Evidence from Literature
• Nurse Practitioners existed in North America many years
• Reviews suggest Nurse Practitioners equivalent to GP (Horrocks et al 2002)
• Same day consultations – no differences in outcomes. (Kinnersley et al 2000)
Evidence from Literature
• Patients seeing Nurse Practitioners – are more satisfied
• Nurse Practitioners offer longer consultations• Evidence has compared mainly minor illness
International Models
• Denmark• GP Care - free• Resembles old GP
system UK.• Telephone based medical
advice by GP• Demand rising
• Netherlands• Medical Insurance• OOH Co-operatives• Many co-located with A/E• Triage Nurses• Professional self-
regulation
International Models
• USA• Medical Insurance• Large variation • Call handling service• Signposting• Nurse Triage• 90% referred to GP• Urgent care centres
• Australia• Consultations paid for
85% refunded • Variable models• Nurse Call centres• GP Telephone triage• Health Direct – nurse led
service• Performance indicators
United Kingdom
• Scotland• NHS 24• OOH Centres• Staffed by mixture
clinicians• Quality standards• Accessibility availability,
safe & effective care• Audit
• Wales• Commercial providers• NHS Acute Trust• Mainly GP led• Some Nurse Triage• NHS Direct – Wales has
call handling and Nurse Triage service
OOH Models
• Varies across UK• Some GP led• Some Nurse led• Some multidisciplinary• No one seems to know what is the ideal skill mix• Varies according to Geographical area
What is the ideal Model
• Nobody Knows………………………• Systems in place• Processes• Standard Procedures• Performance Reporting• Clinical Governance• Training Programmes
Primary Care Foundation
• Swift Response• Highly trained staff• Streaming patients• Local bases• Skilled mixed professionals• Effective Advice and treatment
Activities
• Urgent Care Course• Skill Mix Development• Patient streaming project• Evaluation of dental triage• ECP Pilot • Nurse triage Pilot• Home Visiting Pilot
Define Skill set• General Practitioners• Nurse Practitioners• Minor Illness Nurses• Emergency Care Practitioners• GP Registrars• Trainee minor illness nurses• Trainee N/P• Trainee ECP• Trainee Radiographers
Nurse Practitioner
Prescribes fromformulary
and can use PGD’s
Nurse Practitioner
Can assess all patients via telephone or face to face
Diagnoses
Can treat and
complete around 90%
of cases
Orders investigations
Provides treatment
Refers
Minor iIlness Nurse/ECP
Can initiate some treatment
Reports to Nurse Practitioner or
GP
Assesses a range of common conditions
via telephone or face to face
Unable to prescribe
Can not produce prescriptions for signing
Can complete 50% of cases Minor Illness Nurse
ECP
Can administer medication via
PGDs
Diagnoses from list of common presentations
Trainee Minor Illness Nurse/Paramedic
Directly and then indirectly
Supervised Can initiate some treatment
Reports to Nurse Practitioner or
GP
Directly and then indirectly
Supervised to Assesses a range of common conditions via telephone or face to face
Unable to prescribe
Can not produce prescriptions for signing
Working towards completion of 50%
of cases before able to work as
Minor Illness Nurse Trainee Minor Illness Nurse
Directly and then indirectlySupervised administer medication via PGDs
Training to diagnose from list of common
presentations
PROJECTS
• Review of Consultations and analysis of competencies
• Review of Consultations re completion rates
• Audit – comparing Nurse's GP,s NP’s
Review of Consultations
• Levels were identified ABCDEF• A/B = HCA’s / Paramedic• C = Nurse’s / ECP• D = Nurse Practitioner• E = GP Registrar• F = GP Principle • Consultations were marked with the clinical grade
considered competent to complete the consultation
EXCLUSIONS
• D Level (NP)• Palliative Care• Verification of Death• Neonates (under 3/12)• Repeat Prescriptions• Pregnancy (over 3/12)• Mental Health Sectioning• Pathology Results
• C Level (Nurses/ECP’s)• All plus Under 5’s
• B (HCA/Paramedic)• All of the above plus• Cardiovascular• Respiratory• Gastro-intestinal• Some Genitio Urinary
Reliability
Clinician 1 and 2 Comparison
0
20
40
60
80
100
120
A B C D E F
Grade
Cons
ulta
tion
Clinician 1
Clinician 2
Concentric Model of Competencies Standards Within Competence Increasing from A-F
E/F DC B A
Domain 2Clinician-Patient Relationship
Domain 3 Assessment of patient health/illness
Domain 4
Case Management and monitoring the quality of health care practice Domain 1
Professional and Ethical Practice
Degree NP with Prescribing
Basic N/P Experienced Nurse
PrescriberECP
HCA Paramedic
Junior NurseHCA
GP
Graph To Show Average Competency Development Over a Two Year Period
Nurse Practitoner
HCA Paramedic
Minor Illness Nurse
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
0 3 6 9 12 15 18 21 24
Time (Months)
Co
mp
etan
cies
Independent Perscriber
Course Course Length Competency Time
Minor Illness Course 3 Days 3 Months
Physical Assessment Skills 5 Days 6 Months
Independent Prescribing 6 Months 6 Months
Full Nurse Practitioner Degree
24 Months 24 Months
Review of Consultations
• Aim was to determine the skill mix required to deliver the service
• 100 consultations were reviewed• Different shift patterns were selected• TCN competency framework was developed
with classifications
Minor Illness Nurse/ ECP
52%48%
Analysis of 100 consultations
Completion Rates of non-medical Clinicians
Results
• F level could complete 100% (GP)• D level could complete 83% (NP)• C level could complete 52% (Nurse/ECP)• B level could complete 12% (HCA Paramedic)
• Case Mix varies midweek evenings/weekends
Skill Mix Review
Skill Mix Review of Consultation
0
2
4
6
8
10
12
14
16
A B C D E F
Grade
Co
nsu
ltatio
n
Mid Week Evening
Saturday AM
Sunday PM
Results• Mid Week evenings
• Saturday AM
• Sunday PM
• More complex problems• CDF levels required• Scope to use a variety of
skill mix• C level utilised to full
potential with lower ratio of NP/GP
• D level utilised high ratio to GP
Audit
• Extrapolate Three months data from HMS• Identify Clinicians who meet the following
criteria• 1) Have undertaken 100 Telephone triages in
the time period• 2) Have undertaken 50 base consultations• 3) Have undertaken NO home visits
Audit
• Comparisons made
• Triage Performance Outcomes• Length of time of Triage Consultation• Length of time of Base Consultation• Admissions• Bench marked against company averages for
the time period
Triage Performance Outcomes
Average Outcomes
0
10
20
30
40
50
60
Triage Advice % 54.00 56.83 53.40
Triage BV % 33.13 32.33 36.00
Triage HV % 12.63 11.00 10.30
N/P Nurses GP
Consultation Times Admissions Rate
Performance (Average)
0
2
4
6
8
10
12
14
16
Triage Times 5.77 7.52 5.60
BV Times 12.87 15.22 10.39
Admissions Rate % 1.80 0.52 1.59
N/P Nurses GP
Consultation Times
Admissions Rate GP vs NPPerformance (Average)
0
2
4
6
8
10
12
14
Triage Times 5.77 5.60
BV Times 12.87 10.39
Admissions Rate % 1.80 1.59
N/P GP
EvaluationMinor Illness Nurse v GP
• Nurses perform longer consultations• Nurses have low admission rates probably as they
tend to select less unwell patients.• They tend to work within their competency to avoid
duplication so outcomes are similar to other clinicians• The nurse results for triage may be biased as it was
not possible to exclude the dental triage from these stats.
• (Most of the dental outcomes will be advice)
EvaluationNP vs GP
• Nurse Practitioners consultation times are slightly longer than a GP’s
• Triage difference = 0.17 secs• Base difference = 2.48 mins• Admissions very little difference 0.21%• This could be attributed to the holistic
framework that nurses deliver care from and the more rigorous documentation
Audit Conclusion
• N/P and GP perform to similar performance levels
• N/P cost approximately 50% less to employ• Nurses are working productively according
to their competency• It would appear that it is both cost effective
and safe to change the skill mix in OOH delivery.
Audit Completion of Calls
• Aim was to determine if nurses are able to complete cases without referral to GP’s
• One weeks nurse consultations reviewed• Various Nurses with various skills• Various Shift times• Different days of week
Results
• 92.6% of consultations completed by the nurse• 7.4% referred to GP• OOH nurses on various clinical shifts can complete the
vast majority of consultations• Appropriate levels of skills used in service delivery results
in patients being seen and completed in one consultation• Lower grade clinicians refer more patients to GP’s
What do we want?• Efficiency • Drive down costs• Effectiveness • ensure safe practice with clinical governance central to delivery• Collaboration • stakeholder engagement• Team Working • create climate of mutual respect through clear roles,
responsibilities. • Common vision
Future Model
• Explore skill mix • Determine safe efficient model• Develop GP light OOH service• Develop other clinicians• ? IT support system • Competitive tendering• Successful new business.
The Way forward
• Patient focused quality service• Delivering to agreed specification• Working with all stakeholders• Understand and resolve any service issues• Developing new services for the benefit of
patients.• Exploring future options in skill mix
THANKYOU
Contact DetailsSally GardnerNurse Consultant Take Care NowTelephone – 01473 299531
• Email – [email protected]