Skill mix and role redesign: The North West way Helen Kilgannon Juliette Swift

1. Skill mix and role redesign: The North West wayHelen Kilgannon & Juliette Swift 

2. Outline What is skill mix? Why change skill mix? The North West approach What is the evidence? Some North West examples of impact and benefits Lessons learned along the way & next steps

3. What is Skill Mix? - Definition !!!!!!!! Distribution of individuals/ posts/ grades/ skills - Use of individuals/ posts/ grades/ skills Would a picture of the career framework be useful here to illustrate movement up and across?Would a picture of the career framework be useful here to illustrate movement up and across?

4. What is Skill Mix? Substitution Expanding of the breadth of a job; working across professional divides or exchanging one type of worker for another. Delegation Moving tasks up / down traditional uni-professional ladders Innovation Creating new jobs via the introduction of a new type of worker Enhancement Increasing the depth of a job by extending the role or skills of a particular group of workers (Definitions taken from Classification of Changes in Skill Mix in Health Care; Sibbald et al, 2004)

6. Role redesign Professional role revision has a number of aims: To reduce the medical workload To increase capacity and extend the range of services available to patients To improve the quality of care and/or to reduce costs (The Health Foundation, 2010)

7. Drivers for changing Skill Mix Skills/staff shortages or demography Cost containment Quality Improvement Technological innovation New initiatives/policies Transforming Community services (Adapted from Buchan et al 2000) QIPP

8. QIPP � A smaller Workforce? A better approach is to look at whether or not staff are doing work that adds value. Eliminating waiting, duplication, unnecessary movement and other sources of waste is a necessary first step. NHS Confederation (2010)- Dealing with the down-turn Skill mix changes are one tool to do this� NW 12 High Impact skill mix changes

9. The North West approach SHA Workforce modernisation strategy Workforce planning Managing demand for new roles to meet local needs Multi-professional approach Evaluation, measuring benefits and impact Case studies and high impact examples of skill mix change

10. Some sources of evidence.. Sibbald et al (2004), Laurant et al (2009), The Health Foundation (2010). Formal evaluation studies in the NW Non Medical Consultants- (Gavin Daley and Mullen 2010) Advanced Practitioners Acton Shapiro 2006-2009, Holbourne 2006) Non medical Prescribing (UCLAN 2010 www.prescribingforsuccess.co.uk ) Assistant Practitioners (University of Manchester2004-2007, UCLAN 2008) NW Case studies 2008-present Other NW sources eg posters, award nominations and business cases

11. The evidence� In general, a lack of evidence on the impact of skill-mix change makes further research necessary Sibbald et al 2004 Service developments are quite some way ahead of the research-based evidence in this area Given it�s potential to improve the quality of care, role revision is a viable strategy to consider when addressing the challenges facing healthcare The Health Foundation 2010 Some NW evidence� NW evaluations of impact and process include Assistant Practitioners, Advanced Practitioners, Non Medical Consultants and Non Medical Prescribing NW evaluations show improved access, waiting times, care closer to home & positive return on investment. Also highlight the importance of organisational readiness and culture (lessons learned)

12. The evidence� Some national evidence re professional role revision, studies have considered a range of factors including clinical outcomes, patient satisfaction and cost effectiveness There is no detrimental effect of revising the roles of non-medical professionals and in some cases there is a positive effect on the quality of patient care Efficiency gains may be achieved if doctors stop providing the services that are transferred to other health professionals and instead invest their time in activities that they alone can perform Eg there was a reduction in mortality when paramedics administered pre-hospital thrombolysis Eg extended pharmacist roles reduced unnecessary drug prescriptions, resulting in cost savings

13. What is the impact? Potential Role Substitution Return On Investment (ROI) Baseline Cost of qualified registered professional Band 5 mid point �23,345 Cost of qualified Assistant Practitioner Band 4 mid point �19,495 ROI calc ROI = Basic Grade Radiographer cost- AP cost x 100 AP cost 23,345 � 19,495 x 100 = 0.20 x 100 = 20% Cost Saving 19,495

14. Assistant Practitioner example Palliative care respite team comprising of five APs who provide respite care, intensive support at end of life and crucial support to the District Nurses. assess situations, make patients comfortable to enable them to remain at home and preventing ambulance service calls. uses clinical skills to benefit patients especially at end of life when timely access to care is essential, eg check syringe drivers and catheterise patients as required without delay. Assistant Practitioner participates in training to increase awareness and improve knowledge in care homes around end of life care.

15. NW examples � non medical prescribing Survey of non-medical prescribers (628 responders) and medical practitioners (70 responders) �Non-medical prescribing has a positive impact on efficiency and effectiveness of services� 83% actively prescribing 45% had changed a medication to save costs in the last year 92% had corrected errors and reduced poly-pharmacy Medical practitioners considered that non-medical prescribers were a positive investment�

16. NW Examples � Greater Manchester Neonatal Transport Service Advanced Practitioners transport newborns requiring intensive care across GM To replace previous provision of neonatal transport by middle grade doctors Aiming for a fully AdP-led service by 2010-2015 �AdPs now undertake the majority of intensive care transfers and provide a standard of care which is at least the equal of their medical counterparts� (Consultant Neonatologist). In 2008, 30 transfers per AdP, 5 transfers per Doctor Timings and physiological measurements closely matched for babies transferred by AdPs and Doctors.

17. NW Examples - Advanced Practitioner in ENT Services AdP manages own caseload including 6 clinic sessions per week seeing new and follow-up clients Along with 2 theatre sessions per week assisting the surgeon, a role previously undertaken by junior doctors. AdP also takes part in the �on-call� rota Reduced waiting times ENT services are now meeting a 5 week target for new referrals. Prior to the AdP role, average waiting time to see the Consultant was >10weeks. Clients can now attend the AdP-led clinic within 2-3 weeks AdP sees most post-op clients which has reduced the number of appointments for the Consultant�s clinic

18. Non medical consultants �My role was brought in to facilitate redesign of the pathway for patients with musculoskeletal pathology to enhance quality and reduce waiting times. This led to the creation of the MCAS which has now been fully operational for 5 years. The MCAS is a triage and treatment service which has resulted in large scale reduction in waiting times to both orthopaedics and rheumatology and has helped achieve the 18 week referral to treatment target.� �I am currently building a team to manage the non-invasive ventilation (NIV) service, helping others participate in the physiotherapy-led clinic, and developing a new weaning service. The NIV service and physio-led clinic have enabled many patients to return to work despite needing ventilatory support, and travel safely for holidays where previously they could not.� One sponsor said ��The Tissue Viability Nurse attracts significant income from research trials -this is used to pay some of the salary costs of her team�.

19. Non medical consultants �Changes in Trust wide wound management practice leading to reduction in discomfort for patients and reduced length of stay� �Redesign existing respiratory pathways to provide better outcomes for patients and the health economy e.g. Care closer to home through oxygen therapy review with saving of over �100k, Sleep service review � streamline pathway resulted in reduced waiting time for treatment from 6months to 4 weeks�. Need for further research/audit in relation to emergency hospital admissions for children and the benefits of care closer to home. The COAU reduced emergency admission rate from 69% to 35%. (Gavin-Daley and Mullen 2010)

20. Lessons Learned Helps and hinders when changing skill mix and introducing new roles Organisational readiness & role clarity Needs analysis Leadership & board level support Mentorship and support for WBL Funding & sustainability

21. Next steps in the NW- challenges and opportunities Build on excellent work to date 12 high impact skill mix changes Outcomes and Benefits framework New provider organisations New sectors, geographical patch and staff ���������need to be brave and bold Skills networks Greater provider influence Workforce planning emphasis Clarity of employers responsibilities and networks NW Workforce Modernisation Hub Provider owned and led