Table 3 Situations that are perceived as crises by primary care teams and selected representative citations

a) Internal crises in practices

 Breakdown of technical infrastructure

For example, caused by a blackout, technical devices like computer or telephone are out of order. Furthermore, failure of single technical devices such as the insurance card reader or a software used for electronic health record can cause a crisis for a practice. In this context a virus or hacker attack was named as well

“[…] if this stupid card reader doesn’t work right now, then I don’t know what to do […] And of course that’s another crisis.” (SP1_Int22)

 Disputes with patients or within the team

This ranges from patients that show dissatisfaction or verbal complaints up to offences, abuse and even violence against the practice staff. Aggression of patients was described to be an increasing problem in practices. Besides this, lawsuits, medical errors and negative ratings of practices on the internet that cause patients to choose a different practice for treatment are named as crises

Furthermore, personal differences may occur within the team and can lead to practice split-ups in the worst case

“But you’ve also been spat at in the practice. […] Yes, well, there is also this kind of patients who don’t accept things, who then become really abusive and insulting.” (SP1_Int14)

 Damage to the building

Water damage, burglary or a damage/dysfunction of an elevator implying barriers of reachability for patients with walking disabilities can be seen as an internal crisis

“water damage in endoscopy, yes, that’s a crisis.“ (SP1_FG2)

 Medical emergency

Medical emergency situations on patient level, like a heart attack or a stroke were mentioned. This was primarily named by practice staff that announced a lack of knowledge in handling these specific situations

„Reanimation, resuscitation, in other words, life-threatening emergencies, […] Let’s summarize it like this. That is literally also a crisis.” (SP1_Int23)

 Inspections

Some participants described a visit for inspection, e.g. hygiene inspections conducted by a health department or similar, to be a crisis for them as these visits cause a high workload in advance and may bring organisational consequences for the practice when deficiencies are being identified

“[…] but it actually also fits a crisis: the announced visit of the health department to check the practice.” (SP1_Int2)

 Staff shortage (temporary)

Temporary staff shortage may be caused by acute illness of staff, pregnancy and maternity leave or longer lasting illness. Some participants even described situations as a crisis that are actually not extraordinary, just because of a lack of staff to cope with it

“[…] a few years ago quite a lot of medical assistants became pregnant [laughs] five at once, […] and it is generally, if important employees in each level suddenly leave the unit – that does not have to be a big crisis, but it can become one.” (SP1_FG2)

b) Crises on health system level

 Staff shortage (long-term)

Most of the participants mentioned a long-term and increasing staff shortage in medical professions as serious crisis for practices and on health system level. As crises on practice level, retirement of physicians resulting in open job offers and closure of the practice if no replacement can be found was named. This was described to be resulting in a shortage of practices, especially in rural regions, resulting in a higher workload for existing practices. Working conditions were described to be increasingly unattractive. Therefore, participants stated that especially younger staff would prefer to work in joint practices with a good infrastructure. Furthermore, participants mentioned that it is becoming increasingly difficult for them to find well-trained staff. This was specifically named for medical assistants

Staff shortage not only occurs in the practice itself, but was also named to be relevant for nursing homes and ambulance service. Participants perceived that their own workload increases due to a lack of this external staff. This was named primarily by staff of general practices as they have to compensate staff shortage in nursing homes by a higher number of visits

“Well, lack of personnel in the first place. Yes, I see it as quite a big problem everywhere. (SP1_Int_09)

 Supply shortage

Participants named a shortage of vaccines (influenza, covid-19 and other), medication and medical devices as a periodically reoccurring crisis for practices. Especially in the context of the first phase of the covid-19 pandemic, a massive shortage of face masks, disinfectants and other protective equipment was named

“The first major crisis is always supply bottlenecks. We have seen this quite a few times for example with influenza [vaccines] or other important drugs.” (SP1_Int_05)

 Increasing care needs

Care needs are described as increasing steadily and are predicted to keep increasing in the future. This was mentioned in the context of demographic change, an increase in chronically ill and geriatric patients, as well as an increase in patients with mental illness that tend to require a higher need for consultation. Along with this, participants described the increasing care needs to become a crisis especially in the context of increasing staff shortage

Besides these long-term developments, an acute disaster affecting many persons at the same time was also described as possible crisis for practices as they cannot cover to treat an extremely high number of patients

 Changes in health system infrastructure

As changes in the infrastructure of the health system, centralization of health facilities and local relocations were named. Because of these, specific areas might be perceiving a shortage of care facilities (especially in rural areas and districts with high poverty). Few participants described that for example a practice in their neighbourhood decided to discontinue home visits as they bring no financial benefit to the practice. This led to the own practice having to additionally care for these patients by making home visits

“[…] there are of course also, let’s say, structural crises at the local level. Doctors joining forces or pharmacies getting bigger, retail or, let’s say, frequency structures changing, a large medical centre being built somewhere, the clinic spreading out into outpatient care in some form or other, that can of course also be difficult.” (SP1_Int5)

 Digitalization

Digitalization was named as crisis for practices on three different levels. First, participants perceived the transformation itself as a crisis when their technical affinity was described as low. Some mentioned that especially older physicians and medical assistants refused to deal with and implement technical approaches in order to “sit this one out” until they retire. Second, technical affinity was also described as low in some older, chronically ill patients who were said to “get left behind” by the digital transformation process in healthcare. Third, digitalization was named as a crisis whenever the technical devices implemented in the practice failed (see “Breakdown of technical infrastructure”). One medical assistant expressed concern about being replaced by machines in the future

“If you like, this is an approach to solving crises – but the path until digitization is properly implemented can still be a crisis.” (SP1_Int6)

 Social crises

Social crises in general could also affect primary practices. In particular, migration and the care of refugees were named as crises for practices as they perceived a high workload. Along with this, participants named that they had to treat diseases that they have never been confronted with yet, which resulted in a crisis for them

“[Another participant from focus group] mentioned the refugee crisis, because we were very much involved in the care. Partly communication was not possible, I think that some colleagues were also quite afraid when they had to go to the refugee accommodations. So, I think there were actually different things that felt like a crisis […].” (SP1_FG02)

c) Overarching crises

 Epidemic/pandemic

For most participants, the current pandemic of covid-19 was the first and most significant crisis that came to their mind. Besides covid-19, Ebola, H1N1, influenza, gastrointestinal diseases and local outbreaks of paediatric diseases (e.g. in schools or day care) were named. Most of the participants expect further disease outbreaks like the covid-19 pandemic or other, new viruses in the future

„I think that through the climate crisis, […] through the pandemic as a whole, so a lot of things in medicine will change as well.” (SP1_FG1)

 Economic crises

As economic crisis on health system level, a shortage or shift in the payment of health care was feared. Due to social insurances, funding might lack with increasing poverty and unemployment. Besides this, participants concerned that they had to cope with the increasing care needs but will perceive payment cuts at the same time which might lead to redundancies of practice staff. Furthermore, concerns about financial losses due to a predicted decrease of treatments that require out-of-pocket-payment (IGeL), or due to restrictions of funding were described (increasing care needs and decreasing funding rates at the same time)

“An economic crisis may occur.” (SP1_Int5)

 Local disasters

Local disasters such as damage in a nuclear power station or a fire of industrial companies located in the neighbourhood of the practice were named as possible occurring crisis situations

“[…] these fears, well, for example nuclear power plants – we have one in 60 km distance – what else is going to happen? Can this also erupt like Chernobyl? (SP1_Int1)

 Climate change

Some participants already named climate change as an upcoming crisis by themselves and few were even using the term “climate crisis” instead of “climate change”. Some saw consequences of climate change but did not perceive them to be a crisis and a few did not see any consequences for practices at all as they haven’t yet thought about possible impacts of climate change. But generally, climate change was associated with effects on practices on many levels. In this context, heatwaves were mentioned primarily. Many participants already perceived periods of extremely high temperature in their practices. Described consequences were: patients that could not come into their practice during that time, damage on medication that was stored in a badly ventilated room, dehydration or bad health condition of patients and staff, worse health outcomes of patients after (ambulatory) surgery and a slow recovery after sedation, failure of medical technique such as ultrasound, higher workload due to extra home visits and visits of nursing homes with patients suffering from heat-related illnesses, up to the need for an acute shutdown of the practice. Besides heat waves, other extreme weather events such as floods, storms, cold spells, heavy rain or snow, black ice were named as possible consequences of the climate change. Those extreme changes of weather were predicted to increase symptoms of migraine, back pain, gout and arthrosis (weather changes), asthma and COPD (higher humidity) and longer and more intense allergy seasons. An increase of mental illness was named in the context of climate change as well. Only few participants named the occurrence of tropical diseases, but many named an increase of vector-borne diseases and saw a link between new occurring viruses like covid-19 and climate change. A general change in the range of diseases because of changing environment was prognosed. This was also named in the context of forced migration due to climate change. As further consequences of climate change, a shortage in resources such as water, nutrition and power were mentioned

„Climate change or the climate crisis will certainly have an impact on practices.“ (SP1_Int2)