Principal findings and comparison with prior work
The study series was able to generate a broad picture of the current status of GP care with regard to support for family caregivers. Due to their position in the German health care system, GPs perform extensive primary care tasks. GPs are the first point of contact for patients and therefore often familiar with their patients and the patients’ family members for many years; there is a trusting doctor-patient relationship [
6,
27‐
29].
The results obtained in the course of the sub-studies show that the GP setting has great potential to act as a central support for this group. Discussions with family caregivers about care (organisation) and care circumstances are widespread in everyday practice and are based on a high level of trust on the part of caregivers. Especially the low-threshold accessibility for various problems, the familiarity with the personal circumstances as well as the attention to the person in need of care are experienced positively.
This confirms previous studies which underline the major importance of GP support for the target group under consideration and see GPs as being in a position to make key contributions to the longer-term stabilisation of home-care settings [
6,
7,
14,
28‐
30,
51,
52]. Both caregivers and GPs believe that the primary care setting has great potential to address and deal with the problems of caregivers [
7,
14,
29,
30,
52]. For example, a study conducted in Ireland highlights the priority role of the GP in developing longer-term coping and resilience strategies in home-care settings [
53]. For their part, Greenwood and colleagues [
30] were able to work out that the primary care setting can play a central role in supporting and relieving the burden on caregivers and effectively coordinate further care.
Nevertheless, the results of the present study also reveal weaknesses which mean that, despite being very aware of the need to support family caregivers, GPs are not always able to meet the needs of home-care situations as part of their everyday practice [
6,
51,
54]. This is true, for example, with regard to the role of GPs in identifying and anticipating care difficulties. Caregivers would also like the GP to play a greater advisory role when it comes to organising the framework conditions for care and signposting them to help and support services. Additionally, the sub-studies confirmed the findings from previous studies that GPs do not always consider the physical and emotional needs of family caregivers to the same extent as those of the person requiring care [
30,
36,
37,
39,
42,
52].
In particular, the comparatively low level of GP referral activities and collaboration with support services in the provision of care results in restrictions and delays in the effective support and (preventive) stabilisation of caregivers. As noted in various studies, GPs in Germany - especially in rural regions - are often solitary providers and cannot access interprofessional networks and collaborations [
24,
26,
30,
40,
43‐
46,
54]. The results of the survey of family caregivers are confirmed, for example, by a Canadian study conducted by Parmar et al., who find that GPs fail to consistently address the need of caregivers and care recipients for early and regular signposting to respite services [
45,
55]. When family caregivers are referred to such support services, they benefit from timely access to information on organising care [
8,
52], which allows the caregiver to stay at home longer without care crises (e.g., hospitalisations) arising [
24,
56].
Another issue is that the GP team does not always identify family caregivers in a timely and systematic way, making it harder to identify specific needs and anticipate pressures. Overall, the results demonstrate the value of active communication by the GP team in relation to the family caregiver group. In the qualitative studies by Burridge et al. conducted in Australia, it is notable that caregivers do not always feel confident to voice their problems, if GPs do not signal to them that they see themselves as a point of contact [
39,
57]. Against this backdrop, it makes sense to strengthen GPs’ conversation skills in dealing with caring relatives through further training. If communication can be more open between both parties, family caregivers will be less reluctant to report feelings of burden, depression, and stress [
51]. A systematic assessment of the caregivers’ general well-being, performed by the GP, is essential for the prompt adjustment of home care [
58].
A fundamental problem not only of the German, but also of other health systems is fragmentation, meaning that the sectors are separated. As a result, primary care is often not integrated into multi-professional care, which also affects the care of family carergivers [
59]. In Germany in particular, there is often a lack of staff who can relieve and supplement the GP, offer support to caregivers and competently assign them to support services [
30].
In this context, it is worth mentioning that only a proportion of GPs train non-clinical practice staff and involve them so that they can take on specific tasks such as identifying and supporting family caregivers [
24,
30,
40,
47]. Studies like those by Krug et al. [
40] show that the detection of exhaustion in caregivers is not systematic among staff members, but rather a reaction to warning signals that the caregivers show to the practice team. This problem is often related to a lack of knowledge and awareness [
32,
35]. At the same time, various studies show that there is a great need for delegation in primary care since GPs are often overworked already in most countries [
47]. Therefore, practice staff should be more systematically involved in the detection and support of family caregivers [
35]. Staff members who have undergone appropriate training can also take on referring and mediating activities to advisory and support networks. If the practice team is networked with other service providers, this not only relieves caregivers, but also the practices themselves; the mediator role of the GP’s practice can be strengthened. Requests made to the practice team could then be passed on to competent actors in the network. For example, closer cooperation with long-term care insurance funds, which GPs sometimes use in the context of care advice [
40], and the local care support points could help relieve caregivers. Where such collaborative solutions exist in everyday practice, GPs also find it much easier to meet the needs of caregivers [
51]. Practice management is of particular importance with regard to the involvement of the practice staff. On the one hand, prerequisites should be created under which it is possible to identify and observe caregivers (e.g. regularly changing work areas). On the other hand, it depends on systematic arrangements with regard to the documentation of abnormalities (e.g. entering signs of stress in the patient file) [
37,
42].
In order to stabilize home care settings, there is also the need for structured interdisciplinary forms of care that combine medical, nursing and further care offers in order to offer person-centered and evidence-based support [
60‐
62]. The lack of effective outpatient crisis intervention structures often leads to hospital admissions in crisis situations, which may result in serious complications for patients [
63]. There is some discussion on the introduction of case and support managers to assist GPs in supporting family care situations [
52,
59,
64,
65]. Case managers offer the advantage that they are cross-sectorally networked and can act as a link between GPs and other care providers (e.g. care services, support networks, emergency clinics), so that risk stratifications for those in need of care and carergivers can be carried out at an early stage [
59].
Also important in care planning is the issue of adequate referral to care-supporting systems, networks and services. In this context, however, it has been found that GP teams often complain about inadequate integration into professional care and advisory networks [
40]. A central lever for making GP support for family caregivers more effective is undoubtedly the closer integration of GPs into counselling and support services [
66]. To this end, it will be important to strengthen interdisciplinary communication, to establish collaborative municipal networks in the area of health promotion [
44,
58] and to provide GPs with a reliable knowledge of advisory services in their area in order to facilitate the straightforward referral of caregivers. A systematic review by Plöthner et al. points out the importance of strengthening outpatient care structures [
51]. The researchers draw the conclusion that establishing an outpatient care system, which supports families and friends in providing (elderly) care while meeting the needs and wishes of informal caregivers, is of high relevance. An important prerequisite for this is to take into account family doctors with their own contractual elements, ensuring that they are appropriately remunerated when they take on advisory, mediating and caring activities for a caregiver network [
21,
51,
56]. Scientifically supported model projects are already trying to strengthen the anchoring of GP-based care in regional advisory and support networks [
30,
31,
59,
60].
The increased focus on evidence-based guidelines is also an important tool for better addressing the needs of caregivers. For example, manageable care plans derived from guidelines could help GPs tailor care management to the care needs of the caregiver and the patient [
46,
49]. In doing so, the assessment of the care situation and its impact on the general well-being of the caregiver can approached in a structured way [
66]. Clear and efficient guidelines from early diagnosis to adequate referrals can certainly improve the GP’s ability to support time- and energy-consuming home-care situations. Consequently, intervention trials focusing on the skills of GPs could be helpful in improving home-care outcomes regarding the family caregiver [
32,
37].
Not only in Germany, but also internationally, there is a lack of longitudinal studies that include doctors, nurses (e.g. palliative care patients) and family caregivers in order to support the development and effectiveness of family GP-related interventions [
67] that maintain or increase the quality of life of patients and their relatives [
68]. An exception is the implementation of the Gold Standards Framework in Great Britain, in which family caregivers are explicitly included [
69]. The caregivers‘perspectives and experiences were taken into account, e.g. the need for a professional coordinator [
70] and the support of district nurses [
71]. The extent to which such approaches can be adopted in the more fragmented German health system is part of future research projects.