Growing the GP team – how does GP work change with expansion of the practitioner team?

Problem

In recent years, increasing health care demand, that is in part attributable to population health demographics and transfer of care to community settings, has led to increasing workloads for general practice across the UK. Recruitment and retention of GPs has not kept pace with workload increases which further damages the attractiveness, longevity and sustainability of a GP career. To reduce pressure on GPs, health policy documents have proposed that GP practices and networks should employ a wider range of allied health professionals, such as clinical pharmacists, physiotherapists, physician associates and paramedics.

Changes in workforce composition mean that practices need to consider how best to deploy the skills and experience of newer types of practitioner, reducing pressure on GPs but maintaining high quality health care for patients. As part of a comprehensive study of the scale, scope and impact of changes in the practitioner composition of the primary care workforce, we investigated how current, and previously un-tested, diversification of the primary care workforce composition (or skill mix) has affected the working lives of GPs.

Approach

We conducted an in-depth case study at 5 purposively selected GP practices, using interviews and observations to gather information about how clinical and administrative staff were implementing skill mix. A survey and focus groups allowed patients to indicate how accessing health care has changed. Using a broadly interpretivist approach to analysis of how work was organised and how services were delivered and experienced we coded, discussed and refined our understanding of these data. Findings were triangulated with an analysis of large scale datasets that looked at associations between workforce composition and outcomes in terms of quality markers, practitioner and patient satisfaction, and utilisation of hospital services and costs.

Findings

This paper focuses on findings from the case study component that are particularly pertinent for GPs engaged in implementing skill mix in their own practices.

Firstly, we examine issues surrounding the (non-)standardisation of practitioners in these roles by discussing how practices addressed the individually-variable range of skills, experience and capabilities of practitioner employed in nominally similar roles.

Secondly, we look specifically at how supervision and performance management of practitioners with differing capabilities presents challenges for GPs, and at strategies adopted by practices to accommodate this additional work.

We also discuss how GPs reflect on the changing nature of their caseloads, including increasing complexity and reduced opportunities to maintain established relationship-based care.

Consequences

Finally we consider wider implications of these changes across a number of areas: potential adaptations for GP training programmes and early careers, resources needed to support GPs and managers to optimise management of skill mix, impact on job satisfaction for GPs and overall impact on patient experience.