How can we support service delivery in primary care through role substitution?

Conference:

SAPC ASM 2020 - cancelled due to pandemic

Talk Code:

V.3

Presenter:

Bethany F Anthony

Twitter:

@BethanyFAnthony

Co-authors:

Miss Bethany F Anthony1, Professor Nefyn H Williams2, Dr Joanna M Charles3, Dr Julia Hiscock4

Author institutions:

1School of Healthcare Sciences, Bangor University, 2Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool 3Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, 4North Wales Centre for Primary Care Research, Bangor University

Problem

The workload crisis in primary care is one of the most urgent and important issues facing the delivery of primary care in the UK. The increased use of nurses and allied health professionals to perform some roles instead of GPs is now widespread. A scoping review of reviews identified qualitative and economic evidence gaps in the literature. Based on this, the aims of this study were to explore the advantages, disadvantages and consequences of role substitution in primary care.

Approach

A mixed methods design was chosen to respond to the breadth of the study aims. Two systematic reviews were conducted to uncover the economic and qualitative evidence on role substitution in primary care. A survey of twenty primary care cluster leads was run to assess the current use of role substitution within primary care practices in Wales. Qualitative interviews were conducted with twenty-one purposively sampled patients and healthcare professionals and analysed using Framework to explore the barriers and facilitators to role substitution. A health economic analysis (case study of two practices) was used to explore the budget impact of role substitution in primary care.

Findings

The systematic review identified six economic evaluation studies. There was some evidence that substituting GPs with nurses to treat common minor health problems is cost-effective. A separate qualitative systematic review focusing on pharmacists, physiotherapists and occupational therapists identified eleven qualitative studies; highlighting a number of barriers and facilitators to pharmacists and physician associates providing general medical services instead of GPs. The primary care cluster leads who completed the survey reported that on average, 96.6% of practices across these clusters were using role substitution. Respondents offered a variety of strategies to increase the uptake of role substitution including ongoing support to employ and train allied health professionals and increase independent prescribing by nurses and pharmacists. The budget impact analysis indicated a reduction in GP appointments, and a rise in nurse and allied health professional consultations across the two practices. The qualitative analysis is ongoing and includes findings on allied health professional and care navigator roles, patient factors and factors relating to the primary care team and wider healthcare system.

Consequences

This PhD study has suggested a need for information, guidance or standards on role substitution to help the development of this model of care. Despite the growing prevalence of role substitution, a lack information for practices was identified on how best to implement role substitution successfully and how best to enhance service delivery under this model. The fact that these standards do not yet exist could have significant implications on service delivery as well as patient care and satisfaction.

Submitted by:

Bethany Anthony

Funding acknowledgement:

This PhD studentship is funded by Health and Care Research Wales.