1. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros MUNROS is funded by the European Commission FP7 programme, HEALTH-F3-2012-305467EC. Project co-ordinators Prof Bob Elliott, r.elliott@abdn.ac.uk and Prof Christine Bond, c.m.bond@abdn.ac.ukr.elliott@abdn.ac.ukc.m.bond@abdn.ac.uk www.abdn.ac.uk/munros Robert Elliott and Christine Bond THE MUNROS PROJECT Exploring the introduction of new professions and professional roles: examples from breast cancer Scottish Cancer Trials Breast Group Meeting, Edinburgh, January 2016

2. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Background Health care workforce has changed in response to increased demands and financial constraints New health professions and enhanced roles for established professions have been developed – potential to contribute to increased efficiency, but – workforce planning tools do not take these changes into account No systematic study to date Hypotheses to be examined – Professional mix of teams has changed – Same tasks are being undertaken by different professionals in similar settings – Changes have reduced expenditures for same outcomes – Work force planning models based on these new team configurations can be developed

3. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros High level MUNROS overview Breast cancer findings

4. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros MUNROS 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 – Develop a template for workforce planning based on competencies needed to undertake tasks not on professional numbers

5. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Conceptual Framework: health service production function

6. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Project overview Heart disease (STEMI) Breast cancer Type 2 diabetes 9 countries 12 hospitals 60 primary care settings Scotland (lead) England Norway Germany Italy Czech Rep. Poland Turkey.

7. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Today we focus on these 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

8. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Health systems and skill mix Literature Review* Structured survey of partners Case studies *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: 10.1016/j.healthpol.2015.04.00110.1016/j.healthpol.2015.04.001

9. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Health systems and skill mix Nine partner countries representative of different health care systems in Europe Confronted similar barriers to care: geography, social inequalities, financial and organisational constraints Care pathways exist to standardise care, except for Poland, Turkey, Czech Republic

10. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros New professional roles Extended roles in very specific clinical areas: o Diabetes Nurse New Technical roles deploying specific technical skills o Dialysis technician New independent profession(s)/al roles with legal autonomy and clinical responsibility doing work previously done by doctors. o Advanced nurse practitioner o Physician associate o Non–medical prescribers New dependent roles

11. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros 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

12. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros How new roles develop Physicians remain in charge: physicians distribute tasks Extended roles depend upon personal relationships built over years Professionals in new roles go beyond their scope of practice when needed

13. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Surveys Health Care Professionals Health Care Managers Patients

14. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Effects on process and outcomes of workforce change Effects on organisation and delivery of care: Health care professionals and managers surveys All the health professionals (est.360 per country per pathway) engaged along each pathway and their managers (est. 72 per country per pathway) o Identify new roles and changes in established professions roles o Who does what, and for how long? o Who decides who does what? o Perceptions of barriers to and facilitators of changing skill mix o Effects on integrated care Effects on outcomes: Patients surveys 30 patients per site per condition and same number from 1 0 Care o The patient experience: who they saw, what those people did, o Satisfaction o Health service utilisation

15. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Scottish response rates: breast cancer 11 Hospitals Health care professionals 80/17945% Health care managers 13/4330% Patients 105/25042% Primary Care Health care professionals 31/4766% Health care managers 13/13100% Patients 63/12849%

16. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Respondent professions N (%) Advanced qualification (%) Medical staff 61 (56)Consultant/Sp.34 (31)32 (94) GP23 (21)17 (74) Junior4 (4)2 (50) Nursing23 (21)Advanced4 (4)4 (100) Specialist12 (11)7 (58) General7 (6)3 (13) AHP17 (16)Radiographer15 (14)14 (93) Physiotherapy1 (1)1 (100) Psychology1 (1)missing Pharmacist6 (6)Hospital/Clinical5 (5)5 (100) Community1 (1)1 (100) Admin./ other 2 (2)Admin.1 (1)missing Other1 (1)missing

17. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Contribution (nature and scope ) of new professional roles to care

18. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Task list: care pathway StageArea of activity Task Diagnosis Imaging ultrasound Imaging mammogram Do mammogram Radiological interpretation Clinical interpretation Admin. Work eg result reporting Imaging MRI Biopsy Assessment Inform patient Carrying out surgery/managing therapy Follow up/managing complications Palliative care

19. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Summary StageArea of activity Consultants involved Adv./Sp. Nurse involved Radiographer involved Diagnosis Imaging ultrasound yny Imaging mammogram yny Imaging MRIynn Biopsyyny Assessing/ staging yny Inform patientyyn Surgery/therapySurgeryyyn Chemotherapyyyn Radiation therapy ynn Endocrineyyn Biologicalyyn

20. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Task list: who does what in diagnosis Area of activityTaskConsultants n (%)Radiographers n (%) Imaging mammogram Do mammogram2 (11)12 (92) Radiological interpretation 12 (66)5 (35) Clinical interpretation14 (77)3 (23) Administrative work11 (61)4 (30) BiopsyPatient prep.18 (60)11 (91) Take biopsy24 (80)7 (58) Pathological interpretation 5 (16)0 (0) Clinical interpretation12 (40)1 (8) Administrative work9 (30)3 (25)

21. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Changes in the roles of established professions

22. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Changes in the care pathway: Health Care Professionals’ perceptions over last five years 1 st 2 nd 3 rd

23. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Changes in staff roles: Health Care Professionals’ perceptions for last five years Percentage of respondents

24. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Barriers to and incentives for different types of skill mix

25. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros New roles: aspirations and opportunities Staff group% would like a new role % have an opportunity for a new role Doctors1712 Advanced/Specialist nurses 8060 General nurses5729 Radiographers5347 Nurses least satisfied with current role

26. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Motivating factors for undertaking new roles: advanced/specialist and general nurses

27. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Perceptions of factors affecting opportunities for undertaking new roles: health care professionals Less of an opportunity or neither: Risk management procedures, Regulation and legislation, Medical technology, Increased requirements for academic qualifications, Information technology, Workforce shortages in your profession

28. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros External factors driving skill mix changes: health care professionals

29. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros External factors driving increased skill mix: health care managers

30. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros External factors driving increased skill mix: health care managers * Professionals’ top three

31. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros External factors driving increased skill mix: health care managers * Professionals’ bottom three

32. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Patient satisfaction (1-7) Waiting time

33. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Concluding thoughts from survey Only Scottish data Evidence of change in team composition Evidence of role substitution Perceptions of drivers of change in team composition similar for health care professionals and managers – Consensus that main drivers about professional relationships, and new technologies – Regulation and policy have less influence Patients are satisfied Next steps – Explore costs and outcomes – Use data to inform a workforce planning tool

34. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Thank you Any questions? www.abdn.ac.uk/munros

35. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros 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-F3-2012-305467EC. 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.