Title: Implementation of the non-medical practitioner workforce into the urgent and emergency care system skill-mix in England: a mixed methods study of configurations and impact.
Funder: Department of Health and Social Care

Abstract: Demand for urgent and emergency care services is growing every year, especially urgent treatment centres (UTCs). People are going to Emergency Departments (ED) with more complicated issues and many patients are admitted to hospital. There are not always enough doctors for these departments, and staff are leaving or going off sick in high numbers. One solution is to employ ‘non-medical practitioners’. These are qualified staff from other healthcare backgrounds who work at the same level as doctors. Some research shows that patient results are the same if they see a non-medical practitioner as if they see a doctor. We need to know what balance - known as ‘skill-mix’ - of nonmedical practitioners, doctors and nurses in a team and service achieves the best results. _x000D_ _x000D_ This study will explore the result of different skill-mix in ED/UTCs in England, to make recommendations about the best balance. _x000D_ _x000D_ Patient and public involvement (PPI) representatives have helped design the study. There will be an independent PPI panel who can feed in their views and experiences to all parts of the study. The panel will be run by an experienced patient and public involvement expert, who is a member of the core study team. _x000D_ _x000D_ We will split the study into four phases over two-and-a-half years._x000D_ _x000D_ Phase One (months 0-12) will find out in detail what the staffing models are in EDs/UTCs. We will look at published research evidence and at NHS public documents, and we will interview regional and national senior NHS clinicians, managers, commissioners and lay representatives. Then, we will look for patterns in information about staff which is already collected regularly across England. We will look at what non-medical practitioners do and how independently they work in two different ED/UTCs. We will ask the panel of patient and public involvement representatives and a panel of non-medical practitioners to help us to understand these findings. We will develop a system for classifying ‘skillmix’ in each organisation. We will also think of a way to measure how much support and supervision non-medical practitioners need._x000D_ _x000D_ Phase Two (months 13-18) will use look at figures regularly collected from all NHS Trusts in England between 2017 and 2021, to assess whether different skill mixes lead to different patient outcomes. We will look especially at the number of patients who return again to the ED within a week._x000D_ _x000D_ Phase Three (months 13-24) will involve looking in detail in six ED/UTCs. We will collect in depth local data to add to the national data we looked at in Phase Two. This will include looking closely at staff records and patients’ clinical records to tell us more detail about skill-mix in the organisations and the outcomes for patients. We will gauge how independently the types of practitioners assess and treat patients. We will also survey and interview patients so that we can understand their experience, and we will interview staff for their views._x000D_ _x000D_ Phase Four (months 25-30) will pull all of the results together. We will ask our panels of patient and public involvement representatives and non-medical practitioners to help us again. We will make recommendations on skill-mix and levels of independence that will deliver the best outcomes for patients, for staff and for the NHS._x000D_ _x000D_ We will publicise our findings and evidence-based recommendations with professional, patient and public groups. We will use presentations, summaries, web-based video and social media to share our findings with patients, staff and employers.

Lay abstract: Primary research question:_x000D_ What is the impact of different non-medical practitioner skill-mix in Emergency Departments (ED) and Urgent Treatment Centres (UTC) in acute hospitals on patient and service processes and outcomes? _x000D_ _x000D_ Background:_x000D_ Increasing demand for emergency care has occurred alongside staffing shortage, particularly of doctors. Re-shaping of the workforce has resulted, including the introduction of non-medical practitioners (NMPs), such as nurse practitioners and physician associates. Despite 20 years of NMPs in EDs, there is limited evidence of effectiveness of individual roles, and none as to appropriate skill-mix of staff, at what level of independence from senior medical staff._x000D_ _x000D_ Aim:_x000D_ To explore the impact of different skill-mix including NMPs in EDs and UTCs on patient experience, quality of care, clinical outcomes, activity, staff experience and costs in acute NHS trusts in England, in order to inform workforce decisions of clinicians, managers and commissioners._x000D_ _x000D_ Methods:_x000D_ We will conduct a mixed methods study in four phases._x000D_ _x000D_ Phase One (months 1-12) aims to describe the rationale for, and configurations of, the NMP workforce in EDs/UTCs in England, and to develop analytical tools._x000D_ _x000D_ •We will undertake and publish a scoping literature and policy review on NMP development and skill-mix outcomes, informed by interviews with senior NHS clinicians, managers, commissioners and lay representatives (Work package [WP]1)._x000D_ _x000D_ •We will describe quantitatively the NMP and other clinical workforce (skill-mix) using NHS Digital and NHS Benchmarking national data, 2017-2021; and qualitatively the level of independence/supervision of NMPs and doctors, through observation (WP2)._x000D_ _x000D_ •We will triangulate WP1 and 2 results in consultation with patient and public and NMP representatives, and the study steering committee, to develop three analytical tools: a skill-mix ratio classification, a quantitative measure of independence and supervision, and a logic model for NMP skill-mix (WP3). _x000D_ _x000D_ _x000D_ Phase two (months 13-18) aims to utilise the analytical tools to assess the impact of skill-mix ratios on national ED/UTC indicators of quality._x000D_ _x000D_ •We will conduct and publish a quasi-experimental study of associations of skill-mix ratio classifications with our primary outcome (rate of unplanned return to the ED/UTC in seven days, a proxy for clinical safety), secondary outcomes (national indicators of ED/UTC quality and performance), and cost-effectiveness. (WP4)_x000D_ _x000D_ _x000D_ Phase three (months 13-24) aims to explain the effectiveness and acceptability of skill-mix ratios through investigation in six local-level case study sites._x000D_ _x000D_ •We will repeat WP4 analysis with added precise local quantitative data on NMP types (trust management information), controlling for level of independence/supervision of the clinician (collected via structured observation). We will add patient satisfaction as an outcome, collected prospectively via questionnaire (WP5)._x000D_ _x000D_ •We will investigate the experience of including NMPs in the skill-mix through qualitative interviews with patients and staff (WP6)._x000D_ _x000D_ _x000D_ In Phase four (months 25-30) we will prepare a synthesis of findings, using our logic model, for structured discussion at a stakeholder event to prepare recommendations and outputs._x000D_ _x000D_ _x000D_ Anticipated impact and dissemination:_x000D_ _x000D_ We will produce knowledge of skill-mix outcomes to translate into workforce models with our NHS partners; and disseminate throughout the study, using academic outputs and media accessible to stakeholders.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE