Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK.
Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK.
Soc Sci Med. 2022 Sep;308:115224. doi: 10.1016/j.socscimed.2022.115224. Epub 2022 Jul 19.
Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England.
We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors.
Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups.
Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.
增加初级保健中新临床角色的员工就业被认为是解决全科医生和护士短缺的一种解决方案。然而，关于这对实践结果的影响的证据有限。我们研究了在英格兰的普通实践中技能组合的变化如何改变结果。
我们获得了 2015 年至 2019 年期间 6296 家英国普通实践中员工的年度数据，并将专业人员分为四类：全科医生、护士、卫生专业人员和医疗保健助理专业人员。我们将涵盖可及性、临床效果、用户体验和卫生系统成本维度的 10 个护理质量指标联系起来。我们使用固定效应和一阶差分回归来模拟员工组成和结果的变化，同时调整实践和人口因素。
所有四类员工的就业人数都随时间增加，卫生专业人员的增幅最大（从 2015 年的每个实践 0.04 个全职员工增加到 2019 年的 0.28 个），护士的增幅最小，增长了 3.5%。全科医生和护士人数的增加与实践活动和结果的变化呈正相关。新角色的引入与患者满意度呈负相关：卫生专业人员增加一个全职员工与总体患者满意度和预约满意度降低 0.126 [0.175，-0.078]和 0.116 [0.161，-0.071]标准差相关。药剂师改善了药物处方结果。所有员工类别都与更高的卫生系统成本相关。不同员工群体之间几乎没有直接的互补或替代关系的证据。
引入支持全科医生的新角色对质量或患者满意度没有直接的影响。问题可能源于需要调整实践组织的复杂适应以及这些角色对患者的新颖性。这些发现表明，在鼓励初级保健中更多雇用不同专业人员的政策实施方面应持谨慎态度。
