Measuring workload of Swiss general practice: a five-yearly questionnaire-based survey on general practitioners’ self-reported working activities (2005–2020)

DOI: https://doi.org/10.4414/SMW.2022.w30196

Introduction

General practitioners (GPs) play a key role in the delivery of health care and are usually the primary point of contact for patients' medical concerns [1, 2]. Approximately 70% of the Swiss population consult a GP every year, requiring two to three consultations on average [2]. The demand for GPs in Switzerland is rising as the population ages and becomes increasingly multimorbid [3]. Therefore, ensuring a sufficient supply of GPs is greatly important and a major challenge [4]. In 2011, the Organisation for Economic Co-operation and Development (OECD) defined one GP per 1,000 inhabitants as optimal primary healthcare [5]. However, for Switzerland, a survey of structural data from medical practices and outpatient centres in 2019 calculated a density of only 0.74 GPs per 1,000 inhabitants [6]. Below-average access for patients to GPs is observed particularly in rural regions of the Swiss midland [7]. A shortage of GPs must also be counteracted to save costs [8]. GPs and paediatricians manage 94.3% of all health problems in Switzerland and incur only 7.9% of health costs [9]. In addition, a shortage of GPs results in longer waiting times for patients and an increased workload for GPs [10]. In the UK, GPs are experiencing a huge demand for consultations, coupled with more complex patient care and increasing documentation requirements [11]. A trend towards increasing workload in primary care has also been observed in several other European countries [1, 12, 13]. A growing burden of work may cause burnout within the profession or lead to job abandonment, as well as affecting the overall quality of the healthcare system [12]. Assessing GPs’ workload is therefore essential to reduce such negative outcomes and plan future health care.

Data on GPs’ workload in Switzerland are limited. In 2010, the Swiss Primary Care Active Monitoring (SPAM) was launched, aiming at developing an instrument focusing on the quality of the Swiss primary care system [14]. The Federal Statistical Office regularly records structured information on GPs’ practices and outpatient centres (MAS-survey) [6]. Further, the Swiss Medical Association (FMH) publishes yearly statistics on the demographic characteristics of Swiss physicians, but real-time data on GPs’ daily workload are scarce [15]. The primary aim of this study was to analyse the workload of Swiss GPs at five-year intervals. GPs’ self-estimated time spent on face-to-face consultations, house calls, nursing home visits and clinical administrative work was of particular interest. Secondarily, the number of GPs working in single, double and group practices was analysed, along with the median number of patients seen by a GP per week and the mean consultation time.

Methods

Four questionnaire-based, cross-sectional surveys were conducted in 2005, 2010, 2015 and 2020 among a representative sample of Swiss GPs from the German-, French- and Italian-speaking parts of Switzerland.

Participant recruitment

The study population was a representative sample from the FMH database in 2005 and 2015. Physicians specialised as “General Medicine FMH”, “Internal Medicine FMH”, “General Internal Medicine FMH” and “Practical Doctor”, and physicians without a specialist title (“Med. Pract.”) who worked in a practice or ambulatory sector, were included. The samples in 2005 and 2015 were random, but the GPs evaluated in 2005 were contacted again in 2010. In 2020, the register of the online company Comparis.ch was the basis for the sample selection. Registered GPs specialised in “General Internal Medicine FMH” were identified. The sample selection was additionally adjusted with the Register of Medical Professions (MedReg). GPs with additional specialist titles (e.g., gastroenterology) and physicians working in hospitals were excluded (see table 1).

Survey design

The questionnaires for 2010, 2015 and 2020 originated from the first survey in 2005. This was developed with guidance from the British Medical Journal [16] and included closed-ended questions regarding working hours, work habits, motivation and plans for future workload. In the course of the four surveys conducted, only a few adjustments were made to the questionnaire. The changes were mainly graphical-visual, to facilitate the completion by the GP. No changes were made in terms of the content and the questions had the same wording in all four surveys. For this study, data on GPs’ workload (face-to-face consultations, house calls, nursing home visits and clinical administrative work) were analysed. Gathering these data was part of all questionnaires since 2005, using identical question phrasing.

Ethical considerations

The questionnaire was sent together with an invitation letter, informing the GPs that the data would be collected anonymously. The study team was unable to identify the person completing the questionnaire. Therefore, the study did not fall under the remit of the federal law Human Research Act, Art. 2.

Assessment of GPs’ workload

The workload of physicians can be assessed in half-days. One half-day corresponds to a workload of 4 to 6 hours in Switzerland [17]. A full-time position is defined as an average weekly workload of 10 half-days [17]. Taking part-time into account, the workload can also be stated in full-time equivalents (FTE), with 55 hours per week corresponding to a workload of 100% [18]. In the surveys from 2005 to 2015, the workload was reported in weekly hours. The number of half-days was only recorded in 2020. Therefore, for the present study, workload is reported as hours per week and FTE. Additionally, for the year 2020, workload is presented as half-days. The selection of variables was made based on previous literature, indicating differences in workload across demographic variables such as gender, age, practice type, language and region [9, 19, 20].

Statistical analysis

Analysis was conducted in R (R Core Team 2020) [21], mainly with the R packages “dplyr” [22] and “ggplot2” [23]. Frequencies were shown for nominal and ordinal scaled variables. Mean and standard deviation (SD) were presented for normally distributed numeric variables, and median and interquartile range (IQR) were used otherwise. Group comparisons with nominal and ordinal scaled variables were calculated with the chi-squared test. The two-sample Student's t-Test (assuming variances not being equal using the Welch approximation to the degrees of freedom) was used for group comparisons with numeric variables. Multivariable linear and ordinal logistic regression analyses were performed to assess the relationship between dependent (FTE, total weekly workload and duration of consultation) and independent variables (year, age, sex, practice type, language, region and employment). Ordinal logistic regression (or simplified ordinal regression) is used to predict an ordinal dependent variable (categorical variable for which the possible values are ordered) given one or more independent variables. We performed the ordinal regression using the “MASS” [24] package. All tests were two-sided, and a p-value of <0.05 was considered statistically significant.

Results

Overall, 1,780, 1,275, 1,299 and 2,037 GPs returned the questionnaire in 2005, 2010, 2015 and 2020, respectively. The demographic characteristics of the study participants in the four surveys are presented in table 2. The mean age of GPs in 2020 was significantly higher compared to 2005 (54.9 [SD = 7.94] vs. 51.4 [SD = 10.2] years, p <0.001). In 2005, 16.5% of GPs were female. The proportion of women significantly increased to 36.2% in 2020 (p <0.001). Language regions (German, French, Italian) were adequately represented in all surveys (table 2) [6].

In 2005, 12.4% of the GPs worked in group practices (>2 GPs). This proportion significantly increased over time: in 2020, almost every second GP (45.0%) was working in a group practice (p <0.001). The number of single-handed practices substantially decreased from 2005 to 2020 (figure 1A).

Figure 1 A: Proportion of practice types 2005–2020. B: Mean full-time equivalents (FTE) in men, women and both since 2005.

The median number of patients seen by a GP per week in 2020 was 80 (IQR = 50–105), although only data for 2020 were available here because the question was only asked in the last survey. In 2020, most GPs reported planned consultation time slots of 15 minutes (42.6%), followed by 20 minutes (32.1%) and 30 minutes (21.0%). The remaining percentages were consultation times of either <15 minutes (1.1%) or >30 minutes (3.1%). Multivariable ordered logistic regression showed that sex (female), language (French or Italian) and the location of the practice (city or agglomeration area) were independently associated with longer time slots for consultations in 2020 (table 3).

Assessment of GPs’ total weekly workload 2005 to 2020

The GPs’ workload significantly decreased over the last 15 years from 50.2 hours per week to 43.4 hours per week or from 90.9% FTE in 2005 to 78.9% FTE in 2020 (p <0.001). In 2020, GPs worked an average of 7.9 half-days/week. Across all survey years, women worked on average 12.7 hours or 23.2% FTE less per week than men (p <0.001). In 2020, women worked on average 6.8 half-days per week and men 8.5 half-days per week (p <0.001). In linear regression, the total weekly workload in the multivariable model decreased for women, over the last 15 years, with age, for employed GPs, and for GPs working in group and dual practices (table 4).

Further, a significant interaction existed between time and sex on workload (p = 0.015). The decreased average workload across years was significantly less pronounced in women (–4.4% FTE) than in men (–9.0 % FTE; women: 70.8% FTE in 2005 to 66.4% FTE in 2020; men: 94.9% FTE in 2005 to 85.9% FTE in 2020; figure 1B).

Additionally, GPs with weekly working hours of 45 hours or more (≥80% FTE) were analysed. In 2005, 71.8% (n = 1,278) of GPs reported weekly working hours of 45 hours or more compared to only 49.8% (n = 983) in 2020 (p <0.001). In the subgroup with long weekly working hours in 2020, the proportion of women was smaller (18.2% in ≥45 h/week workload vs. 53.8% in <45 h/week workload, p <0.001), GPs were working more frequently in single practices (44.0% in ≥45 h/week workload vs. 23.4% in <45 h/week workload, p <0.001), and the mean age was higher (55.9 [SD 9.2] in ≥45 h/week workload vs. 53.8 [SD 10.9] in <45 h/week workload, p <0.001).

GPs’ weekly clinical and administrative workload

GPs’ time spent on face-to-face consultations with patients gradually decreased from 37.2 hours per week in 2005 to 31.1 hours per week in 2020 (p <0.001). The workload in terms of home visits also decreased over time (2.9 hours per week in 2005 vs. 1.7 in 2020, p <0.001). GPs’ clinical activities in nursing homes were stable from 2005 to 2015 and dropped to some extent in 2020 (2.3 hours per week in 2005 vs. 1.6 in 2020, p <0.001). The workload for clinical administrative tasks nearly remained stable over the years (9 hours per week). Details are shown in figure 2. In 2020, GPs spent 79.0% of their working time in direct patient contact (consultations, house calls or nursing home visits) and 21.0% on clinical administrative work on average.

Figure 2 Workload in face-to-face consultations, house calls, visits to nursing homes, clinical administrative work, and total workload for years 2005–2020.

P-values indicate significant (p <0.001) workload changes across years within types of consultations.

Discussion

Assessing the workload of Swiss GPs at five-year intervals since 2005, a decrease in GPs’ overall workload was observed. In 2020, Swiss GPs averagely worked around 7 hours less per week compared to 2005. This decrease was mainly at the expense of direct face-to-face encounters with patients, whereas clinical administrative work relatively increased. A likely explanation for the overall decrease in workload is the steadily increasing number of GPs working part-time. With 37%, Switzerland has the second most part-time workers in Europe, after the Netherlands [25]. A study published by the association of the Young Swiss Family Doctors (JHaS) showed that 76% of young GPs are currently working four days or less per week [26]. This trend towards part-time work can also be observed in other countries [27,28,29]. For example, GPs from Australia reported that part-time work enables coping with the increasing pressure of more complex and multiple health needs and more administrative requirements [28]. In this qualitative study, GPs spoke of the changing nature and additional challenges in general practice. An essential transformation of care in general practice is that patients have greater biomedical complexity from comorbidities and chronic conditions than has been the standard in the past. In general practice, a holistic, preventive and cost-effective approach in partnership with the patient is crucial. Realistically, such an approach needs time and cannot be achieved in short consultation slots. This is particularly true for consultations dealing with psychosocial issues, which can be time-consuming and also are emotionally challenging for the treating GP. Such aspects could also explain that the younger generation prefers to work part-time to recover from the time pressure during the working day at the practice and achieve a contented work-life balance. Reducing the number of consultations each day and thus expanding the consultation time per patient could be a possible strategy for gaining control over time to deal with patients presenting with numerous issues [28].

In contrast to our findings, in various countries, an increase in workload has been observed [1, 12, 13, 30]. In the UK, for example, the overall workload of GPs rose by 16% from 2007 to 2014 [30]. In particular, the number of consultations, the total number of patients and the duration of consultations increased during this period. For instance, the crude annual consultation rate per person increased by 10%, from 4.7 in 2007 to 2008, to 5.2 in 2013 to 2014, and the number of consultations significantly increased by 12% over the seven years. Plans to address this problem included reducing non-direct clinical workloads such as administrative work, increasing the number of GPs, strategies to reduce patients’ health-seeking behaviour and improving the attractiveness of the profession [30]. The 2019 International Health Policy Survey (IHP) also recorded an increased proportion of GPs working 45 hours per week or more in several countries [31]. A particularly significant increase was recorded in Norway (29%) [31]. The reasons most frequently cited by Norwegian GPs were increased bureaucracy related to documentation and management of a practice, changes in legislation, and changes in patient expectations and help-seeking behaviour [1]. For example, GPs experienced an increasing workload per patient and a shift of medical tasks from secondary to primary care as well as rising patient expectations about health services, treatment options, and their overall health and wellbeing [1].

In our survey, a relative increase in clinical administrative work over the years might be hypothesised since the time spent on face-to-face encounters decreased while the time for clinical administrative work remained stable. A relative increase in administrative work is worrisome and needs further attention since sound evidence exists that more administrative tasks are a risk factor for decreased job satisfaction and burnout of GPs [32, 33]. One solution to tackle the overload of administrative clinical work is that selected tasks carried out in general practice could be automated. Previous work in this area has looked at the opinions of GPs on automation. Blease et al. found that GPs were sceptical about the capacity of technology to replace or perform certain tasks in general practice better than humans [34]. Specifically, they see limited potential for automation in the areas of diagnosis, prognosis, personal treatment plans, referrals to other health professionals and empathetic care. In general, GPs must possess several key characteristics that are fundamental for high-quality patient care and cannot be replaced by robotic or IT-based processes. These include social intelligence, empathy, communication skills, creativity and improvisation. What is needed is to understand both the extent of automation in general practice using currently available technologies and to show which parts of the staff workflow and task list would be most amenable to automation. Automated solutions can improve accuracy, save time and increase capacity [34]. Wills et al. performed a mixed-methods study in six general practice health centres in England to assess the potential for automating administrative tasks [35]. The data collection included ethnographic case studies, focus groups, interviews and an online survey of automation experts. The authors found that roughly 44% of administrative tasks carried out by staff in general practice are mostly or completely automatable using currently available technology. The complete and quick replacement of paper-based medical records in general practices is crucial and urgent. This allows fast and easy access to pre-generated texts in desktop word processors or electronic medical record notes. Automated report generation and custom search queries to input patient data to different systems is another form of time-saving automation. Automation technologies are most useful when clinicians have the right information at the right time. Basic forms of automated telephone answering are already used, but more sophisticated systems are available that would enable a voice assistant to help triage the numerous phone calls that a practice can receive in a day [36]. Additionally, clinical documentation by GPs could benefit from automation. Artificial intelligence (AI) promises to accomplish this task by automating documentation [35]. Speech recognition and natural language processing technology can support the creation of notes in real time by listening in on patient–physician conversations [37, 38]. Further, during the note creation process, AI-enhanced decision support software can analyse a note’s content and provide real-time evidence-based recommendations to physicians (e.g. differential diagnosis, suggested evaluation, treatment guidelines) using dynamic clinical data mining [39]. Risk scores such as atherosclerotic cardiovascular disease to guide statin treatment or automated CHA₂DS₂-VASc score assessment to guide anticoagulation decisions can be calculated as part of note creation to augment clinical decision-making [40].

The results of the present study confirm the findings of a previous survey in Swiss general practice reporting an emerging feminisation and over-ageing of GPs and the fact that they are increasingly working in group practices [41]. Evidence from several European countries confirms this phenomenon [19, 20]. The average age of GPs in around 30 European countries rose from 44 to 51 years between 1993 and 2011, and the proportion of women rose from 44% to 61% [20]. Regarding the practice type, the UK is in first place with more than 90% group practices, ahead of the Netherlands with around 75% [19]. This shift towards group practices, more female GPs and part-time work also represents the “new generation” of GPs. Buddenberg-Fischer et al. described this new generation in 2008, who strive for a well-balanced integration of work and private life and therefore favour the model of part-time work [42]. Those GPs rate their intrinsic and extrinsic career motivation lower and extraprofessional concerns higher than former GPs who considered their profession as a vocation and sacrificed themselves for their patients [42]. Although previous studies showed that GPs had difficulties in balancing work and private life and were therefore at higher risk of developing burnout, [43–45] the trend of the new generation to work part-time could also be a reaction to the unhealthy overload of previous GPs [28, 42]. As we see in this study, not only women are responsible for this change in working habits. Male GPs have also begun to reduce their workload. Although women, in contrast to men, still increasingly work part-time, this trend can now also be observed among men [46]. Already in 2019, FMH statistics showed that Swiss male physicians worked 8.7 half-days per week on average in ambulatory care. This is in line with the results of our survey and corresponds to a decrease of 0.4 half-days compared to the FMH data on workload published for the first time in 2008. Consequently, these changes among the new generation of GPs include an increasing number of female GPs working part-time, but also a trend of both female and male GPs paying greater attention to balancing their professional and private lives [42].

In the next ten years, around 56% of the GPs in Switzerland will retire due to age [47]. Consequently, the “old generation”, namely the male GP working full-time in a single practice, is considered to be a discontinued model. In recent years, several measures came into place to increase the number of GPs and improve the attractiveness of the profession in Switzerland [47]. For instance, more students were allowed to enter medical schools, and the remuneration of GPs was increased by legislative acts of the federal government [47]. However, the trend of young GPs working part-time remains and presumably will not change soon [26, 47]. Thus, the question must be emphasised of whether sufficient GPs in the future will ensure the population’s demand for primary care. This is particularly important given the ageing population and increasing number of patients suffering from chronic disease [48].

Strengths and limitations

A few caveats must be borne in mind. The sample in 2010 was a follow-up on the 2005 sample and not a new random sample from the total GP population as in 2015 and 2020. However, the impact on study objectives appears minor since data on GPs’ workload seems reliable if a similar sample is questioned at a five-year interval. The response rate was 34% in 2020, 36% in 2015, 71.7% in 2010 and 59% in 2005. Comprehensive reviews examining survey response rates within primary care literature have reported rates varying from 10.3% to 61% [49]. Thus, the response rates of the four surveys analysed are within expectable ranges, and the representativeness of the samples studied seems satisfactory to meet the objectives of the study. The sample size was different in the four surveys, ranging from 1,275 (in 2010) to 2,037 (in 2020). Despite this variation, the margin of error in the survey remains constant at ±2% at a 95% confidence interval, assuming a population size of 6,000 GPs in Switzerland. Notably, very scarce data exist on GPs’ workload in Switzerland, and the participants recruited for the four waves of this study represent the largest number of participants published yet. The data gathered is based on GPs’ self-report and therefore prone to over- or under-reporting. In our view, a substantial bias in the result seems unlikely. In general, GPs seem to have a genuine interest in providing reliable data, and thus also in contributing to empowering general practice in a political context.

Conclusions

The study demonstrates a decrease in GPs’ overall workload over time from 2005 to 2020, indicating that the new generation of GPs prefers to work part-time. This decrease is at the expense of direct face-to-face encounters with patients (face-to-face consultations, house calls and nursing home visits). Over the last 15 years, a clear trend exists towards more women in Swiss general practice, persisting over-ageing of GPs, replacement of single-handed practices by group practices, and increasing burden of administrative tasks, a risk factor for burnout and reduced job satisfaction. To maintain an efficient healthcare system in the future, substantial efforts are crucial to provide a positive and motivating insight into general practice to pre- and postgraduate students and to improve the operational working conditions of GPs.

Acknowledgements

We wish to thank all participating GPs for their contribution to this study.

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Appendix: German version of the 2020 survey

The German version of the 2020 survey inis available in the pdf version of the article.