Skill mix in primary care, working hours, time used on management, and burnout among general practitioners

BackgroundDecades of under investment in primary care and inattention to suboptimal recruitment and retention of GPs and nurses have contributed to a workforce crisis. The General Practice Forward View sets out how the government is planning to achieve a strengthened model of general practice. A key element of this proposal is to expand the workforce by employing an increasingly diverse range of practitioners i.e. ‘skill mix’. The commitment to broadening skill mix in primary care is reiterated in the NHS Long Term Plan (LTP), with the announcement of a 5-year deal to boost investment in primary care. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.AimThis presentation offers an early analysis of the scale and distribution of current skill mix in general practice across England. This is part of a wider study about how skill mix is affecting outcomes, costs, and experiences of healthcare in England.MethodDescriptive analysis of a longitudinal practice-level workforce data set using the practice-level workforce Minimum Data Set (wMDS).ResultsWe will present early findings about how staffing has changed and average changes within a region or a clinical commissioning group.ConclusionThese data will indicate the extent of progress towards achievement of the LTP vision of skill mix employment. Findings will inform our future analysis of the structures, contexts, and processes of these new ways of working and provide policymakers, commissioners, and practices with evidence about the wider effects of skill mix.

Skill mix in primary care should be governed by research-based evidence of how skills may best be distributed among health professionals in order to optimize the cost-effectiveness of health service delivery. There is a dearth of research in this area, yet many changes in skill mix within primary care have still to be adequately researched. Existing evidence of the nature and cost-effectiveness of skill mix change is scattered across the specialist literature of many different disciplinary groups, making it difficult to form a coherent overview of service provision. This paper reports on a project that sought to create a comprehensive database bringing together specialist literature relating to skill mix in primary care, as resource for health services researchers, providers and purchasers in the UK.

BackgroundDue to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation.MethodsA qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP.ResultsEmployment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs’ caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs.In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees’ motivation to start the master’s programme and GPs’ prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking.ConclusionsRole standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.

This literature review focuses on patient satisfaction with skill mix in primary care. This is an important, rapidly changing, topic as the range of health professionals working alongside GPs increases and the roles of staff change. The review is intended to assist primary care organizations in developing skill mixes that meet patients' preferences and needs.A number of characteristics that influence the type of services that patients want were discovered. Older people and those from ethnic minorities want a ‘traditional’, GP-led service. Access is important to younger people and those in full-time work. Those from lower socio-economic groups value nurses, but have found the increasingly complex organization of services a problem. There are different levels of knowledge and expectations about health services and information on the skills and knowledge of professionals, what they do and the links between them, needs to be available.A number of aspects of care are important to patients. Patients liked nurses as they were good communicators, formed good therapeutic relationships, gave information on illnesses and spent more time. The location of services is important and patients liked services provided in the home or community. Continuity of care is key, but has been presented as old fashioned and reorganizations may have reduced continuity; skill mix could be viewed as forming a barrier between doctor and patient, but personal lists and teams where practices are divided into smaller units with shared support may help. The competence of health professionals is clearly vital and patients considered nurses competent, although they had concerns about nurses and pharmacists taking on some new roles.The literature focuses on patients' views about doctors and nurses, although they also want a wider range of services and professionals available in primary care: occupational therapy, link workers, CAB advisers, pharmacist advice and mental health workers. Despite being satisfied with nurses, some patients still wanted to see a doctor next time or felt that a doctor should be available. GPs can help build awareness and confidence in patients about the roles and contribution of the team.

Subjects that breed euphemisms are usually contentious, and skill mix (reprofiling, grade mix, and multiskilling) is no exception. In her recent review of the topic, Leone Ridsdale has provided us with a much needed synopsis of the debate.1 The pursuit of skill mix in the new NHS has divided managers and health care professionals. With staffing accounting for 70% of NHS spending and managers under pressure to cut costs, the attractions of giving tasks to the lowest grades of staff who can perform them are obvious. In such an environment professionals fear the gradual erosion of the quality of care2,3 and trade unions see the spectre of redundancy.4 The debate over skill mix has heightened the belief among health professionals that managers do not understand the complexity of their knowledge and skill.5 The dangerously simplistic approach of the NHS Value for Money Unit's report Skill Mix in District Nursing did nothing to allay these fears.6 District nursing was reduced to a series of mechanistic tasks that could be counted and reallocated. In this model of skill mix highly qualified, …

The study described in this paper is set against a background of rapid changes in primary (community) care delivery in the United Kingdom (UK) and consequently the methodology of the study has been shaped by three broad issues - workforce changes, increase in workload and changing roles and boundaries. Ten 'ordinary' general practices (general practitioners (GPs) and the 'attached' community nurses) participated in the study and a large amount of data were collected over a 2-week observation period. Three study objectives are described, relating to workload, delegation and attitudes to delegation. The characteristics of the workload of the three main groups of community nurses (practice nurses, district nurses and health visitors) are described and compared. Thirty-nine per cent of all the GP consultations (836) had a delegatable element and 17% were deemed to be delegatable in their entirety. General practitioners most frequently referred to delegation to practice nurses in the current team and nurse practitioners in an enhanced team. The study identified the activities most amenable to delegation to these two groups of nurses. Attitudes to delegation were sought through focus group discussions, with reservations being expressed by both doctors and community nurses. This study provides evidence that GPs are prepared to delegate a considerable proportion of their workload; this clearly has implications for the nursing profession.

Reforming England's National Health Service

A study of the interface between general practitioners and other members of the primary health care team.

Background General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment. Limitations These findings may reflect turbulence during a period of rapid skill mix change in general practice. The current policy of employing staff through primary care networks is likely to accelerate workforce change and generate additional challenges. Conclusions Skill mix implementation is challenging because of the inherent complexity of general practice caseloads; it is associated with a mix of positive and negative outcome measures. Future work Findings from this study will inform future funding applications for projects that seek to examine the nature and impact of evolving multiprofessional teams in primary care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

Paying the price for quality in primary care

BackgroundIn primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs.AimThe aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers.MethodsAn operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: “No Skill Mix”, “Minimal Direct Access”, “More Prevention” and “Maximum Delegation”. The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England.ResultsThe operational research model suggested that 73% of clinical time in England’s state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:“No Skill Mix”, the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: “Minimal Direct Access”, where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. “No Skill Mix”. Scenario 3: “More Prevention”, that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. “No Skill Mix”. Scenario 4 “Maximum Delegation” where all care within dental therapists’ jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. “No Skill Mix”.ConclusionAlternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce.

EDITOR, - Iona Health emphasises that decisions on changes in skill mix should be driven by needs and not costs.1 At a time when demand for services is outstripping supply, however, an eye to costs is wise. The rapid development of the role of practice nurses was spurred by the availability of finance (reimbursement of 70% of the salary costs; the nurses perform fee for service tasks; and reimbursement for health promotion work) at least as much as by patients' needs. Practice …

Nurse staffing levels in American hospitals: A 2001 report

There is a general consensus that there is a crisis in general practice in the UK with a ‘perfect storm’ of workload pressures, inadequate funding, and low morale. Responding to a catastrophic fall in recruitment and poor retention of experienced GPs, a national 10-point ‘general practice workforce action plan’ has been laid out by NHS England (NHSE).1 Health Education England commissioned Professor Martin Roland to chair a Primary Care Workforce Commission to gather evidence and make recommendations not only to address the current crisis, but also to project forward and attempt to ‘future proof’ the profession. Proposed changes are intended to support the development of ‘a modern primary healthcare system’ in the context of ‘challenging and fulfilling careers for health professionals’, and maintaining pride in the ‘standard of care’ delivered to patients.2 Professor Roland has the right credentials for the job, having maintained a clinical workload as a GP alongside his distinguished academic career. Furthermore, during his leadership, the National Primary Care Research and Development Centre undertook a portfolio of studies addressing primary care workforce issues, including skill mix in primary care, equity in the geographical distribution of GPs, and GP satisfaction and work stress.3–6 In this Commission, his team of equally experienced colleagues, academic GPs, and external experts took evidence from a wide range of bodies, including individual GP practices, clinical commissioning groups (CCGs), national bodies such as the Family Doctor Association and the Royal College of Nursing, and charities such as National Voices, and made site visits to observe innovative practices and organisations. The focus of these recommendations is on ‘primary care’ rather than general practice, but, while the report rejects uniformity in favour of locally appropriate variations, it identifies GP practices as vital units in the coordination and delivery of safe and …

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper