Researchers urge caution over increasing non-medical clinical roles in GP practices

The employment of non-medical staff with clinical roles in primary care has been linked to negative impacts on patient satisfaction in a study by University of Manchester researchers.

The analysis of 6,296 English general practices between 2015 and 2019 is the most detailed to date exploring the impact on delivery and patients' experience of healthcare of the introduction of new roles including social prescribers, clinical pharmacists, paramedics and physician associates.

Published in the September 2022 issue of the journal Social Science & Medicine, the study is a response to the growing trend for professionals other than GPs to be involved in treating patients in general practice settings.

As is happening in many other countries, the move has been proposed by the NHS as a solution to critically low numbers of GPs and nurses. Until now, evidence of its impact on practice outcomes has been limited.

Using national data, the study explores the statistical relationship between the workforce composition and ten indicators of accessibility, clinical effectiveness, user experiences and health system costs.

The researchers grouped roles into four categories: GPs, Nurses, Healthcare Professionals (HP) and Healthcare Associate Professionals (HAP).

Healthcare Professionals included clinical pharmacists, physiotherapists, physician associates, paramedics, podiatrists, counselors, and occupational therapists.

The Health Associate Professional group included dispensers, health care assistants, nurse associates, pharmacy technicians, psychological well-being practitioners and social prescribing link workers.

The study showed that employment increased over time for all the staff groups, with largest increases for Healthcare Professionals—from an average of 0.04 full time equivalent (FTE) per practice in 2015 to 0.28 in 2019.

The smallest increase was observed for Nurses, who experienced a 3.5% growth.

The employment of more staff in traditional primary care roles, such as GPs and Nurses, was positively associated with changes in practice activity and outcomes.

Patient satisfaction with primary care services showed a negative trend over the study period. The study found this drop in satisfaction to be larger in practices that had employed more HPs.

On average, a one FTE increase in HP staff employed at GP practices was associated with a 2.4% drop in overall patient satisfaction which is roughly equivalent in magnitude to the overall decrease observed between 2015 and 2019.

Similarly, a one FTE increase in HP was associated with a 1.3% drop in patient satisfaction with making an appointment, about a quarter of the overall decrease of 7.2%.

On the plus side, however, pharmacists contributed positively towards some tasks, improving the quality of medicine prescription and reducing the burden of these activities for existing staff.

The changes in workforce composition did not show significant relationships with other primary care outcomes measured in the study.

In addition, there was surprisingly little evidence of any complementarity or substitution between different staff groups, suggesting that any contribution made by HP and HAP staff to GP practice outcomes happened independently.

Lead author Dr. Igor Francetic said, "The introduction of new roles to support GPs does not have straightforward effects on service quality or patient satisfaction.

"In fact we provide substantial evidence of detrimental effects on patient satisfaction when some Health Professionals and Healthcare Associate Professionals are employed. Patient satisfaction is a crucial dimension of quality of care, as it contributes to individuals' willingness to seek care through GPs.

"There was limited evidence of interaction—in terms of either substitution or complementarity—between the GPs and other roles, suggesting they contribute independently to outcomes and quality in primary care. This goes against the common wisdom that some of these new roles will reduce the workload of existing GPs.

He added, "The results of our statistical analyses together with qualitative evidence gathered by colleagues at The University of Manchester suggest that these problems arise from the complex adaptation required to adjust practice organization and from patients being unaccustomed with these new professionals and their competencies.

"The introduction of several of these new roles requires substantial supervision from GPs and complex changes to how work is organized that may ultimately reduce efficiency.

"These findings have profound implications for the implementation of policies emphasizing the benefits of introducing staff with non-traditional roles in primary care.

"That is why we urge caution over the implementation of policies encouraging more employment of different professionals in primary care."