Background Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortage of GPs. However, the evidence this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England.
Methods We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked to 10 indicators of quality of care, practice activity, prescribing, and health system costs. We used both fixed-effect and first-differences regression models to relate changes in staff composition to changes in outcomes, adjusting for practice and population factors.
Results Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups.
Conclusions Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.
Keywords – Health Services Research; Primary care; General Practice
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