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)

• Same day consultations – no differences in outcomes. (Kinnersley et al 2000)

Evidence from Literature

• Patients seeing Nurse Practitioners – are more satisfied

• Nurse Practitioners offer longer consultations• Evidence has compared mainly minor illness

International Models

• 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

• 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

United Kingdom

• 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

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

What is the ideal Model

• Nobody Knows………………………• Systems in place• Processes• Standard Procedures• Performance Reporting• Clinical Governance• Training Programmes

Primary Care Foundation

• Swift Response• Highly trained staff• Streaming patients• Local bases• Skilled mixed professionals• Effective Advice and treatment

Activities

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

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

Nurse Practitioner

Prescribes fromformulary

and can use PGD’s

Nurse Practitioner

Can assess all patients via telephone or face to face

Diagnoses

Can treat and

complete around 90%

of cases

Orders investigations

Provides treatment

Refers

Minor iIlness Nurse/ECP

Can initiate some treatment

Reports to Nurse Practitioner or

GP

Assesses a range of common conditions

via telephone or face to face

Unable to prescribe

Can not produce prescriptions for signing

Can complete 50% of cases Minor Illness Nurse

ECP

Can administer medication via

PGDs

Diagnoses from list of common presentations

Trainee Minor Illness Nurse/Paramedic

Directly and then indirectly

Supervised Can initiate some treatment

Reports to Nurse Practitioner or

GP

Directly and then indirectly

Supervised to Assesses a range of common conditions via telephone or face to face

Unable to prescribe

Can not produce prescriptions for signing

Working towards completion of 50%

of cases before able to work as

Minor Illness Nurse Trainee Minor Illness Nurse

Directly and then indirectlySupervised administer medication via PGDs

Training to diagnose from list of common

presentations

PROJECTS

• Review of Consultations and analysis of competencies

• Review of Consultations re completion rates

• Audit – comparing Nurse's GP,s NP’s

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

EXCLUSIONS

• 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

Reliability

Clinician 1 and 2 Comparison

0

20

40

60

80

100

120

A B C D E F

Grade

Cons

ulta

tion

Clinician 1

Clinician 2

Concentric Model of Competencies Standards Within Competence Increasing from A-F

E/F DC B A

Domain 2Clinician-Patient Relationship

Domain 3 Assessment of patient health/illness

Domain 4

Case Management and monitoring the quality of health care practice Domain 1

Professional and Ethical Practice

Degree NP with Prescribing

Basic N/P Experienced Nurse

PrescriberECP

HCA Paramedic

Junior NurseHCA

GP

Graph To Show Average Competency Development Over a Two Year Period

Nurse Practitoner

HCA Paramedic

Minor Illness Nurse

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0 3 6 9 12 15 18 21 24

Time (Months)

Co

mp

etan

cies

Independent Perscriber

Course Course Length Competency Time

Minor Illness Course 3 Days 3 Months

Physical Assessment Skills 5 Days 6 Months

Independent Prescribing 6 Months 6 Months

Full Nurse Practitioner Degree

24 Months 24 Months

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

Analysis of 100 consultations

HCA Paramedic

12%

88%

Completion Rates of non-medical Clinicians

Minor Illness Nurse/ ECP

52%48%

Analysis of 100 consultations

Completion Rates of non-medical Clinicians

Analysis of 100 consultations

Completion Rates of non-medical Clinicians

Nurse Practitioner

83%

17%

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

Skill Mix Review

Skill Mix Review of Consultation

0

2

4

6

8

10

12

14

16

A B C D E F

Grade

Co

nsu

ltatio

n

Mid Week Evening

Saturday AM

Sunday PM

Results• 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

Audit

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

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

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

Triage Performance Outcomes

Average Outcomes

0

10

20

30

40

50

60

Triage Advice % 54.00 56.83 53.40

Triage BV % 33.13 32.33 36.00

Triage HV % 12.63 11.00 10.30

N/P Nurses GP

Consultation Times Admissions Rate

Performance (Average)

0

2

4

6

8

10

12

14

16

Triage Times 5.77 7.52 5.60

BV Times 12.87 15.22 10.39

Admissions Rate % 1.80 0.52 1.59

N/P Nurses GP

Consultation Times

Admissions Rate GP vs NPPerformance (Average)

0

2

4

6

8

10

12

14

Triage Times 5.77 5.60

BV Times 12.87 10.39

Admissions Rate % 1.80 1.59

N/P GP

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)

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

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.

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

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

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

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.

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

THANKYOU

Contact DetailsSally GardnerNurse Consultant Take Care NowTelephone – 01473 299531

• Email – sally.gardner@takecarenow.co.uk