Where I end and you begin: Additional roles in British general practice

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan

General practice increasingly works under a multidisciplinary team model involving traditional and innovative roles. Within the NHS Long Term Plan, Primary Care Networks (PCNs) are focussing on using the skills of a greater range of allied health care professionals and expansion of the multidisciplinary team to offset a projected gap between supply and demand within primary care.¹  The Additional Roles Reimbursement Scheme (ARRS) aims to fund 26,000 additional roles in general practice, including roles such as clinical pharmacists, community paramedics and physician associates.   Here in BJGP Life, Ruth Abrams and Georgette Eaton described how these ‘essential roles are required to be responsive to the existing workforce and patient needs’, but highlight the need for job role clarity, appropriate allocation of work and adequate supervision.

Whilst some of the roles under the ARRS, for instance dieticians and physiotherapists, seem fairly well defined and understood by clinical teams and patients, other roles such as physician associates, nurse practitioners and community paramedics, are more recently emerging and involve duties that overlap with the traditional remit of a GP.  A recent BBC Panorama investigator who went ‘undercover’ as a receptionist an at Operose Health-operated practice, states that ‘Our investigation found the company let less qualified staff see patients, rather than doctors, without adequate supervision.’  ‘Less qualified’ is a loaded statement given an MDT approach, but it is important to consider the public understanding of additional roles in primary care.

What do patients understand about the role of allied health professionals in primary care?

Patient perceptions affect whether or not changes to the primary care workforce changes are accepted, and the extent to which new roles gain legitimacy.²  Public acceptability and understanding of these roles remains unclear.  In a study of experience of patient experiences when consulting with physician associates, understanding about the role of physician associates (PAs) fell into one of three categories: certain and accurate, certain and inaccurate, and uncertain.  The certain and inaccurate, and uncertain categories are concerning. The finding is mirrored in research looking at deployment of nurse practitioners in practice.  The variability in understanding of the PA role was intrinsically linked to provision of information about the role from the practice and from the PA themselves.³  Whilst PAs generally inspired high trust and confidence, patients felt deceived by their practice and the PA if the role was not fully explained to them.  Deception is never a good feeling for a patient to come away with after a healthcare encounter.

And what’s in a name?  These additional roles are varied and evolving. Alarmingly, a study of specialist nursing roles (including some based in hospital) revealed 595 job titles (including nurse practitioner, advanced nurse practitioner) in use across almost 18,000 specialist nurses.⁴  A systematic review of the contribution of paramedics in UK primary care echoed confusion around the job titles of paramedics both amongst patients and clinicians who were unclear about the role and scope of practice of the paramedics.⁵  Perhaps the confusion around the role is due to a lack of standardised practice; the review by Eaton et al highlights the role of paramedics as assessing and treating urgent, non-complex patients, but emphasised that paramedics in UK primary care are working at different levels of autonomous practice in different primary care settings.⁵

BBC Panorama, public perception and a spotlight on physician associates

Much of the recent BBC Panorama investigation focusses on Operose Health and its rapid growth across England (i.e. Britain’s Biggest GP Chain).  The show looks at links between Operose and the US based Centene Corporation and levels accusations about profiteering, claiming that the chain of GP surgeries were using PAs because they are ‘cheaper’ to employ than GPs.  Interesting, however, that the narrative in some of the news headlines focus on belittling the roles of PAs (i.e. ‘UKs biggest GP chain replacing doctors with less qualified staff’) rather than looking at the risks of private company ownership of NHS services.

PAs are a relatively recent addition to the primary care team; US-trained PAs were only introduced to the UK in the 2003.   The level of supervision required has been compared to that of a trainee clinician or trust grade doctor; PAs can work autonomously and are responsible for their actions and decisions with appropriate support.  The Faculty of Physician Associates is clear the PAs cannot replace GPs, warning that ‘by employing a PA, it does not mitigate the need to address the shortage of GPs or reduce the need for other practice staff. They can help to broaden the capacity of the GP role and skill mix within the practice team to help address the needs of patients in response to the growing and ageing population.’  On the flipside, some GPs have warned that the evidence for PAs reducing workload and costs is uncertain.⁶ As more PAs join GP surgeries, we need to look closely at whether these roles are achieving the aims set out by their introduction to UK primary care.

The future for additional roles in primary care

MDT working is here to stay, and we are all likely to see more emerging roles in our practices as the ARRS scheme expands.  At the micro level, to avoid feelings of deception, patients should be aware that they are seeing an allied health professional when booking their appointment and with a simple introduction (Hi, I’m Priti, a Physician Associate) during the consultation.  And while awareness-raising work about additional roles can be implemented at the practice level to help with issues around nomenclature and roles (for instance with information on the practice website), Evans et al emphasise a need for macro-level awareness campaigns at a national level to promote acceptance and engagement.⁷  What will be interesting as time goes on is our increasing understanding about the actual, versus promised clinical and cost-saving contribution of additional roles within the primary care workforce.

References

1. Beech JB, S.; Charlesworth, A.; Evans, H.; Gershlick, B.; Hemmings, N.; Imison, C.; Kahtan, P.; McKenna, H.; Murray, R.; Palmer, B. Closing the gap: Key areas for action on the health and care workforce. 2019.
2. Chapple AR, A.; Macdonald, W.;Sergison, M. Patients’ perceptions of changing professional boundaries and the future of ‘nurse-led’ services. Primary Health Care Research and Development. 2000;1:51-9.
3. Halter M, Drennan VM, Joly LM, Gabe J, Gage H, de Lusignan S. Patients’ experiences of consultations with physician associates in primary care in England: A qualitative study. Health Expect. 2017;20(5):1011-9.
4. Leary A, Maclaine K, Trevatt P, Radford M, Punshon G. Variation in job titles within the nursing workforce. J Clin Nurs. 2017;26(23-24):4945-50.
5. Eaton G, Wong G, Williams V, Roberts N, Mahtani KR. Contribution of paramedics in primary and urgent care: a systematic review. Br J Gen Pract. 2020;70(695):e421-e6.
6. McCartney M. Margaret McCartney: Are physician associates just “doctors on the cheap”? BMJ. 2017;359:j5022.
7. Evans C, Pearce R, Greaves S, Blake H. Advanced Clinical Practitioners in Primary Care in the UK: A Qualitative Study of Workforce Transformation. Int J Environ Res Public Health. 2020;17(12).

Featured image by Tim Marshall on Unsplash