Title: How general practice team composition and climate relate to quality, effectiveness and human resource costs: a mixed methods study in England
Funder: Department of Health and Social Care

Abstract: Background: General practice is under pressure: General Practitioners’ (GPs’) workloads are increasing while recruitment and retention problems have reduced the number of GPs per capita, and shortages of primary and community nurses have exacerbated staffing problems. New roles, organisational forms and contractual models of primary care are emerging. Effective and efficient use of the GP workforce is important, but evidence on how practice organisation, skill mix and team climate influence performance is scarce. Aim: To explore how organisation, skill mix and climate in GP teams relate to quality of care, clinical effectiveness and human resource costs. Design: Concurrent, parallel, multistage, mixed methods in 7 work packages (WPs): WP1: Overview: (i) policy review; (ii) new practice models; (iii) construction of a ‘Practices Database’ covering, for all English practices (n~7600): skill mix (NHS Digital primary care Minimum Data Set), other practice characteristics (routinely available data), and model type, (iv) workforce costs WP2: Systematic review of impact of team composition and climate on staff and patient outcomes WP3: Practice-level modelling (using Practices Database) of associations between skill mix (e.g. % of total FTEs GPs / other care staff) and quality of care (QOF clinical summary score, CQC inspection rating, patient experience survey indicators), controlling for practice characteristics. Production function approach to identify the output contribution of different staff, substitution possibilities and cost savings. WP4: Patient-level modelling of association between practice skill mix and clinical effectiveness (hospitalisations for ambulatory care sensitive conditions e.g. diabetes complications, asthma), controlling for patient level confounders. Patient outcomes from linked primary and secondary care data (n=546 practices, Farr Institute), merged with Practices Database for analysis. Economic analysis to identify savings from clinically effective staff deployment. WP5: In-depth qualitative analysis. a) focus groups (8) with service users for perspectives on how teams affect care; b) survey of staff in a sample of practices (n~240) to explore team climate and burnout in relation to workforce and performance indicators; c) case studies in 12 varied practices (traditional model, with task substitution and role creation, and new models), using staff interviews, observations and patient survey, to assess how skill mix and team climate are associated with effectiveness and patient experiences. Synthesis using receptive contexts for change and interactionist theory. WP6: Knowledge transfer. Two groups (GP primary care practitioners, commissioners) in 4 regions, total of 144 participants, score potential components of implementation guidelines (developed from findings of WPs 2-5) over two rounds, to reach consensus on final guidance to support future decision making (RAND/UCL Appropriateness Method). WP7: Active dissemination strategy to engage commissioners, primary care providers, statutory and non-statutory bodies. Benefits and potential impact. The research will produce evidence about which skill mix and team climates work best in primary care, and role and task substitutions that reduce costs while maintaining or improving outcomes. This will enable GP partners, managers and commissioners to make informed decisions that address current staffing problems and future workforce requirements.

Lay abstract: General practice is central to the running of the National Health Service. People seeking advice about health problems usually go to their general practitioner (GP) first (unless it is an emergency). General practitioners deal with a large range of health and social care issues for the local people who are registered with them. They have traditionally employed a team of staff (e.g. nurses, care assistants, receptionists, managers), and they liaise with other community services (e.g. midwives, health visitors) for certain functions. General practice is currently under pressure because many GPs are retiring or leaving for other reasons, and more newly trained doctors are working in hospitals. There is also a shortage of nurses to work with GPs. At the same time, more people have long-term conditions and need regular care from GP teams, and some tasks that used to be done in hospital are being transferred to general practice. This means that it is very important that GPs organise their teams efficiently so that as many patients as possible can be treated. There is a lot of variation in the staffing arrangements in general practices. The trend has been for practices to become larger over time, and to include a wider range of staff (e.g. physiotherapists, pharmacists). Recently some GPs have combined into ‘super-practices’ or federations. There is very little evidence, however, to tell GPs and service commissioners what size or structure of practice, or what mix of professional staff, works best for patients. The aim of this research is to provide such evidence. It will explore how the composition of GP teams, and the relationships among team members (called team climate) affects the quality of care and health outcomes for patients, and the costs for the practice. Using a variety of methods, we will: 1. Conduct a literature survey to look for lessons about skill mix from other countries that have similar health care systems to the NHS. 2. Analyse big data sets that are already available, and use statistical methods to investigate how differences in the organisation and skill mix of practices in England are related to the quality and effectiveness of the care provided. Quality indicators will be based on inspection ratings and the patient experience survey, and effectiveness will be measured by the number of patients hospitalised for conditions that should be managed within general practice. 3. Explore how workforce issues affect staff wellbeing and job satisfaction through a survey of staff in a sample of practices nationwide. 4. Investigate how team relationships (climate) affect daily working and patient experiences by observing and interviewing staff in 12 selected practices. 5. Ask a sample of GPs and commissioners to review our findings and help us create guidelines for all practices about what is the best mix of professional staff, and how to ensure that their teams work well together. 6. Use innovative means to disseminate the findings throughout the GP community, and to NHS managers, government organisations, academics and the public. We have linked with our local Clinical Commissioning Group to access opinions from lay representatives during the preparation of this application. The chairperson of the CCG Patient and Public Engagement committee is a co-applicant. Under his leadership, we will establish a Service User Group that will contribute to all stages of the research.

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