In this piece Dr Imelda McDermott, a Research Fellow at University of Manchester, explores policy challenges across both general practice and community pharmacy and proposes key recommendations for developing a sustainable healthcare workforce.
Building a sustainable healthcare workforce for the future
For many, securing timely access to primary care has become a frustrating reality. Long waits for appointments can delay diagnoses and treatment, impacting our overall health and wellbeing. This isn’t just a personal inconvenience but symptomatic of a deeper challenge facing our healthcare system: building a sustainable workforce to meet the growing demand for primary care services.
One policy solution proposed is diversifying the healthcare team. The theory being that having a wider range of practitioners can alleviate some of the burden on general practitioners (GPs), allowing them to focus on more complex patient cases.
This article discusses the evidence-based challenges associated with implementing such policies across both general practice and community pharmacy and proposes key recommendations for developing a sustainable healthcare workforce.
Additional roles in general practice: Does it hold its promise?
The 2019 NHS Long Term Plan outlines key goals for the upcoming decade, including a new service model, backed by £4.5 billion a year in real terms by 2023/24 of fresh investment, to support the expansion of community multidisciplinary teams aligned with Primary Care Networks (PCNs). PCNs are designed to be established by general practices collaborating to provide fully integrated community-based healthcare for populations of 30,000–50,000 people. The recruitment of non-GP practitioners has been a key policy to address the workforce crisis. Through the Additional Roles Reimbursement Scheme (ARRS), backed by an investment of £891 million, PCNs can get reimbursed for employing additional roles. Initially, five roles were selected: pharmacists, physician associates, paramedics, physiotherapists, and social prescribers. Now, there are 17 roles including dietitians, podiatrists, and mental health practitioners.
Challenges
Some roles are more readily accepted than others. For example, pharmacists have a distinct skill set and qualifications in medication; hence, pharmacists are seen as being able to do a better job than doctors in areas such as medication reviews, with positive effects on prescribing practices and patient safety. However, the employment of physician associates – who hold an undergraduate degree, usually in a biomedical or health/life science, and have less training than GPs but perform some of GPs’ roles – has challenged the professional boundaries and created jurisdictional disputes and divisions within medicine. The move to diversify the workforce has been seen as “down-skilling” and “destruction” of general practice.
Evidence reveals that skill mix does not have straightforward effects on patient outcomes, such as quality or patient satisfaction. This is because introducing a wide range of practitioners requires effective categorisation of healthcare patients’ reported problem(s) and an understanding of practitioners’ capabilities, which change as they upskill themselves.
The policy intention is for these additional roles to reduce GP workload. However, evidence suggests that, despite regulatory changes to enable these practitioners to reduce GP workload, these additional roles have not improved GPs’ workload or job satisfaction levels and risk reducing patient continuity of care. The need to provide supervision for these staff has created a new and unexpected increase in workload for many GPs.
Leveraging community pharmacies: Balancing opportunities and risks
The rationale behind this policy is that community pharmacies are usually located in more deprived areas and hence can improve patient access. Initiatives like Pharmacy First, started in January 2024, enable patients with minor ailments to be seen directly by pharmacists, without being referred by GPs, for seven common conditions. A future policy direction involves pharmacists independently prescribing medications. Currently, pathfinder sites within integrated care systems are testing various models for independent prescribing in community pharmacies, with evaluations ongoing. To facilitate this broader shift, all newly qualified pharmacists from September 2026 will be independent prescribers on the day of their registration.
To further maximise pharmacy teams’ skillset, pharmacy technicians will adopt greater roles and responsibilities. A planned legal framework for delegation within pharmacies will allow pharmacy technicians to assume tasks like supplying prescription-only medicines under patient group directions (PGDs). This means they are permitted to supply or administer medicines to a pre-defined group of patients and gain enhanced roles and responsibilities with regard to medicines supply (dispensing). Additionally, potential changes to pharmacist supervision requirements might allow pharmacy technicians to dispense medications and supervise other team members under ‘authorisation’ by pharmacists.
Challenges
Unlike traditional NHS providers, community pharmacies are private-sector organisations delivering NHS services. They range from privately owned independent pharmacies (1-5 branches) to corporate-owned multiples. The priorities of larger community pharmacy organisations are to balance healthcare and profit, with some placing excessive pressure on pharmacists to meet targets, adding to workplace stress.
Private-sector providers delivering NHS services are not new. Lessons can be learned from the 2008 initiative, which introduced alternative providers of primary care services such as walk-in centres. The need for tight contract monitoring and meeting key performance indicators was found to be costly and time-consuming, which is unsustainable in an already stretched workforce.
There is a lack of understanding of the role of pharmacy technicians, which has led to pharmacists’ reluctance to delegate appropriately to free them to do more clinical services. Moreover, many pharmacy technicians are leaving the profession because of limited career opportunities.
Recommendations
Employment of additional roles needs to be supported with resources to provide supervision for those transitioning to new roles to facilitate the development of skills, confidence and capabilities during the transition period. Satisfaction with the support and supervision received is linked to whether healthcare professionals are more likely to remain in their current clinical practice or leave their service and potentially the profession. However, there is a critical gap in our understanding of the specific support requirements for each role, the intended purpose of such support, who should be delivering what support, and how the support should be delivered in practice.
Extending community pharmacy services requires quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within patients’ primary care pathways. Patients and the public appeared to view community pharmacy services as beneficial. However, there is a need to legitimise the extension of pharmacists’ clinical roles as clinicians to enable acceptance by pharmacists themselves, other healthcare professionals, and ultimately, patients and the public. Accordingly, there is also a need to provide role clarity for pharmacy technicians, which will be fundamental for upcoming policy and legislative changes.
Although diversifying the healthcare team has its benefits, the long-term plan for the next government should be on the recruitment and retention of GPs across the UK. Job satisfaction for GPs needs to be linked to their ability to meet professional standards and respond to patients’ needs rather than achieving incentivised targets. Many of the root causes of the GP crisis need to be addressed, such as feeling undervalued by the public, media, and government, job-related stress, declining morale and stress related to the unique partnership models. The next government should also develop strategies to ensure future generations see general practice as a fulfilling and sustainable career choice.
About the author
Dr Imelda McDermott is a Research Fellow at the Centre for Primary Care and Health Services Research and Centre for Pharmacy Workforce Studies at the University of Manchester. She is a social science researcher with 15 years of experience in health policy analysis, specialising in primary care workforce. Imelda’s research includes projects funded by the National Institute for Health and Care Research (NIHR), NHS England and the Department of Health and Social Care (DHSC) funded Policy Research Unit. She has contributed to projects addressing wider system issues, including commissioning, competition in the NHS and the development of Integrated Care Systems.
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