An investigation of skill mix in primary care
Research type
Research Study
Full title
An investigation of the scale, scope and impact of skill mix change in primary care
IRAS ID
244153
Contact name
Sharon Spooner
Contact email
Sponsor organisation
University of Manchester
Duration of Study in the UK
2 years, 0 months, 0 days
Research summary
Research Summary
Many general practices are finding it difficult to recruit additional doctors (GPs) to deal with their increasing workload. Practices are therefore employing a wider range of types of health care professionals in a change that is generally referred to as ‘skill mix’ and which aims to ease pressure on GP appointments.
Patients can consult directly with non-GP practitioners; nurses who prescribe medicines, pharmacists who advise about medications; or a newer type of practitioner called ‘physician associate’ for help with a diagnosis and advice about treatment.
However, there is limited information about how patients may experience care differently when non-GP practitioners are introduced or how this change affects the quality and costs of care. We also need more information about how practitioners from different backgrounds work together and whether supervision or duplication of work may limit the extent to which their employment reduces GP workloads.
To find out about this, we will first look at the ‘big picture’ of what happens when GP practices employ new types of practitioners. National data will tell us how widely change in skill mix is happening in GP practices and we can look at how that change may affect what happens; e.g. how many patients are referred to hospital specialists or given prescriptions.
To get more information we will talk to practice staff about how practitioners work together, and we will ask patients whether they like these new roles and if they know how to get most benefit from them. We will ask GPs and Practice Managers about why they choose to employ different types of practitioner and what they expect them to do.
The combination of these research activities will tell us about the consequences of changes in skill mix and help to identify how practices and patients can benefit most.Summary of Results
Background Recruitment and retention of GPs have fallen behind increasing demand for primary healthcare 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 patients' experiences, and how skill mix changes are associated with outcome measures and costs.Design
NHS Digital workforce data (2015-2019) was used to analyse employment changes and look at their association with outcomes data such as GP Patient Survey, GP Worklife Survey, Prescribing, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August-December 2019) explored factors motivating GP practices’ employment decisions. An in-depth case study of five GP practices in England (August-December 2019) examined how a broader range of practitioners is experienced by practice staff and by patients. We conducted interviews with staff and observed them at work. We asked patients about their experience of booking and having an appointment with different types of practitioners.Results
We found a 2.84% increase in reported full-time equivalent (FTE) per thousand patients across all practitioners during the study period. The FTE of GP partners decreased while FTE of salaried GPs, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. GPs and practice managers reported different motivating factors regarding skill mix employment; GPs saw it as a strategy to cope with a GP shortage while 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, supervisory and other responsibilities, and analysis of the GP Worklife survey data suggested that GPs’ 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, GP patient survey data indicated that higher patient satisfaction was associated with higher GP FTE. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. FTE per thousand patients). Higher clinical pharmacist FTEs per thousand 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.Conclusions
Skill mix implementation is challenging due to the inherent complexity of general practice caseloads and is associated with a mix of positive and negative outcome measures.REC name
North West - Greater Manchester South Research Ethics Committee
REC reference
18/NW/0650
Date of REC Opinion
23 Nov 2018
REC opinion
Further Information Favourable Opinion