In Germany, general practitioners (GPs) have a leading role in primary care. Traditionally, other medical professions, including nurses, do not have a structural role in the organization of primary healthcare. GP-practice assistants mainly conduct non-medical tasks such as administration of appointments and coordination of the work flow of the practice. During the last years, however, the organization of GP-practices has changed towards a more team oriented approach involving the entire practice-staff. Practice assistants can now qualify for more specialized tasks (e.g. case management and other medical tasks [1, 2]).
The Association of Statutory Health Insurance Physicians is responsible by law to guarantee an adequate number of physicians providing ambulatory care for each administrative district in Germany. The supply of ambulatory care is based on a fixed ratio between the numbers of physicians in practices and inhabitants of a defined region (usually at the county-level). This ratio is dependent on the speciality of the physician and differs somewhat between rural and urban regions. In Germany, a region is undersupplied with GPs if the ratio is below 75% of the calculated number of GPs for this region. Between 75% and 100%, the care situation in a region is categorized as imminently undersupplied .
About 20% of the GPs in Germany are 60 years of age or older and will retire in the next few years . Few younger physicians are willing to start a private practice in a rural area, especially in the eastern part of Germany. In some regions, shortages in primary care are already existent or can be expected within the next years.
At the same time the number of elderly people living in the eastern part of Germany is rapidly increasing, due to demographic changes and migration to urban areas. This leads to a higher absolute number of age-associated chronic diseases and multimorbidity [5, 6]. Elderly patients receive a significantly higher number of GP-home visits than younger patients (under 65-years old patients: on average 2.7 home visits/year, 65-79-years old patients: on average 6.3 home visits/year, 80+ year old patients: on average 8.5 home visits/year) .
However, the overall frequeny of GP-home visits decreases in Germany as well as in other European countries. A study of van den Berg et al. based on data of 183 Dutch GP-practices shows that the proportion of home visits decreased from 14.1% of all patient contacts in 1987 to 7.4% in 2001 . The decrease has two main causes: fewer home visits involving children and involving patients with less urgent diagnoses. Obviously, a GP having to deal with a large number of patients has to weigh medical and non-medical factors (e.g. workload, availability in his practice) and will more often decide against conducting a home visit .
A qualitative study of Theile et al. among 24 GPs in Germany shows that GPs frequently conduct home visits with little or no medical indication. Home visits with vulnerable, elderly people, however, were often imperative . Hence while the need for home visits will probably increase as a consequence of the growing number of older patients, the workload of GPs, particulary in rural areas, is expected to rise in the near future due to an undersupply of physicians.
The delegation of home visits to qualified GP-practice assistants could provide one possibility to support GPs. To examine the option of delegating GP-home visits, we developed and implemented the AGnES concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) [10, 11].
The main aim of the AGnES concept is to decrease the workload of GPs, especially in sparsely populated regions with an imminent or already existing undersupply of GPs. The concept enables the available GPs to provide care for more patients in a larger area .
All AGnES projects were conducted in “daily-routine-settings” with minimum intervention. The participating patients were selected by their treating GPs. The only inclusion criterion was that the patient, in the opinion of the GP, needed one or more home visits that could be delegated to a qualified practice assistant. The GP decided about the frequency and type of care provided during the home visit.
All together, 53 GPs and 40 AGnES-practice assistants participated in seven field studies between 2006 and 2008 in four federal states in Germany. The participating AGnES-practice assistants all received training specifically developed for this project [10, 12].
In total, 11,228 home visits were carried out involving 1,430, mostly multimorbid patients with a mean age of 78.6 years (standard deviation: 10.7 years). 89% of the patients had limited or no mobility .
A previous analysis showed that the home visits conducted by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. Thus, the additional possibility to provide home visits did not lead to a supply-driven increase of the total number of home visits .
The main aim of the AGnES projects was to support GPs in underserved regions and to enable GPs to increase their number of patients. To examine whether this aim was achieved, participating GPs were interviewed. About 90% of the participating GPs reported a reduced workload due to the AGnES-practice assistants. In an evaluation, the GPs stated that for more than 92% of the participating patients the quality of care provided by the AGnES-practice assistants was comparable to the usual care .
To obtain a more objective indication for the influence of the AGnES-concept on the workload of the GPs, we analyzed the development of the total number of patients treated in participating GP-practices in one of the project regions, the county Oberspreewald-Lausitz in the Federal State of Brandenburg. We choose this region for two reasons:
The county Oberspreewald-Lausitz has an imminent undersupply of GPs: in the year 2008 the degree of supply with GPs in this county was 95%. In 2011, this percentage decreased to 87%, indicating an imminent undersupply of primary medical care. A shortage of GPs is necessary to increase the number of patients not at the expense of other practices in the region.
The ambulatory healthcare centre in which all four participating GPs and the two non-participating GPs had their practices provided detailed data for the analysis.
The research questions are:
How many additional patients can a GP theoretically include in his practice under ideal conditions?
Did the implementation of the AGnES-concept actually result in an increase in the number of patients in the participating GP-practices in the county Oberspreewald-Lausitz in the Federal State of Brandenburg?