Published: 02/12/2004, Volume II4, No. 5934 Page 36 37

A host of innovative appointments and skill-mixing is helping inner city London trusts address their recruitment problems and embrace the new GP contract. Graham Clews reports

Recruiting the right quantity and calibre of staff is one of the biggest challenges faced by NHS managers in London. A shortage of GPs has been a particular problem in inner city areas, making it even more difficult to hit the 48-hour access targets for patients to see a GP.

Solutions are manifold, with developments such as alternative provider medical services - which opens up the primary care market to private providers - getting the headlines. But there is a more subtle change afoot - what City and Hackney teaching primary care trust chief executive Laura Sharpe describes as 'the quiet revolution in general practice'.

London PCT managers accept that recruiting more GPs is always going to be a problem, even with the increase in numbers announced in the NHS plan. So they are using other developments in primary care to make significant changes to the way services are offered to patients.

Effectively, by shifting much of the work previously carried out by GPs to other primary care staff, they can reduce the number of GPs they need.

Some of the changes in primary care policy will involve GPs in more complex and time-consuming work, such as the combination of the quality requirements in the new general medical services contract and a greater emphasis on chronic-disease management.

This makes the delegation of many of their tasks, where appropriate, an even more logical solution.

The creation of diverse primary care teams, rather than the traditional model of a GP and staff, is intended not only to release GPs to concentrate on more complex work, but also to ensure that patients receive the right service at the right time from the right person.

Nurses, therapists and practice staff can all help fill this gap, but now there is a need for another tier in the primary care team, and one solution is the creation of physician assistants.

Waltham Forest PCT in east London is one of three PCTs in England piloting the use of physician assistants, and the only one to focus purely on primary care.

The pilot, which is funded by the Modernisation Agency, is part of the PCT's aim to deliver 60 per cent of generalist care within the general practice team, with GPs concentrating on the more complex 40 per cent.

By developing the physician assistant role, the PCT also hopes to take forward some of its other goals, as well as reducing the demand for more GPs. The aim is to develop a wider range of services that can target local health needs, to reduce hospital admissions, and to shift care from the secondary sector to primary care.

The PCT aims to draw its physician assistants from different roles within the NHS and eventually from other areas, including the armed services and science graduates.

Stephanie Shaw, formerly a community nurse, is one of the PCT's three trainee physician assistants: 'It is completely different from the nursing model and the intensive training programme will provide us with the time and support required to get our heads around this.'

Waltham Forest PCT chief executive Sally Gorham says the scheme has brought it home to people that nurses and other primary care staff are extremely competent and are able to take on many tasks previously carried out by GPs.

Within Waltham Forest PCT's scheme, GPs have been fully engaged from the beginning, and according to the PCT the GPs involved feel that contributing to a national pilot provides increased status for the ongoing work.

Being involved in the project has also enabled them to develop their own thinking around the development of the new roles.

The PCT's director of nursing quality and workforce Liz Delauney says: 'This pilot has been a fantastic opportunity for the PCT to adopt a pioneering approach to workforce development. We see it as being the first step in our plans to influence a radical shift in thinking around workforce redesign in primary care within north-east London.' When the new GMS contract went live earlier this year, the London Modernisation Board pronounced that the new contract would be a 'massive step forward in freeing up primary care in London'. It identified access to primary care as a major problem, particularly in the East End, and suggested that using the new contract to shift the workload away from GPs could be the solution.

Other PCTs are looking at skill-mix as a solution to London's workforce problems.

But while almost everyone agrees that it can help enormously, it is not a panacea.

Islington PCT human resources lead Lucy Anderson points out that if PCTs are to shift their recruiting emphasis away from GPs they will have to compete with the private sector. This is difficult in itself because of the problems with expensive housing, poor transport, and the high cost of living in London, she argues.

But she agrees that the key to successful solution of recruitment problems is to move away from such a reliance on clinical staff.

'I think everyone knows about the problems with doctors and nurses, but addressing the other issues could release more clinical staff back into clinical duties, ' she says.

'Clinical staff are always telling me that if they could get decent admin support they could achieve so much more with their patients'.