MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, Christine Bond and Antoinette deBont THE MUNROS PROJECT Exploring the introduction of new professions and professional roles Joint meeting of the CMO/CNO Luxembourg October 12 th 2015

MUNROS is funded by the European Commission FP7 programme Background Spending on workforce is the largest single item of health care expenditure in EU member states To contain health care expenditure and manage and increasing demands, changes to the health care workforce have been introduced in many European countries New health professions and enhanced roles for established professions have been developed New professional roles have potential to contribute to increased efficiency in service delivery Workforce planning tools do not take these changes into account No systematic study to date

MUNROS is funded by the European Commission FP7 programme High level MUNROS overview

MUNROS is funded by the European Commission FP7 programme Project Aims/Outcomes To produce a systematic description and comparison of differences in: – Contribution (nature and scope ) of new professional roles – Changes in the roles of established professions – Barriers to and incentives for different types of skill mix – Costs and benefits of different skill mixes – Effects on integration of care – Outcomes for patients due to differences in skill mix Ultimately – A template for workforce planning based on competencies needed not professional numbers

MUNROS is funded by the European Commission FP7 programme Hypotheses Skill mix in teams could be increased Increasing skill mix in teams has same outcomes Increasing skill mix is more efficient Work force planning models based on competences and different team configurations can be developed

MUNROS is funded by the European Commission FP7 programme Conceptual Framework: health service production function

MUNROS is funded by the European Commission FP7 programme Project overview Mapping health system integration, skill mix and competencies Understanding health systems Mapping skill mix Methodology and Study Design Case studies Questionnaire design Data Collection, Management and Analysis Impact on clinical practice and organisation of care Outcomes: the Patient Experience Outcomes: Process, Productivity and Clinical Effect Changes in Costs and Benefits Translation into Policy: Delivering Impact New Professional Roles and the Integration of Care Management of Human Resources and Successful Workforce Planning Scientific Structure, Policy Engagement, Impact and Dissemination Heart disease (STEMI) Breast cancer Type 2 diabetes 9 countries 12 hospitals 60 primary care settings

MUNROS is funded by the European Commission FP7 programme Current status

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, What is known? Policy reports and routine data

MUNROS is funded by the European Commission FP7 programme Europe wide review of health systems Nine partner countries representative of different health care systems Universal health care coverage in all except Turkey, but barriers to care remain: geography, social inequalities, financial, organisational Quality of care important but no standard definition Performance management used in all countries; waiting time common to 8/9 Care pathways a common way to standardise care except for Poland, Turkey, Czech Republic Integrated care the ideal but barriers reported; no single model

MUNROS is funded by the European Commission FP7 programme New professional roles in new health care services – Advanced roles. – Case manager in a very specific clinical area: – Extended roles. – Diabetes Nurse in specific technical skills – Technical roles. – Dialysis technician New independent profession(s)/al roles with legal autonomy and clinical responsibility to work that used to be done by doctors. – Advanced nurse practitioner – Physician assistant – Non–medical prescribers New dependent roles

MUNROS is funded by the European Commission FP7 programme New professional roles in partner countries – New independent professions in Netherlands, England and Scotland – Extended roles and new technical roles (dependent roles) in Germany, Italy, the Czech Republic and Turkey – Very few new professions/ professional roles in Norway and Poland

MUNROS is funded by the European Commission FP7 programme Outcomes of new professional roles: a systematic review 1048 studies identified; 41 evaluation studies included – Specialist nurses (SNs:) and advanced nurse practitioners (ANPs) – Specialist nurses 3/3 improved health care utilisation 5/6 improved patient information 4/6 improved patient satisfaction – Advanced nurses 5/5 improved clinical outcome 3/4 improved patient information 5/8 improved patient satisfaction Tsiachristas, A., Wallenburg, I., Bond, C.M., Elliott, R.F., Busse, R., van Exel, J., Rutten-van Molken, M.P., de Bont, A., the MUNROS team Costs and effects of new professional roles: Evidence from a literature review Health Policy 2015 doi: /j.healthpol /j.healthpol

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, What do we learn by observing practice?

MUNROS is funded by the European Commission FP7 programme The Case studies

MUNROS is funded by the European Commission FP7 programme Case studies Guiding questions – What are the extended roles of health care professionals? – How are extended professional roles created? – What are the main drivers that explain the observed differences, if any, in the extended roles within and between countries?

MUNROS is funded by the European Commission FP7 programme Selection of the care pathways Care is delivered by various caregivers – Advanced roles in at least two countries – Extended roles in at least two countries Selected disease has high burden to society Routine data on outcomes available Heart disease (STEMI), Breast Cancer, Type 2 Diabetes

MUNROS is funded by the European Commission FP7 programme Data collected We conducted 16 case studies in 8 countries We conducted in-depth semi-structured interviews with physicians, nurses, technicians and managers (n=160) We observed the health care professionals at work (620 hours)

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, What are the extended roles of health care professionals?

MUNROS is funded by the European Commission FP7 programme Independent advanced roles ‘The next patient enters the consultation room, together with her husband. (..)The woman tells that she suffered from an awful headache last time, and has been crying for the last 24 hours. She can’t take it anymore. The nurse practitioner thinks it was caused by the Neulasta [a medicine that can be administered during chemotherapy to strengthen the immune system]. She suggests to quit the drug: It’s your last course today’. (Field notes Netherlands)

MUNROS is funded by the European Commission FP7 programme Independent advanced roles ‘The patient asks about the risk of not taking it. The nurse practitioner answers that she has only a small risk of getting an infection. The patient has had a throat infection before. “The GP didn’t want to give me anything to alleviate the pain”. The nurse practitioner says that she shouldn’t call the GP: you need to call us! Anytime! Do you have the number? Or ask your GP to contact the hospital. There is always someone around’. (Field notes hospital Netherlands)

MUNROS is funded by the European Commission FP7 programme Dependent technical roles “There is a requirement that the equipment has to be serviced by a technician. (…) We all had radiology training and got certificated valid for five years”(Technician, Poland). ‘One of the important conditions for the correct radiation treatment is the positioning (fixation) of the patient to ensure a precise, stable and easily reproducible position.. The RA performs a CT scan, including a series of transverse CT cuts that provide information about the placement of the tumour deposit and the density of tissues’ (Field notes Czech Republic).

MUNROS is funded by the European Commission FP7 programme Overview of roles

MUNROS is funded by the European Commission FP7 programme Over view of countries

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, How are extended professional roles created?

MUNROS is funded by the European Commission FP7 programme How new roles develop - the literature- By claiming exclusive authority over tasks and competencies – Claims for exclusive knowledge (Freidson, 2001 – Discard the ‘dirty work’ (Hughes, 1962) – Set a legal scope of practice (Abbott 1988) – Claims change in competition with other professions (Abbott)

MUNROS is funded by the European Commission FP7 programme How new roles develop - the literature- Technologies reshape the roles of professionals (Martin 2009) – Knowledge is no longer exclusive Managerial reforms reshape relations between professions and organizations (Noordegraaf 2011) – Organizing is key to professional development (Muzio 2011) – Standardization and accountability is key to professional development (Evetts 2011)

MUNROS is funded by the European Commission FP7 programme How new roles develop -case studies- Physicians distribute tasks Extended roles depend upon personal relationships built over years “I started here in ’95. I had been working here for 10 years already when someone asked me if I wanted to do more within my scope of practice. They offered me a position as PA” (Physician Assistant Netherlands)

MUNROS is funded by the European Commission FP7 programme How new roles develop -case studies- Physicians define a local or individual scope of practice The legally defined scope of practice does not make a difference “It is up to the cardiologist that implants a device how much I can do during surgeries. The cardiologists differ in what they leave up to me (…)” Physician Assistant Netherlands.

MUNROS is funded by the European Commission FP7 programme How new roles develop -case studies- Professionals in new roles are not allowed to carry out tasks that are legally assigned to them Professionals in new roles go beyond their scope of practice when needed to ‘keep things going’ At the wards, they [physician assistants ] may take bloods, they have a kind of a bigger, broader remit and really, their roles are quite flexible. It’s really what the service needs. In places they’d go in and act as an assistant in surgery. They are roles in their own right but they go across quite a wide range, from wards to theatres to clinics (Manager Scotland)

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, What are the main drivers that explain the observed differences, if any, in the extended roles within and between countries?

MUNROS is funded by the European Commission FP7 programme Two directions Specialization: – an increasing level of expertise in a specific disciplinary area that is adopted by a select group of the profession and which is legitimised through use of a specific title and generally involves specific training (Nancarrow 2005) – depends on the ability of the professional group to delegate certain aspects of their work to other providers (Hughes, 1962, Allen, 1982)

MUNROS is funded by the European Commission FP7 programme Two directions Generic roles: – professionals are increasingly becoming connected to organizations, and are transformed by them(Noordergraaf 2014) – professionals take organizing and managing into the core of their work and claim organizational capacities to mark their role (Muzio 2012)

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, Integrated care Co-ordination of care delivery to a patient with new general professional roles within a care organization (e.g. expansion of services) and/or between care organizations (e.g. primary and secondary care) Traditional care delivery with one specialist within a care organization responsible for the care delivery to a patient, supported by general nursing, technical and/or administrative staff Physician-centred care Multiple specialists within a care organization involved in care delivery to a patient, simultaneously and/or consecutively, based on the required expertise, supported by specialized nursing, technical and/or administrative staff Expertise-centred care Generic roles Improve quality of care / patient outcomes  Increase share in health services Specialized roles Development medical technology Development information technology

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, Can we generalize the findings of the case studies?

MUNROS is funded by the European Commission FP7 programme The surveys

MUNROS is funded by the European Commission FP7 programme Effects on process and outcomes of workforce change Setting (per country) Three conditions, 12 hospitals, 60 primary care settings Effects on practice and organisation Health care professional and manager surveys: Understanding the impact on clinical practice and the organisation of care Effects on outcomes Patient surveys: The patient experience Routine data: Process and productivity indicators and clinical effect

MUNROS is funded by the European Commission FP7 programme Health care professional and manager survey – All the health professionals (est.1260 per country) engaged along each pathway and their managers (est. 540 per country) – To describe and contrast in each partner country – New roles and changes in established profession roles o Who does what o Who makes the decisions – Perceptions of barriers to and facilitators of skill mix – Effects on integrated care

MUNROS is funded by the European Commission FP7 programme Perceptions of barriers and facilitators for skill mix change

MUNROS is funded by the European Commission FP7 programme Changes in the care pathway: Health Care Professional perceptions

MUNROS is funded by the European Commission FP7 programme Changes in staff roles: Health Care Professional perceptions

MUNROS is funded by the European Commission FP7 programme Motivating factors for undertaking new roles: health care professionals 50% would like to have a new role; 58% have no opportunity for a new role

MUNROS is funded by the European Commission FP7 programme Perceptions of factors affecting opportunities for undertaking new roles: health care professionals

MUNROS is funded by the European Commission FP7 programme External factors driving skill mix changes: health care professionals

MUNROS is funded by the European Commission FP7 programme Health care managers influences on decision making

MUNROS is funded by the European Commission FP7 programme Factors influencing increased skill mix in teams: health care managers

MUNROS is funded by the European Commission FP7 programme External factors driving increased skill mix: health care managers

MUNROS is funded by the European Commission FP7 programme External factors driving staff mix changes Professionals top 3: 1.Shifting influences within health care professional groups whereby e.g. nurses have gained more influence 2.Redesign of health services 3.New technology for managing diseases Managers top 3: 1.Redesign of health services 2.Need for audit trail 3.Shifting influences within health care professional groups

MUNROS is funded by the European Commission FP7 programme External factors driving staff mix changes Professionals bottom 3: 1.Payment systems for health care professionals 2.Workforce policies such as European Working Time Directives. 3.New legal rights for professionals Managers bottom 3: 1.Workforce policies such as European Working Time Directives. 2.Payment systems for health care professionals 3.New legal rights for professionals

MUNROS is funded by the European Commission FP7 programme The patient perspective

MUNROS is funded by the European Commission FP7 programme Patient survey

MUNROS is funded by the European Commission FP7 programme Patient survey Questionnaires to patients within each pathway, within selected hospitals/primary care to understand their experiences (n=2160). To investigate the impact of the new professional roles on patient experience – who they saw – who did what – experience of care – health service utilisation Patient outcomes – satisfaction, Discrete Choice Experiment (DCE) – Quality of Life: EQ-5D-5L index

MUNROS is funded by the European Commission FP7 programme Who patients saw At hospital out-patientAt GP visit

MUNROS is funded by the European Commission FP7 programme Experiences of care

MUNROS is funded by the European Commission FP7 programme Experiences of care

MUNROS is funded by the European Commission FP7 programme Patient satisfaction (1-7)

MUNROS is funded by the European Commission FP7 programme Perceptions of care

MUNROS is funded by the European Commission FP7 programme Concluding thoughts from survey Preliminary data, only from Scotland Small differences between the health care professionals and health care managers. – Drivers are more about local practice and professional relationships not regulations and policies? Patients are satisfied – Many unclear who is providing care and unaware of changes – Experience of care suggests it is not ‘patient centred’ – Doctor is still seen as ‘main’ provider – Care feels integrated Final data set will allow analysis between care pathways (within hospitals), within countries (between hospitals) and between countries.

MUNROS is funded by the European Commission FP7 programme Bringing it all together

MUNROS is funded by the European Commission FP7 programme Bringing it all together Driver to skill mixPoliciesCase studiesSurveys Workforce polices+-- Payment systems+-- Technological advance +++ Professional authority +-+ New approaches to care +++ Academic training+?- New profession+?-

MUNROS is funded by the European Commission FP7 programme Where do we stand? Revisiting the hypotheses Skill mix in teams could be increased – Skill mix has increased in the last five years Increasing skill mix in teams has same outcomes – Still to be confirmed but many similarities between countries despite differences in regulations. Increasing skill mix is more efficient – Not yet confirmed but Increasing skill mix is more supportive to the staff Increasing skill mix is well coordinated Work force planning models based on different team configurations can be developed – Skill and competencies matter in planning

MUNROS is funded by the European Commission FP7 programme Discussion Do we need new professions to enhance the quality of care? – Regulation for advanced roles has little impact – New roles do less than they are allowed to do Is there an alternative to professionalization of nurses and other non-medical health care professionals ? – New technologies – Service redesign

MUNROS is funded by the European Commission FP7 programme Next steps Confirm patient outcomes using routine data Measure changes in costs and benefits Identify optimal models of care (skill mix and integration) Develop work force planning tool

MUNROS is funded by the European Commission FP7 programme Patient outcomes Assess the impact of the new professional roles Clinical and process outcomes Productivity in secondary care settings Hospital processes (eg length of stay), productivity (eg patient turnover), outcomes (eg 30 day mortality), patient safety outcomes (eg hospital acquired infections) Data extraction at national, hospital and patient level

MUNROS is funded by the European Commission FP7 programme Measure changes in costs and benefits Distinguish whether changing skill mix within teams delivering health services has or might result in cost containment Undertake an economic evaluation to model the costs and effects associated with changing skill mix Investigate the balance of cost and benefits and to identify incentives for changing skill mix

MUNROS is funded by the European Commission FP7 programme New professional roles and the integration of care Objectives Integrate the findings of the previous work packages Describe the existing patterns of health care in the participating countries and how skill mix change might be employed to improve the integration of care within care paths Develop optimal models of integrated care in terms of improved patient outcomes and cost effectiveness of care Identify critical elements of these optimal models and solutions to barriers at organisational and care team level informed by examples of good practice, and the associated costs

MUNROS is funded by the European Commission FP7 programme Management of human resources and successful workforce planning Develop a workforce planning tool – Multiprofessional not uniprofessional – Based on what needs to be done Projected disease prevalence and health care need Tasks needed to provide care to a patient with a particular disease Information on which professional can deliver those tasks effectively

MUNROS is funded by the European Commission FP7 programme Acknowledgements We thank o European Commission for funding this research programme ‘Health Care Reform: The iMpact on practice, oUtcomes and cost of New ROles for health profeSsionals (MUNROS), under the European Community’s Seventh Framework Programme (FP7 HEALTH-2012-INNOVATION-1) grant agreement number HEALTH-F EC. o All those who supported and guided this work both within the MUNROS research project team and as external associates. o All the MUNROS research and project partners for their continuing collaboration in this research.

MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, Thank you

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme Extra slides follow

MUNROS is funded by the European Commission FP7 programme WP 4 develops questionnaires for WP5, for Health Care Professionals and Managers Demography (age, qualification, location, role) Organisation of care along the care pathways Professions involved Tasks undertaken by each profession Time taken to complete tasks Frequency with which undertake tasks Perceptions of facilitators and barriers to changing skill mix

MUNROS is funded by the European Commission FP7 programme WP 4: develops questionnaires for WP6 for Patients Demography, co-morbidities and EQ5D Position on the care pathway Tasks performed by different professionals Perceived degree of integration between primary and secondary care Experience and satisfaction with their care and the outcomes of care Costs of accessing services; travel time and other direct and indirect costs

MUNROS is funded by the European Commission FP7 programme The MUNROS Approach

MUNROS is funded by the European Commission FP7 programme Measuring Skill Mix

MUNROS is funded by the European Commission FP7 programme Workforce Planning Above allows us to identify those tasks which are done by more than one type of professional: those tasks where substitution possible And to identify the different skill mixes, combinations of health professionals, that could be used to produce a given level of output along each pathway. When combined with cost data it allows us to identify: o the least cost skill mix that could produce a given level of output. Or o the highest level of output that can be produced for a given level of costs (and skill mix) Independently we try to estimate the population need for the procedure - combining an estimate of the prevalence of the disease resulting in this procedure with population size. The above enables us to identify the different skill mixes that might be used to meet population need for procedure

MUNROS is funded by the European Commission FP7 programme The integration of the care pathway

MUNROS is funded by the European Commission FP7 programme Perceptions of integration

MUNROS is funded by the European Commission FP7 programme Specialisation of care: health care professionals

MUNROS is funded by the European Commission FP7 programme Specialisation of care: health care managers