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Thursday 27 October 2016
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The multi-skilled practice team

The government has announced that it will be providing a ‘rescue package’ to help ease the burden on general practice’s shoulders. But until this comes into force practices across the UK have had to look at other ways to solve the heavy workload faced by surgeries and their teams

General practice is the bedrock of the NHS but has become an increasingly pressurised environment for all those who work within it. A long-awaited ‘rescue package’ for English practices was expected to be announced by the government as Management in Practice went to press but any new measures are expected to take some time to be enacted.
Chaand Nagpaul CBE, chair of the British Medical Association’s general practice committee, warned last year: “The only deal fit for general practice is one that will lift the profession off its knees from the weight of unsustainable workload. The irrefutable fact is that demand has absolutely outstripped our capacity and we simply don’t have the GPs, appointments, staff or space to meet these escalating demands.”
What can – and are – practices doing to cope with the pressure in the short term? The main issues for practices across the UK are usually around workforce and workload.
These include replacing GPs who are leaving or retiring; finding locums to cover holidays, illness and other gaps; and doing the same for other staff, including practice nurses, healthcare assistants or receptionists. In many practices, the practice manager will have a very hands on role in this – and they are finding it ever tougher.
In Scotland, one practice manager, who did not wan’t to be named, says: “It is difficult to recruit GPS even in city practices – and that is true for partners and salaried doctors alike. Locums are hard to come by and
those that are around are charging inflated fees.”
It’s a similar position in North Wales, says Dwysan Edwards, a practice manager in St Asaph. Some local practices have handed back contracts and are now being run by health boards, offering a different model of care but often using locums – which can make it harder for other practices to find a locum to cover for holidays and sickness.

Using the team
The long-term answer to this is either to train more GPs – and unfortunately many medical students don’t see general practice as an attractive career – or to reduce the workload, which has to be done by GPs. Many practices are developing other staff to take on tasks that would once have been done by a GP. Edwards’ own practice has an advanced nurse practitioner, who will see some patients independently.
One approach is using all existing staff at ‘the top of their licence’. This means that simpler tasks are based down the chain so that doctors spend more time doing what only doctors can, nurse practitioners do only what they can, and so on. This can be an effective use of time when a patient can be seen by someone else. However, patients are not collections of tasks and inevitably sometimes staff will end up doing elements of care which could, theoretically, be done by someone with fewer qualifications or skills.
Upskilling other members of the practice team is also helpful. “We have trained cleaners to be receptionists, receptionists to be phlebotomists, phlebotomists to be healthcare assistants, and healthcare assistants to be nurses,” said Val Hempsey, a practice manager from Gateshead. This can help in some cases but unfortunately other key members of the team can be hard to recruit as well.
Looking at extending the range of skills available in the practice is another way of relieving pressure on the existing team. This can include physiotherapists, emergency care practitioners and pharmacists. Unlike doctors and nurses, ‘supply’ of some of these practitioners has exceeded demand, making them easier to recruit.  
Hempsey’s practice has developed primary care navigators – in some cases former receptionists who have been trained up to take on a new role, for example. These help patients find the help and support they need from the healthcare system. “Our team has become different – that is the only way I can see the future working,” she says.

The multidisciplinary team
With up to 30% of GP consultations thought to involve musculoskeletal problems, there are opportunities for changing how patients with these conditions access care. In about a third of clinical commissioning group (CCG) areas in England, patients have direct access to physiotherapy support and don’t have to go through the process of GP referral.
In a small number of other practices, physiotherapists work as part of the practice team and patients can be directed to them, when appropriate. The Chartered Society of Physiotherapy (CSP) argues this can allow GPs to spend more time with the patients who need their skills and could save practices money. The CSP calculates that if all patients with musculoskeletal conditions in an average practice were seen by a physio rather than a GP it could save £2,500 a week.
In a pilot in West Cheshire, more than 700 patients who would have seen a GP were diverted to a physio instead. This pioneering work is now in place in 36 practices in the area (see box: Musculoskeletal practitioners in GP surgeries ).
Another group that is reducing pressure on some surgeries is paramedics. In parts of Kent, paramedics and paramedic practitioners employed by the South East Coast Ambulance (SECAmb) Service Foundation Trust, have been carrying out some home visits on behalf of surgeries as well as dealing with 999 emergencies.
GPs decide which patients or groups of patients are suitable for this and the paramedics will then visit them at home. The additional equipment the paramedics carry means they can do some clinical investigations not normally carried out by GPs on such a visit, such as 12 lead ECGs (electrocardiogram).  
The scheme is in its early days but there is some evidence that not only does this take the pressure off GPs, who may struggle to find the time for home visits, paramedics may refer a relatively low percentage of such patients into hospital.
Dr John Ribchester, senior partner at the Whitstable Medical Practice, says: “The figures have been impressive and we expect it will prove very successful. In our first week we referred 32 patients to be assessed and 20 of them were dealt with by the SECAmb paramedic practitioners, 10 were dealt with at home in liaison with the doctor and only two needed to be referred on for admission.
 “The team also dealt with the referred 999 calls in the area and the transfer to A&E was also down so it has been an excellent start.”
One area where there is a surplus of trained staff is pharmacy, and a government programme has aimed to use some of their skills to help take some of the pressure off in primary care.
Pharmacist Ravi Sharma – who works in a practice in Stanmore, London – says there is a lot that pharmacists can do. “This is about having pharmacists in practices in patient facing roles,” he says. “Pharmacists have great core skills and they are very transferable skills.”
They can help with repeat prescribing; sorting out any medicine-related issues; liaise with other healthcare professionals over anything pharmaceutical; see some patients independently; run clinics for those with long-term conditions; and get involved in self care and health promotion, he says.
“That takes a massive amount of pressure off GPs and the healthcare team, but it also increases access,” he says. “From a practice manager’s perspective it can help with the quality and outcomes framework, the Care Quality and Commission (CQC) work, and local enhanced services and directed enhanced services. If you have a good relationship with a practice manager you can do a lot together.”
The bad news is that practices outside the national pilots have to fund this themselves, although in many cases pharmacists can be employed on a part-time or sessional basis, or across a group or federation of practices. The pilot offers tapered funding from 60% in the first year down to zero after three. It will cover around 7 million patients in England, however some sites are still in the early stages of developing the service.
Aside from workforce pressures, the workload associated with ‘bureaucracy’ and regulation is another burden that takes up time for both GPs and practice managers. For Hempsey, the most immediate pressure is a CQC inspection. She has been working 12-hour days to prepare for this. “The pressure beforehand is absolutely intense,” she says. “It is palpable. This is supposed to be about raising standards and patient care and it is having the opposite effect.”
The general bureaucratic workload of practices is also an issue for her practice. “It is not seeing the patient that is the problem. Some need longer appointments as they get older with more conditions. But there is a huge increase in other things that we have to do.”

Supporting each other
Relieving some of the pressures in general practice can be as much about how staff feel supported as practical measures around workload. For example, support from peers can be important. Hempsey says that many of the staff in her practice meet with similar staff from other surgeries in forums, which can reduce isolation.
“I think practices need to help and support and work together,” she says. “There is a lot we can do en masse.”
That includes sharing good practice, even sharing staff sometimes and swapping experiences. She and other practice managers from the area also stepped in when one practice had severe problems and was put in special measures. Within six months it had turned around.
Making jobs more interesting can help too. Edwards’ practice is now doing more research that can provide an additional source of incomes and make roles more attractive to doctors and other staff. Becoming a training practice can also be a rewarding experience and may help ‘sell’ a practice to potential GPs.
But for many practices the worries continue. While things can sometimes be stabilised temporarily by using team members in a different way, there is always concern about what happens if a GP leaves or they need a long-term locum. The position may vary slightly around the country – in Scotland, for example, GPs are not involved in commissioning in the same way as in England so there is not that demand on their time – but the pressures remain.
Practices can do a great deal to help themselves but there are limits. As Hempsey points out: “The workload is massively increasing and continues to do so. We are taking more from secondary care into primary care.” It’s hard to see that stopping.

Musculoskeletal practitioners in GP surgeries
Three-out-of-10 patients a GP sees will have musculoskeletal problems – and often GPs are able to do little for them or can only refer them onto physiotherapy services.
A pilot scheme in Cheshire has provided an alternative for these patients – seeing a physiotherapist working across clusters of GP practices and skilled in offering either appropriate onward referral or self-care advice.
Key to this has been getting receptionists to ask patients what the problem is and, where it is musculoskeletal, offering them an appointment with a physiotherapist rather than a GP. To ensure this can be offered quickly, it may be at another practice in the cluster.
The evidence from an early part of the pilot suggests this leads to an 18% reduction in investigations, and a 23% drop in orthopaedic referrals. Both of these offer substantial savings – but the greater part of the savings is likely to come from GPs being freed up from seeing MSK patients. The target is for the MSK team to see 1,000 patients a month.
Karin Daelemans, lead therapist for the scheme, says patient satisfaction was extremely high and GPs loved it as well. The scheme has now been rolled out to all 36 practices in the area with the aim of evaluating it further, and making a financial case for it to continue.

Alison Moore, freelance healthcare writer.