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www.cfwi.org.uk
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CF W O R K F O R C E B R I E F I N G
WI
SCANNING
How Could tHe CommunItY
workForCe allevIate Some
oF tHe PreSSure on general
PraCtItIonerS and ImProve
joInt workIng aCroSS
PrImarY and CommunItY
Care?
HEALTH AND SOCIAL CARE
SYSTEM DESIGN Achieving better
integration between health, social
care and support organisations
DEMOGRAPHIC AND
SOCIAL Planning to meet the
needs of an ageing population
with an ageing workforce
P
rimary care faces
challenges ahead as a
result of the ageing
population, rising patient
expectations, increase in
complex comorbidities,
and the financial climate. Between
1995 and 2008, the number of gP
consultations rose by 11 per cent
(deloitte, 2012). For the average
patient, the number of consultations
per year rose from 3.9 in 1995 to 5.5 in
Fig.1
FINANCIAL AND ECONOMIC Planning service
delivery given the uncertainty about levels of
funding in the future and how this will affect
future demand for and supply of care services
2008, with the biggest increases
taking place among the over-70
population (Health and Social Care
Information Centre, 2009).
If the pattern of consultations remains
unchanged, Deloitte expects there will
be a total of 433 million GP
consultations by 2035 and 180 million
of these consultations would be for
people aged 65 and over, nearly double
the current number (Deloitte, 2012).
CfWI modelling (shown in figure 1) used
in reviewing the GP workforce projects a
sustained rise in demand, and an
undersupply across general practice
(CfWI, 2013). Given that some GPs will
take on commissioning responsibilities,
their time is going to be even more
stretched in the future. Meeting
increased demand through GPs alone
may not be possible. This briefing
explores how the wider community
workforce could be used to alleviate
some of this pressure.
55,000
50,000
Demand and supply forecasts for GPs
in four medical scenarios
Demand: scenario 1-6
Supply: scenario 1-6
Supply: baseline GPs
Demand: baseline GPs
The scenarios are based on a range
of views gathered by stakeholders. To
find out more about the scenarios
please access our report at
www.cfwi.org.uk/publications/gp-indepth-review-preliminary-findings .
Source: CfWI (2013)
Full-time equivalent
Big picture challenges
HORIZON
45,000
40,000
35,000
30,000
2010
2015
2020
2025
2030
Year
THE CENTRE FOR WORKFORCE INTELLIGENCE 209-215 Blackfriars Road London SE1 8NL T +44(0)20 7803 2707 E [email protected]
www.cfwi.org.uk | www.horizonscanning.org.uk
BPC Community care:Layout 1 07/10/2013 12:43 Page 2
workForCe BrIeFIng | HOW COulD THE COMMuNITy WORKFORCE AllEvIATE SOME OF THE PRESSuRE ON GENERAl PRACTITIONERS AND IMPROvE JOINT-WORKING ACRO
redesigning the gP practice
workforce: Nurse
practitioners
redesigning the gP practice
workforce: Physician
assistants
One way to alleviate pressure on GPs is
to base other types of community
worker in GP surgeries. Nurse
practitioners, for example, could
redesign primary care activities and
optimise skill mix to reduce pressure on
GP time and address financial
challenges. However, while a review by
laurant found quality of care is similar
for nurses and doctors, it is not clear if
using nurse practitioners decreases the
doctor's workload (laurant et al, 2009).
Physician assistants (PAs) are mid-level
practitioners that have a scienceorientated first degree. Healthcare
professionals with a first level
qualification in, for example, nursing,
physiotherapy or who are working as a
paramedic can also apply to a physician
assistant course. The PA role has a
history of over 40 years in the united
States (uS), where there are now over
80,000 working PAs, and, within Europe,
the Netherlands adopted the model
seven years ago and now has 700 PAs.
However, the role is still relatively new to
the uK with about 200 PAs currently
known to be working across
approximately 30 acute trusts (Parle and
Ross 2012). The uK has recently been
exploring the use of PAs in clinical
practice and the university of
Southampton is due to publish research
commissioned by the National Institute
of Health Research (NIHR) investigating
the contribution of physician assistants
to primary care in England.
Nurses tend to provide more health
advice and achieve higher levels of
patient satisfaction than doctors.
However, although they have lower
salary costs, nurses may order more
tests and use other services, which could
offset these cost savings. Indeed, a study
in the Netherlands found that adding
nurse practitioners to GP surgeries did
not reduce the workload of GPs (laurant
et al, 2004). The number of contacts
during surgery hours increased in the
intervention group, particularly for
patients with chronic obstructive
pulmonary disease or asthma, and there
was no significant change in the number
of out-of-hours consultations or in
workload of GPs.
The home care organisation Buurtzorg in
the Netherlands has demonstrated an
alternative model of delivering care
which reduced the number of unplanned
episodes and resources used per patient.
Small self-steering teams of nurses visit
patients to deliver all of the home care
patients’ needs. Although this has higher
costs per hour there are overall
productivity gains through fewer hours
in total (KPMG, 2013).
CF
WI
© 2013
CENTRE
FOR
WORKFORCE
INTELLIGENCE
Centre FOR workForCe IntellIgenCe
Recent English and Scottish pilots of PAs
employed in general practice or out-ofhours services reported that PAs were
well accepted by patients, undertook
work previously done by medical staff,
consulted medical staff less frequently
and exhibited greater diagnostic skills
than extended roles in nursing. Although
there is a relatively small number of PAs
in England currently, there is a potential
scope for an increasing service
contribution to general practice in
England in the future. In the united
States, for example, around 45 per cent
of the PAs distributed by primary care
specialty, work in family medicine (AAPA,
2010).
The flexibility of PAs also makes them
attractive contributors to secondary care
provision. In the uS, physician assistants
will usually work in several specialties in
their career. Physician assistants are a
workforce that can complement the
work of GPs and the wider practice skill
mix in seeing younger patients with
fewer indicators of co-morbidity and
fewer medically acute problems and can
be deployed to triage patients and/or
see same day appointments.
the wider community
workforce: Pharmacists
Another way to alleviate pressure on GPs
is to divert demand to the wider
community workforce. The community
workforce is largely composed of
generalist community workers, but with
the increasing prevalence of long-term
conditions and co-morbidities, there
may also be a need for more specialists
in the community. This could be in the
form of community workers with
specialist interests, or specialists who
work in the community.
GPs have traditionally been seen as the
gatekeepers to the system. But
community pharmacists could play a
role in providing services, and
signposting people to other areas of the
health and social care system. They are
local, accessible and convenient, and it
has long been recognised that
pharmacists are a ‘major untapped
resource for health improvement’ (DH,
2005). Primary care pharmacists work
closely with GPs and can offer advice on
good prescribing, which can lead to
more effective first-time prescriptions
and can help to address capacity issues
in the NHS. Participants at the recent
CfWI pharmacy in-depth review scenario
generation workshop (held in January
2013) considered that there was a good
case for an expanding role for
pharmacists. This could involve routine
testing, helping to manage long-term
conditions, and advising patients on the
use of technology.
There is mixed evidence about the
impact of pharmacists in primary care
(Ballantyne, 2011). Pharmacist-led
medication reviews can have positive
medication-related outcomes, but these
do not seem to translate into
measurable benefits to patients or
health services (Holland et al, 2006). In
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ACROSS PRIMARy AND COMMuNITy CARE?
CfwI gP in-depth review project
CfwI have been commissioned by the department of Health to conduct an
in-depth review of the gP workforce. the review will assess:
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current workforce numbers to forecast supply
key drivers affecting workforce demand
regional variations in demand
and make recommendations for future workforce planning.
This work is due to be published in
2013. More information about this
project can be found at the
following link:
www.cfwi.org.uk/our-work/medicaland-dental-1/gp-in-depth-review
The review will also address issues such as GP workload and the 2015 recruitment
target and beyond, as well as wider issues around primary care delivery.
one study, GPs did not follow up on
recommendations made by pharmacists,
with a suggestion of lack of respect
shown to pharmacists by physicians. In
another, patients saw doctors as having
‘higher authority’, and this was a barrier
to pharmacists providing advice
(Ballantyne, 2011). It may be necessary
to change the public perception of
pharmacists’ roles and to highlight the
importance of working in a
multidisciplinary way to improve
outcomes of pharmacy-led
interventions.
redesigning the gP practice
workforce: Social workers
Surrey County Council is exploring the
idea of putting social workers into GP
practices (Surrey County Council, 2012).
This has previously been tried by other
councils. Many local areas have assigned
social care staff to surgeries, and they
participate in regular meetings held at
practices to help patients stay in their
own homes and communities. This could
help to improve joint working across
health and social care workforces. In an
iMPOWER survey, more than half of GPs
admitted they don’t understand the
wider care services available for patients
and just 15 per cent of GPs said they
understand all the options (iMPOWER,
2013). 78 per cent of social workers
believe GPs often don’t understand or
encourage alternative options to
residential care. According to Jeremy
Cooper, the findings reveal GPs, social
workers and local authorities are locked
in a dysfunctional relationship, with lack
of understanding between them
generating unnecessary demand for
residential care – the highest cost area
of adult social care. Helping GPs
understand the wider social care services
available could help deflate demand,
keeping 60,000 people out of residential
care and saving more than £600 million
a year (iMPOWER, 2013).
redesigning the gP practice
workforce: Community
patient groups
Community patient groups are a
valuable, untapped resource to support
patients. They increasingly provide
services and help to improve care in the
community. Patientview has been
tracking patient groups for over a
decade, and has seen huge increases in
their number (CfWI interview with
Patientview, 2013). Patientview’s latest
statistics, which it believes
underestimates the actual size of the
patient group sector, shows 20,841
patient groups in the uK, most of which
are local or regional. In a survey of 170
local or regional groups, Patientview
found that 89 per cent of groups supply
information to patients, 80 per cent offer
peer-to-peer support, 45 per cent
provide advocacy on behalf of patients,
36 per cent raise money for medical
research, and 18 per cent supply
healthcare services such as cancer
screening. Scaling this up shows there
could be well over 3,000 patient groups
supplying services in the community.
This represents a great opportunity for
more care to be delivered in the
research study
A randomised trial investigated the impact of pharmacist interventions for
heart failure patients: home visits by pharmacists who provided education
about conditions and medication to patients, and gave follow-up advice to
GPs. There were no significant differences in hospital admissions at six
months, quality of life, or mortality between the two groups. In addition,
analysis suggested overall primary care activity (including home visits,
attendances at general practices, and phone calls) increased by 17 per cent
(Holland et al, 2007).
community and empower patients, but
requires patient groups and other
elements of the health and social care
workforce to support and complement
each other. Better links need to be
forged between all elements of the
community workforce to maximise these
opportunities.
redesigning the gP practice
workforce: Case
management
Increasing numbers of GP patients are
older people, and are likely to have many
professionals involved in their care, for
example district nurses, domiciliary care
workers, and community workers who
specialise in specific long-term
conditions. Case management is needed
to coordinate the input of these
professionals. This is often done by GPs,
but to varying degrees of success
because of the time required. GPs are an
expensive resource to use for this
activity, which could potentially be done
by another member of the community
workforce, such as a community matron.
It would require organisational and time
management skills. It would also entail a
good understanding of different
professions’ roles and the services
available, and how to draw on these roles
and services.
the role of technology
There is potential to use the wider
community workforce more effectively,
but technology may also play a role in
addressing these challenges. Telehealth
and telecare could have an impact over
the short-medium term, and may even
transform the whole community model.
As the system becomes increasingly
complex, with sub specialities and
multiple services available, complex
decision-support tools could be
developed. This could lead to a situation
where there is a role in primary care to
help direct patients to the services they
need.
BPC Community care:Layout 1 07/10/2013 12:43 Page 4
workForCe BrIeFIng
what are the implications for education and training?
Delivering more care in the community (and using the community workforce to alleviate pressure on GPs and improve joint
working) will require an increase in the proportion of the health and social care workforce based in the community. Recent
CfWI engagement found the majority of nurses continue to work mainly in hospitals, and that any progress with shifting care
into the community has tended to happen on a local scale and in specific areas such as mental health (CfWI, 2013). The
number of full-time equivalent (FTE) community nurses has only marginally increased over the last decade, from 14.5 per
cent of qualified nurses in 2001 to 15.1 per cent in 2011 (RCN, 2012).
One of the main barriers is the lack of change in the education and training approach, and in the curriculum to develop future
nurses (CfWI, 2013). It may be important to deliver more training in the community to prepare members of the workforce to
work in this setting, addressing both the skills they need and expectations about what their job will involve. The age
demographic of the existing community nursing workforce is older than that of acute nurses. This suggests that newly
qualified nurses are still working in acute rather than community settings after their training. In Guy’s and St Thomas’
Foundation Trust, a ward and community rotation programme, supported by a ‘buddy’ scheme, is currently being piloted to
encourage nurses to work in both acute and community settings. Great Ormond Street Hospital (GOSH) has combined
inpatient and outreach roles to expose nurses to working across settings, enabling greater flexibility and integration of care
(CfWI, 2013). Training workforces together could improve joint working across health and social care workforces. This could
normalise the concept of joint working, and remove some of the oft-mentioned barriers around different languages and
cultures. The Surrey Health & Social Care joint Training Partnership (SjTP) is a collaboration between health and social care
agencies which delivers joint learning and development training. This learning and training enables health and social care
staff to train together with service users, carers and members of the voluntary sector to support the delivery of integrated
care (Surrey County Council/The learning Enterprise, 2012).
New roles may also be developed in the future, with implications for education and training. In 2010, Skills for Health
developed scenarios to consider possible future workforce roles, one of which was ‘personal health navigator’ (Skills for
Health, 2010). This person could be a care coordinator, carrying out activities such as advocate, broker and information
organiser. Another future role identified was a level 4 generic community worker. This role could involve working with people
with long‐term conditions and would be part health, part social care and part education.
references
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impacts in primary health care: are we asking
the right questions? Southern Med Review
4(1), 17-21. Accessed online Mar 2013:
http://apps.who.int/medicinedocs/
documents/s18432en/s18432en.pdf
Centre for workforce Intelligence (2013a). GP
In-depth review, preliminary findings.
Accessed online Apr 2013: www.cfwi.org.uk/
publications/gp-in-depth-review-preliminaryfindings
Centre for workforce Intelligence (2013b).
Shift of Care: Acute to Community.
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