Where I end and you begin: additional roles in British general practice

[摘要] General practice increasingly works under a multidisciplinary team (MDT) model involving traditional and innovative roles. Within the NHS Long Term Plan, primary care networks (PCNs) are focusing on using the skills of a greater range of allied healthcare professionals and expansion of the MDT to offset a projected gap between supply and demand within primary care. The Additional Roles Reimbursement Scheme (ARRS) aims to fund 26 000 additional roles in general practice, including roles such as clinical pharmacists, community paramedics, and physician associates (PAs). In BJGP Life, Abrams and Eaton described how these ‘essential roles are required to be responsive to the existing workforce and patient needs’, but highlight the need for job role clarity, appropriate allocation of work, and adequate supervision.While some of the roles under the ARRS, for instance, dieticians and physiotherapists, seem fairly well defined and understood by clinical teams and patients, other roles such as PAs, nurse practitioners, and community paramedics are more recently emerging and involve duties that overlap with the traditional remit of a GP. A recent BBC Panorama investigator, who went ‘undercover’ as a receptionist at an Operose Health-operated practice, states that ‘Our investigation found the company let less qualified staff see patients, rather than doctors, without adequate supervision.’ Here, ‘less qualified’ is a loaded statement given an MDT approach, but it is important to consider the public understanding of additional roles in primary care.PATIENTS’ UNDERSTANDING ON ALLIED HEALTH PROFESSIONALS Patient perceptions can affect whether or not changes to the primary care workforce changes are accepted, and the extent to which new roles gain legitimacy. Public acceptability and understanding of these roles remain unclear. In a study of patient experiences when consulting with PAs, understanding about this role fell into one of three categories: certain and accurate, certain and inaccurate, and uncertain. The ‘certain and inaccurate’ and ‘uncertain’ categories are concerning. The finding is mirrored in research looking at deployment of nurse practitioners in practice. The variability in understanding of the PA role was intrinsically linked to provision of information about the role from the practice and from the PAs themselves. While PAs generally inspired high trust and confidence, patients felt deceived by their practice and the PA if the role was not fully explained to them. Deception is never a good feeling for a patient to come away with after a healthcare encounter.And what’s in a name? These additional roles are varied and evolving. Alarmingly, a study of specialist nursing roles (including some based in hospital) revealed 595 job titles (including nurse practitioner and advanced nurse practitioner) in use across almost 18 000 specialist nurses. A systematic review of the contribution of paramedics in UK primary care echoed confusion around the job titles of paramedics both among patients and clinicians, who were unclear about the role and scope of practice of the paramedics. Perhaps the confusion is due to a lack of standardised practice; the review by Eaton et al highlights the role of paramedics as assessing and treating urgent, non-complex patients, but emphasised that paramedics in UK primary care are working at different levels of autonomous practice in different primary care settings.

[学科分类] 卫生学