The Acceptability of Task-Shifting from Doctors to Allied Health Professionals
Results from a representative telephone survey of members of the National Association of Statutory Health Insurance Physicians
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Background: The shifting of medical tasks (MT) to Qualified Medical Practice Assistants (MPA) is an option that can be pursued to ensure adequate health care in Germany despite the increasing scarcity of physicians. The goal of this study was to determine the acceptability of medical task-shifting to MPA among the general population.
Methods: In a nationwide, representative telephone survey, 6105 persons aged 18 or older were asked whether they would be willing to receive care from a specially trained MPA at a physician’s office. Their responses were tested for correlations with sociodemographic characteristics by means of bivariate (chi-squared test, Mann–Whitney U test) and multivariable statistics (logistic regression).
Results: Of the respondents, 67.2% expressed willingness to accept the shifting of MT to an MPA for the treatment of a minor illness, and 51.8% for a chronic illness. Rejection of task-shifting was associated with old age, residence in western Germany, and citizenship of a country other than Germany. For example, non-Germans rejected task-shifting more commonly than Germans, for both minor illnesses (odds ratio [OR] 2.96; 95% confidence interval [2.28; 3.85]) and chronic illnesses (OR 1.61; [1.24; 2.10]).
Conclusion: Further studies are needed to investigate the motives for rejection of medical task-shifting to MPA in order to assess the likelihood of successful nationwide introduction of a uniform delegation model.
Task-shifting from doctors to members of various non-medical specialized professions is routine practice in the Anglo-Saxon countries and Scandinavia (1, 2). In Germany only narrowly defined medical tasks (MT) are delegated, mostly to Qualified Medical Practice Assistants (MPA) (eBox) (3, 4). Although the concept of redistributing certain medical activities has existed since 1975 (5), the requirements, as well as the services eligible for delegation, were first defined in 2013 (6). The prerequisite of delegating tasks is supervision by the physician who has the authority to issue instructions. She or he has the duty of selection, instruction, and supervision (5) and retains full responsibility.
The reallocation of MT to MPA is considered a practicable strategy to counteract the consequences of demographic change and shortage of physicians, especially in rural areas. The aim is to create structures that make it possible to maintain the quality of care and simultaneously alleviate doctors’ workload (2, 7, 8).
In recent years in Germany, various training models have been used to qualify MPA to take over tasks eligible for delegation and equip them to carry out specific tasks (7, 9). In evaluating these projects the perspectives of the participating physicians, MPA, and patients on the delegation have been studied (7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18). Altogether the results show that delegation was broadly acceptable to all participants (15, 18, 19). Almost nothing is known, however, about attitudes in the general population, independently of previous experience.
For Germany, the results of two survey studies are currently available: Höppner’s purely descriptive study on the basis of a representative population survey carried out in 2007 shows that about half of the participants were prepared to consult an MPA instead of a physician for minor illnesses (e.g., colds, gastrointestinal problems, or headache) (20). Data from a nationwide survey of members of the National Association of Statutory Health Insurance Physicians (KBV, Kassenärztliche Bundesvereinigung) in 2017 indicate a greater readiness to be treated by an MPA for minor illnesses than for chronic disorders (21). The KBV survey was the first to ask participants explicitly whether shifting of MT to a specially trained MPA, without any direct contact with a doctor, was acceptable. To date the results of the KBV survey are available only in a descriptive format, rather than embedded in studies (21). The extent to which an expansion or nationwide introduction of such delegation models might be successful in Germany can be assessed only on the basis of more detailed insights into the population’s acceptance of the shifting of MT to MPA. Our aim was to study this aspect on the basis of the following specific questions:
- Which population groups refuse the shifting of medical tasks to MPA in the event of a minor illness?
- Which population groups refuse the shifting of medical tasks to MPA in the event of a chronic illness?
To answer these questions we conducted telephone interviews with German-speaking residents aged 18 or older during the period 15 May 2017 to 27 June 2017. The weighted sample is representative for this group and comprises 6105 persons (Table 1). For the group of German speakers of non-German nationality, the representativeness is limited (eMethods). Study participants were asked whether they were prepared to receive healthcare from an MPA, for a minor or for a chronic illness, without contact with a doctor (eMethods).
Willingness to be treated by an MPA for a minor illness
Two thirds of participants (67.2%; 95% confidence interval [66.02; 68.38]) would agree to receive care from an MPA for a minor illness, 27% would not do so, and 1.5% reported previous experience of receiving care from an MPA (21). In the bivariate analyses, sex, age, educational attainment, employment status, region, nationality, and subjective state of health were significantly associated with willingness to receive care from an MPA (Figure 1). Persons without German nationality (“non-Germans”) were twice as likely as German nationals to refuse care from an MPA. Respondents aged 65 or older were unwilling to accept task-shifting to an MPA significantly more often than those in the 18–34 age group (Figure 1).
The multivariable analyses confirmed the following associations: non-Germans (odds ratio [OR] 2.96; [2.28; 3.85], those older than 65 (OR 1.76; [1.37; 2.55]), women (OR 1.53; [1.34; 1.74]), residents of western Germany (OR 1.26; [1.07; 1.48]), and persons in subjectively poor health (OR 1.37; [1.16; 1.63]) refused care from an MPA more frequently than the members of the respective reference groups, as defined in Table 2. Education-specific associations and association with employment status were not seen in the multivariable analyses.
Willingness to be treated by an MPA for a chronic illness
Of the participants with chronic illnesses, 51.8% [50.55; 53.05] were willing to receive care from an MPA, while 38.7% were unwilling. The proportion of participants who reported that they were already receiving care from an MPA for their chronic illness was 1.3% (21). Bivariate analysis of sociodemographic characteristics revealed that the following factors were significantly associated with the acceptance of task-shifting to MPA (Figure 2):
- Educational attainment
- Employment status
- Subjective state of health
- Chronic illness
Similar to the question about task-shifting for minor illnesses, older age groups were more critical than younger people, and more non-Germans than German nationals refused to accept MPA performing MT. Those with limited formal education (general or intermediate secondary school leaving certificate) were more inclined to be critical towards task-shifting from doctors to MPA than those with a higher formal education. Persons with a pre-existing chronic illness were more likely to reject task-shifting to an MPA (Figure 2). The associations between the acceptability of task-shifting to an MPA and age, nationality, region, and educational status persisted in the multivariable analyses. Persons older than 65 (OR 1.64; [1.24; 2.18]), non-Germans (OR 1.61; [1.24; 2.10]), residents of western Germany (OR 1.21; [1.04; 1.40]), and those with limited formal education (OR 1.20; [1.04; 1.39]) rejected task-shifting from physicians to MPA significantly more often than persons in the respective reference groups (Table 2).
The results show a mostly positive attitude among the population towards reallocation of MT from physicians to MPA. Two thirds of those questioned were willing to receive care from an MPA for minor illnesses, as were slightly more than half of those with chronic illnesses, in each case without contact with a doctor. It is difficult to compare these results with those of studies from other countries, because the healthcare and training systems in Germany differ greatly from those elsewhere. In the Anglo-Saxon countries and Scandinavia, for example, MPA have been well integrated into medical care for several decades (22, 23). In Germany to date—except in the study reported by Höppner (2008) (20)—only persons who had already agreed to delegation of MT have been studied (1, 14, 15, 18, 19, 24). The data confirm that such patients predominantly rated task-shifting as positive (1, 24).
Comparison of the study reported by Höppner with data from 2007 and the present survey from 2017 shows that the proportion of people in favor of task-shifting from physicians to MPA has notably increased over 10 years. While in Höppner’s study 51% of participants were willing to receive healthcare for minor illnesses from specially trained MPA instead of a doctor, in our survey the proportion was 67%. For chronic illness the proportion of persons in favor of task-shifting from doctors to MPA had more than doubled: in 2007, 20% of survey participants were willing to entertain the idea of receiving healthcare from specially trained MPA (20), by the time of the KBV survey in 2017 the figure had risen to 52%.
In the Höppner study men were more critical than women of task-shifting from physicians to MPA, whereas in the KBV survey more women objected. The question of whether these results related to changed attitudes between the sexes or methodological differences (telephone survey versus written questionnaire; bivariate and multivariable analyses versus descriptive analyses) cannot be answered at this point. An earlier study of ours on the most commonly articulated complaints of patients in the German healthcare system showed, however, that women were more critical about different aspects of healthcare services than men. Based on a quantitative content analysis, we studied 13 505 letters of complaint sent to the federal government’s patient representatives during the period from 2004 to 2007. The results revealed that women criticized individual areas of healthcare provision, e.g., the prescription of medical services or the doctor–patient relationship, significantly more often than men (25). In analogy to the Höppner study, in our 2017 survey too, those with limited formal education (general or intermediate secondary school leaving certificate) were more critical towards reallocation of MT to MPA than those with a higher level of formal education. After the multivariable analysis, however, those with a limited formal education objected to task-shifting from physicians to MPA significantly more often than those with a higher education level only in the chronic illness setting. The acceptance of task-shifting from physicians to MPA for minor illness was no longer significantly associated with educational status.
The additional stratified evaluations of the survey show that especially non-Germans, persons living in western Germany, and those over 65 years of age objected to task-shifting from physicians to MPA significantly more frequently than their counterparts in the respective reference groups. Possible reasons for this are cultural and age-related attitudes and preferences vis-à-vis the doctor–patient relationship. Different studies in German found a rather paternalistically determined perspective on this relationship in patients with a family background of immigration from Turkey (26) and in Russian-speaking immigrants (27, 28). It is plausible that redistribution of MT from physicians to MPA is regarded more critically among those who have internalized the idea of a paternalistic doctor–patient relationship to a greater extent. The rejection of task-shifting to MPA that was noted among older patients is consistent with the findings of the Höppner study (20). Here, too, the reason may be a more paternalistically determined concept of the doctor–patient relationship (29). A possible explanation for the positive attitude of people living in eastern Germany is that in the former German Democratic Republic (GDR), community nurses providing much of the patient care in rural areas had been part of the healthcare service since the 1950s, and this role was reintroduced by means of the AGnES project in 2005 (18, 30, 31). People who experienced life in the GDR can therefore be assumed to be more familiar with the delegation of MT from doctors to MPA, so general acceptance of the task-shift was greater in the present study.
While the focus of our study was on attitudes towards task-shifting among the general population, other studies in Germany have investigated the perspectives of primary-care physicians or MPA towards delegation. Here too, those questioned showed a predominantly positive attitude (32, 33, 34).
Experience in other countries points towards a global trend away from the delegation of individual tasks towards more cooperative styles of working, but in Germany this process is currently still subject to delays because of traditional role concepts, legal frameworks, and the existing billing/reimbursement systems (35).
As regards the effect of and evidence for delegation models in primary medical care, a systematic review showed positive effects in terms of patient satisfaction and rates of hospital admission and mortality (36). Against this background and in view of the results presented here, it seems promising to press ahead with the transfer of MT to MPA. One way forward might be the development of a nationwide standardized delegation model that allows the allocation of treatment for minor illnesses to MPA. The scope and content of such tasks could be elaborated in an interprofessional workshop, as outlined by Egidi et al. (34). In that study, doctors and MPA jointly developed examples of treatment pathways for four consultation scenarios (flu-like infection, gastrointestinal infection, tick bite, request for prescription) that had previously been classified as “trivial” in a scored survey (34).
Because the survey of the KBV was a cross-sectional study, only data on current attitudes could be collected and no deeper motivations could be researched.
A further limitation of our study lies in the fact that we investigated only the general willingness of the population as regards task-shifting from physicians to MPA, but did not differentiate in detail between the delegation and substitution of healthcare services. The questions captured only whether subjects would consent to receiving healthcare from an MPA without any further doctor–patient contact. We did not investigate whether the MPA consulted the doctor—that is, acted on the doctor’s instructions—or whether the doctor would have oversight and responsibility. It is therefore not clear whether subjects’ agreement to receiving healthcare from an MPA relates only to the situation where the ultimate oversight and responsibility lies with the physician (delegation) or whether it also relates to a scenario in which the MPA treat patients independently, without supervision, and on their own responsibility (substitution). Further studies are needed to answer this question.
The data were collected by telephone, and only people with a landline were contacted (21, 37). This meant that mainly older persons rather than younger ones were reached (38). Telephone surveys are also associated with a high degree of standardization. It was not defined, for example, what was meant by “minor illnesses” or which tasks the specially trained MPA were going to take over in treatment of minor or chronic illnesses at the physician’s office without any contact between doctor and patient.
A further limitation is that adequate proficiency in German was required in order to participate in the KBV survey; consequently, attitudes towards task-shifting from physicians to MPA among non-Germans with no knowledge of German remains unclear. Since our results show that it was primarily non-Germans who were critical towards task-shifting to MPA, we would, for future surveys, recommend formulating the questionnaires of the KBV surveys in different languages and with sensitivity to persons with a migration background.
In the present study, we were able to undertake regional analyses based on community size and location in eastern or western Germany. For future studies, one might consider linking the findings with structural data, e,g., employment or unemployment rate, in order to generate a regional index (39, 40) and thus arrive at even more meaningful regional results.
Our population showed a high degree of willingness to agree to the redistribution of MT to non-medically trained personnel, e.g., receiving treatment from MPA. It therefore seems worthwhile to develop a consistent nationwide delegation model that permits the treatment of patients with minor illnesses, e.g., coughs and colds, to be transferred to MPA. The feasibility, acceptance, and outcome of such a model could be tested in a pilot study. We recommend taking into consideration the results of the present study.
Particularly the reasons for rejection of task-shifting to MPA by older survey participants, non-Germans, and those with limited formal education should be researched further. The insights thus gained will help to shape the basic and advanced training of health professionals.
The study is part of the NAVICARE project, which is funded by the Federal Ministry of Education and Research (BMBF) in the context of the focus on structural development in health services research (funding code 01GY1601).
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 24 September 2019, revised version accepted on 18 February 2020.
Translated from the original German by Birte Twisselmann, PhD.
PD Dr. rer. medic. Susanne Schnitzer
Institut für Medizinische Soziologie und Rehabilitationswissenschaft
Charité-Universitätsmedizin Berlin CC1
Virchowweg 22, 10117 Berlin, Germany
Cite this as
Jedro C, Holmberg C, Tille F, et al.: The acceptability of task-shifting from doctors to allied health professionals—results from a representative telephone survey of members of the National Association of Statutory Health Insurance Physicians. 117: 583–90.
Institute of Social Medicine and Epidemiology, Brandenburg- Universitätsmedizin Theodor Fontane, Brandenburg an der Havel: Prof. Dr. phil. Christine Holmberg
National Association of Statutory Health Insurance Physicians (KBV), Berlin: Dr. rer. medic. Florian Tille
Molecular Epidemiology Research Lab, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin: B.Sc. Jonas Widmann
Institute of Biometry, Charité–Universitätsmedizin Berlin: Dipl.-Biomath. Alice Schneider
Institute of General Medicine, Charité–Universitätsmedizin Berlin: MPH Judith Stumm, Dr. med. Susanne Döpfmer
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