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Pauline Nelson, University of Manchester
New non-medical roles and why are they important in general practice
When patients seek an appointment with their GP these days, they may instead be offered a consultation with a different type of professional who is not a GP – a Physiotherapist, or a Paramedic (roles that are generally more familiar in hospital settings), or even a completely new type of professional, such as a ‘Social Prescriber’. As the number of GPs is declining, non-medical health professionals like Physician Associates, Practice Pharmacists and others are becoming more and more widespread in GP surgeries. This drive to introduce a greater level of ‘skill-mix’ alongside GPs started with the (General Practice Forward View) and has gained momentum in recent months. For example, the NHS Long Term Plan and the new GP Contract Five-Year Framework, both released in early 2019, are seeking to further expand the quantity and type of non-GP professionals in GP surgeries over the next five years. Against the backdrop of GP shortages, the vision is for an extra 20,000 new roles professionals to plug the gaps and help general practice adapt to managing an ageing population with increasingly complex health care needs. Despite positive reports in the national press about new non-medical professionals in the NHS, it is far from clear at this point whether new roles are achieving their aims.
Challenges associated with new roles
As part of our NIHR CLAHRC Greater Manchester Organising Health Care Programme of research, we reviewed the literature on skill-mix changes in primary care and concluded that when new roles are introduced, it can be difficult to establish whether or not they are actually making a difference. Lots of different outcomes associated with new roles had been measured, however most of the research designs were weak and evidence not convincing. Importantly, we saw no studies at all on releasing GP time, the key reason that new roles are being brought in such high numbers in the first place. Secondly our review suggested that it was unlikely new roles would slot neatly in to primary care without some challenges, because ‘substituting’ other workers for GPs is not as simple as it sounds.
We wanted to look more closely at how new roles work in practice and so focused on three schemes that were being tried out in general practices in one area of Greater Manchester: a training scheme for Advanced Practitioners, a training scheme for Physician Associates and one fully commissioned service of neighbourhood Practice Pharmacists. From in-depth interviews and focus groups with a range of stakeholders involved in each scheme (i.e. training and service leads, new roles trainees and practitioners, GPs and practice managers) we were able to compare how the three new roles were functioning on the ground and identify some common issues across schemes and not just for individual roles. The study report and our paper in the British Journal of General Practice give full details, however in summary, we saw that introducing new roles has both intended and unintended consequences. We also identified four key factors that affect the success of skill-mix changes in general practice.
Four key factors to maximise the potential of new roles in general practice
If we are to get the best out of skill-mix changes for patients, new roles professionals themselves and indeed general practice, the many different stakeholders involved in implementation of these schemes need to:
1. Create space for meaningful communication and engagement before introducing roles
Many of the unintended consequences we saw in relation to the introduction of new roles arose as a consequence of inadequate engagement and expectations management between stakeholders prior to and during implementation. It is important that time is set aside for dialogue between stakeholders (policy-makers, training leaders, HEIs, GP federations, primary care provider organisations, Clinical Commissioning Groups, general practice staff and new roles leaders), to determine the goals of skill-mix change and ensure all parties have a realistic vision of what might be achieved, and by when. In the urgency to implement policy, important discussion about how to match workforce skill-sets to local population need is often missed. If unaddressed, this may be a significant barrier to the sustainability of new professional roles in general practice.
2. Define and differentiate new roles more clearly
We highlighted the confusion and tension that can sometimes arise when a professional’s scope of practice is not sufficiently defined or when boundaries between professional roles are blurred. Policy-makers, regulatory bodies and training organisations need closer working to define and differentiate the purpose and scope of new roles more clearly. This might reduce ambiguity and boundary issues, set more realistic expectations about what roles can achieve, prevent inappropriate use of roles and support professionals’ learning more effectively.
3. Train new roles professionals specifically for the general practice setting
We saw how education and training greatly affect the feasibility of skill-mix changes. General practice is characterised by the presentation of undifferentiated and wide-ranging health problems, meaning staff must develop strong skills in dealing with uncertainty and risk. Crucially, regulatory bodies, training organisations, higher education institutions (HEIs) and general practice leaders must work to ensure that new roles professionals are supported to develop skills in risk management. A second important issue for regulatory authorities and trainers is the importance of independent prescribing (IP) as not all roles currently have the right to become IP qualified. If this is a key tenet of their value to general practice, there must be better planning in relation to training and role regulation.
4. Get better at showing whether new roles are making a difference
Our work highlights the difficulty capturing evidence of the success of skill-mix change, given the many possible goals of skill-mix change (e.g. filling GP gaps; releasing GP time; improving patient outcomes, satisfaction, choice, access and safety; increasing staff wellbeing; providing higher quality care and achieving cost-effectiveness). Inter-disciplinary researchers need to work more closely with policy-makers to generate better ways of evaluating outcomes associated with new roles. We need ways of measuring the longer-term economic impact of these changes, and in particular capturing changes in GP workload (though some recent work in this area is promising). We also need to identify whether such changes are meeting patients’ needs. Only by doing this will GPs be convinced of the contribution of these roles, an essential step towards a sustainable multi-professional system of general practice.
It remains to be seen how the Interim NHS People Plan just published will guide future workforce planning in primary care, meanwhile the four key factors outlined here could assist stakeholders involved in new roles initiatives with planning to maximise roles’ potential and increase their sustainability in general practice.
Date Published: 04/06/2019