The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

BACKGROUND: This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. METHODS: We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. RESULTS: Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. CONCLUSIONS: While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

Regional variation in practitioner employment in general practices in England: a comparative analysis.

BACKGROUND: In recent years, UK health policy makers have responded to a GP shortage by introducing measures to support increased healthcare delivery by practitioners from a wider range of backgrounds. AIM: To ascertain the composition of the primary care workforce in England at a time when policy changes affecting deployment of different practitioner types are being introduced. DESIGN AND SETTING: This study was a comparative analysis of workforce data reported to NHS Digital by GP practices in England. METHOD: Statistics are reported using practice-level data from the NHS Digital June 2019 data extract. Because of the role played by Health Education England (HEE) in training and increasing the skills of a healthcare workforce that meets the needs of each region, the analysis compares average workforce composition across the 13 HEE regions in England RESULTS: The workforce participation in terms of full-time equivalent of each staff group across HEE regions demonstrates regional variation. Differences persist when expressed as mean full-time equivalent per thousand patients. Despite policy changes, most workers are employed in long-established primary care roles, with only a small proportion of newer types of practitioner, such as pharmacists, paramedics, physiotherapists, and physician associates. CONCLUSION: This study provides analysis of a more detailed and complete primary care workforce dataset than has previously been available in England. In describing the workforce composition at this time, the study provides a foundation for future comparative analyses of changing practitioner deployment before the introduction of primary care networks, and for evaluating outcomes and costs that may be associated with these changes.

Motivating factors behind skill mix change: results from a practice managers' survey in England.

BACKGROUND: The expansion of the primary care workforce by employing a varied range of practitioners ('skill mix') is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans. AIM: To identify key motivating factors behind practice workforce decisions and their future workforce plans. METHOD: An online questionnaire was sent to practice managers in England. Data collection is ongoing; however, 1000 practices have responded to the survey so far. The questionnaire was composed of questions related to current workforce, motivating factors behind employment decisions, planned future workforce changes, financial assistance with employing staff (for example, HEE or CCG funding) and ideal workforce. RESULTS: Early results indicate that practices that have employed physician associates have done so to increase appointment availability (78% of practices) and release GP time (68%). Sixty-six per cent of practices who have employed pharmacists have received some form of financial assistance with 21% of practices still receiving assistance. When asked to construct an ideal workforce, 'new' roles accounted for 20% of that workforce on average, which is a significantly larger proportion than those roles currently account for. CONCLUSION: Although data collection and analysis are ongoing, the results of the survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles such as pharmacists, PAs and paramedics.

Skill-mix change in general practice: a qualitative comparison of three 'new' non-medical roles in English primary care.

BACKGROUND: General practice is currently facing a significant workforce challenge. Changing the general practice skill mix by introducing new non-medical roles is recommended as one solution; the literature highlights that organisational and/or operational difficulties are associated with skill-mix changes. AIM: To compare how three non-medical roles were being established in general practice, understand common implementation barriers, and identify measurable impacts or unintended consequences. DESIGN AND SETTING: In-depth qualitative comparison of three role initiatives in general practices in one area of Greater Manchester, England; that is, advanced practitioner and physician associate training schemes, and a locally commissioned practice pharmacist service. METHOD: Semi-structured interviews and focus groups with a purposive sample of stakeholders involved in the implementation of each role initiative were conducted. Template analysis enabled the production of pre-determined and researcher-generated codes, categories, and themes. RESULTS: The final sample contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants' perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training-practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability. CONCLUSION: This in-depth, in-context comparative study highlights that introducing new roles to general practice is not a simple process. Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.

Changing the skill-mix of the health care workforce.

OBJECTIVE: Changing workforce skill-mix is one strategy for improving the effectiveness and efficiency of health care. Our aim was to summarise available research into the success or failure of skill-mix change in achieving planned outcomes. METHODS: A systematic search for existing reviews of research into skill-mix was conducted. Databases searched included: MEDLINE, CINAHL, PsychINFO, Cochrane Library, HMIC, Centre for Reviews and Dissemination, and Department of Health Research Findings Register. Search terms included keywords defining the type of publication, clinical area, type of health personnel and the focus of the article (role change, skill-mix, etc.). English language publications from 1990 onwards were included. Two reviewers independently identified relevant publications, graded the quality of reviews and extracted findings. In addition, the wider literature was scanned to identify which factors were associated with the success or failure of skill-mix change. RESULTS: A total of 9064 publications were identified, of which 24 met our inclusion criteria. There was a dearth of research, particularly for role changes involving workers other than doctors or nurses. Cost-effectiveness was generally not evaluated, nor was the wider impact of change on health care systems. The wider literature suggested that factors promoting success include: introducing 'treatments' of proven efficacy; appropriate staff education and training; removal of unhelpful boundary demarcations between staff or service sectors; appropriate pay and reward systems; and good strategic planning and human resource management. Unintended consequences sometimes occurred in respect of: staff morale and workload; coordination of care; continuity of care; and cost. CONCLUSIONS: In order to make informed choices, health care planners need good research evidence about the likely consequences of skill-mix change. The findings from existing research need to be made more accessible while the dearth of evidence makes new research necessary.

Factors influencing turnover and retention of midwives and consultants: a literature review.

This study is a review of literature on the factors affecting the retention and turnover of hospital consultants and midwives. While there is widespread concern and acknowledgement of staff retention problems for professional occupations within the NHS, far less research has analysed the causes of the staff retention problems for the occupations in question. This study shows that there is a dearth of literature in this area and that systematic comparative analysis of retention and turnover factors through both primary and secondary research is urgently required in order that policy-making can take place on the basis of informed choice. Tentative initial findings were that lack of appreciation or perceptions of not being valued are key factors influencing turnover for both occupations. Working hours, workload and work schedules are also common concerns to both groups. In addition, career development, promotion and appreciation of contribution were important retention factors for midwives, while a supportive professional environment, reduction in workload and working hours and more flexible work patterns were important to consultants.