Rethinking workforce boundaries: roles, responsibilities and skill mix and readiness for change in general practice

Title: Rethinking workforce boundaries: roles, responsibilities and skill mix and readiness for change in general practice
The Problem
The last 10 years has seen major changes in the way services are delivered in primary care. Skill mix, has offered many practices real opportunities for doing things differently. As the introduction of advanced nurse practitioners (ANPs) and health care assistants (HCAs) into the primary care workforce demonstrate. While workforce redesign has its critics, in a context of skill shortages, cost containment, policy reform, quality improvement and increasing volume of interventions delivered in primary care, new ways of working are becoming the norm. Yet introducing skill mix change is not without its challenges. A local evaluation of outcomes from ANP preparation programmes found some, although just a minority of, graduates experienced resistance to establishing their new role. The aim of this study therefore was to explore the features of those general practices that successfully accommodate and demonstrate readiness, to engage with skill mix change.
The Approach
Realistic evaluation3case study4design was used, as evaluating context is deemed as important as interventions. Seven GP practices drawn from across West Yorkshire (UK) with experience of skill mix change serving different populations (demography, geography and size) were invited and five agreed to participate. Following ethical approval a questionnaire -Team Climate Inventory [TCI-14] - was administered to all practice staff. Subsequently semi-structured interviews with ANPs, GPs, PNs, HCAs and business managers (n=24) were conducted. These were recorded, transcribed and analysed using thematic analysis. Exploratory analysis of TCI-14 data was undertaken using SPSS Version 18.0 followed by hierarchical regression modelling using MLwiN (Version 2.18) software
Findings
A total of 122 clinical and non-clinical informants from five practices completed the TCI-14. A total of 122 clinical and non-clinical informants from five practices completed the TCI-14. Mean TCI-14 scores were consistently high (50.8 – 59.0 summed across all subscales), for all practices, suggesting willingness to work collectively toward shared goals. Size of practice made no difference to mean scores. However higher mean scores were associated with proportion of non-clinical staff (p=0.026), respondents employed longer in the practices (p=<0.001) and male respondents (p=0.007). Comparison of TCI-14 with patient experience Quality and Outcome Framework (QOF) scores showed no significant association between these variables.
Qualitative data analysis suggests that the attributes that contribute to readiness to introduce skill mixing are organisational openness, transparency, commitment and staff capability. However these appear to be initiative specific, not representative of any unrestrained openness to change.
Consequences
Organisational willingness (demonstrated by TCI-14 score) may offer some indication of readiness to consider change. Yet willingness alone may not be enough to ensure successful implementation. Indeed readiness to innovate may be different from readiness to implement and be driven by different motivations.