organisationally, you are just not a company boss alone, I would say. You can also work part-time. If you have an office. It’s easier to reconcile that with family life.” (K11)
“Economically, […] entrepreneurship. I see myself as being able to do that, so to speak. But I lack the real expertise or experience in business management or in founding a company. So, I would like to have some support, maybe even guidance in the first few months, both in the start-up phase and in the operating phase. […] Economic aspects, personnel planning, personnel management. In the end, you never learnt that. And it’s not the purpose of the university to teach business management as a doctor. But you are still an entrepreneur. And you have certain duties.” (C03)
As mentioned before, the contract with the public health insurance group entails a fixed spectrum of services as well as further regulations. The interviewed GPs who do not have this contract consequently feel restricted by this prospect in terms of flexibility and autonomy (n = 8). The wish to provide “care as they see fit” included having enough time for a holistic care approach as well as alternative medicine. Restrictions in freedom to increase income and take decisions as the “chief” were further barriers to working as a GP in a PCU.
“Cooperation is great, but I want to decide for myself what I want to do in my practice.” (H08)
“I just wanted to go into private practice because […] I was quite interested in offering broad-based general medicine. But also, to make the time available and accordingly to get the money for this time. […] If I need a bit more money, then I do more hours, if I need a bit less money, then I do more hiking and less hours.” (A01)
Half of the GPs mentioned that they had individual arrangements (n = 6) perfectly tailored to their professional and private lives. Since they are satisfied with their current situation, it would be hard or too late to convince them to dismantle what they perceive as their perfect individual solution.
“That I actually have two jobs, the ones that I like and that are compatible with the family.” (E05)
“[…] I have actually built up a network. And that, that just fits me and how I see medicine. And that’s why I decided to go this way. […] And how I like to have my people treated. […] I can’t imagine doing it any other way now.” (J10)