Results

The global response rate was 71.7%, representing a total of 519 family doctors. Some 43.5% (226) of them practice in the Madrid region, and 56.5% in the Andalusian region. No significant differences were found between respondents and non-respondents when independent variables such as age, gender, and each region's health service were considered.

Table 1 is a descriptive sample of the main independent variables used in this study. Some 73.3% of GPs surveyed are below 40 years of age. For the variable years of professional activity, more than half the GPs (54.1%) had been practising for less than 15 years. Moreover, 77.6% of them had been practising in a PCT for less than five years.

EVALUATION OF THE IMPORTANCE OF DIFFERENT SOURCES OF INFLUENCE

The concept of “importance” refers to the effectiveness of different strategies or sources of influence in provoking changes in professional practice. According to the results obtained from this question (see table 2, distribution of mid-ranges), the most important source of influence was attendance at training courses, reading articles and reports (some 60% of the sample ranked this source first in the score of importance). In second place was the establishment of self developed protocols produced by the health centre's professionals. In third place we found discussion with colleagues on how to handle a given health problem, and occupying last place in the ranking was the existence of financial incentives and information provided by pharmaceutical company representatives.

Table 3 shows partial correlation coefficients and the statistical significance level for each one of the variables of the response variable for “importance.”

For female GPs and younger GPs of both genders, attending training courses and reading articles and reports is significantly more important as a factor for change in their professional practices than it is for male GPs and older GPs of both genders.

GPs who serve as health centre directors see the implementation of self developed protocols, or clinical guidelines agreed upon by the health centre's professionals, as more important in influencing medical practice than others who do not occupy managerial positions. GPs who dedicate more time to bibliographical sessions and continuing education also consider these protocols to be more important than do others who dedicate less time to such activities.

GPs who identify themselves more strongly with the feeling of being part of a medical professional system, compared with a health organisation, consider their discussions with colleagues to be a more important factor for change than do companions who identify less strongly with this sentiment.

The implementation of protocols coming from the managerial level is more important to female than to male GPs. For those working in a temporary employment situation, the existence of such protocols exerts a more important influence on their medical practice than on companions working under permanent contracts. For GPs in centres authorised to provide undergraduate and resident training, their implementation is less important than for their counterparts in non-authorised centres.

The existence of financial incentives as a change mechanism is more important to men than to women. Furthermore, GPs in an unstable employment situation consider them to be more important than do those working under permanent contracts. We also learned that GPs with a large number of publications think such incentives are more important than those who publish less. In another comparison, we found that GPs who belonged to teams with a high degree of group cohesion considered incentives to be less important than those working in less cohesive groups.

Older GPs and those who spend more time in appointment-based clinics, consider information provided by pharmaceutical company representatives to have a more important influence on their professional practice than younger GPs and those who spend less time in such clinics. Among GPs whose sense of belonging to a medical professional system was greater than their feeling of being part of a health organisation, this information was deemed to be less important.

EVALUATION OF THE LEGITIMACY OF DIFFERENT SOURCES OF INFLUENCE

Figure 2 shows the opinion on “legitimacy” given by respondents as related to different strategies, groups and/or institutions exerting some influence on medical practice. The graph shows the mean scores (and standard deviation) obtained for every item. The first five sources of influence considered to be more legitimate correspond to elements of the “professional system.”

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Figure 2

Legitimacy of different sources of influence on medical practice.

Table 4 shows partial correlation coefficients and the degree of statistical significance for the “legitimacy” variable. Scientific organisations are considered by GPs with postgraduate training and those with a greater level of employment satisfaction to have more legitimacy to influence medical practice. Professional associations are considered more legitimate by doctors with postgraduate training and by those practising in the Madrid region. Academic institutions are perceived as less legitimate by GPs in centres authorised to provide resident training. However, they are viewed as being more legitimate by health centres' directors and those spending more time in appointment-based clinics. Politicians are viewed as being more legitimate by health centres' directors as well as by GPs who feel that they belong to a health organisation. GPs in an unstable employment situation consider them to be less legitimate in so far as influence on their work is concerned.

Health services' managers are considered to be more legitimate by GPs who spend more time in appointment-based clinics and by those who feel that they belong more to the health organisation than to the medical profession. Older GPs consider them to be less legitimate to influence their professional practice. Financial incentives are less legitimate for GPs attending a greater number of patients per day, for those spending a greater number of hours in appointment-based clinics, for female GPs, and for GPs practising in teams with a greater degree of innovation. The pharmaceutical industry is considered to be less legitimate by some doctors who have completed their residency training and by some GPs who feel that they belong more to the organisation than to the profession.

Table 5 summarises the way different independent variables show statistically significant differences for every one of the sources of influence on medical practice.

Discussion

The response rate (71.7%) is considered to be acceptable, especially as this type of study usually has a lower one. We believe this high degree of participation is determined, to a great extent, by the fact that questionnaires were collected by hand. Furthermore, the study of social and demographic characteristics of non-respondents (age, gender, and health service) showed no significant differences in relation to respondents. Thus, it can be assumed that the non-response bias does not significantly affect this study's conclusions.

When the two samples of GPs from the study's different regions were analysed in relation to the variables presented in this study, both showed similar characteristics.

It should be noted that our results have some limitations as we collected GPs' opinions, rather than straightforwardly “observing” or “measuring” concrete behaviours or practices. The advantage of this approach is that it enabled us to consider a large number of aspects related to professional practice that otherwise could not have been evaluated. However, such an approach is also subject to the usual limitations that affect studies based on the opinions of an individual as it tends to reflect widely held social values rather than the participants' own real opinions. The social sciences define this as the social desirability bias. Consequently, these results express different legitimised systems of values17-19 that predominate among primary care GPs in Spain.

GPs included in the survey carry out their tasks within a multidisciplinary teamwork scheme. This model of care, based on the health centre concept, currently covers 60% of Spain's population. These teams are called PCTs, and include family doctors, paediatricians, nursing staff, and other professionals. This model adopts preventive functions at both the personal and community health level. Family doctors have a list of 2000–3000 people assigned to them. Patients are free to choose their doctor. Professionals work full time (40 hours a week) on a salary basis with small financial incentives (10% to 25% of their gross salary) depending on capitation, whether they work in rural areas, and so on. In addition to daily surgery time for all patients, they usually provide specific appointment-based clinics where more time is reserved to attend previously identified complex patients. GPs working under the “old model,” and who only provide curative care on a part time basis, have not been studied.20

Despite the limitations mentioned above, we consider the results of this research to be similar to those of other studies and theoretical approaches to the medical profession.14 18 21 22 We observe that the main sources of change that influence the way doctors practise their profession, both in terms of importance and legitimacy, come from the professional system setting (training courses, scientific articles and reports, colleagues, professional associations, etc). The research also shows that strategies developed at the managerial level, such as compulsory implementation of protocols, financial incentives, reviews and audits, or the part played by health managers, are considered to be less important and less legitimate by professionals.

The main differences found according to GPs' gender are consistent with the results of other studies on the issue.23-25Female GPs accept the existence of protocols coming from the managerial level more easily than their male counterparts. This suggests they have a more integrated concept of professional practice, one which enables them to accept input from other staff members and professionals within the health system, not just from doctors.

Moreover, the greater legitimacy assigned by women GPs to internal audits leads us to believe that it would be easier to implement quality improvement strategies in predominantly female teams. In contrast, male GPs rank the existence of financial incentives higher on the score of importance than female GPs. Age also shows differences as to the importance and legitimacy assigned to the “organisational setting.” Younger GPs consider external audits or health managers to be more legitimate than do older doctors, which might suggest a distinct conception of professional practice that enables them to “allow” other professionals to “control” or collaborate with them in their work.

It is interesting to note that in relation to gender and employment, female GPs and GPs in an unstable employment situation evaluate an important management instrument, top-down implementation of protocols, more highly than other alternatives. This may be because of two important factors that determine the development of medical practice in Spain: (a) the increase in the number of women entering the labour (and health) market, and (b) that approximately 50% of all GPs are in an unstable employment situation. Furthermore, both groups (women and GPs under temporary contracts) together with those who have a greater workload (greater number of patients and more hours in appointment-based clinics) more negatively evaluate another key instrument in today's management culture, financial incentives.26 27 This may have to do with the doctors' perception that economic incentives in Spanish primary care are small.28

These reflections could prove useful for implementing change within the health services. Reforms are almost exclusively focused on managerial actions, whereas the content of medical professional practice is defined and regulated through the GPs' “professional system” (as is the case in other professions that occupy powerful positions within the system). In so far as GPs are concerned, the design and/or implementation of any type of strategy aimed at modifying decision making must first take this reality into account.

Efficiency and quality levels in the health services will increasingly be influenced by management's capacity to facilitate the implementation of specific approaches to change or to get actions adopted or modified within that set of professional practices that constitute medical behaviour.29

In the future, health management will have to introduce new elements designed to ensure both the global quality of the process and its efficiency in terms of cost of care.10 The concept of quality is thus being redefined via a limited interpretation (precise and correct treatment of organic diseases) and will include aspects such as patients' personal care, the provision of adequate information, politeness and emphasis on tangible aspects within the health care framework. Clearly, the current concept of quality incorporates users' satisfaction as an essential element.

Social and cultural changes will oblige management staff to deal with other elements of the physician-patient relationship, particularly those not directly rooted in purely clinical aspects of care. Such elements, in addition to being more subtle and sensitive, are also more difficult to measure and evaluate. In such a context, hardline business management techniques could have an undesirable effect on the physician-patient relationship. Managers will have to adopt workplace strategies that bolster the motivation of health care professionals. They will also have to appropriately coordinate elements such as: other professional groups (through elements of internal marketing)30; users' global satisfaction (external marketing)³¹; effective management of available resources (econometric techniques); increased activities in prevention and public health (with special emphasis on newly emerging health problems)32; etc. This panorama presents a very complex social and health setting, one in which it will be increasingly necessary to introduce new studies that contribute to providing more efficient guidance on the part to be played by the health services.

The theoretical approach proposed here needs to be complemented with other more specific or global ones that incorporate studies on human behaviour such as: the theory of reasoned action33 and the theory of social learning,34 the dynamics of organisational change,35 and other similar sociological approaches that consider the configuration of different “social practices” as socially constructed models of behaviour.21

The opinions expressed by GPs, which were an important contribution to this paper, should help us to reflect on the suitability or relevance, or both, of different managerial strategies that have been implemented in the health system. These results could lead us to raise key questions such as whether health services management should be more oriented toward individual behavioural aspects,36 for example, financial incentives, or whether it should have a more global focus, for example, by promoting change in and from that set of norms and values that regulates the medical profession and is known as the “professional system.” These conclusions should especially be taken into account when planning changes in professional practice.