changing skill mix is it the answer? professor bonnie sibbald national primary care research &...
TRANSCRIPT
Changing Skill MixIs it the answer?
Professor Bonnie Sibbald
National Primary Care Research & Development Centre
University of Manchester, England
Challenges
• Rising demand
• Rising cost
• Variable quality
• Medical workforce shortages
Expectations
Changing skill mix can-
• Reduce demand for high cost personnel
• Reduce cost of care.
• Maintain (or increase) the quality of care
Does it Work?
Substitution
Systematic review of nurse-doctor substitution in primary care
• First contact for urgent problems ( 5 studies)
• First contact and ongoing care (7 studies)
• Management of chronic condition (4 studies)
Laurant et al. Substitution of doctors by nurses in primary care. In Cochrane Database of Systematic Reviews. April, 2005.
.
Patient Outcomes
0
5
10
15
20
25
30
35
No.
Out
com
es
Physical health Satisfaction
DoctorNurseSame
Process of care & Productivity
0
2
4
6
8
10
12
14
No.
Out
com
es
Quality Consult length Consult number
DoctorNurseSame
Resource Utilisation
0
5
10
15
20
25
30
No.
Out
com
es
Tests Scripts Services
DoctorNurseSame
Cost
Chambers 1977 No difference
Lattimer 1988 Nurse cheaper
Lewis 1967 No difference
Spitzer 1973 No difference
Venning 2000 No difference
Conclusions
Patient outcomes• No difference in physical health • Patient satisfaction higher for nurses
Process of care• No difference in quality of care• Nurses tend to give more advice
Resource utilisation• Productivity lower for nurses• Costs the same
System-level Impact
Larger teams with increased role differentiation
among members
Associated with …Economies of scale and scopeHigher technical quality of careIncreased speed of access
System-level Impact
But has unintended effects on -Continuity of care Coordination of care
And high capital costs associated with -Education & trainingChange managementLicensing & regulation
Policy Implications
Changing skill mix is a plausible strategy for increasing workforce capacity.
But beware
High capital costs
Reduced personal continuity of care
Difficulties with care coordination