Wherever you sit in the NHS, the next five to ten years looks tough, if not impossible.
In hospitals the number of people admitted with complex medical problems and high personal care needs keeps growing. At the same time, there are significant recruitment and retention difficulties, particularly in areas of greatest workload pressure – A&E and the medical wards. Agency and locum spend is growing, although a challenging cost improvement programme is premised on its reduction.
Primary care faces similar demand pressures, with struggles to recruit GPs and practice nurses. Community and mental health service workforce not only face a growing workload from “business as usual” but also need to change and expand their offer to provide more appropriate care to the population. And they need to do this when the numbers in their skilled nursing workforce have declined and they have difficulty recruiting psychiatrists and geriatricians.
Can changes in skill mix help provide a way through some of these problems?
Skill mix – changes in the way staff work, including staff taking on new roles and responsibilities – can often result in a different ‘mix’ of staff delivering care. This question of whether it can address some of the challenges facing the NHS is something that the Nuffield Trust aims to explore over the next six months, working in partnership with NHS Employers. We kicked off our work last week with a seminar attended by people across the system including many of the key experts in this area. We had a 100 per cent consensus that skill mix does offer some solutions: solutions that, at their best, can deliver measurable improvements for patients, staff and finances.
New professional roles
A good example is the work underway at Heart of England Foundation Trust (HEFT). The Trust is replacing its largely medical workforce model, heavily reliant on locum and agency staffing, with ‘Advanced Clinical Practitioners’ (ACPs). ACPs are experienced senior non-medical clinicians (such as allied health professionals or pharmacists) who are trained to work at a senior clinician level, and are therefore able to substitute for doctors over time.
They are able to see, treat and manage patients across the age and complexity spectrum; from those attending with minor problems, through to those experiencing major life-threatening injuries and illnesses within a consultant-led team. HEFT, under the clinical leadership of Garry Swan and the ED team, have a decade of experience of developing the ACP role within the Trust’s Emergency Directorate. Repeated local audits have provided the evidence of the role’s efficacy.
Over the next five years the trust plans to train up to 250 new ACPs and fund some of this by the withdrawal of up to 120 locum and middle grade medical posts. The trust believes that this investment will deliver a flexible clinician-led workforce (consisting principally of permanent doctors and ACPs) to deliver care that is more consistent, timelier and safer for patients.
As well as reducing reliance on a diminishing supply of junior doctors it will also avoid the cyclical ‘system relearning’, that coincides with trainee changeover and locum use, and that acts as significant impediment to any improvement initiative. It is anticipated that this programme will also deliver net savings to the trust.
Our future work aims to identify and showcase more solutions from settings across the NHS and, not forgetting the interdependence with social care, look at examples here too.
The seminar discussion also touched on a number of other important issues. Discussions on changing skill mix often assume a waterfall effect, senior staff handing off tasks or responsibilities to more junior, less well paid staff. But benefits are also gained from senior staff taking a more active and comprehensive role in care and, as the HEFT example shows, staff can be developed and supported to move up the skills escalator and take on senior decision making roles.
Offsetting the risks
Deconstructing roles into tasks, and then reallocating tasks according to the skill required to do the task, also carries risks. A routine task can provide the opportunity for clinical observation and the human connection that strengthens the bond between clinician and patient. The example was given of the bed bath. Seen by some as too menial a task for a nurse, giving a bed bath can be a diagnostic and therapeutic exercise. So if it is to be undertaken by someone else – that element must not be lost.
Better outcomes at a lower cost
We considered two contrasting models of support for people in the community. The first was the Buurtzorg Model from the Netherlands, where self-managed teams of skilled nurses provide comprehensive community care to vulnerable older people in their homes. Historically care was provided by a constellation of different staff, including many unskilled staff.
The second was Iora Health in the US, which provides comprehensive primary and community care to complex older patients. Iora delivers this with a very small number of GPs supported by health coaches, nurses and social workers working to help patients take better control of their health and condition.
The two services have very different approaches to skill mix (one uni-professional/high skill, the other multi-professional/mixed skill) but both deliver better outcomes at lower cost, with high levels of staff and patient satisfaction. However, they do have a common factor – high levels of devolution and autonomy, with professionals working flexibly, focused on the needs of the patient not professional role demarcations.
We believe that changes in skill mix provide the opportunity to deliver the 'quadruple aim' in care improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care while improving the work life of health care clinicians and staff.
Over the next six months we plan to share insights as to how this can be achieved. If you’d like to receive updates on this project, you can sign up on our website.
Imison C (2015) ‘Facing future challenges: do changes in skill mix offer some solutions?’. Nuffield Trust comment, 25 June 2015. https://www.nuffieldtrust.org.uk/news-item/facing-future-challenges-do-changes-in-skill-mix-offer-some-solutions