Introduction
Method
Design
Framework
Participants
Data collection and data analysis
Ethical considerations
Results
Respondent | Gender | Age | Years of work experience as PT | Years after graduating APP | Currently practicing APP | APPs working under supervision | |
---|---|---|---|---|---|---|---|
APP 1a
| Female | > 50 | > 25 | > 2 | Yes | + b
| |
APP 2a
| Female | > 50 | > 30 | > 2 | No | + b
| |
APP 3a
| Female | > 60 | > 30 | > 2 | Yes | + | |
APP 4a
| Male | > 50 | > 20 | > 2 | Yes | + | |
APP 5 | Female | > 35 | > 10 | < 2 | Yes | - c
| |
APP 6a
| Female | > 45 | > 20 | < 2 | Yes | - c
| |
APP 7a
| Male | > 55 | > 35 | > 6 | Yes | + | |
APP 8a
| Female | > 40 | > 20 | > 2 | Yes | + | |
APP 9a
| Female | > 40 | > 15 | > 4 | No | Na | |
APP 10a
| Male | > 30 | > 10 | > 2 | No | Na | |
APP 11a
| Male | > 40 | > 15 | < 2 | No | Na | |
APP 12a
| Male | > 40 | > 20 | < 2 | No | Na | |
Respondent
|
Gender
|
Age
|
Years of work experience
|
Practice composition
|
Number of patients registered to GP practice
|
Number of collaborating APPs
|
APPs working under supervision
|
GP1a
| Male | > 55 | 25 | 1 GP, 1 permanent alternate | 2200 | 2 | + |
GP2a
| Female | > 40 | 13 | 2 GP | 2900 | 1 | - |
GP3a
| Female | > 50 | 21 | 1 GP, 1 HIDHA, 1 HAIOS | 3000 | 1 | + |
Themes | Subthemes | Axial codes |
---|---|---|
Both GPs’ trust in APP and a clear added value of APP are critical for starting implementation | GPs need to trust APP | |
GPs doubt added value of APP | ||
APPs need continuous support from GPs | APPs need the full commitment of GPs to start | APPs cannot refer to secondary care on their own |
Limited availability of patient information | ||
Triaging patients lacks criteria | ||
APPs and GPs want to scale-up | ||
GPs and APPs struggle with who is in charge of the care pathway | ||
APPs require support from GPs while they build-up their self-confidence | Insecurity during delivery of care | |
Insecurity during team interactions | ||
More work experience increases their self confidence | ||
Establishment of proper reimbursement is crucial | ||
APPs believe that their position needs strengthening | GPs want to retain their authority and control | Competencies and attainment levels are poorly crystalised |
Different preferences for type of employment and final responsibility | ||
APPs experienced tension between GPs’ standards and their working methods | ||
More guidance from the professional association is desirable | APPs want more backing from trade organisation | |
Trade organisation needs to be a driving force towards stakeholders | ||
APPs found limited added value in the training they attended | Work experience influences the added value of the training | |
Curriculum needs more in-depth and practical training | ||
Implementation of the APP model creates tension over ownership | No place for APP among physiotherapy yet | Gaining trust amongst physiotherapists with whom they need to collaborate |
Controversy over the positioning of APPs | ||
Finding the balance between taking over GP care and safeguarding core values | Deployment of APP jeopardises patient-centred care | |
Ensuring the independent delivery of care appears to be an unfeasible ideal | ||
GPs must be able to maintain the delivery of general medical care at a qualified level | ||
APPs and GPs need to develop a common language |
Both GPs’ trust in APP and a clear added value of APP are critical for starting implementation
GPs need to trust APP
The most important factor is trust. Trust that those who are doing the project, APP X and APP Y, are competent in the matter. That they are also prepared to behave in this way, and not say, this is a disguised way of bringing in more clients at the end of the day, so that is the most important thing, I think. [GP 1]
GPs doubt added value of APP
Because of course there are so many different therapists with all kinds of functions. It has to be very clear what exactly the added value is for us to refer a patient to an APP instead of a 'regular' physio. [GP 2]
And the problems with the elderly are just very heavy, when you have so many elderly. I have a lot of elderly people, and they all live at home, and I have a lot of demented people, and there is little home care. It is a familiar story. Not enough places, they cannot be admitted, or do not want to be admitted. That is what takes up most of my time. That will continue to be my practice. So that is where I need the most support actually. [GP 3]
APPs need continuous support from GPs
APPs need the full commitment of GPs to start
And I can only speak for my own GPs, something I've discussed a lot over the last year, GPs don't want to grow in the size of their practices either, they're not waiting for 30 practice support staff. The role that we have now is actually quite fine, nice, I don't have anything to do with you, I don't have to take care of you when you're sick, you take care of it there, we take care of it here, that's what these GPs like very much. And my GPs are not waiting for APP to come in as well. [APP 4]
APPs require support from GPs while they build-up their self-confidence
It would be a death blow of course, everyone makes mistakes, but it would mean the end of everything if we had a lot of misdiagnoses in the initial phase. Then, immediately, seeds of doubt are sown, and of course, we cannot have that. [APP 4]
APPs needs practical support from multiple GPs to carry out their practice
I think that in our case she [APP] should actually work for several practices, because one practice – even though I have a large practice – one should have more opportunities available. You always have people who think, I would rather go to the GP because then I will see the doctor again, too. Or imagine, you have already been through a lot with a patient and then the patient prefers the GP. Not that it is necessarily better in terms of content, but because the GP is a trusted figure. [GP 3]
Establishment of proper reimbursement is crucial
GPs were not really keen on using funds from the innovation fund of the health insurers for this purpose. Many GPs had also just made additional investments in physician’s assistants. So that was an issue. Also, because we have another group of GPs here, some of whom think that extended scope is unnecessary. [APP 10]
APPs believe that their position needs strengthening
GPs want to retain their authority and control
Initially that would not matter to me. I think that we should say that, as a goal, it will eventually be fully under APP own authority. Certainly, to get the GPs on board I think that you must first do this under the GP’s authority, until they themselves conclude, no, you can do this on your own just fine, and I don’t need to be behind this, like some version of extension of care. So, I think that this must be introduced step by step. In particular if you also notice that they [GPs] are going to get up in arms, then you should introduce that very slowly. And prove yourself first. You must. [APP 6]
I should like it to be under my supervision because I think that in this way I can offer an extra service to my patients, a broader selection of diagnostic skills and I do not throw this [treatment responsibility] out. So, for as far as this goes, I want them [patients] to go to it [APP], and then they often return to me, and we discuss what the proposed treatment plan is. In this way I do not let go of them. [GP1]
More guidance from the professional association is desirable
I understand that as well, because it is a new association and must be built from the ground up. Furthermore, it is not their main task, they also have of course their own jobs to do. But certainly, for this project, things [documentation] have been agreed upon and were to have been sent in, but this has not happened, which is a pity, because as a pioneer, you really need support. And that is not happening. Or at any rate, too little. [APP 2]
APPs found limited added value in the training they attended
This is fine for a few weeks, going a bit deeper into things, but does not compare with the role they play abroad, nor the training they receive for this…. They have had a completely different training in this, and this I think, is what is keeping us from getting any further with this APP story in the Netherlands. [APP 9].
Implementation of the APP model creates tension over ownership
No place for APP among physiotherapy yet
How do I notice this happening? Not providing information, not sharing patients, getting angry with you the moment you see a patient and call about it, or do a report, or have an other idea. If you want to set up a project about APP care, and you go to a big player in the neighbourhood who also has a similar plan, something broader, and you say, well, let us join forces, then it is all impossible. No, it is all too sensitive, too much me, me, me…. This leads to extremely unpleasant conversations. [APP 1]
The other one, practice X, just wants to scale-up. And they also want to be a part of it [setting up an APP practice in the region], but then it is no longer about the content. The worst thing I found, was that nobody has done training in APP, but they pretend to be on top of it... I think the Society, that is the regional representative of KNGF, believes that every physiotherapist should be able to be an APP. I do not agree with him at all. Manual therapy and sport physiotherapy may think so, but the KNGF has a completely different opinion. At least in our region, the KNGF simply airs this. This is already a difficult matter. [APP 3]
Finding the balance between taking over GP care and safeguarding core values
On the other hand, I discussed this [lack of independent care delivery], with fellow physios already during my training, and they all say, are you crazy, everyone works that way within primary care. And they all pass the buck to each other. So, I let it rest for a while. They are right, I think the same way, but that is partly a hypocritical remark for everyone. So, then everyone needs to put his own house in order, and then we can all be morally justified. But to be honest, because I am quite a moralist, if I let go of that, I think it is going to be a difficult issue. I agree, I totally agree, I think that is the way it should be, in the ideal world, but I think we are a long way from that. [APP 11]
Totally different, if you think it might be a good idea to involve a secondary care orthopaedic, then the GP says, oh, no, you mustn't, because that is seen as primary care in disguise. So, you definitely should not do that! You are just not aware of all these strategically sensitive things. And you think you have a great product, and the GP thinks, how so? I do not need you at all. So how are you going to connect with them? [APP 1]