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.

Primary research question:

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? Background:

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.

Aim:

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. Methods: We will conduct a mixed methods study in four phases.

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.

•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).

•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).

•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).

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.

•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)

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.

•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).

•We will investigate the experience of including NMPs in the skill-mix through qualitative interviews with patients and staff (WP6).

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. Anticipated impact and dissemination:

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.