Skill mix in primary care : patient, professional and management perpectives
Aim: This research is a study into the organisation and management of health services in Torbay Care Trust. It takes an overview of skill mix in primary care, considering the topic from the perspective of service recipients (patients), providers (professionals) and shapers and resourcers (management). The topic focuses on delegation and service diversification involving general practitioners, their directly employed team and community nurses attached to practices. Between and within the groups there are areas of agreement but also divergence of opinions and the key issues to be explored emerge from the literature. Approach: The study takes a combined case study, ethnography and survey approach. The patient research begins with focus groups and interviews and the data is triangulated with a survey; 22 patients were interviewed and 241 (28%) questionnaires returned. The professional research begins with a questionnaire survey, to test findings from the literature, followed by interviews to pick up areas where views differ; 128 (46%) questionnaires were returned and 8 professionals interviewed. The management research uses in-depth interviews as little existing research is available; eight individuals holding management roles in general practice, a primary care trust, a strategic health authority and at the national level were interviewed. Main findings: Influences on views: Influences on patient views were the use of services, age, working and health status. For professionals, job role was the main influence. Interpretation of the term `skill mix in primary care': Delegation to nurses was important to all. Diversification, teamwork and job satisfaction were important to professionals and management; however, concerns on overlapping roles and specialisation emerged. Service factors: Communications and continuity were important to patients, although concerns about continuity were raised. There was patient support for GPs taking on a limited range of specialist tasks. Professionals were most supportive of this skill mix development. Drivers and issues: Access was important to patients and meeting the access standard was important for management. GP workload, and recruitment and retention of nursing staff, were noted as drivers as were contractual changes. Problems included attitudes, different employers of team members, competencies, accountabilities and lack of training/supervision. Efficient use of time was important to patients and management. Professionals were concerned about time for implementation. Professionals involved: Attached nurses were mentioned infrequently and they were less likely to feel part of the primary care team. GP-employed nurses, particularly practice nurses, were mentioned frequently in terms of taking on work from GPs. Their job roles emerged as similar to district nurses. GPs identified tasks they would delegate to nurses, mainly chronic disease management. Support staff mentioned included receptionists and health care assistants. Conclusions This research is unique and adds to knowledge as it offers insights into skill mix in primary care from the perspectives of patients, professionals and management. Perspectives specific to each group emerge as do shared values. Skill mix in this study also incorporates both of the concepts of delegation and diversification, rather than one or the other. Views on interpretation of the term `skill mix in primary care', service issues, drivers, variables that affect skill mix and, views on professionals involved are used to arrive at a new model for the development of skill mix in primary care. Implications for policy can be identified across the health care system including the need to increase patient awareness and provide information, the use of contractual changes to promote skill mix and issues around premises and training. For practices and PCTs, tasks which can be delegated to nurses and assistants have been identified. There is also some support for GPs with special interests and other professionals based at the practice both of which could be implemented.