This week the Nuffield Trust published a new research report, Reshaping the workforce to deliver the care patients need. To coincide with the research, we will be unpicking the major themes from the report in a series of comment pieces from our researchers and expert guest contributors. In this blog, Dr Mike Holmes shares learning from his experience of implementing new professional roles into his GP practice in Hull.
Difficulties recruiting GPs and an ever-increasing workload are issues well known to my practice. The Haxby Group – where I am a partner – is a large practice delivering care to 50,000 patients across the cities of York and Hull.
Hull, the UK’s City of Culture in 2017, has historically struggled to recruit GPs, with some GP training schemes just 50 per cent filled. There has often appeared to be some hesitancy from newly qualified GPs to take salaried or partnership posts – with some choosing to take time out, others preferring to go overseas, and some wanting to work as locums.
Indeed, the locum market poses a significant challenge for practices. Locums are expensive and often do not provide the best clinical care – since locums may limit what they offer to a specified number of appointments, and offer few home visits and very little continuity of care. And of course, they have no ownership over practices themselves.
At Haxby, in response to these difficulties in recruitment and the delivery of care, we have taken a proactive stance, embracing the challenges and trying to be innovative in our approach to them.
New medical practitioners
I spent two years as Associate Medical Director at Hull Clinical Commissioning Group working to attract GPs to the city, with little success. Our practice experiences have mirrored that. So we have chosen to focus on other medical practitioners that can work collaboratively with GPs as part of the primary care team in order to provide a quality service for patients.
In 2015 we started to recruit paramedic practitioners to the team: we have three currently working at our practice. In order to support them in their transition to primary care, we have been careful to provide the necessary supervision and training on consultation skills, have supported their access to external education and welcomed them into our 'interprofessional learning' programme – fortnightly multi-professional education events that take place in both Haxby Group cities.
Since we are an advanced training practice in Yorkshire and the Humber, we play a leading role in bringing undergraduate nursing students into primary care as well as providing preceptorship schemes for new practice nurses and supporting a region-wide apprenticeship scheme.
New roles for pharmacists
In York, we had not really experienced difficulties recruiting GPs until the last 6–12 months, so here our focus has been on looking to generate more efficient ways of working. This, too, has resulted in a focus on new types of practitioner. Our attention was drawn to pharmacists, and in 2012 we employed our first. Her initial focus was on prescription management: research that we undertook revealed we were spending huge amounts of time in this area, with what we felt to be poor-quality results. With the pharmacist well and truly focused on this task, the quality rose rapidly and patient satisfaction followed. The work was supported by GPs and governance achieved through robust protocols.
Since our successful bid, our pharmacist team has rapidly expanded to a team of eight, and within that time period the workload has also expanded. Our pharmacist team now have face-to-face patient contact and conduct management and review of long-term conditions. They also have responsibility for specific disease management and processing discharge summaries. In future, we hope to involve them in assessing undifferentiated acute illness, visiting care homes and carrying out domiciliary medication reviews. Frankly, the list of possibilities grows daily as each of us hears about the other’s experiences. We have now spread the pharmacy team across both cities and are working with other practices in our York Federation to introduce pharmacists into their practice.
Is it worth it?
Having these different types of professional roles creates valuable diversity within the practice and offers us many benefits. Pharmacists add a layer of expertise, and as part of a collaborative team we feel enabled to deliver better care, with dedicated time to look at prescribing, quick turnaround time for prescriptions and freed-up GP time in order to focus on care for patients with more complex health problems. Likewise, paramedics have taken pressure off the urgent care service, complementing beautifully what we do as GPs. But, ultimately, the biggest benefit is that these roles are stabilising the service and gradually making the role of being a GP more sustainable and attractive.
Being an at-scale primary care organisation has definitely facilitated this work – my role as clinical lead for the Royal College of General Practitioners' Supporting Federation Programme has allowed me to see how advanced clinical practitioners are being used around the country – and this is shared on our Online Learning Network.
There are many lessons to be learned for those aiming to adopt a similar approach.
Be open-minded about the possibilities. Ensure efficient governance procedures are in place. Work collaboratively; create an atmosphere of trust and openness; and allow learning to occur naturally. Do not put pressure on any clinician to operate outside their sphere of competence. And importantly, involve patients in the process.
As we consolidate and build on the pharmacists, advanced nurse practitioners and paramedics in our team, our focus turns to others. Physician's associates are set to become more prevalent, and we as a profession must be ready to welcome them into our practices. We must understand what they have to offer and how they can work with us. Furthermore, mental health workers in a similar collaborative role, and as suggested in the General Practice Forward View, may prove incredibly beneficial for our patients.
So, despite the challenges, I feel optimistic about the future workforce in general practice. Perhaps my optimism is strengthened through proactivity, a team approach and by working at scale. I hope it is not misplaced.