Skill mix in primary care

Subjects that breed euphemisms are usually contentious, and skill mix (reprofiling, grade mix, and multiskilling) is no exception. In her recent review of the topic, Leone Ridsdale has provided us with a much needed synopsis of the debate.1

The pursuit of skill mix in the new NHS has divided managers and health care professionals. With staffing accounting for 70% of NHS spending and managers under pressure to cut costs, the attractions of giving tasks to the lowest grades of staff who can perform them are obvious. In such an environment professionals fear the gradual erosion of the quality of care^2,3 and trade unions see the spectre of redundancy.4 The debate over skill mix has heightened the belief among health professionals that managers do not understand the complexity of their knowledge and skill.5

The dangerously simplistic approach of the NHS Value for Money Unit's report Skill Mix in District Nursing did nothing to allay these fears.6 District nursing was reduced to a series of mechanistic tasks that could be counted and reallocated. In this model of skill mix highly qualified, skilled clinical professionals are asked to delegate the core of their work to unskilled workers and find themselves undertaking a supervisory or management role or even being made redundant. Redundancy has become more likely as the economic recession reduces job opportunities, encouraging people to stay longer in the job they have, slowly moving up salary scales, and exacerbating a top heavy mix of grades.

This is the bleakest vision of a review of skill mix and is driven by the need to cut costs. At its best, however, careful consideration of skill mix offers much in terms of aligning services more effectively and more appropriately to the health needs of local populations. But this can be achieved only by a team sharing common objectives. The multidisciplinary primary health care team can provide an ideal environment for this kind of approach. In such a team each group of staff is represented by a few people, all of whom have a personal working relationship with all the others. They recognise that skill is a product of ability and experience as well as grade - a point that district wide reviews seem to have failed to grasp.

A culture of long service and low turnover of staff exists, which means that skill mix must be developed with existing staff, with room for manoeuvre only when staff leave. The painstaking Newcastle Nursing Skill Mix Review showed that each group of staff has a unique cluster of skills that contributes to the work of the team.2 The skills and contribution of each staff group must be explicitly valued and practitioners encouraged to expand the scope of their practice. The potential for delegation within each aspect of the workload can be explored, and it must be remembered that delegation brings both benefits and responsibilities. Different styles of delegation will suit different people.

Delegation provides opportunities for clerical and reception staff to share the challenges and rewards of providing clinical care (for example, venesection and simple clinical measurements). The development of relevant national vocational qualifications should ensure suitable training.7 No one should be asked to take on skilled tasks without adequate training and support.

Scope exists for reallocating responsibilities between almost every group within the primary care team. The most debated examples entail reallocation from general practitioners to practice nurses, and from district nurses and health visitors to health care assistants. The Burlington randomised trial of nurse practitioners in Canada showed that they performed as well as general practitioners in dealing with a range of tracer conditions.8 The nurses, however, saw only half as many patients as the doctors.

Similarly, Stillwell, who pioneered the nurse practitioner role in Britain, saw patients at 20 minute intervals, which is more than twice the average consultation time of general practitioners.9 Nurse practitioners could therefore be the more expensive option given their level of renumeration (up to pounds sterling 23 750) and their average hours of work (37.5/week). On the other hand, much has been achieved by practice nurses in the systematic care of chronic disease in primary care, and considerable potential exists to develop this work further.10 The government's apparent reluctance to introduce nurse prescribing, however, makes such developments more difficult.

The introduction of generic community nurse training under project 2000 seems to threaten the traditional roles of district nurses and health visitors. This contrasts oddly with the presence of increasing numbers of nurse specialists in the community. These include community psychiatric nurses, stoma care nurses, diabetic and asthma liaison nurses, and palliative care nurses. Each new post generates new questions of effectiveness and efficiency because of overlapping roles.

As family health services authorities assume responsibility for commissioning community nursing services there is greater scope for increasing the integration of the primary care team, with more sharing of objectives and less wasteful duplication of records. Nurses need to retain adequate professional support under any new arrangements, but there is much to gain.

In the face of so much contentious debate and uncertainty all innovation and change must be properly evaluated. In her excellent review Ridsdale has emphasised the importance of systematic research into the effects of alterations in skill mix in primary care and has proposed a series of detailed studies.1 Only by measuring the effects of what we do can we move beyond a narrow cost cutting agenda and explore the potential of skill mix to improve our patients' care.