How general practice team composition and climate relate to quality, effectiveness and human resource costs: a mixed methods study in England

Background: General practice is under pressure: General Practitioners’ (GPs’) workloads are increasing while recruitment and retention problems have reduced the number of GPs per capita, and shortages of primary and community nurses have exacerbated staffing problems. New roles, organisational forms and contractual models of primary care are emerging. Effective and efficient use of the GP workforce is important, but evidence on how practice organisation, skill mix and team climate influence performance is scarce. Aim: To explore how organisation, skill mix and climate in GP teams relate to quality of care, clinical effectiveness and human resource costs. Design: Concurrent, parallel, multistage, mixed methods in 7 work packages (WPs): WP1: Overview: (i) policy review; (ii) new practice models; (iii) construction of a ‘Practices Database’ covering, for all English practices (n~7600): skill mix (NHS Digital primary care Minimum Data Set), other practice characteristics (routinely available data), and model type, (iv) workforce costs WP2: Systematic review of impact of team composition and climate on staff and patient outcomes WP3: Practice-level modelling (using Practices Database) of associations between skill mix (e.g. % of total FTEs GPs / other care staff) and quality of care (QOF clinical summary score, CQC inspection rating, patient experience survey indicators), controlling for practice characteristics. Production function approach to identify the output contribution of different staff, substitution possibilities and cost savings. WP4: Patient-level modelling of association between practice skill mix and clinical effectiveness (hospitalisations for ambulatory care sensitive conditions e.g. diabetes complications, asthma), controlling for patient level confounders. Patient outcomes from linked primary and secondary care data (n=546 practices, Farr Institute), merged with Practices Database for analysis. Economic analysis to identify savings from clinically effective staff deployment. WP5: In-depth qualitative analysis. a) focus groups (8) with service users for perspectives on how teams affect care; b) survey of staff in a sample of practices (n~240) to explore team climate and burnout in relation to workforce and performance indicators; c) case studies in 12 varied practices (traditional model, with task substitution and role creation, and new models), using staff interviews, observations and patient survey, to assess how skill mix and team climate are associated with effectiveness and patient experiences. Synthesis using receptive contexts for change and interactionist theory. WP6: Knowledge transfer. Two groups (GP primary care practitioners, commissioners) in 4 regions, total of 144 participants, score potential components of implementation guidelines (developed from findings of WPs 2-5) over two rounds, to reach consensus on final guidance to support future decision making (RAND/UCL Appropriateness Method). WP7: Active dissemination strategy to engage commissioners, primary care providers, statutory and non-statutory bodies. Benefits and potential impact. The research will produce evidence about which skill mix and team climates work best in primary care, and role and task substitutions that reduce costs while maintaining or improving outcomes. This will enable GP partners, managers and commissioners to make informed decisions that address current staffing problems and future workforce requirements.