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OOH The Way Forward

OOH The Way Forward. Sally Gardner Nurse Consultant Out of Hours. Nurse Development in OOH. WHY? Workforce Issues (nGMS). Evidence from Literature. Nurse Practitioners existed in North America many years Reviews suggest Nurse Practitioners equivalent to GP ( Horrocks et al 2002)

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OOH The Way Forward

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  1. OOH The Way Forward Sally Gardner Nurse Consultant Out of Hours

  2. Nurse Development in OOH • WHY? • Workforce Issues (nGMS)

  3. 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)

  4. Evidence from Literature • Patients seeing Nurse Practitioners – are more satisfied • Nurse Practitioners offer longerconsultations • Evidence has compared mainly minor illness

  5. 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

  6. 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 International Models

  7. 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 United Kingdom

  8. 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

  9. What is the ideal Model • Nobody Knows……………………… • Systems in place • Processes • Standard Procedures • Performance Reporting • Clinical Governance • Training Programmes

  10. Primary Care Foundation • Swift Response • Highly trained staff • Streaming patients • Local bases • Skilled mixed professionals • Effective Advice and treatment

  11. Activities • Urgent Care Course • Skill Mix Development • Patient streaming project • Evaluation of dental triage • ECP Pilot • Nurse triage Pilot • Home Visiting Pilot

  12. 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

  13. Can assess all patients via telephone or face to face Orders investigations Can treat and complete around 90% of cases Nurse Practitioner Diagnoses Prescribes from formulary and can use PGD’s Provides treatment Refers Nurse Practitioner

  14. Assesses a range of common conditions via telephone or faceto face Can complete 50% of cases Can initiate some treatment Minor Illness Nurse ECP Diagnoses from list of common presentations Reports to Nurse Practitioner or GP Can administer medication via PGDs Unable to prescribe Can not produce prescriptions for signing Minor iIlness Nurse/ECP

  15. Directly and then indirectly Supervised to Assesses a range of common conditions via telephone or faceto face Working towards completion of 50% of cases before able to work as Minor Illness Nurse Directly and then indirectly Supervised Can initiate some treatment Trainee Minor Illness Nurse Training to diagnose from list of common presentations Reports to Nurse Practitioner or GP Directly and then indirectly Supervised administer medication via PGDs Unable to prescribe Can not produce prescriptions for signing Trainee Minor Illness Nurse/Paramedic

  16. PROJECTS • Review of Consultations and analysis of competencies • Review of Consultations re completion rates • Audit – comparing Nurse's GP,s NP’s

  17. 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

  18. 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 EXCLUSIONS

  19. Reliability

  20. Graph To Show Average Competency Development Over a Two Year Period

  21. 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

  22. Completion Rates of non-medical Clinicians Analysis of 100 consultations

  23. Completion Rates of non-medical Clinicians Analysis of 100 consultations

  24. Completion Rates of non-medical Clinicians Analysis of 100 consultations

  25. 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

  26. Skill Mix Review

  27. 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 Results

  28. Audit • Three groups • GP’s • Nurse’s • NP’S • Compare Three Months data

  29. 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

  30. 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

  31. Triage Performance Outcomes

  32. Consultation Times AdmissionsRate

  33. Consultation Times Admissions Rate GP vs NP

  34. 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)

  35. 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

  36. 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.

  37. 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

  38. 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

  39. 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

  40. 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.

  41. 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

  42. THANKYOU Contact Details Sally Gardner Nurse Consultant Take Care Now Telephone – 01473 299531 • Email – sally.gardner@takecarenow.co.uk

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