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 longer consultations Evidence has compared mainly minor illness

5. 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

6. 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

7. 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

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. Nurse Practitioner Prescribes from formulary 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

14. 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

15. 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 indirectly Supervised administer medication via PGDs Training to diagnose from list of common presentations

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. 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

19. Reliability

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

22. CourseCourse LengthCompetency Time Minor Illness Course3 Days3 Months Physical Assessment Skills5 Days6 Months Independent Prescribing6 Months Full Nurse Practitioner Degree 24 Months

23. 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

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

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

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

27. 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

28. Skill Mix Review

29. 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

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

31. 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

32. 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

33. Triage Performance Outcomes

34. Consultation Times Admissions Rate

35. Consultation Times Admissions Rate GP vs NP

36. Evaluation Minor 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)

37. Evaluation NP 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

38. 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.

39. 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

40. 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

41. 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

42. 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.

43. 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

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