Last year, Dr Imelda McDermott and Dr Sharon Spooner published an article in On Primary Care highlighting policy-driven organisational changes in how general practice is delivered. In this blog, Dr McDermott and Dr Spooner are joined by Professor Kath Checkland and they argue that the future face of general practice is about more than innovative consulting formats that became more prevalent during the COVID-19 pandemic. 

• COVID-19 has altered general practice, with technology-supported consultations becoming the norm.
• As general practice continues to adjust, allied health professionals will play a larger role in primary care and increase skill mix within practices.
• Skill mix has the potential to improve patient access to specialist practitioners but general practice must be mindful that this may have wider consequences, including constraints on patient choice, in addition to requiring reception staff to communicate more effectively with patients and practice managers to distribute work effectively between practitioners with different skillsets.

As we move beyond the most restrictive period of COVID-19 infection-control measures in the UK, there has been much debate around the ways in which NHS GP practices will deliver healthcare. This has largely focussed on the potential benefits and challenges of providing healthcare ‘remotely’ using technology-supported consultations, for example, telephone, text, video and e-consultations.

It has been a lively debate in which GP leaders voiced resistance to continuing adoption of a ‘remote by default’ policy that was proposed by Matt Hancock, the former Secretary of State for Health and Social Care, citing potential risks and exacerbation of health inequalities. Clear evidence about patients’ perspectives on this has yet to emerge.

However, it is already clear that general practice has changed in other ways. As the number of qualified GPs continues to fall, one policy solution to improve access to appointments is to employ a range of other ‘allied health professionals’ to carry out some of the work traditionally done by GPs. This includes clinical pharmacists, advanced nurse practitioners, paramedics, physiotherapists and physician associates. These changes in ‘skill mix’ will have an impact on the services available and the ways in which healthcare is delivered by GP practices.

Different practice teams; different patterns of distributing work

For many decades, the model of general practice operating in the UK NHS has been that patients bring all manner of medical and health-related problems to GPs, whose generalist knowledge allows them to treat most problems based on their own diagnostic assessment and to refer to specialist colleagues when needed.

In contrast, the knowledge and skills of many practitioners now entering general practice is more specialised. Their transition to working in general practice may not follow a single training programme that is characterised by a well-defined standard of knowledge or skills. This leads to lack of clarity and wide variation in the problems or health conditions that practitioners are competent to discuss with patients and the extent to which they need advice from colleagues. Since every GP practice is unique in its combination of practitioners, health characteristics of patients and internal organisational structures, each practice must work out how to make any necessary adjustments to operate with a wider range of variously skilled practitioners.

Our recently completed study analysed how practices, practitioners and patients are experiencing increased skill mix. We identified several challenges amongst new opportunities for access and service delivery.

Processes – to match patients’ needs and practitioners’ competencies

Our study noted that GP practices have developed new processes to actively manage access to healthcare with the aim of getting each patient and their health problem to a suitable practitioner. Key requirements of these processes, illustrated in our recently released animated video, include:

• Understanding the nature of the problem/s
• Understanding the skill set, competencies and experience of every practitioner
• Availability of an appropriate appointment (that is acceptable for the patient)
• Accessible help, support or advice from a more experienced colleague if a practitioner is unable to deal with problem/s fully and independently

However, these steps are not straightforward. Research shows that patients frequently seek help with more than one problem and some problems are inherently difficult to articulate. Moreover, practitioners’ skillsets may not be comprehensively described and are likely to change over time. Matching patients’ problems and practitioners’ competencies may override patients’ preferences for receiving continuing care from the same practitioner and sufficient flexibility must be built into work schedules to facilitate ad hoc interactions with experienced practitioners.

Wider impacts of skill mix implementation

There are significant organisational challenges generated by the implementation of skill mix. Practice managers need to closely involve their teams in the development and operation of processes to guide the allocation of appointments. Adjustments were also needed to ensure that work schedules allowed sufficient time and space for practitioners to seek and give advice, but the intrinsic unpredictability of general practice caseloads and variation in individual practitioners’ requirements meant that continued monitoring and review of these processes were inevitable.

The introduction of appointment allocation processes and different ways of working also have additional implications. For patients, there is an increased expectation that they disclose information about their healthcare need in advance to a non-clinically trained receptionist or using an online template. They may also be asked to accept healthcare from a practitioner whose role and competencies are unclear and may need to invest additional effort in getting to know and trust new members of staff. For practitioners, the selective distribution of less complex cases to less highly qualified practitioners increases the proportion of more complex cases reaching those who are more experienced. These experienced practitioners must also be on standby to advise and support colleagues, and some will have roles in their education, training and performance management.

Lessons learned

• The availability of a wider range of practitioners in general practice required reception staff to have enhanced training in communicating effectively with patients of the nature of their problem. They also needed clear, accurate and updated information about the various capabilities of all practitioners.
• In contrast to traditional roles of business management, practice managers needed to understand and achieve balance of the skillsets, competencies, and experience of every practitioner. This involved working more closely with diverse clinical teams and to engage with skill management across the clinical and administrative team.
• Patients value the relationships built with practitioners over time but access to appointments is also valued. Patients are more likely to accept newer types of practitioners when more experienced support is on hand. Patients’ ability to choose a preferred practitioner is limited both by lack of information about what practitioners can do and lack of opportunity to exercise choice.

The new normal for general practice is therefore defined by more than new modes of consultation; differences in workforce composition lead to different experiences of accessing and delivering care in ways that are continuing to evolve. As the shift to diversification of the general practice workforce continues, these new processes, working patterns and experiences may also be associated with different health outcomes and costs.

NIHR-funded study https://fundingawards.nihr.ac.uk/award/17/08/25

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