'Being qualified as a practice-assistant' alone explained
16per cent of the variance of the
delegation-index. A larger proportion of qualified practice-assistants performed the following
tasks: advising patients about common ailments (fever, diarrhoea, cough); giving information
to patients about the results of investigations; giving injections; performing vene punctures for blood sampling; measurement of Hb, blood glucose, ESR; application of suitable dressings; removal of sutures; ear syringing; performing hearing tests (audiometry); blood pressure checks; cauterization of warts; ECG recordings; application of glue to lacerations;
biochemica] tests on faeces and history talcing.
Delegation of tasks to the unqualified practice-assistant is focussed mainly on administrative activities. Writing out repeat prescriptions is done by almost every practice
assistant.
Practice-assistants working more than
15
hours per week scored significantly higher on the delegation-index.Stepwise, multiple regression analysis revealed four predictors of task delegation: the availability of a treatment room, the type of practice, being qualified as a practice-assistant and a written contract of employment.
The more FTE's ancillary staff employed the higher the delegation. However, one has to take into account that type of practice, list size, FTE's of genera! practitioners and FTE's of practice-assistants are inter-related. Therefore stepwise, multiple regression analysis was carried out which showed three predictors of task delegation at 'type of practice' level: the availability of a treatment room; the type of practice; qualifications of the practice-assistant.
Sub-group analysis was performed to see if the type of practice influenced the [total number and) type of tasks undertaken by the practice-assistants.
The four types of practice were not significantly different as far as the following variables are concemed: years of experience and years of employment of the practice-assistants;
working hours per week of the practice-assistants; the availability of a treatment room.
Group practices and health centres employed significantly more often a qualified practice
assistant compared to single-handed or dual practices. The range of tasks undertaken by practice-assistants employed in solo practices or dual practices were very similar. Not once was a task significantly more often undertaken by these practice-assistants compared to the practice-assistants in group practices or health centres.
The type of practice in which the GP works and the GP's working style were strongly related to actual delegation of tasks to the practice-assistant. A 'traditional working style' shows a negative correlation with the delegation-index; it entails: not showing feelings of uncertainty to the patient, not calling on colleagues GP's for advice, trying to solve a problem through medication first. The higher the physician's score on medico-technical activities, the higher the delegation. In contrast, the higher the physician's score on the ratio home visits versus patient contacts in the surgery, the lower the delegation to the practice
assistant. Age and sex of the GP and years of experience as a GP did not correlate with the delegation-index.
Stepwise, muliple regression analysis showed four predictors of task delegation at GP
level: the type of practice in which the GP is working, the availability of a treatment room
162
for the practice-assistant, the employment of a qualified practice-assistant and ' medico
technical activities by the genera! practitioner.
In chapter
6
data conceming the patient contact registration are presented.58574
Patients, who had
925 14
consultations with the practice assistant, with106529
reasons for encounter (rfe) were analysed. Of the total number of patient contacts registered by GP's and practice assistants the practice assistant dealt with23
percent.32
Percent of rfe's were by phone.74
Percents of consultations were for repeat prescriptions; in10
percent of consultations one or more new prescriptions was issued and in16
percent of consultations no medication was issued.In
10
percent of consultations a diagnostic task was performed; in9
percent of consultations a management task (health educational tasks, medico-technical tasks) was performed and in9
percent of consultations administrative tasks were registered.Diagnostic tasks involved mainly examination of urine specimens. Medico-technical tasks were the greater part of the management tasks. The main predictors for these diagnostic and management tasks were 'being qualified as a practice assistant' and the availability of a treatment room. The most frequently registered administrative task was 'writing out a referral card (for insurance purposes).
The practice assistant wrote out
60
percent of all the repeat prescriptions, registered by the GP and the practice assistant. One third of all repeat prescriptions were issued after a consultation over the phone. Repeat prescriptions were mainly concemed with antihypertensive medication, sleeping pills and tranquillizers.
In
10
percent of consultations a new prescription was issued. The unqualified practice assistant issued as many new prescriptions as the fully qualified practice assistant. New prescriptions were issued for a cough, sore throat, urinary symptoms, headache and worms, in order of decreasing frequency. Over half of these consultations were by phone.The qualified practice assistant registered twice as many rfe's-without-medication and medico-technical tasks were delegated more often to her. She also registered twice as many diagnostic tasks as the unqualified practice assistant, who gets mainly administrative tasks delegated to her.
The higher the score on the delegation-index the higher the number of diagnostic and management tasks performed. However, there is a negative correlation with repeat prescriptions issued .
Using the delegation-index based on the actual registration data, the most important factors showing a correlation with task delegation are: the availability of a treatment room, being qualified as a practice assistant and the type of practice. There is also a positive correlation with a written contract of employment and with the number of working hours per week. There is a negative correlation with the age of the practice assistant.
In chapter
7
the results of analysis of a questionnaire for GP's are presented.436
GP's responded.
99
Percent of GP's employed ancillary staff, although in7
percent the wife of the GP was the only ancillary staff member. In86
percent a practice assistant was employed. Two-thirds of the practice assistants were fully qualified. In almost75
percent of practices the practice assistant had access to a treatment room. Two-thirds of GP's thought that employing0. 8
FTE ancillary staff was insufficient. In case there would be a70
percent salary reimbursement for ancillary staff (max2
FTE)60
percent of GP's would employ more ancillary staff.Over
80
percent of GP's had a favourable attitude towards task delegation;6
percent were opposed to task delegation and the remainder did not express their opinion.Half of the GP's indicated that Jack of time of the practice assistant is the most important limiting factor for task delegation. One-third of GP's mentioned the fact that they would rather do the things themselves as a limiting factor. GP's practising a high degree of delegation were slightly younger
(43
years versus47
years) and had more often received vocational training (compulsory since1974)
than doctors practising a low degree of delegation. In addition the GP practising a high degree of delegation employed more often a qualified practice assistant and made more often a treatment room available to her. Doctors practising a high degree of delegation were more likely to practise with a group of doctors.lf existing limiting factors would be removed GP's would delegate
2
-3
times as many tasks.Analysis showed the same predictors for task delegation. Almost all,
9 1
percent, said that delegation increases the practice assistant's satisfaction with work.55
Percent said that delegation increases the doctor's satisfaction with work.74
Percent indicated that delegation results in a better distribution of skills.In chapter
8
a review of the literature on the British practice nurse is presented. The role of the practice nurse has expanded rapidly over the past decade. The stage is set for an expansion in the numbers of practice nurses, and also a further extension of their role.However, cash limits on salary reimbursement may stifle innovation and progress. The current arrangements for training practice nurses are inadequate and there is an urgent need for continuing education. Lack of a vocational training profile is in part responsible for the large inter-nurse variation in tasks performed. The role of the practice nurse therefore looks set to grow in an uncoordinated way. There appear to be similarities between the type of work done nowadays by the Dutch practice assistant and the British practice nurse anno
1980.
In chapter
9
the results are discussed. The role of the practice assistant has developed in a remarkable way. In genera!, however, the role of the practice-assistant is still perceived as a task oriented assistant, rather than an independent practice-assistant. Receptionists tasks are part of the conventional role of the practice-assistant. For these tasks they need an awareness of, and sensitivity to the problems of the patients, and, indeed, this (reception) 1 64work at the point of first contact is probably the most important single function within any practice (Reedy,
1972).
The role of the practice-assistant is gradually extending into areas of primary contact and management. A number of practice-assistants were actively involved in the treatment and management of medical problems presented by the practice population.
However, enormous variations in pattems of work have emerged. Especially with regard to medico-technical tasks, health educational tasks and management tasks. Apparently, there is room for extension of the role of the practice assistant.
23
Percent of all consultations were registered by the practice assistant. However, a estimation of about one-third of all patient contacts would be fair, since the practice assistant did not have to register the tasks they performed resulting from a consultation with the GP.Moreover, from
1
July1987
to1
April1988,
repeat prescriptions were only registered for only half of the registration period. Patient contacts by phone for appointments or for requesting house calls were not registered. 'Answering the telephone' is the task delegated most. About one-third of all rfe's were presented over the phone. The percentages given for diagnostic and management tasks would have been much higher if the rfe's presented over the phone would have been excluded. Because for all diagnostic and management tasks one needs a face to face contact.'Writing out a repeat prescription' was the most common task performed by the practice assistants. 'Writing out a new prescription' was next in line. If not writing out a prescription the practice assistant would be busy writing out a referral card, examining a urine specimen or performing a medico-technical task: Giving injections, wound care or syringing an ear.
About half of the practice-assistants expressed a wish to extend their role with appropriate support. These practice-assistants clearly favoured future delegation of medico
technical tasks and preventive and screening activities (cervical smears). These activities should form an integral part of the practice-assistants' vocational training programme.
The GP's indicated they are willing to delegate more tasks. If existing limiting factors, such as lack of time (of the practice assistant), lack of space, insufficient salary reimbursement, would be removed they would delegate
2 - 3
times as many tasks.Excluding the tasks presently delegated to more than
70
percent of practice assistants, the following tasks could be considered for delegation: health educational tasks like advising patients with chronic diseases and giving dietary advice; follow-up of high risk patients (diabetes, hypertension); application of surgical dressings of all kind; measuring height and weight; vene puncture for blood sampling; measurement of blood glucose, ESR, hemoglobin;ear syringing; hearing test; microscopie examination of vaginal discharge; cervical smears;
wound suturing; suture removal; contraceptive pill checks; blood pressure checks; treatment of warts with liquid nitrogen; ECG recordings; lung function tests (peakflow meter); allergy tests; history taking; typewriting referral letters; computer tasks. These tasks will have to be made available to the practice assistant by ways of delegation-models or clinical algorithms.
Existing conditions will favour task delegation if general practitioners work in group practices or health centres, use an appointment system, employ qualified practice assistants only and have a treatment room available for the practice assistant.
A government policy specially aimed at the development of group practices and health centres is an important prerequisite for the development and implementation of task delegation. Practice automation and the implementation of systematic preventive care will also be facilitated in this way.
Another line of policy should be aimed at the job qualifications of the practice assistants. Only half of the practice assistants participating in the National Survey were fully qualified and only
60
percent of the GP's employed a fully qualified practice assistants.lmproving on the knowledge and skills of the practice assistant in general is one of the most important prior conditions for task delegation. It is recommended that only qualified practice assistants should be employed in order to increase the efficiency of the practice assistant's vocational training. It is also recommended that only GP's or practices employing qualified practice assistants should be eligible for salary reimbursement. Salary reimbursement for ancillary staff is based on the employment of a practice-assistant with four years of implementation of task delegation has been developed at the University of Groningen, Dept.
of Family Practice.
Further recommendations include refresher courses for practice assistants and for practice assistants and GP's jointly. Several refresher courses are organized by the Dutch Association of Practice Assistants (NVDA).
The general practitioner's attitude towards task delegation is favourable. However there are limiting factors of which the most important one appears to be Jack of time of the practice asssistant. This coincides with the view expressed by the practice assistants themselves. In case there would be a
70
percent salary reimbursement for ancillary staff (max2
FTE)60
percent of GP's would employ more ancillary staff.A remarkable finding is that the GP's attitude towards delegation of tasks hardly influences the factual ex tent of task delegation. Apparently, the concrete predictors described are of more importance.
With the expectation that in the future GP's are likely to be working in group practices and health centres, it is possible that, as more doctors practice from groups and take more interest in efficient methods of practice organization, delegation may become more common.