Policy Bite: Maximising the role of primary care workforce

March, 2017

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Meeting the demand for primary care: Maximising the role of primary care workforce was written by Professor Amanda Howe, Dr Jamie Murdoch, University of East Anglia.


The challenge for primary care services to negotiate tensions between meeting patients’ needs effectively and managing demand for care is a global problem. Rising life expectancy and improved options to help diagnosis and treatment (Office of National Statistics, 2016) mean that doctors both in community and hospital settings have to manage increasingly complex patients with multi-morbidities, who may take multiple medications and need ongoing management that requires greater input from the healthcare system.

As primary health care provision increases, the primary care workload has also increased: in the UK there has been a 5.2% increase in the number of GP (family doctor) consultations from 2007 to 2014. These consultations have got longer in duration (6.7% increase) over the same time period (Hobbs et al., 2016), though whether they are long enough to manage all the patient’s needs remains under debate. The challenge of managing this increase in workload is compounded further within a context of reductions to public health budgets (Fisher, et al., 2016), and an overall governmental aim to reduce health sector spending. In recognition of these challenges, the World Health Organisation’s Global Strategy on Human Resources for Health 2030 (WHO, 2015), has highlighted the importance of optimising workforce capacity by maximising the potential of community and primary care health workforce.

Appropriate planning and education strategies and incentives, and adequate investment in the health-care workforce, including general practice and family medicine, are required to provide community-based, person-centred, continuous, equitable and integrated care.” (WHO, 2016., p. 13)

Inextricably linked to these changes are increased pressures to reduce attendance at overburdened Emergency Departments, who often are the first port of call for patients who cannot access (or cannot afford) a primary care provider. All clinical teams have to decide how best to determine the level of urgency for individual patients, and decisions therefore have to be made about what level of clinical expertise is required, at what cost, to meet which patient need. Task shifting – for example, determining which aspects of care nurses can deliver instead of GPs - is one response to this concern, and a frequent topic of debate and research. Nurses can be as effective as doctors at treating some patients with complex case presentations (Pirret, et al., 2015) and leading certain clinical teams (e.g. Ndosi, et al., 2013), but this depends on case mix and the work they have to do; and they may be able to substitute for doctors to deliver elements of out-of-hours care (van der Bizen, et al., 2016). In the UK, community pharmacists are also being seen as another strategy to free GP time to conduct medication reviews for chronically ill patients (NHS England, 2015).

Redistributing the activities of everyday general practice from physicians to other health care professionals, at a lower cost, therefore offers a potential solution for addressing the challenges of primary care supply and demand, and recent international evidence identified 39 countries are task-shifting primary care activities from physicians to nurses (Maier & Aiken, 2016). However, decisions to substitute the expertise of physicians for professionals with different levels of training and expertise requires careful consideration, as such initiatives could represent a risk to patient safety and be counter-productive for attempts to make cost-savings. A good example comes from our own research at the University of East Anglia of how the urgency of patient’s presenting problems are assessed and managed over the phone; an approach known as ‘telephone triage’.

Telephone triage is increasingly being used internationally as the first point of contact for patient access to urgent and emergency care. Pressures to reduce waiting times and keep costs low has meant that those at the frontline delivering telephone triage are typically nurses supported by computer decision support software (CDSS). However, in an analysis of audio-recordings of triage calls, synchronised with video-screenshots of nurse’s use of CDSS, our research (Murdoch et al., 2015) identified evidence of CDSS adversely affecting nurse communication with patients. This evidence included patients struggling to communicate their problem in a format ‘required’ by the software; nurses directing answers from patients that did not fully reflect their symptoms, and thus led to inaccurate records; and nurses ignoring patient’s suggestions about treatment and diagnosis as they were preoccupied with completing software tasks.

These findings raise questions not only about the right level of clinical expertise required to deliver triage, but also the role of technology in supporting safe and effective care of patients. Similarly, studies of non-clinical call handlers working in the UK’s NHS 111 service have also shown how call handlers use ‘pseudo-clinical’ expertise to direct and advise patients (Turnbull et al., 2012). Notions that employing non-clinicians will save a health system money also appear to be ill-founded, with evidence of the U.K. NHS ‘111 helpline’ increasing the use of ambulance services (Turner, et al., 2013). Research such as this demonstrates that General Practice / Family Medicine must take a detailed consideration of the range of available evidence before making decisions about shifting tasks from physicians to other professionals, including conducting localised evaluations of service delivery.

In a world where populations are becoming increasingly mobile and diverse, challenges for primary care in meeting the scale and quality of patient demand are here to stay. The ability to deploy a flexible workforce will be essential in responding to such challenges. However, it is critical that we don’t invest in task-shifting solutions without a detailed consideration of the research to support such changes. To do so runs the risk of adding to our burden, not relieving it.

References
van der Biezen M., Schoonhoven L., Wijers N., van der Burgt R., Wensing M. & Laurant M. (2016) Substitution of general practitioners by nurse practitioners in out-of-hours primary care: a quasi-experimental study. Journal of Advanced Nursing 72(8), 1813–1824. doi: 10.1111/jan.12954

Fisher, E., O’Dowd, N. C., Dorning, H., Keeble, E., & Kossarova, L. (2016). Quality at a cost. Quality Watch annual statement. Available from: http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20annual%20statement%202016%20(final)%20WEB.pdf

Hobbs, F.D.R., et al., Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. The Lancet, 2016. 387(10035): p. 2323-2330.

Maier, C. B., & Aiken, L. H. (2016). Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study. The European Journal of Public Health, 26(6), 927-934.

Murdoch, J., Barnes, R., Pooler, J., Lattimer, V., Fletcher, E., & Campbell, J. L. (2015). The impact of using computer decision-support software in primary care nurse-led telephone triage: Interactional dilemmas and conversational consequences. Social Science & Medicine, 126, 36-47.

NHS England. Clinical pharmacists in general practice: pilot. 2015 27/07/15]; Available from: http://www.england.nhs.uk/commissioning/primary-care-comm/gp-action-plan/cp-gp-pilot/.

Ndosi, M., Lewis, M., Hale, C., Quinn, H., Ryan, S., Emery, P., ... & Hill, J. (2014). The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Annals of the rheumatic diseases, 73(11), 1975-1982.

Office for National Statistics. National life tables, UK: 2013–2015. 2016 29/11/16]; Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04

Pirret, Alison M. et al. (2015) Nurse practitioners versus doctors diagnostic reasoning in a complex case presentation to an acute tertiary hospital: A comparative study, International Journal of Nursing Studies , Volume 52 , Issue 3 , 716 - 726

Turnbull, J., Prichard, J., Halford, S., Pope, C., & Salisbury, C. (2012). Reconfiguring the emergency and urgent care workforce: mixed methods study of skills and the everyday work of non-clinical call-handlers in the NHS. Journal of health services research & policy, 17(4), 233-240.

Turner, J., O'Cathain, A., Knowles, E., & Nicholl, J. (2013). Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ open, 3(11), e003451.

World Health Organization. Global strategy on human resources for health: Workforce 2030. Draft for the 69th World Health Assembly. Report by the Secretariat. (2016) Available at: http://www.who.int/hrh/resources/16059_Global_strategyWorkforce2030.pdf