Barriers to primary prevention in general practice
The fact that primary prevention overall was seldom practiced in general practice was mainly associated with the structure of general practice in Germany. Four structural issues were highlighted: 1), The organization in the office of a general practitioner, 2), the reimbursement scheme for general practitioners, 3), the role of a general practitioner and their view of patients, and 4), the socioeconomic circumstances of patients.
1) The organization of the office
General practitioners overall had high patient volume which led to long waiting times for patients. Therefore persons who were not ill were unlikely to come to the office.
Person 2: Healthy people will do everything but certainly not sit in a full waiting room. (focus group 2)
Indeed, some of the discussants had changed the structure of their practice to allow for a larger amount of primary prevention activities by means of the healthy check-up that was reimbursable for patients 35 and older. One of them had implemented a system that all patients aged 35 and older were reminded of the check-up; another GP had reserved one afternoon solely to conduct such health check-ups. This also allowed for patients to return for several visits during the time they tried to change behavior.
Person 3: I decided that I want to focus my practice on primary prevention. However, to do so, I changed the structure of my practice. Because it does need time. So you need to organize the practice in such a way that you are able to discuss primary prevention options. (focus group 4)
Person 1: We do a lot of check-ups. We actively talk to our patients to encourage them to participate. The entire practice team.
Person 2: Yes, we also have a system to record when the check-up was done and when it should be done the next time.
Person 3: So what do you then with the check-ups? Do you tell them to be physically active for example?
Person 1 and 2: Of course! (focus group 4)
2) Reimbursement scheme
The way the practice was organized was inherently connected to the existing reimbursement scheme. Primary prevention is not part of this schema, except for the above-mentioned health check-up.
Lack of time was considered as another factor that hindered primary prevention efforts in general practice. All discussants agreed that successful primary prevention required time to talk about it with patients. Similarly, if someone wanted to change their behavior, this needed follow-up appointments in order to ensure long-term behavior change through continued motivational support. Such close monitoring was neither part of the present reimbursement scheme nor was it feasible due to the high patient volumes in the offices.
Person 4: We usually include lifestyle counseling in our regular routine. But when it is actually happening when someone for example, wants to stop smoking but needs our help, it becomes difficult. What do we do with such a person? Shall I just give him a prescription, period? Usually such an approach does not help the patient to quit smoking. So, we have to invest time and see the patient several times and talk with him. But how shall we take the time for these conversations?
Person 1: Yes, primary prevention is not part of our job description or our reimbursement schema. We deal with disease. So primary prevention really does not play a role in our practice, except that we mention it to people. (focus group 4)
3) Perceptions regarding their role as GP and their view of patients
All discussants mentioned lifestyle changes to their patients when they thought it was appropriate. Appropriateness was assessed based on the reason of the visit and the patient.
Person 1: I will talk about smoking if someone comes with bronchitis or a cold. Then I ask if they smoke and that they need to quit smoking in the future. Otherwise it will not go away. Especially if someone comes with a cold and if the patient can then hear a noise from their own breathing and one listens to the lungs and is able to say, listen your bronchial airways are damaged. Such a symptom makes it more palpable to the patient if I talk about smoking to them. (focus group 1)
For most of the GPs, the decision to discuss lifestyle changes was based on the specific issue with which the patient presented. For example, if a patient presented with a disease that was affected by unhealthy lifestyle habits (for example, bronchitis and cigarette smoking), GPs would take the opportunity of the situation and address lifestyle changes. Similarly, it seemed easier for GPs to discuss lifestyle changes when a patient had symptoms that would be alleviated once lifestyle changes were adopted. However, some of the discussants thought it was possible to introduce lifestyle issues more generally but they questioned the effectiveness of such an approach.
Person 4: Of course I can talk about weight reduction to a patient who comes because of a sickness. The question though is how effective is it?! (focus group 1)
Most participants argued against a routine discussion of behavior changes in general practice for two reasons: a), patients needed a desire to modify their behavior, and b), physicians were critical of taking on a role of “health policing.”
a), Participants believed that in order for behavior change to be successful it had to be motivated from within oneself and needed to be relevant to the patient’s life. Such a motivation could be encouraged by the GP if the lifestyle change was related to the reason for the health care visit. For instance, most GPs agreed that they would not discuss smoking cessation with a patient who presented with back pain. However, they would certainly talk about physical activity and weight reduction in such a situation.
Person 1: For example, if someone comes because of a cold and I notice that this person smokes. I can talk about smoking [because it may influence the duration of the cold]. But of course, you cannot talk to a person about safer sex who comes because of a cold. (focus group 2)
They also thought that the will of the patient to change was important. This was another reason why many of the discussants did not consider a standard discussion of behavior change useful in general practice.
Person 3: Yes, I do believe that the will to change has to come from the person herself. It has to be their project. (focus group 1)
Person 3: I think, the fear of growing old and becoming frail and in need of help is something that leads people to change their behavior or to participate in courses on behavior change. Others will not do it. (focus group 2)
b) Some of the discussants were against a standardized approach to lifestyle intervention in general practice based on the perception they had of general practice. They were critical of a normative understanding of how people should live their life based on health. Some discussants questioned the role of a GP as someone overseeing how adults should live their lives.
Person 3: I am not sure if we should put health first place. Of course, physicians always do that. But there are people who don’t. There are people who want to smoke and they know this may mean that they do not live as long. And I think it should not be the task of primary prevention to change people’s behavior if they do not want to do so. These are adults and they have the right to choose. (focus group 1)
Person 2: Sometimes primary prevention is very normative about how one should live. And it actually can be quite nice to not live according to health principles. Still, we should address it when appropriate but not in a standardized format. We don’t have to save people. I don’t want a patient to leave my office with a feeling of being converted.
Person 1: Indeed, I find it quite interesting to ask about the focus of primary prevention in the legal realm. They target smoking cessation, physical activity, losing weight. However, being happy and quality of life are not part of this approach. (…)
Person 1: Yes, and it is important that we as physicians also accept the ways people live and still take good care of them. There should not be a value associated with these behaviors. (focus group 1)
4) Competing demands: The socioeconomic circumstances of patients
Socioeconomic circumstances were seen as a barrier to target behavior change. GPs’ patients discussed precarious financial and social conditions. This led to what participants identified as “competing demands.” Such patients faced many challenges in their lives such that changing an unhealthy lifestyle was a low priority and one that was difficult to argue for from the GP’s perspective.
Person 4: The social situation in which the patients are, no money available, and also to quit smoking is so much more difficult, if you are out of work and sitting at home, your electricity has been cut. This burden is too much for a physician’s office it is not the realm we can address. To help with all of these social aspects is not possible for us. And then other problems are simply more important than smoking. (focus group 1)
Suggestions for ways to integrate primary prevention into general practice
During the focus groups GPs shared their visions and suggestions for successful primary prevention involving general practice. These are presented in Table
2 along with relevant quotes.
Table 2
Suggestions for improving primary prevention efforts in general practice: quotations of the most salient focus group results
- Creation of a larger primary prevention network |
“I mean, there have to be structural changes, so that the primary prevention is defined as a medical job (…). And I could also imagine a collaboration between the offers of the health insurance companies and local communities. (…) And locally. Not anywhere in the middle of the city in a big institution, where all people have to collect, but it has to happen where people work, where they live. In the neighbourhood.” (Person 1, Focus Group 4) |
- Increase of primary prevention efforts in a network of community planning, infrastructure, and schooling |
“The statutory health insurance had a program in schools, where they sent physicians to class as well as to teachers to discuss [primary prevention]. So I went into a primary school class and talked about nutrition. (..) After the class, I had a counseling session with each student one-on-one and we talked about eating disorders. And one of them knew exactly that he was eating because of stress and what he should be doing instead. And I think that is the way to go. We need to go to schools (Person 4: Yes, we should go to schools). There we can still influence kids. The experience at the time was great. The students were very open and interested.” (Person 2, Focus Group 3) |
- Reimbursement structure that allows for follow-up meetings and counselling sessions on behavior change | |
In the discussions, primary prevention was seen as a task that extended beyond the responsibility of medical practice. Improving patients’ health was seen as a joint endeavor of doctors, communities, schools, day care centers and individuals.
GPs suggested the development of a network of stakeholders to foster successful primary prevention including collaborations between GPs, paediatricians, communities, and health insurance companies to organize programs that fit the needs of each individual community.
As mentioned before, most patients served by GPs were ill and often presented with multiple ailments. For that reason, GPs felt that primary prevention as behavior change needed to be introduced at an earlier stage in life. The ideal target groups for primary prevention were children and young adults. These age groups were rarely in contact with a GP. Children were usually seen by paediatricians and young adults did not frequently access the services of health care providers. Thus public infrastructure and school programs were seen as crucial settings for primary prevention.
Finally, GPs suggested a restructuring of the GP reimbursement schemes in ways that allowed a successful and effective prevention focus in practice and recognition of prevention as a medical task.
Most of the GPs agreed that their training qualified them to provide information on the physical effects of unhealthy behaviors. Explaining the physical consequences of unhealthy behavior in various settings, including schools and daycare centers in addition to their practices, was seen as the way they could offer support in prevention networks.