Task shifting in primary care to tackle healthcare worker shortages: An umbrella review

Figures & data

Figure 1. Study identified and included into the current review.

Table 1. Details of studies describing task shift to nurses in primary care.

Author, year	Setting	Evidence reviewed	Task shift	Conclusions
Anthony, 2019 [26]	Primary care	Economic evaluation studies	Role substitution of work (any) that was previously completed by a GP to nurses in primary care.	Nurse-led care for common minor health problems was as effective and less costly than GP care. However, this is reliant on salary differences in the setting.
Chapman, 2004 [36]	Primary care	RCTs, analytical intervention, and observational studies	Improving access to primary care by recent innovations in the United Kingdom, including nurse-led telephone consultations in general practice and nurse-practitioner led care.	There appears to be improved access to primary care through diversification of care provision to nurses, which was as safe and effective as care by GPs.
Karimi-Shahanjarini, 2019 [15]	Primary care	Qualitative Studies	Doctor-nurse substitution including preventive care, follow-up, health promotion, maternity care as well as acute and chronic care such as diabetes, dementia care and wound care.	There is limited understanding of nurses’ role among patients, and differences between nurse-led and doctor-led care. Patients generally preferred doctors when task was considered more ‘medical’ but may accept the use of nurses to deliver services that are more health promotive or preventive in nature.
Kredo, 2014 [34]	Primary care	RCTs and observational studies	Physician to nurse substitution to either initiate and maintain ART or nurses follow up patients previously initiated on ART by doctors, for maintenance care of ART.	Some evidence suggest shifting responsibility from doctors to adequately trained and supported nurses for managing patients probably does not decrease the quality of care and, in the case of nurse-initiated care, may decrease the numbers of patients lost to follow-up.
Laurant, 2018 [14]	Primary care	RCTs	Physician-nurse substitution of roles and services in primary care except for mental health problems.	Nurse-led primary care may lead to fewer death in diseases such as cardiovascular care, diabetes and rheumatic diseases. Consultation time was longer but they also had better patient return rates.
Martinez-Gonzalez, 2014 [31]	Primary care	RCTs	Physician-nurse substitution to provide care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease, incontinence, mental health and addiction.	Meta-analyses showed greater reductions in systolic blood pressure in favour of nurse-led care (WMD −4.27 mmHg, 95% CI-6.31 to −2.23) but not diastolic blood pressure (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (WMD −0.08 mmol/L, 95%CI −0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI −0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups.
Martinez-Gonzalez, 2014 [30]	Primary care	RCTs and economic evaluation studies	Nurses (in any type of role) substituted physicians as case manager and could delegate clinical responsibility for tasks that were formerly performed by physicians’ alone.	Patients were generally more satisfied with nurse-led care (SMD 0.18, 95% CI 0.13–0.23). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64–0.91) and mortality (RR 0.89, 95% CI 0.84–0.96).
Martinez-Gonzalez, 2015 [32]	Primary care	RCTs	Task shifting of care from family physicians, paediatricians and/or geriatricians to nurses in all roles.	No differences in the quality of care provided by nurses and physicians were noted. Patients who received nurse-led care achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients.
Martinez-Gonzalez, 2015 [33]	Primary care	RCTs	Physician-led care (family physicians, paediatricians and geriatricians) to nurse-led care (all nurse roles) based on a substitution model.	Trained nurses could provide care that was at least equivalent to those provided by physicians in the management of chronic diseases such as hypertension, asthma and obesity management. Other potential roles that could be shifted to nurses with favourable outcomes include health education and promotion.
Martinez-Gonzalez, 2015 [27]	Primary care	RCTs	Physician-led care (family physicians, paediatricians and geriatricians) to nurse-led care (all nurse roles) based on a substitution model.	Task shifting to nurses could effectively improve patients’ return rate for consultations (OR: 1.22, 95% CI: 1.09–1.37) and was cost effective. However, this needs to come hand-in-hand with having access to resources, including staffs, equipment and supplies, quality leadership and a sound referral system.
Ogedegbe, 2014 [24]	Primary care in low-middle income countries	RCTs	Physician to nurse substitution for medication prescribing, medication adjustment, home visits and health education among individuals with hypertension and diabetes.	Some evidence of improvement in blood pressure and glycated haemoglobin among care recipients.
Rashid, 2010 [35]	Primary care	Qualitative studies	Doctor-nurse substitution on clinical roles traditionally performed by doctors, including minor ailments and pain management.	Work delegation to nurses provided a means of organising workload within a practice. Patients generally felt nurses were able to deal with simple conditions but preferred to consult with a general practitioner for more ‘complex’ conditions due to concerns over nurses’ knowledge base, particularly in diagnostics and therapeutics, and their levels of training and competence.
van Ginneken, 2013 [25]	Primary care in low-middle income countries	RCTs and observational studies	Specialist-nurse substitution to provide care for people with mental, neurological and substance-use disorders.	The introduction of nurse achieved similar outcomes in reducing perinatal depression, severity of mental disorder, carer burden and re-admission rates compared to usual care. Nurse-led intervention could also reduce the amount of alcohol consumed among those with alcohol issues.
Weeks, 2016 [13]	Primary and secondary care	RCTs, controlled before-and-after studies and interrupted time series analysis	Non-medical prescribing by nurses versus medical prescribing for acute and chronic disease management.	After training, nurses could prescribe medications and manage a range of chronic conditions with comparable outcomes to doctors.
Whiteford, 2016 [29]	Primary care	RCTs	Doctor nurse substitution to care for patients with chronic ear, nose and throat complaints.	Studies indicated a higher level of patient satisfaction, cost benefits and lower levels of pain/discomfort in nurse-led clinics.

ART: antiretroviral therapy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trials RR: relative risk; SMD: standardised mean difference; WMD: weighted mean difference.

Table 2. Details of studies describing task shift to pharmacists in primary care.

Author, year	Setting	Evidence reviewed	Task shift	Conclusions
Anthony, 2019 [26]	Primary care	Economic evaluation studies	Role substitution of work (any) that was previously completed by a GP to pharmacists in primary care.	Pharmacist-led services for medicines management of coronary heart diseases were as effective as, but more costly than GP care. Management of chronic pain by pharmacists was more effective but more costly than GP care.
Chapman, 2004 [36]	Primary care	RCTs, analytical intervention, and observational studies	Improving access to primary care through pharmacist-led initiatives.	There was weak evidence that pharmacists can manage patients. Evidence supports pharmacist’s role in treatment of minor ailments using over-the-counter medication with low rates of onward referral to GPs.
Jebara, 2018 [38]	Community pharmacy	Surveys and qualitative studies	Independent pharmacists prescribing whereby pharmacists are permitted to assume professional responsibility for performing patient assessments; ordering drug therapy‐related laboratory tests; administering drugs; selecting, initiating, monitoring, continuing, and adjusting drug regimens.	There were positive views and experience on independent pharmacist prescribing from various group of stakeholders. Regardless of the implementation stage, benefits on ease of patient access to healthcare services, improved patient outcomes and reduced physician workload were reported. In addition, pharmacists reported empowerment due to better use of skills and knowledge and improved job satisfaction. Nevertheless, organisational issues related to financial support, role recognition and access to patient clinical records need further attention to ensure success and sustainability.
Nkansah, 2011 [39]	Primary care	RCTs	Physician to pharmacist substitution for management of drug therapy, including prescribing and modifying medication for hypertension.	Patients achieved better blood pressure control when managed by a pharmacist compared to physician.
Paudyal, 2011 [28]	Community pharmacy	RCTs and observational studies	Shifting care for minor ailments care from physicians to community pharmacists.	Community pharmacists-led minor ailment scheme was effective as there was a low re-consultation rate and high symptom resolution suggesting minor ailments were dealt appropriately. These consultations were less expensive than GP consultation.
Weeks, 2016 [13]	Primary and secondary care	RCTs, controlled before-and-after studies and interrupted time series analysis	Non-medical prescribing by pharmacist versus medical prescribing for acute and chronic disease management.	Non-medical prescribing by pharmacists who had a high degree of autonomy and collaborative support can deliver comparable outcomes to usual medical care prescribing by doctors.
Zhou, 2019 [40]	Primary care	Qualitative studies	Prescribing delegation from GPs to pharmacists, either supplementary, independent or collaboratively.	Several identified barriers to pharmacist prescribing include inadequate training, support from stakeholders and funding/ reimbursement. These studies highlight the importance of fostering a favourable socio-political context and prescriber competence through clear policy pathways, targeted training courses, raising stakeholder recognition and identifying specific funding, infrastructure and other resourcing.

RCT: randomised controlled trials.

Table 3. Details of studies describing task shift to other allied healthcare workers in primary care.

Author, year	Setting	Evidence reviewed	Task shift	Conclusions
Anthony, 2019 [26]	Primary care	Economic evaluation studies	Role substitution of work (any) that was previously completed by a GP to community health practitioners.	Task shifting and role substitution by community health practitioners in remote communities was feasible with equivalent care delivered by GP, and was cost-saving.
Barnard, 2015 [37]	Primary care	RCTs and observational studies	Abortion procedures administered by mid-level providers (midwife or any other healthcare workers who has less training than doctors) compared to doctors.	Mid-level providers could be useful alternatives for medical or surgical abortions to reduce the number of deaths and the disability caused by unsafe abortion in resource limited setting. However, mid-level providers would need to be sufficiently trained and better monitoring of safety is required before widespread implementation.
Colvin, 2013 [41]	Primary care	Qualitative studies	Task shifting to and from midwife for midwifery services.	Task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, but requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact.
Ogedegbe, 2014 [24]	Primary care in low-middle income countries	RCTs	Physician to non-physician substitution who provided patients with the WHO cardiovascular package protocol, which was a clinical decision and support tool for assessment and management of cardiovascular risk factor, lifestyle counselling, drug treatment protocol and referral pathways.	Small improvements in blood pressure among intervention group recipients.

RCT: randomised controlled trials.

Figure 2. Elements for successful task shift.

Anthony BF, Surgey A, Hiscock J, et al. General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care. Br J Gen Pract. 2019;69(682):e304–E313.

 PubMed Web of Science ®Google Scholar

Chapman JL, Zechel A, Carter YH, et al. Systematic review of recent innovations in service provision to improve access to primary care. Br J Gen Pract. 2004;54:374–381.

 PubMed Web of Science ®Google Scholar

Karimi-Shahanjarini A, Shakibazadeh E, Rashidian A, et al. Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;4:CD010412.

 PubMed Web of Science ®Google Scholar

Kredo T, Adeniyi FB, Bateganya M, et al. Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy. Cochrane Database Syst Rev. 2014;2014(7):CD007331.

 Google Scholar

Laurant M, van der Biezen M, Wijers N, et al. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev. 2018;7:CD001271.

 PubMed Web of Science ®Google Scholar

Martínez-González NA, Tandjung R, Djalali S, et al. Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis. PLOS One. 2014;9(2):e89181.

 PubMed Web of Science ®Google Scholar

Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214.

 PubMed Web of Science ®Google Scholar

Martínez-González NA, Tandjung R, Djalali S, et al. The impact of physician-nurse task shifting in primary care on the course of disease: a systematic review. Hum Resour Health. 2015;13:55.

 PubMed Web of Science ®Google Scholar

Martínez-González NA, Rosemann T, Tandjung R, et al. The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review. Swiss Med Wkly. 2015;145:w14031.

 PubMed Web of Science ®Google Scholar

Martínez-González NA, Rosemann T, Djalali S, et al. Task-shifting from physicians to nurses in primary care and its impact on resource utilization: a systematic review and meta-analysis of randomized controlled trials. Med Care Res Rev. 2015;72(4):395–418.

 PubMed Web of Science ®Google Scholar

Ogedegbe G, Gyamfi J, Plange-Rhule J, et al. Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials. BMJ Open. 2014;4(10):e005983.

 PubMed Web of Science ®Google Scholar

Rashid C. Benefits and limitations of nurses taking on aspects of the clinical role of doctors in primary care: integrative literature review. J Adv Nurs. 2010;66(8):1658–1670.

 PubMed Web of Science ®Google Scholar

van Ginneken N, Tharyan P, Lewin S, et al. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev. 2013;2013(11):CD009149.

 Google Scholar

Weeks G, George J, Maclure K, et al. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev. 2016;11:CD011227.

 PubMedGoogle Scholar

Whiteford C, White S, Stephenson M. Effectiveness of nurse-led clinics on service delivery and clinical outcomes in adults with chronic ear, nose and throat complaints: a systematic review. JBI Database System Rev Implement Rep. 2016(4);14:229–256.

 PubMedGoogle Scholar

Jebara T, Cunningham S, MacLure K, et al. Stakeholders’ views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol. 2018;84(9):1883–1905.

 PubMed Web of Science ®Google Scholar

Nkansah N, Mostovetsky O, Yu C, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev. 2010;2010(7):CD000336.

 PubMed Web of Science ®Google Scholar

Paudyal V, Hansford D, Cunningham S, et al. Pharmacy assisted patient self care of minor ailments: a chronological review of UK health policy documents and key events 1997–2010. Health Policy. 2011;101(3):253–259.

 PubMed Web of Science ®Google Scholar

Zhou M, Desborough J, Parkinson A, et al. Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences. Int J Pharm Pract. 2019;27(6):479–489.

 PubMed Web of Science ®Google Scholar

Barnard S, Kim C, Park HM, et al. Doctors or mid-level providers for abortion. Cochrane Database Syst Rev. 2015;27(7):CD011242.

 Google Scholar

Colvin CJ, de Heer J, Winterton L, et al. A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery. 2013;29(10):1211–1221.

 PubMed Web of Science ®Google Scholar