Primary care workforce composition and population, professional, and system outcomes: a retrospective cross-sectional analysis

Background The diversification of types of staff delivering primary care may affect professional, population, and system outcomes. Aim To estimate associations between workforce composition and outcomes. Design and setting Cross-sectional analysis of 6210 GP practices from a range of geographical settings across England in 2019. Method A multivariable regression analysis was undertaken, relating numbers of staff in four groups — GPs, nurses, healthcare professionals, and health associate professionals — to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions (subsample of practices), and costs to the NHS. Data were obtained from the GP Patient Survey 2019, Quality and Outcomes Framework, prescribing data, the Hospital Episode Statistics database, the NHS Payments to General Practice 2019/2020, and the Tenth National GP Worklife Survey 2019. Results Having additional GPs was associated with higher levels of satisfaction for the GPs themselves and for patients, whereas additional staff of other types had opposite associations with these outcomes. Having additional nurses and health associate professionals was associated with lower costs per prescription but more prescribing activity than having additional staff from the other two groups. Having more GPs was associated with higher costs per prescription and lower use of narrow-spectrum antibiotics compared with the other staff groups. Except for health associate professionals, greater staff numbers were associated with more hospital activity. Conclusion Professional, population, and system outcomes showed a variety of associations with primary care workforce composition. Having additional nurses was associated with lower quality in some aspects, and higher costs and activity. The association between additional healthcare professionals or health associate professionals and higher costs was less than that for additional GPs, but was also linked to lower patient and GP satisfaction.