Skill-mix change and task shifting for musculoskeletal disorders in primary care: From framework development and workforce training to opportunities for service improvement

Abstract

Background

Changing demographics and increasing complexity of patients presenting to primary care, along with a limited supply of healthcare professionals, are putting new demands on existing models of care and new ways of organising primary care are therefore needed. Healthcare in Norway and the United Kingdom (UK) operates within a reality of funding restraints and for it to remain effective task shifting and skill-mix review have been promoted and implemented as key mechanisms for change. For primary care to function well it is imperative that the limited workforce is used effectively. Whilst it is possible to redistribute tasks between different health professionals, the extent to which this can solve a growing problem remains uncertain.

Norway and the UK both have publicly funded national healthcare systems and share a context of high societal cost and loss of health-related quality of life associated with musculoskeletal disorders. A significant proportion of the workload seen in primary care is from musculoskeletal problems, and it is therefore important to look at the potential of skill-mix change and task shifting to improve this area of healthcare. Task shifting in primary care has taken place in Norway and the UK over several years. Whilst the two countries share a reported shortage of General Practitioners (GPs), there are differences to the structure of post-graduate specialisation and career pathways for allied health professionals working in primary care. These different contexts can offer insights around the utility of policydriven changes to address shared challenges.

In this thesis I explore how skill-mix change and task shifting for musculoskeletal disorders in primary care can give opportunities for service improvement, informed by research in England and in Norway. Study I took place in England where we developed a national musculoskeletal core capability framework for first point of contact practitioners. The framework was informed by Study II, which explored the opinions of patients in England about what they want and expect from their GP and other first point of contact healthcare professionals when seeking help with a suspected musculoskeletal disorder. In Study III we evaluated the utility of a postgraduate university module designed for workforce development of allied health professionals, and explored the perceptions of students (physiotherapists, paramedics, and dietitians) and their clinical mentors. Finally, in Study IV we looked at the current model of care for patients with musculoskeletal disorders in Norwegian primary care, from the viewpoint of GPs and physiotherapists.

Methodological points of departure

The studies included in this thesis employ a range of methods. Study I was a multifaceted process, it included a modified three-round Delphi study with a multiprofessional panel of 41 experts nominated through 18 national professional and patient organisations, and a wider online survey. Study II was a qualitative study including four focus groups and we analysed the data through deductive thematic analysis. In Study III we used a qualitatively driven mixed-method approach that included empirical material from online surveys and individual interviews, and Study IV was a qualitative interview study. In studies III and IV we used a reflexive and creative method to explore the empirical material.

The four studies have different methodological points of departure, which illustrates my serendipitous journey through this doctoral project. Studies I and II have constructivist underpinnings but lack an explicit alignment with any identified theoretical framework. Study III combines qualitative and quantitative methods to allow a flexible theoretical framework where realist and constructivist concerns are synergistically combined. Study IV departs from a social constructivist theoretical foundation. In both studies III and IV we use Lipsky’s theories on street-level bureaucracy as a theoretical lens, a theory that shows how professionals implement public policy in their work. In Study IV we also draw upon a Foucauldian perspective on mechanisms of power and institutional structures.

Findings

Study I produced a framework that contains 105 outcomes within 14 capabilities, separated into four domains: person-centred approaches; assessment, investigation and diagnosis; condition management, intervention and prevention; service and professional development. The framework is now being used by practitioners, commissioners, and education and training providers. Findings from Study II enabled the patient perspective to be included in the framework and identified these key concerns and priorities: the problem and its impact; the management of the problem; the practical questions; the future.

Study III included empirical material from 27 online survey responses and eight interviews. Participants perceived the utility of the module, titled Allied Health Professionals First Contact Practice in Primary Care, to be influenced by personal circumstances, professional identity, and mentoring experience, and that profession-specific competence typically fall short of the capabilities required for the primary care gatekeeper role. Our findings can inform and guide postgraduate training for healthcare professionals moving into first point of contact roles in primary care, as well as employers that implement public policy at the street level. Our study can also guide policymakers, who in their endeavour to improve public services must allow autonomous practitioners to interpret and show discretion in their meetings with patients, but also offer clear guidelines, job descriptions, and roadmaps.

Study IV included interviews with five GPs and 11 physiotherapists (eight of whom were also Manual Therapists) in Norway. Our analysis discovered a complex discourse about skill-mix in primary care, where attitudes towards task shifting were influenced by financial considerations, task preferences, and perceptions of competence. Competition and cooperation coexist between the professions, and both alliances and rivalries are fostered by the apparent gradual blurring of the lines between historical hegemony and new models of care. In a context where task shifting is challenged by established practice there were examples of deviations from evidence-based practice and the Choosing Wisely principles, which indicate that GPs and physiotherapists must balance the roles of patient advocate, gatekeeper, and homo economicus. Additionally, it appeared that the management of patients with musculoskeletal disorders is fragmented and to an extent reflects a supply-driven system.

Conclusions and future perspectives

This PhD project advances our knowledge around the potential of task shifting and skill-mix change in primary care, specifically concerning musculoskeletal health. Development and implementation of national capability frameworks are used to guide the direction of travel for system change, and NHS England state that all adults in England will be able to see a musculoskeletal first contact physiotherapist by 2024. Post-qualification educational and professional development initiatives, along with implementation of new roles and accompanying roadmaps, seek to align the required competences and capabilities on the one side with the role requirements on the other.

Friction can develop when the boundaries of professional scope of practice for different professions expand, and this can have detrimental effects at both the system level and at the street-level of patient-healthcare professional interaction. Our studies point out opportunities for improving musculoskeletal primary care, in terms of offering the right care at the right time, by developing better collaboration between healthcare professionals. However, such improvements are contingent on addressing the political and economic foundations upon which healthcare systems rest, and for professional bodies and individual healthcare professionals to reduce protectionism over established boundaries of professional practice.