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

General practice is central to the running of the National Health Service. People seeking advice about health problems usually go to their general practitioner (GP) first (unless it is an emergency). General practitioners deal with a large range of health and social care issues for the local people who are registered with them. They have traditionally employed a team of staff (e.g. nurses, care assistants, receptionists, managers), and they liaise with other community services (e.g. midwives, health visitors) for certain functions. General practice is currently under pressure because many GPs are retiring or leaving for other reasons, and more newly trained doctors are working in hospitals. There is also a shortage of nurses to work with GPs. At the same time, more people have long-term conditions and need regular care from GP teams, and some tasks that used to be done in hospital are being transferred to general practice. This means that it is very important that GPs organise their teams efficiently so that as many patients as possible can be treated. There is a lot of variation in the staffing arrangements in general practices. The trend has been for practices to become larger over time, and to include a wider range of staff (e.g. physiotherapists, pharmacists). Recently some GPs have combined into ‘super-practices’ or federations. There is very little evidence, however, to tell GPs and service commissioners what size or structure of practice, or what mix of professional staff, works best for patients. The aim of this research is to provide such evidence. It will explore how the composition of GP teams, and the relationships among team members (called team climate) affects the quality of care and health outcomes for patients, and the costs for the practice. Using a variety of methods, we will: 1. Conduct a literature survey to look for lessons about skill mix from other countries that have similar health care systems to the NHS. 2. Analyse big data sets that are already available, and use statistical methods to investigate how differences in the organisation and skill mix of practices in England are related to the quality and effectiveness of the care provided. Quality indicators will be based on inspection ratings and the patient experience survey, and effectiveness will be measured by the number of patients hospitalised for conditions that should be managed within general practice. 3. Explore how workforce issues affect staff wellbeing and job satisfaction through a survey of staff in a sample of practices nationwide. 4. Investigate how team relationships (climate) affect daily working and patient experiences by observing and interviewing staff in 12 selected practices. 5. Ask a sample of GPs and commissioners to review our findings and help us create guidelines for all practices about what is the best mix of professional staff, and how to ensure that their teams work well together. 6. Use innovative means to disseminate the findings throughout the GP community, and to NHS managers, government organisations, academics and the public. We have linked with our local Clinical Commissioning Group to access opinions from lay representatives during the preparation of this application. The chairperson of the CCG Patient and Public Engagement committee is a co-applicant. Under his leadership, we will establish a Service User Group that will contribute to all stages of the research.

This research is exploring how team composition and climate affect quality of care, clinical outcomes (effectiveness) and human resource costs in England, in order to inform practice management and commissioning decisions.

The objectives (each mapped to a work package, WP) are to:

1. Provide a descriptive overview of general practice: policy context; delivery models; practice levelvariability in skill mix and human resource costs
2. Review available evidence on how skill mix and team climate affect quality of care, clinical effectiveness, staff wellbeing and job satisfaction
3. Conduct practice level modelling of associations between skill mix and quality of care and explore implications for role substitution and costs
   Conduct patient level modelling of associations between skill mix and clinical effectiveness and implications for costs
4. Examine, in depth, how team working affects quality of care and effectiveness through a survey of service users, a staff survey in a sample of GP practices and case studies in a number of GP practices
5. Engage with GP primary care practitioners and commissioners to develop implementation guidelines
6. Actively disseminate findings widely

We have a Service Users Panel (SUP) will comprising of 10 members recruited from different types of practices (traditional and new models, in varied socio-economic-ethnic areas in Kent and Sussex) which meets four times per year to provide the perspective of patients and the public on issues within the research.

The SUP  assists with preparing information sheets for participants, focus group topics, patient survey questions, statements for the implementation guideline development process and dissemination materials for lay audiences. The SUP has received training for their role and full information about the project at the first meeting. For subsequent meetings, the research team has provided short written updates on progress and issues for discussion. Work Package leaders attend SUPs at appropriate points in the project to describe the work they are doing and seek advice from members. Individual members of the SUP liaise with different WPs. The SUP is chaired by Mr Brady (co-I), supported by the PI and project manager. Members are reimbursed for reasonable travel expenses and time commitment at INVOLVE rates.