Skill-mix change and the general practice workforce challenge

Faced with an ageing population living with increasingly complex health needs and a shortage of GPs and nursing staff, primary care is experiencing unprecedented pressure. Workforce transformation based around new models of care and ‘skill-mix’ change in the form of 5000 new ‘non-medical roles’ to operate alongside GPs is an aspirational solution,1 though generating the right balance of GPs/non-GPs is not without controversy.2 Although practice nurses have been working in extended roles in general practice for a long time3 there are other ‘new’ roles emerging. These encompass both the integration into primary care teams of new types of professional (for example, physician associates), and existing professional roles operating in new ways (for example, paramedics), typically with the expressed aim of releasing the capacity of GPs.4 Thus, skill-mix change may be perceived as a straightforward and common-sense response, ‘substituting’ hard-to-recruit GPs with other, non-medical, health professionals. Recently, a House of Lords Select Committee on the sustainability of the NHS has added its weight to other reports4,5 calling for the greater inclusion of non-medical workforce working under new models of care.6 Re-designing the workforce through skill-mix change is a considerable challenge for organisations, which may indeed bring benefits.5 However, the literature indicates the necessity to understand the implications of changing skill-mix if it is to deliver on its promises. Skill-mix has been conceptualised in three ways to mean: (1) the range of competencies possessed by an individual healthcare worker; (2) the ratio of senior to junior staff within a particular discipline; and (3) the mix of different types of staff in a team/healthcare setting.7 Skill-mix changes have been classified into four broad role modifications:7 enhancement (for example, extension of a primary care practice nurse’s role …