The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

The term co-location is used for the organisational strategy of grouping different professionals in the same facility, which in primary care particularly involves GPs, nurses, other health professionals (such as midwives, physiotherapists, dentists, pharmacists or even specialists of secondary care) and social workers.

Although Groenewegen et al. [22] do not refer explicitly to the concept of co-location, they observed a high variability in the number of professionals working with GPs within the same practice. Of the 34 countries we analysed, almost half (16) are characterised by GPs working with at least three professionals. The largest number of co-located professions with GPs are in Lithuania (8 other professions), Finland (7), Cyprus and Spain (6) and Iceland, Sweden and England (with 5 other professions).

All these countries, where a considerable level of GP co-location is quite widespread, are very different in terms of health system characteristics and primary care development (see Appendix 1). The co-location strategy does not seem to be related particularly to specific health system characteristics. Indeed, although the majority are countries with a tax-funded national health system, there are also transitional countries (Lithuania, Poland, Slovenia), where GPs are co-located in large polyclinics typical of their previous healthcare system, and one country with a social health insurance system (i.e. the Netherlands, with the longest experience of primary care centres with GPs, nurses, social workers, physiotherapists).

Although the majority of countries have strong primary care with GPs playing a gatekeeping role, the two with the largest GP practice (Cyprus with urban and rural health centres, and Iceland with primary care centres located throughout the country) have the weakest primary care system, according to the Primary Health Care Activity Monitor Europe study [30‐33]. However, a significant association was observed between stronger primary care systems, in particular with a better developed primary care workforce and more comprehensive primary care processes, and larger primary care practices with more primary care professions [22].

The experiences of co-location are country dependent and it is difficult to summarize any common policies regulating their implementation. In Lithuania, GPs are co-located in primary care centres and polyclinics which often provide both primary and secondary outpatient services. Finnish primary health centres offer a broad range of primary health care services at the municipality level. In Spain, GPs work together with nurses, social workers, paediatricians, midwives, specialists, dentists, physiotherapists, with a formalised primary care multi-professional team. GP-led health centres in England have a more limited inter-professional collaboration without the presence of social workers. In Sweden primary care is provided in multidisciplinary teams, with at least one GP and one nurse, but often with social workers, psychologists and physiotherapists working at the primary health care centres. Medical homes in Australia and New Zealand promote the person-centred medical home (PCMH) model, with patients having an ongoing relationship with a particular doctor (who leads a multidisciplinary practice team) and primary care that is comprehensive, coordinated and accessible, with a focus on safety and quality.

The key common aspect of all these situations is that GPs and other professionals work together in the same facility, which constitutes the variable of interest to be explored in relation to the GPs’ working methods and patient experiences.

The main explanatory factor included in this study is GP co-location which is defined as a GP located in the same primary care facility with other GPs and/or other professionals. GP co-location is measured by two dichotomised variables:

The two variables were created on the basis of the answers to the GP questionnaire, which contained questions asking whether or not a GP works in the same practice/centre with other GPs, specialists and twelve types of other professionals.

We defined multi-professional GP co-location as GP(s) co-located with a nurse or another health professional (specialist, midwife, physiotherapist, dentist or pharmacist) or social worker. For the nursing role, we considered practice nurses, community nurses and nurse practitioners. If nurses worked with GP(s) without a secretary/receptionist and if they did not provide vaccinations, health information, do check-ups or minor clinical activities, they were not considered as playing a real nursing role, but as a substitute for a secretary/receptionist. The health professionals co-located with a GP are those providing specialised care, maternal care, rehabilitation, oral health care or pharmaceutical services and contribute to comprehensive health care delivery [25, 29, 53]. Finally, multi-professional GP co-location also takes into account the presence of a social worker, who facilitates the integration of the social and health domains in primary care [16, 26, 56].

We investigated the association of the two different dimensions of GP co-location with GPs’ and patients’ experiences, both as a separate (additive) and joint effect (interaction). We also analysed the association between GPs’ and patients’ experiences and co-location of GP with specific professionals, such as nurses, other health professionals (specialists, midwives, physiotherapists, dentists or pharmacists) and social workers.

We studied the relationships between GP co-location and both GPs’ outcomes and patients’ experience.

At the GP level, we explored four dependent variables that we hypothesised would be associated with GP co-location. They concern GP clinical practice, in terms of health care provision, clinical behaviour and inter-professional working. The following GP variables were included:

All previous outcomes were measured through scales constructed through latent class multilevel analyses with items nested in GPs and in countries [52].

The other group of independent variables concerns the experiences of patients. We used scales measuring accessibility (5 questions on the access to GP practices concerning organisational aspects, such as for instance opening hours), comprehensiveness (2 questions on whether GPs represent the first contact for common health problems) and continuity of care with their GPs (3 questions on whether GPs have known the patient on a long-term basis). These scales were constructed through latent class multilevel analyses with items nested in patients, GPs and countries and these had been used in other studies to measure patient perceptions of GP quality [50].

To analyse the relationship between GP co-location and GP outcomes and patient experiences, a multilevel linear regression analysis was used, since all dependent variables can be treated as continuous variables considering the process used to build them. This study included 60,762 patients of GPs who had completed a questionnaire (7163 GPs).

When analysing outcome variables concerning GPs, the country represented the highest level and GP the lowest. A third level (patient) was included in the models analysing the patients’ experiences.

In order to answer the three research questions, we performed four models for each dependent variable, both at the GP and patient levels. In the first two models, we explored the main effects of the two components of GP co-location separately (mono and multi-professional). The results of these analyses are in the Appendix 3.

The third model focused on the interaction of the two variables concerning GP co-location. In this model, we found differences in the relationship with outcomes among four possible settings: 1) only one GP without other professionals (single-handed GP practice), 2) GP with only other GPs (i.e. no other types of professionals), 3) only one GP with other professionals and, 4) two or more GPs with other professionals (Tables 4 and 5). Finally, in the fourth model we considered the three sub-variables of multi-professional GP co-location separately, in order to highlight the specific relationships between co-location with nurses, with other health professionals and with social workers and GP outcomes and patient experiences (results in the Appendix 3).

The interpretation of the results of the four models applied to the GP outcomes enabled us to answer the first research question, while the second research question was answered by the four models applied to the patient experiences. The analysis of differences in the relationships between GP co-location and GP outcomes and patient experience emerging from the comparison of the results among the four models enabled us to answer the third research question (Table 1).

All models were adjusted for GP covariates, such as sex, age and location of practice in urban/rural areas and involvement in disease management. Evening opening times of the GP practice and its location were considered as GP covariates in the adjusted model that analysed patients’ experiences.

All the models concerning patients’ experiences were also adjusted for patients’ socio-demographic and health characteristics (sex, age, education, ethnicity, household income, self-reported health status and chronic conditions), the main reason for the visit to GPs (administrative vs health reason) and for having their ‘own’ doctor.

We reported the variances in the empty model, in the model with only the covariates, and in the model with the covariates plus the variables of interest (the combination of mono and multi-professional co-location).

As a sensitivity analysis, we tested whether the differences concerning the coordination with secondary care were still present when removing GPs who were co-located with specialists. This kind of sensitivity analysis verifies the specific role of specialists in the relationship between GPs co-located with other professionals and integration with secondary care.

We used the GP outcome variables (such as the provision of technical procedures, use of guidelines, collaboration with other providers and coordination between GPs and secondary care) and transformed them into categorised variables to perform stratified analyses in order to verify whether they had an interaction effect with co-location on patient outcomes.

Finally, to obtain more information to answer the second research question, we explored the possible differences in the relationships between GP co-location and patient experience at the country level, by performing a stratified analysis of the models concerning patient outcomes based on the level of strength of the primary care structure in each country [30‐32]. The strength of primary care systems at a national level was categorized in tertiles.

All analyses were performed using Stata 14.

The multilevel regression analysis (Table 4) revealed that the majority of variation in GP outcomes is at the GP level, except for the provision of technical procedures which is mainly related to the country level (intraclass correlation, ICC, 69.2%). Coordination with secondary care and use of guidelines have the lowest ICC at the country level (respectively 13.4% and 20.6%), however, these are still relatively high ICCs.

All types of GP co-location are positively associated with the provision of technical procedures. The strongest relationship is when a GP is co-located with other GPs and other professionals (p < 0.001, Table 4 second column). When GPs are co-located with nurses, they are more likely to provide technical procedures compared to GPs co-located with other professionals (p < 0.001, see Appendix 3).

The use of guidelines is not associated with mono or multi-professional GP co-location (Table 4 third column), except when considering the multi-professional details as separate independent variables (see Appendix 3).

Compared with single-handed GP practices, mono and multi-professional GP co-location GP are associated with more collaboration with different providers (respectively p < 0.05 and p < 0.001), particularly when a GP is co-located with other GPs and other professionals (p < 0.001, Table 4 fourth column). More collaboration with other providers is also related to GP co-located with nurses, other health professionals and social workers, particularly GP co-location with a social worker (p < 0.001, see Appendix 3).

Compared with single handed GP practices, all co-located settings (only mono-professional, only multi-professional and mono and multi-professional) are more coordinated with secondary care (p < 0.001, Table 4, fifth column). GPs who are co-located with other professionals, in particular with specialists, midwives, physiotherapists, dentists or pharmacists, are more coordinated with secondary care (p < 0.01, see Appendix 3). These results are confirmed also after excluding GPs co-located with specialists (results not in tables) and therefore the positive association between GP co-location and integration with secondary care is not due only to the presence of specialists in the same practice/centre with GPs.

We found that some areas of patient experience are strongly clustered at the country and GP levels. The intraclass correlation of both levels ranges from 60% for continuity of care to around 97% for accessibility and comprehensiveness (Table 5).

When GPs are co-located with other GPs and other professionals, patients experience less accessibility compared to patients of single-handed GP practices (p < 0.05, Table 5 second column). Also in the separate models, multi-professional GP co-location continues to be negatively associated with accessibility (p < 0.05, see Appendix 3). Co-location of a GP with social workers has a negative relationship with this patient experience (p < 0.01, see Appendix 3).

Compared to patients of GPs working in single-handed practices, patients perceive less continuity of care when their GPs are co-located only with other professionals or with other GPs and other professionals (p < 0.01, Table 5 third column). This negative association with continuity of care is also present as one of the main effects / as the main effect of GP co-location in a multi-professional setting (p < 0.01, see Appendix 3), and in practices where GPs are co-located with nurses, patients experience even less continuity of care (p < 0.001, see Appendix 3).

Compared with patients of GPs working in single-handed GP practices, patients perceive their GPs who are co-located only in multi-professional settings to provide less comprehensive care (p < 0.05, Table 5 fourth column). Comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.

When we introduced GP outcome variables as covariates into the models analysing patient outcomes, the association between GP co-location and patient outcomes did not change significantly (results not in tables). This was particularly the case with variables such as provision of technical procedures, collaboration with different providers and coordination between GPs and secondary care which are positively related with GP co-location. The direction and strength of relationships which were statistically significant were confirmed. Only the negative associations with accessibility and comprehensiveness of care were slightly reduced when controlling for coordination with secondary care. When these models were stratified by the categorised GP outcome variables, the results were no longer interpretable.

The stratification by strength of primary care at a country level highlighted that in countries with a weak level of primary care, GP co-location is associated with worse patient experience, particularly when GPs are co-located in a multi-professional setting. In countries with a stronger level of primary care (medium and high level), the associations between GP co-location and patient experiences are not significant or, when significant, have a positive direction. In countries with a medium primary care structure, when GPs are co-located with other professionals and/or other GPs, patients perceive a better accessibility to GP care compared to a single-handed GP practice (Table 6).

Almost all our hypotheses on GP outcomes concerning our first research question were confirmed. On the whole, from the point of view of GPs themselves, GP co-location has positive associations with a wider range of services provided, higher use of clinical governance tools and more inter-professional collaboration. The higher provision of technical procedures associated with GP co-location, particularly when they are with nurses, counteracts the notion that GPs have been gradually abandoning the technical aspects of medicine to specialists [59]. A recent study in the Netherlands found that patients prefer to substitute specialist care with GP care mainly for certain medical procedures (e.g. follow-up treatments and non-complex treatments) [58], and thus the broader provision of procedures by a GP co-located with other professionals can be seen as one aspect of a more responsive care approach. Indeed, more comprehensive primary care gives patients access to healthcare services at the primary care level for which they would usually have to go to other providers (in other locations).

This study highlights that GP co-location also has positive relationships with the collaboration with other professionals, confirming that physical proximity intensifies interactions and consequently informal and formal communication and knowledge exchange [17, 18]. GP co-location thus seems to be a first step to overcoming professional barriers and facilitating the consolidation of teamwork [15, 42, 49].

Co-located GPs tend to work more in coordination with secondary care which may be seen as positive in reducing fragmentation in healthcare pathways and ensuring a closer inter-professional cooperation [46]. The increased exchange of advice observed between GPs and specialists goes beyond the co-location of GPs with specialists. It therefore seems that co-location in itself involves organisational changes that then improve the connections between primary and secondary care, thus leading to a better coordination of patient care. However, this closer collaboration between GPs and specialists can be interpreted differently in different countries. Indeed, where specialists are employed by public health services, the increased collaboration with GPs is seen mainly in terms of a potential improvement in the appropriateness and integration of healthcare. On the other hand, where specialists are private professionals, the increased exchange of advice with GPs might be seen as a risk of encouraging more specialist care visits.

We found less strong evidence that co-located GPs use more clinical governance tools. The weak association of GP co-location with the use of guidelines does not seem to confirm the mutual influence of co-located professionals on the uptake of clinical governance tools, which was instead found by de Jong [13] in terms of mutual control in clinical practice. In any case, in completing the questionnaire, GPs may have been influenced by the differences in clinical guidelines in different countries [37].

Concerning the second research question, our hypotheses were almost completely refuted since we found that patients of co-located GPs did not perceive a better quality of care. Indeed, despite the general positive relationships between GP co-location and GP outcomes, GP co-location has a negative relationship with patient experiences in terms of accessibility, continuity and comprehensiveness of care.

These results can be interpreted in two ways. Although corresponding to improved healthcare service delivery from the providers’ perspective, GP co-location is not associated with improved patient experiences, because patients perceive better quality care when they are treated in smaller practices where they have an individual relationship with their own GP [10, 2]. An alternative interpretation is that the observed differences in GP outcomes due to co-location may not yet have led to effective teamwork, due to the challenges related to inter-professional collaboration, such as difficulties in overcoming barriers and conflicts or defining roles and common objectives [34, 41, 45]. In fact, another study underlined the importance of a multidisciplinary team combined with GP co-location in increasing patient satisfaction [6]. Both interpretations are in line with the discrepancy of perspectives between providers and users that Lloyd and Wait highlighted [38] in providing a definition of integrated care. The authors reported that users and providers may disagree as to whether or not a healthcare experience is really integrated. In this case and contrary to our hypothesis, GPs and patients do not experience GP co-location in the same way, maybe because the advantages of GP co-location for the former are not as important for the latter.

The results change when we take into account the differences among countries related to the strength of their primary care structure. Indeed, in countries with a medium or strong primary care, GP co-location is not associated with patient experiences or there are signs of positive associations with some patient experiences. At the same time in countries with a weaker primary care structure, GP co-location is related to very negative experiences from the patients’ perspective. Therefore, there is an interaction effect between GP co-location and the PC strength at the country level. This may be related to the different organisational models of GP co-location in different countries, from simple polyclinics to more integrated primary care centres, which may play a different role in affecting patient experience. In countries with a weak primary care, the organisational models of GP co-location may be implemented without a clear idea of the integration of services and professionals. Therefore patients perceived a lower quality of care in these settings compared to single-handed GP practices. Kringos et al. highlighted that teamwork and multidisciplinary collaboration have been poorly addressed in European primary care, especially in countries with weak primary care systems [33]. Not only do professionals need training to improve multidisciplinary collaboration, patients may also have difficulty in navigating larger facilities, where they deal with many different providers. In order to improve the patient experience, it may be necessary for larger facilities to be organised in a way that guarantees the continuity of care to patients.

In order to answer the third research question, we focused on the differences in the relationships between the different components of GP co-location and GP outcomes and patient experiences. Mono-professional co-location has a less strong association with GP outcomes, while multi-professional co-location has a stronger association with GP outcomes but is negatively associated, or not associated at all, with patient experience.

Compared with single-handed GP practices, GPs co-located with other GPs and professionals, which constitute the most complex form of GP co-location, has the best impact on GP outcomes, while one GP with other professionals represents a very negative co-located setting in terms of patient experience, particularly regarding continuity and comprehensiveness of care.

Regarding GP outcomes, the provision of technical procedures is more strongly associated with the co-location of GPs with nurses. The collaboration with other providers has a stronger association with the co-location of GPs with social workers, while coordination with secondary care is mostly associated with the co-location of GPs with other health professionals, such as specialists, midwives, physiotherapists, dentists and pharmacists.

Regarding patient experiences, co-location of GPs with nurses has the strongest negative association with continuity of care, maybe because in this setting, the nurses are the first point of contact and play the role of primary caregiver in the relationship with patients. In fact, a Cochrane systematic review [35] reported that nurses tended to provide longer consultations than GPs and to take responsibility for the ongoing management of patients with particular chronic conditions. Therefore, when GPs are co-located with nurses, the GPs themselves may be less informed about the medical history or conditions in which patients live. Co-location of GPs with other health professionals has no relationship with patient experience, while co-location of GPs with social workers has a negative association with accessibility. These results can be explained by considering that firstly, the co-location of GPs with social workers is not very common and may also be more related to larger health centres with more limited accessibility.

One major strength of our study is that it explores the relationships of GP co-location both with GP outcomes and patient experiences, providing evidence concerning the process and final outcomes of delivery changes in primary care through GP co-location. Other studies have included the analysis of the different perspectives related to GPs and patients, but with other approaches. Indeed, such studies have focused on GPs’ and patients’ perspectives regarding specific diseases [47] or concerning the quality of primary care [28, 43]. In these cases, the attention is on the juxtaposition between the clinical perspective and that of patients, focused more on the personal aspects of an illness, or between the professional and lay opinions in terms of what is valued in primary care.

In contrast, our study explored the GPs’ and patients’ perspectives in relation to different topics that are relevant for GPs and patients themselves. For GPs, we focused on the range of services provided, the use of clinical governance tools and inter-professional collaboration. For patients, we focused on the accessibility, comprehensiveness and continuity of care as perceived by the patients themselves. For both groups and their related topics of interest, we explored the correlation of these outcomes with a structural and organisational dimension of health services delivery (i.e. co-location of GPs in mono or multi-professionals settings).

The differences in the findings between the GPs’ and patients’ perspectives can be interpreted according to the Donabedian model [14], which focuses on the structure, process and outcomes of healthcare. According to this model, GP co-location can be considered as a structural factor of health services delivery, the topics which interest GPs are the process, whereas the topics of interest for patients are the final outcomes of the health services delivery. Therefore, the positive process (in terms of more technical procedures performed in GP practices, as well as more collaboration of GPs with other primary and secondary care professionals) due to the structural input of GP-colocation does not necessarily correspond to the final positive outcomes (in terms of more the accessibility, comprehensiveness and continuity of care perceived by patients). Indeed, the positive results of GP-colocation as perceived by GPs do not relate to positive results for patients, at least in the countries with a weak primary care, where the structural input of GP-colocation for health services delivery is probably characterised differently compared to countries with strong primary care.

An additional strength of the study is that the large number of countries involved enabled us to differentiate between the patient, practice and country levels and to look at the differences among countries based on their strength of primary care structure.

Our study also has limitations. GP co-location cannot be distinguished in terms of different organisational models and it has not been characterised according to the different composition of co-located teams. There is no information on the actual cooperation between co-located professionals, or on whether patients have actually experienced the inter-professional joint working in GPs co-location settings. Therefore, we cannot connect the structural and organisational dimension with professional integration. Moreover, considering that we used data from an international survey, GPs and patients from different countries may interpret the questions differently, also because of potential discrepancies related to different types of health systems among countries. As noted in another study on GP practice using the same data [22], some terms may have a different connotation from one country to another, in spite of the rigorous translation procedure implemented. Finally, GPs who are co-located with other GPs and/or other professionals may have consciously chosen this type of care setting, and therefore may be more biased towards co-location. This potential bias is perhaps less relevant for patients, as their freedom of choice for a specific practice may be influenced by the different regulatory and normative context existing in different countries, as well by the actual availability of different practices near the place they live.