Chronic staff shortages and changing health needs mean the NHS must think differently about how it supports new ways of working across teams. Everywhere, providers are grappling with how to make best use of the talent, time and resources of their staff to cope with mounting workforce pressures while improving care quality. This is especially true in general practice, with more GPs now leaving the workforce than entering and practice nurses equally hard to come by. That is why the recent joint report from the Health Foundation, the Nuffield Trust and The King’s Fund makes the case for expanding team-based approaches in primary care, including making better use of roles like physiotherapists and pharmacists.
Multi-professional teams offer an opportunity to not only bridge the workforce gap but to widen the offer of primary care by drawing on a broader range of skills and competencies. More than a response to staff shortages, team-based approaches can improve care delivery by ensuring that patients receive comprehensive services led by professionals with the expertise and skills most suited to meet their needs. The NHS Long Term Plan and new GP contract commit to increasing the number of staff working alongside GPs, which will be important for expanding multidisciplinary teamworking and optimising skill mix in primary care.
But as the joint report makes clear, focusing on the supply of new workers on its own will be insufficient to deliver successful change. That requires teams on the ground having the space to design new ways of working and the ability to successfully implement and sustain them. Without careful implementation, the intended benefits of team-based approaches are far from guaranteed.
Expanding the role of pharmacists in practice
It’s a lesson we’ve seen time and again in the Health Foundation’s improvement programmes, which over the years have supported many teams to successfully test new multidisciplinary approaches.
Take the team at Sussex Partnership NHS Foundation Trust, who trained local community pharmacy staff to undertake the physical monitoring of young people on ADHD medication, which was previously done by staff in specialist child and adolescent mental health services (CAMHS) clinics. In a context where many children and families missed school and work to attend clinic appointments, while others struggled to get the support they need, the project has improved access while freeing up CAMHS staff to focus on people who need more intensive help.
Critical to making the project work was a period of strong clinical engagement to bring staff on board. The project team initially met resistance from consultants, who feared that giving up appointments for physical monitoring would distance them from patients. To gain support, the team demonstrated that skill mix changes freed up an estimated 40% of the CAMHS team’s resources so that they had time for more reflective practice and advanced patient care, as well as improved patient experience. The service model has now become standard practice in the New Forest CAMHS team and is in the process of being spread to other CAMHS teams and Adult ADHD clinics across Hampshire and Sussex, and the team wants to extend it to a broader set of conditions.
Another example comes from NHS Highland Pharmacy in Scotland. Faced with severe GP shortages that left many patients unable to access timely care, they developed specialist and advanced pharmacist roles to take on more responsibility for medicines management from GPs, such as annual medication reviews. The team is now using telehealth to expand access to pharmaceutical care to even more patients in remote areas.
'GPs were hugely stretched, and certain things just weren’t getting done. We started to ask ourselves how we could change the role of the pharmacist. We already managed medication for the frailest patients, but what about the other 90% of the population? How could we best help them?' Clare Morrison, Senior Clinical Quality Lead, NHS Highland
Implications of developing primary care teams
Expanding the role of pharmacists required careful articulation of roles and responsibilities to help define how the service would work and create shared expectations around the new work arrangements. We know from the literature that this is a common theme in implementing skill mix change, which often blurs traditional workplace boundaries. Without clarity around the remit of new roles, such changes can create confusion and tensions and lead to gaps in or duplication of work. In the Highland Pharmacy project, the key was co-designing with staff the protocols and standard processes within each job plan. This helped build shared expectations and ensured that people in expanded roles felt confident to take on new responsibilities.
Another interesting finding from this team is that developing expanded primary care teams didn’t free up lots of time for GPs. Instead GP caseloads became filled with more complex patients. While altering skill mix holds real potential for helping teams maximise resources, this highlights the need to think through the implications of workforce changes carefully. If staff in advanced roles are left to oversee only the most complex patients this can increase the intensity of work, pressure and burnout – unless they are prepared or supported to meet the demands of the caseload shift.
Identifying the opportunity and making it work in practice
What these and other improvement projects we’ve funded demonstrate is that there’s an important gap between identifying the opportunity for a new way of working and the reality of delivering it on the ground.
Skill mix changes, like other kinds of service improvement, require organisational readiness, take careful planning and change management, and cannot be divorced from the context in which they take place. And unless national programmes take account of these challenges and support organisations to deliver change on the ground, there’s a real risk the anticipated benefits won’t materialise.
At the Health Foundation, we’re investigating what it takes to effectively implement and maximise the benefits of new multidisciplinary approaches to care and we’re considering how to best support teams making changes on the front line. This is important in considering how the NHS can succeed in tackling its workforce challenges over the coming years and deliver the new models of care that our patients so urgently require.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.
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