Role Comparison in Urgent Care

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Role Comparison in Urgent Care

• Keith Tadd
• Workforce Developer
• Warwickshire PCT

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Drivers For Change
COMMISSIONING A Patient Led NHS
Creating A Patient Led NHS
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Challenges for the NHS

• We need to
• Better understand the impact of future drivers of
  change on the future healthcare workforce
• Develop a flexible workforce that is able to
  respond and adapt as changes occur
• More integration of planning and decision making
  processes (vertical and horizontal)
• Leaders who have the skills and resources to
  develop a long term vision for the workforce
  across their patch

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Challenges for the Workforce

• Future staffing models need-
• More systematic intelligence on where specific
  skills needed
• Willingness to adapt, test and apply new ideas
  that achieve best results for patients through
  innovation
• A strong economic case including knowledge of the
  market and the organisational autonomy needed to
  develop and determine skill mix

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What Patients Want.

• Improved Access Less Waiting
• More services near to them
• Safe, High Quality, Coordinated Care
• Better Information Choice
• Flexible Services
• Understandable Advice
• Build Closer Relationships
• Clean, Comfortable, Friendly Environment

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Issues for our Workforce

• Reduced number of entrants to healthcare
• Large numbers of healthcare leavers
• Inflexible professional boundaries
• Clinical ceiling

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UK Baby boom 1945-71
1,100,000
900,000
Births 100,000s
700,000

500,000
300,000
1938
1948
1958
1968
1978
1988
1998
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Projected impact on nursing workforce retirements
30000
25000
20000
WTE
15000
10000
5000
0
2000
2002
2004
2006
2008
2010
2012
2014
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New Ways of Working
More Staff Working Differently
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Overview of Project

• A workshop developed to explore the multiple
  roles, existing and under development, that help
  deliver the Urgent Care agenda standards within
  Coventry Warwickshire. The objectives were
• 1.      To achieve broad understanding of the
  multiple new roles currently being developed to
  deliver Urgent Care.
• 2.      To achieve broad acceptance that these
  new roles will require the development of
  existing staff and existing services.
• Representative of each role gave presentation on
  their role following set criteria that allowed
  for easier comparisons/ differences to be
  recognised. Attendees then worked in groups to
  debate the advantages and disadvantages of each
  role in delivering the Urgent Care agenda.

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Anticipated outcomes of Workshop

• The production of a Urgent Care Competency
  matrix role v. competency
• Role comparison Matrix a condensed version of
  the above
• Advantages / disadvantages comparison developed
  from the workshop discussions.
• The information generated will inform the
  development of a consistent Workforce Plan for
  Urgent Care

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Physicians Assistant Competency Curriculum
Framework
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Patient Care by Conditions for Practitioners in
Urgent Care
Code Definitions 1A - Able to diagnose the
condition in a patient who is presenting with the
problem 1B - Able to identify the condition as a
possible diagnosis may not have the
knowledge/resources to confirm the diagnosis or
to manage the condition safely, but can take
measures to avoid immediate deterioration and
refer appropriately. 2A - Once the condition has
been diagnosed, either by their supervising
doctor or a clinical specialist, then able to
manage the condition without routine referral. 2B
- Able to undertake the day to day management of
the patient and condition once the diagnosis and
strategic management decisions have been made by
another.
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Role Comparison Matrix

• Training
• On Going Training Needs
• Core components of training
• Principle areas of work
• Referral routes
• Workload
• Management

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Physicians Assistant

• Benefits
• More time with the patients full assessment
• Increased patient satisfaction
• Quickly treated fewer hand offs
• Able to directly refer appropriately
• National standards in competency framework
• 2 years training to Masters level
• Registered professional with re-registration
  assessment all professional life (will be)
• Career potential for some NHS workers that may
  have left the NHS
• Work in Primary/Secondary care - rotation
• Generalist
• Share of GP workload frees GP to take on
  different roles i.e. GPHSI aids RR of GPs
• New role / workforce
• No depletion of current workforce
• National Competencies for training
• HEFCE funding for training
• Permanent part of hospital medical team
• Help meet access targets 24hr GP / 4 hour AE
  wait

• Issues
• Acceptance of a new role
• Not autonomous
• Regulation issues yet to be resolved
• No prescribing rights or use of PGDs (at
  present)
• Supervision issues GP funding
• Acceptance / tribalism
• Certain areas of practice yet to be developed
  i.e. ref to consultant
• Cost training and employment

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Emergency Care Practitioner

• Benefits
• Patients treated in own homes or closer to home
• High patient satisfaction
• Access to diagnostics van
• Reduced waiting
• Fast response service
• Time spent at call 45-60 mins.
• Time spent on health social issues
• Able to directly refer appropriately
• Autonomous worker (role not regulated)
• Educational programme (30 weeks)
• Dual training nurses / paramedics
• Have diagnosis referral guide lines / pathways
• Able to work across several areas rotations
• Work under PGDs
• Hospital avoidance
• Reduced hospital bed stay for new acute care
• More hospital bed days for acute care
• Doctors have more time to see patients with
  more appropriate conditions

• Issues
• Not for complex care
• Time constraints
• No national competencies or educational
  standards
• No regulation
• No national exam
• Creates another silo specialism
• Depletes nurses paramedic workforce by
  attracting them into the role

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Emergency Nurse Practitioner

• Benefits
• More time with the patients
• Increased patient satisfaction
• Quickly treated
• Builds on prior knowledge experience
• Opportunities for development
• Continued examination of competency
• Support role for senior / juniors
• Help achieve AE waiting time targets
• Queue busting
• More effective efficient use of resources

• Issues
• Exclusions (clinical ceiling) locally applied
• Prescribing issues
• Clinical supervision issues - competencies
• Skills update dont use it, lose it
• Consistency in roles / training nationally
• No national standards
• Variable local standards
• Issues re advanced practice registration
• De-skills doctors in AE
• Delivering Benefits within current AE staffing

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Advanced Nurse Practitioner

• Benefits
• More time with the patients
• Increased patient satisfaction
• Quickly treated
• Autonomous practitioner
• Increase in job satisfaction
• Wide skill base
• Very specialist in own chosen expertise
• Nurse led caseload
• Able to Prescribe
• Self management APMS
• Blending role CNS / NP at Masters level
• Building on experience pool of staff
• Application of knowledge in numerous areas
  AE, GP practice etc.

• Issues
• Depletes nurse pool
• going to work to replace doctors
• Generalist role rather than specialist
• Under-utilised to degree of training
• Potential threat of other roles MCP / ECP /
  Nurses
• Salary
• Cost of training backfill

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Community Matrons

• Benefits
• Patient focus
• Prevention of hospital admissions for patients
  with complex LTCs
• Time for full assessment
• Personalised care plans
• Avoids duplication of visits
• Empower educate patients carers to
  appropriate use of services
• Advanced clinical skills
• Able to Prescribe
• Regulated practitioner
• Releases GP time
• Decreases GP demand
• Reduced admissions
• Reduced bed stay earlier discharge
• Reduced cost to PCT acute Trusts
• Reduced prescribing costs
• Focus LTC / case management national drivers
• Nationally driven

• Issues
• Lack of national standards for implementation
  so CMs working differently across the country.
• No national training on chronic disease
  management for CMs
• Training (links to KSF)
• Lack of Community Matrons difficulties in
  recruitment
• Role is a perceived threat to specialist
  nurses
• Lack of understanding of the role by other
  professionals
• Reduced bed days is only theoretical data at
  present set up to fail?
• Demand / capacity issues

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Actions

• Mapping vision for Urgent Care
• ISIP
• Purpose of role
• Respond to health needs of LHC
• Potential for combining ENP / ECP roles
  training
• When developing Primary Care need to map which
  role is fit for purpose
• ANP or MCP
• ANP or CM
• Care co-ordination
• Integrated Clinical Pathways
• Single point of access multiple referral routes

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Actions cont.

• Address supervision issues Workforce Deanery
• Developing current staff - scoping training needs
  ESR
• Need to involve
• GPs
• Commissioners
• Patient Public involvement
• Social Services
• Promoting roles mechanism to do this i.e. Role
  shadowing
• Workshop across Coventry Warwickshire to
  promote integrated role development

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Any Questions?

• Keith.Tadd_at_nhs.net