Financial pressures and changing service demands are driving a diversification of staffing in general practice (GP). One policy response has been the drive towards increasing levels of ‘non-GP’ staff in local practices. Here, Dr Pauline Nelson and Professor Damian Hodgson of Alliance Manchester Business School survey the current situation, direction of travel, and the steps needed to achieve GP sustainability in a changing NHS.

• Increasing ‘non-GP’ staff in general practice can relieve some pressures, but can generate unintended consequences
• Keeping four key considerations in mind can clarify the challenges and opportunities this development presents for GPs
• More needs to be done if the new skills-mix is to become part of a sustainable and successful general practice

General practice in the UK is under unprecedented pressure. Our population is living longer with a range of long-term conditions, while a shortage of GPs and nurses to manage these health issues in general practice means that a crisis is looming, with staff leaving at a worrying rate. If this were not troubling enough, there is also Brexit which could not come at a worse time for the NHS, with the possible departure of non-UK qualified GPs, who currently make up one-fifth of the existing GP workforce The Potential Impact of Brexit and Immigration Policies on the GP Workforce in England.

One seemingly sensible solution to this crisis is the recent policy push to bring in a greater range of ‘non-GP’ staff (such as pharmacists, advanced practitioners, physician associates, physiotherapists or paramedics) to relieve the workload of GPs in general practice The General Practice Forward View. This may a good idea in many respects, but handing over GP work for others to do (‘substituting’ non-GPs to do the work of GPs) is far from simple, for a number of reasons.

Just like New Year resolutions that generate inconvenient problems of their own (witness the rise in chocolate consumption as the nation attempts a ‘Dry January’), getting a non-GP to do GP work can create unintended consequences. While the chance to save money by employing less expensive health professionals in place of GPs seems obvious, this is not the only possible outcome. What might happen instead is two people duplicating the same work, or new professionals carrying out extra work that wasn’t being done before, or perhaps doing GP work more slowly so that it actually costs more in time and money. It might also be a challenge for patients to understand easily what each practitioner can do and to choose who to see accordingly. This means that work needs to be planned carefully, which in turn requires the right ‘skill-mix’ (i.e. the best range of skills, number and mix of professionals) to be put in place. For many small GP practices, these are new and difficult challenges.

Challenges and opportunities of a changing skill-mix

Our National Institute for Health Research Collaboration for Leadership and Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) Rapid Workforce Literature Review (.pdf) summarised what can be gleaned from existing research on skill-mix changes in primary care at home and globally.

In brief, we found that adjusting the skill-mix in general practice teams by introducing non-medical roles can result in care that is of good quality, safe and acceptable to patients, but there’s a rub:  such changes might actually be more expensive or time-consuming to implement, at least to begin with. This depends on what role is introduced, in what context, but most crucially, why and how skill-mix is changed.

Synthesising this literature also enabled us to highlight some of the key issues that general practices could think about when planning to add advanced practitioners, physios, or paramedics etc. to their teams. These considerations are the subject of a current editorial in the British Journal of General Practice Skill-Mix Change and the General Practice Workforce Challenge.

So what needs to be considered in embracing skill-mix changes in primary care?

• Consider the purpose of bringing a non-GP role into the practice

Is the purpose of the skill-mix change to save money/ time, or lighten the load of GPs? Is it to offer patients a new service that didn’t exist before, or provide faster access to appointments? Is it about improving the health of the local population or enhancing the experience of staff working in the practice? Too often, it is assumed that all this can be done simultaneously.  Making clear the primary purpose of the change and the scope of the role from the outset helps to determine who should be employed and in what capacity.

• Think about how the skill-mix change will be managed

Changes to the practice team need to be co-ordinated, or else that vital work falls through the gaps. It takes time, energy and planning to manage the ‘transaction’ costs associated with bringing in new non-GP roles.

• Be aware of the position with regard to professional registration/regulation of the new role

Knowing the regulatory limitations of a role will help teams to set appropriate job specifications and role expectations for newly introduced non-GP team members (for example – paramedics and physician associates are currently not licensed as independent prescribers and this will affect how they operate in general practice).

• Consider the wider changes occurring in general practice and likely impacts of introducing skill-mix changes

Changing skill-mix is also taking place against a backdrop of a wider redesign of primary care around new ways of working New Care Models. Increasingly, individual general practices are coming together to work collaboratively not only within general practice, but with providers of secondary and community healthcare, social care and the third sector. While these waters are as yet largely uncharted, there is a need for general practices to think about potential whole-system effects – how the introduction of new roles into general practice will support, or perhaps be challenged by, the extensive re-organisation of primary care that is currently taking place.

Steps to sustainability

For skill-mix changes in general practice to live up to their promises, expectations around the changes should be realistic and mechanisms put in place to manage the change process. Two issues are of key importance. Firstly, GPs must be able to let go of tasks they are handing over to other professionals, or efficiencies will be lost. Secondly, it must be recognised that substitution of GPs with other health professionals will never be a complete exchange. While non-GP colleagues can work in a similar way to GPs, they are unlikely to be able to do all that a GP can, and do so without oversight – unless of course, they become GPs themselves!

Without a major shift in policy, future visits to your GP surgery will involve fewer sightings of the traditional family doctor and more of the increasingly common varieties of health professionals who are working in general practice in larger numbers. Conditions on the ground need to be right for these roles to co-exist effectively and contribute to the longer-term survival of general practice. 

The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

To find out more about the research that NIHR CLAHRC GM is doing in relation to NHS workforce please visit:  http://www.clahrc-gm.nihr.ac.uk/projects/addressing-long-term-workforce-challenges-general-practice-greater-manchester/ and http://www.clahrc-gm.nihr.ac.uk/projects/salford-primary-care-workforce-study-contribution-to-a-safer-salford/