Who’s who in General Practice? Research can help practices introduce new roles

As in many other developed countries, nurses are the largest group of clinicians working with doctors in GP practices. In England there are nearly 17,400 FTE nurses, which is around one nurse for every two GPs.

Nurses in general practice have a range of responsibilities which, depending on their training and experience may include:

• management of long-term conditions such as diabetes and asthma
• seeing vulnerable groups such as children, and people with mental health problems
• management of acute minor illness and other more general tasks.

The Primary Care Workforce Commission (2015) argued that nurses “could take on substantially more care for both acute and chronic conditions”. A 2021 systematic review found that nurses with advanced clinical skills can provide equivalent, and in some cases superior, care to doctors. Authors concluded that advanced nurse practitioners have a positive impact on clinical and service-related outcomes and “offer a promising solution for addressing the rising complexity of and demand of health service users worldwide”.

However, it is unclear what level of nursing education leads to the best outcomes when nurses act as a substitute for doctors. The advanced training undertaken by nurses varies and advanced nursing roles in the UK are not subject to additional professional regulation.

Nurses’ capacity to prescribe allows them to extend their role. The number of nurses with an Independent/Supplementary Prescriber qualification has increased significantly since March 2018, from 39,677 to 59,326. A 2010 study estimated that one in three practices had a nurse or pharmacist prescriber (see below). Given the recent expansion of pharmacy and advanced nursing roles – this proportion is likely to have grown significantly since then.

More than 7,000 FTE healthcare assistants are employed in general practice. Healthcare assistants are not professionally qualified and their role varies between practices.

Healthcare assistants undertake a range of tasks including:

• clinical observations including blood pressure, new patient medicals, height and weight measurements and body mass index (BMI) calculations and electrocardiogram (ECG) readings
• minor procedures such as taking blood samples, removal of stitches, applying simple dressings
• administration including stock ordering.

Since 2015, the Care Quality Commission (CQC) expects all practices to ensure that newly-recruited healthcare assistants meet Care Certificate standards. These standards outline what health and social care workers need to know and be able to deliver in their daily jobs. They aim to address inconsistencies in training and competencies. The CQC expects healthcare assistants to “have access to a registered nurse or GP for advice and support when needed. The level of supervision needed will depend on the task being undertaken. The degree of risk must have been assessed”.

The impact of the healthcare assistant role on care quality and cost in general practice has not been extensively studied. A review article in 2008 said that the role could release professional staff time and improve access, but its effectiveness would depend on appropriate training, mentoring and supervision.

There is a similar lack of evidence on the impact of the nursing associate role in general practice. This new registered role in England aims to bridge the gap between the roles of healthcare assistant and nurse. It supports the career development and progression of unqualified staff. The role aims to free up registered nurses time to focus on more complex clinical care.

Nursing associates undertake a range of tasks and can:

• perform and record clinical observations (such as blood pressure, temperature, respirations, and pulse)
• carry out clinical health checks.

Around 1,500 FTE nursing associates and trainee nursing associates work in primary care , with plans for further expansion. A 2021 qualitative study found that nurse associates could free up registered nurse time. But it also highlighted uncertainty and unevenness in how the scope of their practice is developing. In primary care specifically, there was uncertainty about their capacity to carry out immunisations and cervical screening. A recent qualitative study also suggested that the current nursing associate training programmes do not fully equip nursing associates to work in general practice. For example, training for cervical screening was highlighted as a gap. The study also found that practice staff wanted more evidence of the role’s benefits.

Nearly 6,600 FTE pharmacists work in GP practices – the equivalent of around one pharmacist per GP practice. They are supported by around 2,200 pharmacy technicians and 2,200 pharmacy assistants or dispensers as well as nearly 700 advanced pharmacy practitioners. The role of pharmacy has grown rapidly within primary care, after early positive assessments of its benefits.

Clinical pharmacists can:

• provide medication advice to healthcare professionals and patients and, for example, undertake structured medication reviews (SMRs)
• optimise medications, prescribe or stop prescriptions
• play an important role in the management of long-term conditions, particularly for those with multiple conditions.

An Independent Evaluation Report funded by NHS England found that pharmacists contribute significantly to patient safety; they have improved medication knowledge in the wider clinical team. A 2019 systematic review found that they improve patient access to primary care. Pharmacists may save GPs’ time through a reduction in scheduled appointments and medication-related administration. The review suggested that they could help reduce A&E attendances, which would make the role cost-effective for the system. But the researchers said further research would be needed once the role was implemented at scale. A recent qualitative study highlighted challenges in the rollout via Primary Care Networks. The authors found variation across networks and pointed to examples of clinical pharmacists facing excessive demands, or alternatively, being allocated basic administration rather than using their skills. Excessive basic administration was a widespread concern.

Early evaluation of the role highlighted issues to be addressed. These included the need for:

• a recognised competency framework
• defined standards
• acceptance of patient-facing pharmacists by existing GP team members and by patients.

Paramedics traditionally provide emergency care through the ambulance service. Their capacity to assess and manage a wide range of conditions raised hopes that they could be a valuable member of the primary care team, and reduce GP workload. Over the last decade, paramedics in the United Kingdom (UK) work increasingly in settings other than ambulance services, with many moving into primary care. Just over 2,300 FTE paramedics (including paramedic practitioners) work in general practice.

The role in general practice has been implemented in different ways. Paramedics’ job titles and level of education vary considerably, as does the level of supervision they receive. Guidance from NHS England aims to standardise the role.

Paramedics can:

• assess and triage calls from patients
• undertake home visits for urgent assessment
• manage minor illnesses, advise patients and signpost appropriate care and services
  Paramedics with advanced skills (an accredited masters degree and 5 years’ post registration experience) can prescribe and manage simple and more complex conditions.

There is so far little evidence that paramedics save costs in primary care. Concerns include the amount of supervision necessary, the length of their consultations, and the potential need for additional consultations with GPs if they can’t resolve a problem.

The role could be made more successful by:

• clear communication with patients from a trusted source about the paramedic’s role in primary care
• full integration within the primary care team workforce
• clarity of the boundaries of primary care team roles, to avoid duplication and frustration
• support, including formal education and clinical supervision
• awareness of paramedics’ skills including their ability to build rapport with patients quickly, their adaptability, and that they know when to ask for help.

Just over 1,700 FTE physician associates work in general practice. Typically they have a first degree in biomedical sciences, and have taken a 2-year course to develop medical skills. They are not qualified doctors and require supervision by doctors.

Physician associates can:

• take medical histories
• carry out physical examinations and make a preliminary diagnosis and care plan
• physician associates cannot currently prescribe independently or order medical tests (but they can prepare documents for a GP to sign).

An observational study in 2015 found that physician associates in primary care see younger patients with less urgent problems and fewer long-term conditions, compared with GPs. After adjusting for differences in the patient group, physician associates and GPs had similar rates of investigations, referrals to secondary care, prescriptions issued, or patient re-consultations for the same or closely-related problem within 14 days. Consultations with physician associates were longer, and cost less, than with a GP. Patients reported high levels of satisfaction with physician associate consultations.

However, recent qualitative research suggests challenges in primary care. The role and its benefits were not clear to GPs, particularly given the level of GP supervision required. Other studies have found a general lack of understanding about the role, as well as a need to demonstrate cost-benefits and allay safety concerns. Plans for statutory regulation should allow physician associates more autonomy and enable them to make a greater contribution to the primary care team.

Musculoskeletal conditions affect people’s joints, bones and muscles, and account for 30% of GP consultations in England.

First contact physiotherapists have advanced practice skills and can:

• assess and diagnose musculoskeletal conditions
• provide expert advice on how best to manage conditions
• prescribe and give therapeutic injections
• refer to specialist services if necessary.

Primary Care Networks employ relatively few advanced physiotherapist practitioners (126 FTE). NHS England has made a commitment that by 2024, all adults in England will be able to see a musculoskeletal first contact physiotherapist at their local GP practice, without being referred by a GP.

A 2020 systematic review found that first contact physiotherapy services deliver comparable clinical outcomes to GP care, are more cost effective and can help manage GP workload. A 2021 mixed methods evaluation also found that they offered high quality care and a good patient experience. This evaluation highlighted the need for further review of the different models of care adopted in different locations.

A 2021 qualitative study found that patients may not understand the role of physiotherapists, and may see diagnosis as the domain of the doctor, so continue to see their GP as the first point of contact. There was particular reluctance among older patients with complex conditions. The authors highlighted issues of effective communication between direct access services and GPs, sharing medical records and actions taken.

More than 4,000 FTE care coordinators work in general practice. They proactively identify and work with people with complex care needs to coordinate and navigate care and support across health and care services. They work in partnership with others in the primary care team including social prescribing link worker(s) and health and wellbeing coach(es).

A care coordinator can:

• help book appointments
• signpost information to patients
• make referrals to services and other health and care professionals.

The social prescribing link worker:

• helps people identify issues that affect their health and wellbeing
• can connect people to non-medical community-based services that help meet their practical, social and emotional needs, including specialist advice services and the arts, physical activity and nature.

It has been argued that social prescribing could improve health and wellbeing, and reduce health inequalities. There is a lack of evidence on the impact of social prescribing on clinical outcomes and costs. A 2019 study of care navigation in England found that social prescribing was carried out in different ways by people with a variety of job titles. This makes it harder for patients to understand what the role is, and how it can help them. It also makes it difficult to assess the impact of the service at national level.

A recent qualitative study suggested that successful integration into general practice requires:

• a shared understanding of the role’s purpose and remit
• appropriate training for role holders
• good communication across services.

A realist review stressed the need for the role’s purpose to be clear to patients and staff.