What skill mix is needed in primary care?

A shortage of GPs, increasing costs and other factors are resulting in the current NHS workforce buckling under the pressure. So what is sustainable for future working?

The Royal College of GPs has identified a current shortfall of 5,000 GPs. Up to a third of them are retiring early within the next five years and some have moved abroad. General practice is facing a crisis with partnerships struggling to recruit GP partners, salaried doctors and, in many cases, even locums. Furthermore, GP training programmes are under-filled by a third in some areas of the UK.

Is the answer to this recruitment gap to employ more GPs? Or could somebody else, for example another clinician, be doing the job?

At a recent Pulse Live conference in London this was the opening debate amongst 2,000 GP delegates. There was a strong vote in favour of not extending the skill mix but to keep employing more GPs to keep their generalist role and avoiding the potential for burn out. Introducing a skill mix can also lead to fears of deskilling, fears of the ‘dumbing down of the quality of care’ and patient safety being compromised.

But is this current model of employing more and more GPs sustainable in a financially strapped NHS?

We conducted two audits looking at what types of case patients were presenting to the Practice Assist service. We analysed data from 70 cases spread across seven practices, then 20 consecutive cases from four practices to cover a diverse patient population. Analysing consecutive cases allowed us to get an idea of what percentage in a typical session could be seen by a non-doctor, such as an advanced nurse practitioner (ANP) nurse practitioner (NP) or pharmacist.

The results showed between 43 and 47 per cent could have been seen by an NP and 7 per cent by a pharmacist.

So, had these cases been filtered out, a GP could have seen the more complex cases. Some worry that this could lead to burnout with no relief of ‘simple easy cases’ in between the complex conditions. However, this is the model for hospital consultants, so surely this is a better and more effective use of resources – as long as there’s additional time given to GPs to adequately manage the more complex patients.

Care UK runs many walk-in centres and urgent care centres successfully with GPs, NPs, ANPs and paramedics working together collaboratively. Based on our evidence so far we conclude that increasing the skill mix will be an essential part of changing the face and future of primary care – with a need for ensuring high standards are maintained through competency based practice, thorough assessment, training and guidance.

The GP role could change to that of overseeing teams and working with patients with more complex care needs whilst supporting the development of allied health professionals. There are many successful examples of well supported skill mixes of teams existing in primary care as presented by one of the speakers at the Pulse Live opening debate.

Fear of change shouldn’t be an inhibitor to evolving general practice and preserving everyone’s sanity. Most importantly, we must focus on maintaining quality of care and keeping the NHS cost effective and free at the point of access for patients.

Dr Reggie Sangha. MRCGP
Medical Director - Practice Assist