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 the first blog of this series, Dr McDermott, Dr Spooner and Professor Kath Checkland looked at how GP practices are managing changes in the practitioner workforce. In this piece, the authors focus on the changes in the workforce and workload, the realities of skill mix in general practice, and some of the lessons learned from their recently completed project looking at the implementation of skill mix in general practice in England.

• GP practices should engage in ongoing skills management of their workforce to monitor work distribution, support for practitioners and delivery of patient care.
• GP practices should review their practitioners’ competencies and assess the impact of working patterns on staff and patient experiences.
• While educational pathways and supportive structures can guide practitioners’ transition from hospital to general practice, a better understanding of practitioners’ competencies through formal and informal interactions can build mutual trust and confidence over time.

The Health and Care Bill 2021-22 is intended to enact policies set out in the White Paper (2021) and NHS Long Term Plan (2019). Details on the workforce are set out in a recently published Health and Social Care Committee report on workforce burnout and resilience (June 2021). The report made recommendations about how to tackle chronic excessive workload, one of which is having “the right number of people, with the right mix of skills across both the NHS and care system”. However, since most of the issues discussed in the report focus on hospitals, there is a lack of reference to what this would mean for general practice. In this blog, we describe the realities of skill mix in general practice and highlight some of the lessons learned from our recently completed project looking at the implementation of skill mix in general practice in England.

Policy mechanisms to increase skill mix in general practice

In addition to providing comprehensive medical care to their own registered patients, general practices in England are increasingly working together to deliver   serving a population of 30-50,000 people. While the employment of non-GPs practitioners by GP practices gradually increased prior to the formation of PCNs, additional funds to support employment of non-GP practitioners (Additional Roles Reimbursement Scheme) are intended to reduce workload pressures, improve access for patients and improve the recruitment and retention of doctors and nurses. The focus was initially on employing pharmacists, paramedics, physician associates, physiotherapists and social prescribers but has been expanded to include care co-ordinators, pharmacy technicians, dietitians, health and wellbeing coaches, nursing associates, occupational therapists and podiatrists.

Workforce composition

Primary care workforce composition shows significant global variation.  Our analysis of workforce composition in England (NHS Digital June 2019 dataset) found that there are also regional variations in the types of practitioners employed. However, it is interesting to note that despite policy changes signalled since 2014, the proportion of newer practitioners in the general practice workforce has remained relatively low. This highlights two things:

Firstly, the scale of expansion in numbers that would be required for them to provide a significant volume of potential ‘substitutes’ for GPs that could have an impact on GP workload or improve access for patients by performing complementary tasks.

Secondly, workforce composition varies not only across countries but also across English regions. Differing local needs and circumstances should therefore be considered in addition to factors that influence availability of training, recruitment levels and retention of practitioners.

Distribution of work in general practice

General practice deals with an innumerable array of undifferentiated problems. Distribution of undifferentiated work is a complex task requiring sufficient understanding of the presenting problem/s and of the capabilities of each practitioner to support safe and effective categorisation and matching which we highlighted in our recent animation. However, with differences in the needs of patient populations and variation in the capabilities of individual practitioners over time, there is no ‘one-size-fits-all’ solution to team composition or ‘optimal’ skill mix’. Instead, GP practices need to engage in ongoing skills management of their workforce, monitoring how work is distributed, how practitioners are supported and how patient care is delivered.

Supervision requirements can increase GP workload

The skill mix policy intention is for expanded multi-disciplinary teams in general practice to address GP shortages by offering patients appointments with ‘appropriate’ non-GP practitioners. However, limited attention has focused upon the consequences of this policy.

In addition to an increase in providing colleagues with ad hoc advice about the care of more complex cases, requirements for the formal training and supervision of non-GP practitioners by GPs can increase rather than reduce GP workload. This is particularly problematic for early-career practitioners but also for those with little experience of general practice work. Our study found GP practices adapted rotas to facilitate supervision for newer practitioners by allocating experienced GPs as a ‘duty’ doctor whose timetable was less structured and meant they were available to help and advise other staff but not as available for consultations during that time. These arrangements meant that any practitioner who was unsure of diagnosis or treatment, could immediately ask the duty doctor for advice. If necessary, the duty doctor could share a joint consultation with the practitioner, adding to the practitioner’s knowledge and skills and properly addressing the patient’s problems.

However, where a supervisory role was carried out without proper allocation of time or reduction in other work, GPs faced an impossible schedule of continuing to juggle the demands of concurrent clinical and administrative work with supporting other practitioners. This adversely affected their work-life balance, causing debrief fatigue.

Lessons learned

• Rather than striving to achieve ‘the right mix of skills’, those involved with workforce planning at both national and local levels need to recognise that in practice, workforce planning is mediated by ongoing skills management. GP practices need to understand and regularly review their practitioners’ competencies and monitor the impact of working patterns on staff and patient experiences. This requires time for the practices to get to know practitioners’ competencies, both role competencies such as qualifications and role-holder competencies such as past experiences and upskilling.
• Policy makers should be aware that the deployment of newer practitioners across primary care networks does not provide an immediate, straightforward or complete solution to the current GP workforce and workload crisis. The need for ongoing supervision of other practitioners by GPs has created a new and for many an unexpected workload. This was particularly onerous where there were fewer GPs performing this role and where they lacked peer support. GPs will need to carefully supervise peripatetic workers (funded by PCN ARRS) with whom they are inherently less familiar and who are only present in each practice on one or two days per week.
• Practitioners undertake initial training in hospital speciality settings that do not adequately prepare them for the mixed caseloads encountered in general practice. There are educational pathways and supportive structures to guide practitioners’ transition from hospital to general practice employment. However, practices and practitioners must navigate roles and responsibilities that fit their own situation. This relies less on how roles may be formally described and more on an in-depth understanding of the competencies of colleagues gained through formal and informal interactions that build mutual trust and confidence over time.

Funding acknowledgement and disclaimer

Funder: the National Institute for Health Research (NIHR) Health Services & Delivery Research (HS&DR) programme (Project number 17/08/25). https://fundingawards.nihr.ac.uk/award/17/08/25

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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