Workload redistribution fails to ease GP pressure: Study

Having a broader range of healthcare professionals consulting with general practice patients led to a redistribution of complex workloads, rather than a reduction in GP pressure, a study in the United Kingdom has found.
 
In response, the RACGP says there are timely lessons from this UK experience – that ‘the way you use your team is crucial to making sure it’s actually successful for everybody’.
 
The Additional Roles Reimbursement Scheme (ARRS) was launched in England in 2019 to expand the multidisciplinary primary care workforce.
 
It was intended to give GPs more time to focus on complex consultations and coordination-intensive care by delegating routine tasks, such as chronic disease reviews, medication checks and preventive care to other staff, including clinical pharmacists and physician associates.
 
However, a study published in the British Medical Journal has uncovered that the scheme increased consultation complexity for all health professionals involved.
 
‘Following ARRS implementation, primary care activity was delivered by a broader workforce managing increasingly complex care. Further research should assess the safety, quality, and system impacts of ARRS roles,’ its researchers concluded.
 
Data was gathered from 369 practices and 3.5 million consultations in 2018 and 2021, involving GPs, nurses, or direct patient care ARRS (DPC-ARRS) roles, which includes pharmacists.
 
Researchers found that all three groups experienced a rise in the proportion of consultations considered ‘complex’ between 2018 and 2021.
 
Practice nurses experienced the greatest increase (from 12% to 18%), followed by DPC-ARRS roles (from 16% to 19%) and GPs (from 14% to 15%).
 
The researchers also described a redistribution of the workload occurring within an environment that was under increased pressure.
 
‘While ARRS has broadened capacity and skill mix in primary care, rising consultation complexity appears to be a system-wide shift driven by ageing populations, deferred care, and post-pandemic recovery, rather than ARRS expansion alone,’ the authors wrote. 
 
‘Simply increasing role numbers is therefore unlikely to reduce GP workload.’
 
RACGP Board and SA Chair, Dr Siân Goodson is originally from the UK where she has worked extensively, and said the findings offer insight for Australian policymakers.
 
‘All healthcare professionals in the study are actually managing more complexity, and from what I’m reading and hearing, it hasn’t improved access, and actually GPs are still overworked and dealing with increasingly complex patients,’ she told newsGP.
 
 ‘It doesn’t seem to have had the desired outcome in reducing GP workload.
 
‘We really do need to work within multidisciplinary teams, but the way we set those teams up is so important to make sure everyone works really well within their scope, and as a team, and that’s when it can work well.
 
‘The worry is fragmentation, and also asking people to do tasks, or delegating tasks, that are beyond their scope and that risk patient safety.’
 
Dr Goodson adds there are good examples of how primary care teams can work effectively without fragmenting care.
 
‘When I worked in the UK, which is 14 years ago now, we did actually delegate far more tasks than GPs do here, and sometimes that was really helpful,’ she said
 
‘But what has happened in the UK since is much greater delegation to a wide range of other health professionals, which in some cases probably works well, but what the end result often is, is that GPs are left seeing very complex patients still with limited time.
 
‘GPs are also having to answer questions, being constantly interrupted by their colleagues who need support when they’re also trying to manage complex cases that may well be beyond their actual scope of practice.’
 
With Australia pushing ahead with plans in various states to increase the role of pharmacists in patient care, Dr Goodson said this study shows that careful steps must be taken.
 
‘We don’t want to be untangling – we want to be setting up a system that works from the start, and we don’t really want patients to have to decide whether their condition is simple and they can deal with it in a shop, in a pharmacy, or whether it’s more complex,’ she said.
 
She adds, however, that there are ‘great roles for pharmacists within general practice, obviously with medical management and reviewing medication plans as their expertise.’
 
‘But this study – and other research and discussions – doesn’t suggest that fragmenting care and having allied health providers, such as pharmacists, providing similar care or reproducing often the same care to a different standard in a different setting reduces the workload on general practice,’ Dr Goodson said.
 
‘Another concern is duplication of tests, and patients having to go from one provider back to their GP, often with a very muddled history by that point, and lots of different input without a very clear story.
 
‘It sometimes actually has the converse result of it adding work to general practice.’
 
The study’s authors recommend having clear role boundaries, implementing standard referral and handover protocols, strengthening supervision and mentorship, and ensuring adequate administrative support.
 
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