Changing Skill Mix Is it the answer? Professor Bonnie Sibbald National Primary Care Research & Development Centre University of Manchester, England

Challenges Rising demand Rising cost Variable quality Medical workforce shortages

Expectations Changing skill mix can- Reduce demand for high cost personnel Reduce cost of care. Maintain (or increase) the quality of care

Does it Work?

Substitution Systematic review of nurse-doctor substitution in primary care First contact for urgent problems ( 5 studies) First contact and ongoing care (7 studies) Management of chronic condition (4 studies) Laurant et al. Substitution of doctors by nurses in primary care. In Cochrane Database of Systematic Reviews. April,

Patient Outcomes

Process of care & Productivity

Resource Utilisation

Cost Chambers 1977No difference Lattimer 1988Nurse cheaper Lewis 1967No difference Spitzer 1973No difference Venning 2000No difference

Conclusions Patient outcomes No difference in physical health Patient satisfaction higher for nurses Process of care No difference in quality of care Nurses tend to give more advice Resource utilisation Productivity lower for nurses Costs the same

System-level Impact Larger teams with increased role differentiation among members Associated with …  Economies of scale and scope  Higher technical quality of care  Increased speed of access

System-level Impact But has unintended effects on -  Continuity of care  Coordination of care And high capital costs associated with -  Education & training  Change management  Licensing & regulation

Policy Implications Changing skill mix is a plausible strategy for increasing workforce capacity. But beware High capital costs Reduced personal continuity of care Difficulties with care coordination