This is a plain English summary of an original research article
Employing clinicians who are not GPs did not reduce GPs’ workload or improve their job satisfaction, research found. In the short-term at least, new roles in general practice for other clinicians, such as paramedics and physician associates, increased the time GPs spent delegating tasks and supervising.
The same study found that patients appreciated the longer appointments they had with other clinicians. But they wanted better information about what other practitioners can do, and how to use new booking systems.
General practice has been struggling to meet the needs of a growing population with increasingly complex conditions. GPs are working longer hours to fit in their work. The mounting pressure is making it difficult to recruit and retain GPs.
To help ease GPs’ workload and improve job satisfaction, other clinicians, such as pharmacists and paramedics, are increasingly being employed in general practice. To date, there has been little research into the impact of this change.
A research team looked at the change in skill mix in general practice over time. They explored practice managers’ views on why practices employ other clinicians. They looked at the impact of employing these clinicians on GPs and the people they are caring for.
There were both positive and negative effects. But overall, the researchers found that employing other clinicians has not so far had the desired impact on GP workload and job satisfaction.
The issue: GPs’ workload is not sustainable
The number of GPs in the UK has increased only slightly in the last 7 years. At the same time, there have been sharp increases in the healthcare needs of an ageing population with more complex health issues (such as living with multiple conditions). GPs’ workload is not sustainable in the long term.
General practices are usually run as independent businesses that have a contract with the NHS to deliver services to a registered group of patients. Different practices have different management strategies and can choose who they recruit.
In order to reduce the pressure on GPs, some general practices have employed other clinicians such as nurses, pharmacists (experts in medicines), paramedics, physiotherapists and physician associates (who help diagnose patients, but do not prescribe). These professionals are expected to take over some tasks traditionally carried out by GPs.
Researchers explored the skill mix in general practices in England, and looked at why practices recruit other clinicians. They asked GPs what impact other clinicians had on their workload and job satisfaction. They asked patients for their views on these changes.
The skills mix in general practice has changed
This part of the study was based on datasets covering 6287 general practices in England from 2015 to 2019. Researchers found a slight increase in the total number of full-time (equivalent) clinical staff. During this period, the number of GP partners declined, but the number of all other clinicians increased. The skill mix in practices varied by region.
The research team looked at results from the GP Worklife Survey, completed in 2015, 2017 and 2019. It showed that GP satisfaction was higher where more GPs were employed, and was slightly lower where there were more other clinicians. GPs’ working hours were longer where there were either high or low numbers of other clinicians. This implies that GPs’ working hours can be reduced where there is an optimal mix of GPs and other clinicians.
Why change the skill mix in general practice?
The managers of 1261 practices completed a survey. It showed that the main reasons for their practices to employ other clinicians were: to increase the availability of appointments, to free-up GP time, and to better match community needs. They hoped the skill mix change would provide better value for money.
Impact on staff of changes to the skill mix in general practice
The team carried out in-depth observation and interviews at 5 general practices. They found that GPs were willing to transfer tasks and accepted the need for an increased skill mix. Some clinicians could take on tasks usually done by GPs, for instance advanced nurses independently made decisions about patients. But many clinicians had limited training or experience, and required supervision.
A broader skill mix made it harder to define roles and match patients to the appropriate clinician. Some practices categorised the skills of different clinicians into frameworks for receptionists to use to match patients to clinicians. Employing other clinicians often meant that GPs’ time was used to train, supervise or to delegate tasks (as well as dealing with more complex cases).
Impact of skill mix change on care quality and cost
The highest quality of care (as measured by the Quality and Outcomes Framework) was seen with more GPs. Higher quality prescribing and lower prescribing costs were seen with more pharmacists. Higher overall NHS costs were seen with overall higher numbers of healthcare professionals, but employing more non-GPs was only slightly cheaper than employing GPs. Higher numbers of other clinicians (apart from nurses and GPs) were associated with more accident and emergency attendances.
What do patients think?
125 patients completed surveys about their recent visit to the general practice; focus groups were held with patients. Overall, patient satisfaction was highest where there were more GPs, and lowest where there were higher numbers of other clinicians. Patients wanted explanations about what the other professionals could do.
Patients found the triage systems (which allocate patients to the most appropriate clinician) difficult to navigate. However, the surveys showed that most felt their appointment was useful (82%) and that they had seen the right clinician (77%). They appreciated the longer appointments with other clinicians, in which they could discuss more than a single ailment. They were satisfied when a GP was available for advice if necessary; this improved their acceptance of the new roles.
Patients valued continuity of care. However, they felt that an increased skill mix in primary care made it less likely that they could see the same clinician for follow-up appointments.
Why is this important?
One of the aims of employing other clinicians in general practice was to free up GPs’ time and increase their job satisfaction. However, this study found that increasing the number of non-GPs in general practice has not increased job satisfaction. Instead, it has taken up GPs’ time with tasks such as answering queries and supervising.
The researchers caution that their findings might reflect turbulence during a period of rapid change. Practices were still working out how to match patients to clinicians; patients were getting used to new roles. Satisfaction and workload may improve with time.
In the meantime, the results suggest areas in which care could be improved.
- clearly communicate to patients and receptionists the role of each clinician, so that people are given appropriate appointments
- simplify triage and booking systems; systems need to be unobtrusive and not ask personal questions
- prioritise continuity of care, so that people with long-term conditions can see the same clinician each time
- give pharmacists a larger role in medicines management, since having more pharmacists was associated with better quality prescribing.
Employing more other clinicians (apart from GPs and nurses) in general practice increased the number of accident and emergency attendances. This could be because GPs refer patients to other hospital departments while other clinicians asked people to self-refer to accident and emergency.
Over time, the impact of current changes to skill mix might evolve. The researchers would like to see ongoing research to monitor GP job satisfaction, care quality, and costs, as other clinicians settle into their new roles. However, they say that other approaches are needed to improve the recruitment and retention of GPs.
The skill mix in general practice varied from region to region. This would be expected since regions care for different populations and have differing practitioner availabilities. The level of supervision from GPs varied between practices and between clinicians. The researchers say clinicians need access to adequate support when working in general practice.
Practice staff need to be clear about what different clinicians can do. The researchers struggled to find information on the different roles. Health Education England has now released roadmaps to describe pathways from undergraduate to advanced practice for clinicians working in primary care. However, these do not cover all roles or describe the changing competencies of individual clinicians. Practices often produced their own lists of skills to help receptionists triage patients. But these lists needed regular updates to be useful.
You may be interested to read
This Alert is based on: McDermott I, and others. Scale, scope and impact of skill mix change in primary care in England: a mixed-methods study. Health and Social Care Delivery Research 2022;10
Blog about the future of general practice by the study authors: Managing Changes in the General Practice Workforce. Spooner S, and others 2021.
Blog about the changes in workforce and workload in primary care by the study authors: Achieving the Right Mix of Skills in General Practice: It’s a Process Not a Destination. McDermott I, and others. 2021.
A recent NIHR Evidence Alert about paramedics working in general practice.
Funding: This project was funded by the NIHR Health and Social Care Delivery Research programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.