Skill-mix change in general practice

It is good to see exploratory research on the introduction of new roles in general practice in Manchester and we agree with the conclusion of Nelson et al that introducing new roles to general practice is not a simple process.¹ However, we disagree with the assertion by the authors that ‘Limited evidence suggests PAs may provide safe and effective care that is acceptable to patients but may also generate activity in terms of return and visits, tests, or prescriptions ordered, and referrals.’

Our comparative observational study of 2086 records of patients presenting at same-day appointments in 12 general practices in England (funded by the National Institute for Health Research) published in this journal² found that there ‘... were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22 (US$10.15) lower (95% CI = −7.61 to −2.46, P<0.001).’

We concluded that the processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost.