Physician workload in primary care: What is the optimal size of practices?

Abstract

Objective

To determine the impact of practice size and scope of services on average physician workload in primary care practices in The Netherlands, and to examine the associations between average physician workload, average assistant volume and organisational practice characteristics.

Methods

This was a cross-sectional study in 1188 general practices in The Netherlands. Measures included physician workload per week per 1000 patients, assistant volume per 1000 patients, practice size defined by number of registered patients (10 classes), scope of disease management services (seven classes), and nine organisational characteristics of the practice.

Results

Physician workload per 1000 patients differed across levels of practice size, but was not related with the range of disease management services provided. In the smallest practices physicians worked on average 26.2 h per 1000 patients and in the largest practices 18.1 h. A higher average assistant volume was overall not associated with a lower average physician workload. Large practices had lower assistant volume per 1000 patients, but provided a wider range of disease management services compared to small practices. Delegation of medical tasks was associated with reduced physician workload per 1000 patients, mainly in smaller practices, and with higher assistant volume per 1000 patients, particularly in larger practices.

Conclusions

In The Netherlands the optimum regarding average physician workload was found in the largest practices, while no obvious association with scope of disease management services appeared. It may be that in large practices medical tasks were delegated to practice assistants to provide a wider scope of disease management services and in small practice to reduce average physician workload.

Introduction

The workload of general practitioners is influenced by the efficiency of the practice in which they work. An inefficient practice can provide a given volume and scope of services only at the expense of a high workload. Changing the practice size or scope of services as well as organisational changes in the practice may increase the efficiency and decrease the workload. The fact that small general practices exist in many countries may suggest that small sized practices have specific advantages, but this may also be related to insufficiently competitive markets in health care. In many countries the size of primary care practices has increased over the last years without a clear perspective on its optimum.

The size of an organisation refers to the volume of services provided, which would translate into the number of patients treated in a primary care practice. The scope of an organisation is defined as the diversity of services provided, which would translate into the range of preventive and curative activities. Economic theory holds that organisations which are smaller or larger than optimal will disappear, if there is a competitive market [1]. “Optimal” refers to a situation in which the long run total costs (such as physician time) per unit of output (such as a patient served) is lowest. The optimal size and scope of an organisation fluctuates with time and varies across societal sectors, but a general finding is that the efficiency does not increase anymore after a period of growth, and it may even decrease when the organisation continues to grow. It is assumed that this is related to higher costs of administration and co-ordination in larger organisations, and to reduced feelings of ownership and participation among workers [1]. Standard economic theory predicts that a primary care practice would have an optimal size and scope, if the (long run) average physician workload is lower than at other levels of practice size or scope.

Optimal size of hospitals has been studied extensively, for instance in relation to clinical outcomes [2], [3], but the optimal size of a primary care practice is a matter of opinion rather than research. Some studies have focused on large primary care providers, mainly in the United States [4] and the United Kingdom [5], [6]. However, there is little insight in the optimal size of the typical primary care practices, which are currently most prevalent in many European countries and elsewhere. These practices range from a few hundred up to a few thousands of patients, served by one, two or a few physicians and from zero up to nearly two assistants per physician. Our primary aim was to identify the impact of practice size and scope of disease management services on average physician workload in Dutch primary care. Also, we examined the impact of average assistant volume and a range of organisational characteristics of the practice.