Title: An investigation of the scale, scope and impact of skill mix change in primary care
Funder: Department of Health and Social Care

Abstract: Many factors have contributed to increasing and unprecedented pressures facing primary care across the UK. Whilst growth in GP numbers has lagged behind other clinical staff, changing population demographics mean that levels of multi-morbidity have increased, and consultations have become longer and more complex as healthcare has shifted from hospital to community settings (Dayan M et al., 2014, Hobbs et al., 2016). A decline in the attractiveness of general practice careers means that GP vacancies remain unfilled, GP workloads increase and patients experience difficulty in obtaining appropriate appointments (Lambert et al., 2017, Lane, 2014). It has been suggested that a change in the combination of practitioners from different training backgrounds, often described as a change in “skill mix”, could offer an effective and efficient solution to the imbalance of supply and demand in primary care (Addicott and Ham, 2014, Primary Care Workforce Commission, 2015, Branson et al., 2003). A range of innovative schemes has been developed to include more non-GP practitioners (NHS England, 2015; Drennan et al., 2017), however, there are limited published data about the scale of skill mix employment, how effectively new practitioner types are integrated into general practice, or the impact on costs, quality or patterns of care. The evolving scale, scope and impact of changes in skill mix at national and practice level, and from practice, practitioner and patient perspectives will be studied under 3 research questions and investigated using linked work packages: 1. What is the scale and distribution of skill mix changes in primary care and how is skill mix change associated with outcomes and costs? Longitudinal trends in the use of skill mix will be accessed in national datasets (e.g minimum Workforce Data Set), linked with practices and examined for associations between employment patterns and healthcare activity, performance and costs (i.e. as indicated by hospital care, prescribing costs, GP satisfaction, patient satisfaction etc). 2. What motivations drive skill mix deployment at practice level and what is delivered by deployment of different practitioner types? A survey of Practice Managers will obtain data not available in national datasets on motivation, duration, implementation and expectations of skill mix deployment. 3. How do skill mix changes affect the experiences of employers, practitioners and patients? Six GP practices with different levels of skill mix will be studied to explore how changing skill mix affects the experiences of clinical staff, non-clinical staff and patients. This will include individual interviews with staff, observations of how practitioners work and interact, and a survey of patients' views on access to care and consultations provided by a range of practitioner types. Through linked work-packages, the study will bring together multiple sources of data and investigate mechanisms which may be driving changes in employment patterns and outcomes. Excellent access to relevant networks and the participation of a broad range of relevant professional groups and commissioning organisations through an active External Advisory Group, will facilitate the wide dissemination of findings to inform policy makers, commissioners and practices and to support the optimisation of patient experience and care.

Lay abstract: More and more health care in the UK is being transferred from hospital to GP practices. However, practices have found it difficult to cope with this increasing workload and this has serious implications for the whole of the NHS. When practices cannot recruit new GPs to take the place of those who leave or retire, one solution is to employ other types of health care professionals who are not doctors to deliver care – this is generally referred to as a change in ‘skill mix’. Research shows that bringing in other types of practitioner can ease the pressure on GP appointments by increasing the number of appointments practices can offer. These practitioners may be nurses who can prescribe medicines, or a new type of care provider called ‘physician associates’, or others who may be able to provide some of the care that people need. Also, they may be easier to recruit than GPs and cost less to employ. However, there is limited information about what introduction of non-doctor practitioners means in practice and how this changes what happens for patients, or how it affects the quality of care that is delivered and whether it is more or less costly for the NHS. We know that the training backgrounds of other professionals are different from GP training, which means we should not assume that they can all easily fit in and work in the same way. For example, their appointments may take longer and they may have different ideas about when to arrange tests or which patients to refer to hospital specialists. Some need to be directly supervised by a doctor or need the prescriptions they issue to be signed-off by GPs, so it is not clear whether this helps ease the pressure on GP appointments. To find out about this, we will first look at the ‘big picture’ of what happens when GP practices employ new types of practitioners. National data will tell us how widely change in skill mix is happening in GP practices and we can look at how that change may affect what happens; e.g. how many patients are referred to hospital specialists or given prescriptions. To get more information about how practices work, we will ask Practice Managers why they choose to employ different types of practitioner and what they expect them to do. When several types of health care professional with different skills are working alongside each other, it works better if patients see the right person first, so we want to know if good information is available to guide patients and how the work of different practitioners is coordinated. We will spend time in 6 practices, talking to staff about how different types of practitioner work together, and we will ask patients whether they like these new roles and if they know how to get most benefit from them. The combination of these research activities will tell us whether different types of practitioners provide healthcare to patients in a different and better way and whether this is related to what care costs in the NHS as a whole. We will look at whether non-GP practitioners can successfully replace GPs for some types of problems, and whether this reduces the overall burden on GPs or creates extra work. Learning how different types of practitioner can contribute to general practice will help to guide practices to recruit and employ the right mix of practitioners. It will also make sure that patients can have confidence that the care they receive in general practice is safe and continues to meet their needs.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE