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The role of healthcare assistants in general practice

Jeremy Dale
MA MB BS PhD FRCGP
Professor of Primary Care
Director of Warwick and Coventry Primary Care Research
(WC-PCR)
Warwick Medical School

Laura Vail
BSc (Hons) MSc
Research Associate Warwick Medical School

Relatively little authoritative guidance is available on the responsiblities of healthcare assistants working in general practice. This article discusses a number of issues that should be considered in relation to the work undertaken by HCAs in this setting.

Healthcare assistants (HCAs) are becoming increasingly important and prominent members of the general practice team. Many more practices are employing them to take on routine tasks that were previously undertaken by practice nurses. The need for general practice HCAs has been encouraged by recent policy, which emphasises the importance of changing skill mix for achieving high standards of care.1

The role is steadily becoming more widespread, with recent estimates suggesting that 55% of general practices currently employ HCAs.2 Although well established in secondary and community healthcare settings, their scope of practice is less clear cut in general practice. So far, HCAs have been implemented on a largely ad hoc basis, with great variation between individual practices. Some limit HCA activity to more administrative or basic screening tasks, whereas others expect HCAs to take on more varied duties, involving direct patient care. A number of issues need to be considered when planning the employment of HCAs but relatively little authoritative guidance is available.

There is considerable scope for a mismatch between the views of the delegating nurses and GPs on what is appropriate for the HCA and the competencies of the particular individual. Relatively little authoritative guidance is available. A number of issues need to be considered in relation to the work undertaken by HCAs discussed in this article.

Why employ an HCA in general practice?
Although the evidence base about HCAs' roles and responsibilities in general practice is limited, it is clear that they can bring benefits to the practice workflow. These include more effective use of GPs' and nurses' skills and time, a reduction in waiting times, increased access to appointments, and increased continuity of care.3-5 They may free up GP and practice nurse time for more specialised activities related to managing long-term conditions or other aspects of general practice work that involves patients with more complex needs. They may also allow longer consultation times and enable continuity of care, and help meet Quality and Outcomes Framework performance targets.

General practice staff who have experience of working with an HCA view the role positively, and feel that it is beneficial for the practice and its patients.3 Furthermore, HCAs' accounts reveal that they enjoy the role and feel they contribute positively to the general practice workforce.6

We recently carried out a study looking at the role of the general practice HCA. Of the many issues that emerged, good preparation appeared to be key to the successful implementation and development of the HCA role. Here we outline issues that need to be addressed by any practice that is considering developing the HCA role within their team.

What role can HCAs perform in general practice?
There is no standard role specification for HCAs working in general practice, and consequently there is scope for unrealistically broad or inappropriately narrow expectations about the work that is suitable for an HCA. The range of tasks that they undertake varies greatly. In part, this depends on the requirements and preferences of the staff working with HCAs, but also the experience and competencies of the individual HCA. Our research, together with the HCA toolkit, a web-based resource which provides advice for employers of general practice HCAs, suggests that many tasks can be safely and effectively undertaken by HCAs who have been adequately trained and are appropriately supervised (see Box 1).7

Defining the scope of practice
Our research highlighted a need for greater awareness about the HCA role among members of the wider general practice team. To avoid confusion, practices need to ensure that all staff members are aware of what the HCA has been employed to do, and also the limitations of the role. The HCA toolkit suggests that practices carry out a skill mix audit, which will help to identify which member of the practice team is currently doing what, and the tasks that could be delegated to an HCA.7

In addition, planned new services should be considered and whether the HCA might help to deliver them. Some practices, for example, have planned to implement in-house phlebotomy and smoking cessation services after introducing an HCA.
Involving all staff in this discussion will help avoid the conflict and resistance to the role that can occur if individuals feel that they have been excluded from decision-making.8 Such discussion may reveal apprehension about introducing the role, and some staff may question the impact that it could have upon patient care, and the roles of other staff members.
Introducing HCAs in general practice can raise questions about roles, responsibilities and patient safety.9

Concerns about the safety and quality of care needed to be balanced with the extra burden of responsibility associated with supervision. Changes in skill mix create opportunities as well as a need to address concerns about the impact that any developments may have on existing roles.

Our research revealed that practice nurses may be concerned about the preservation and respect for their own roles and professional identity. Introducing HCAs has the potential to deskill current staff, with only the "difficult jobs" being left for the practice nurse. There was also a concern that the HCA might contribute to increased needs and expectations on the part of patients, which could lead to increased dependence on the service.

Providing clear information about HCAs' responsibilities may help to ease anxieties and tension. Some practices have recruited an HCA from existing reception staff, and such individuals sometimes continue to perform a dual HCA/receptionist role. This may appear to be an efficient use of skills and resources, but it can cause difficulties for the HCA if the role boundaries become blurred.10

In our research, examples were given of patients reacting negatively if they believed that a receptionist was undertaking duties that should have been in the realm of the nursing team. Having an HCA perform a dual role was also reported to be a cause of tension between the HCA and members of the administrative team.

Training and supervision
Once in post, HCAs need to be adequately trained to undertake the tasks expected of them. At the moment, there are no standard educational requirements for general practice HCAs.
Typically, they undertake a period of in-house training involving supervision and assessment of competency, usually provided by a practice nurse, alongside more formal training programmes such as the NVQ, and procedure-specific training courses.

External training can be very valuable in terms of developing the skills of the HCA and reducing dependence on in-house training. It can also help provide in-house training with structure and impetus. Furthermore, it helps to define the HCA's scope of practice and so offers protection against complaint or litigation, especially if it is associated with an
accredited qualification.

Providing training for an HCA requires time and resources, so it will be necessary to plan for how the practice can realistically supply what will be needed, bearing in mind that extra time and resources may need to be allocated for HCAs who lack previous healthcare experience. Investment in training for HCAs should, in the longer term, be cost effective and will help to ensure that the HCA becomes a more valuable member of the team. This, in turn, can promote the retention of staff in the role. HCAs will require ongoing supervision, and it should be clear how this will be provided and who will have responsibility for this.

The supervision of an HCA is most commonly the responsibility of a designated practice nurse, and will involve delegation of tasks, assessment of competence, and ongoing monitoring throughout practice. Managers need to ensure that the HCA is able to undertake the tasks required for the job, and that appropriate support and supervision is always available. There will also be a need to keep abreast of changes to the role, as it continues to evolve. Finding time to supervise and train an HCA was identified as a key challenge by our research, especially if the HCA had not worked in a healthcare setting before.

Planning the HCA's training package well in advance and, if possible, scheduling the introduction of the role for a less busy time within the practice, may help ensure that the training process goes smoothly. Predictably, the demands associated with training the HCA are likely to be greater for the supervising nurse who has had only limited previous experience as a trainer unless she is given adequate practice support, and/or if the HCA had not worked in a healthcare setting before.

Patients' experiences
HCAs are well known to patients in hospital and community care settings, and patients can be very satisfied by the experience of being cared for by an HCA. Yet, because they are not used to seeing HCAs in general practice, patients may initially have trouble distinguishing between the roles and responsibilities of the HCA and those of more qualified and experienced nursing staff. This has been identified by HCAs working within primary care. It is worth taking steps to minimise confusion, such as displaying posters or leaflets outlining the role within the practice and placing information on the practice website.11

Conclusion
HCAs have an important role to play in general practice. They provide valuable assistance to GPs and practice nurses. Establishing their role, like any other change in the workforce, can bring with it difficulties and challenges. We have outlined some of the key issues that have emerged from our own research findings, and the literature and discussion around the topic, and suggested ways in which these can be addressed.

References
1. Wanless D. Securing our Future Health: Taking a Long Term View. London: HM Treasury; 2002.
2. Andrews H, Vaughan P. Skill mix evolution: HCAs in general practice. Practice Nursing 2007;18(12): 619-24.
3. Burns S, Blair V. Healthcare assistants in general practice. Primary health care 2007;17(6):35-9.
4. Joels L, Benison L. HCAs cut waiting times to see a trained nurse. Practice Nursing 2006;17(6):269-70.
5. Wright C. General Practice. In for the skill. Health Serv J 2002;112(5814):26-7.
6. Smith F. A general practice HCA. British Journal of Healthcare Assistants 2008;2(1):27.
7. Working in Partnership Programme. Health Care Assistant toolkit. Available at: www.rcn.org.uk/development/hca_toolkit
8. Brant C, Leydon G. The role of the healthcare assistant in general practice. Br J Nurs 2009;18(15):926-33.
9. Bosley S, Dale J. Health Care Assistants in General Practice: practical and conceptual issues of skill-mix change. Br J Gen Pract 2008;58:118-24.
10. Vaughan P. A WiPP toolkit for healthcare assistants: what's it all about? British Journal of Healthcare Assistants 2007;1(1):20-1.
11. Longbottom A. Developing a role for healthcare assistants. Practice Management Update 2006;38:3-6. Available at: www.wipp.nhs.uk/uploads/nov06_pmu_p3_6.pdf

Resources
HCA Toolkit
The Working in Partnership Programme, in
collaboration with Staffordshire University, has produced a set of core principles to enable general practice to employ, train and develop HCAs
W: www.rcn.org.uk/development/hca_toolkit

Primary Care Training Centre
Training courses and distance learning courses for healthcare assistants working in general practice
W: www.primarycaretraining.co.uk