Assessing workload in general practice in England before and after the introduction of the pay-for-performance contract.

Aim: This paper is a report of a study conducted to describe changes in practice team size and composition, and the workload of doctors and nursing staff, before (2003) and after (2005) the introduction of the pay-for-performance contract for general practice.

Background: In 2004, a new pay-for-performance contract for general practice was introduced in England. This improved the quality but may also have altered practice workload, including the workload of nursing staff.

Method: Practice profile questionnaires and staff workload diaries were completed in 42 practices in England in 2003 and 2005. Managers provided information on team size and composition in 2003 and 2005. One week workload diaries were completed by doctors and nursing staff in both years. Diaries recorded: hours of work, number and complexity of patient visits, and types of problems (acute, chronic, preventative).

Findings: The number of practice staff increased with greater increases observed for nursing staff than doctors. There was no change in the average number of hours worked per week by nursing staff or doctors but nurse visit rates increased while doctors' rates decreased. The proportion of presenting problems described as chronic or preventative increased for doctors (chi(2)= 8.54, d.f. = 1, P < 0.004) but was unchanged for nursing staff. Nursing staff dealt with more complex visits in 2005 compared to 2003 (chi(2) = 30.70, d.f. = 3, P < 0.001) but there was no change for doctors.

Conclusion: General practices may have responded to the 2004 contract by increasing staffing levels, with nursing staff absorbing a higher proportion of the clinical workload and doctors focusing more attention on chronic and preventive care. Expanding nursing staff roles may increase the quality of primary care but may lead also to intensification of nurses' work.