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, 2005.
.
Patient Outcomes
35
No. Outcomes
30
25
20
Doctor
Nurse
Same
15
10
5
0
Physical health
Satisfaction
Process of care & Productivity
14
No. Outcomes
12
10
8
Doctor
Nurse
Same
6
4
2
0
Quality
Consult length
Consult number
Resource Utilisation
30
No. Outcomes
25
20
Doctor
Nurse
Same
15
10
5
0
Tests
Scripts
Services
Cost
Chambers 1977
No difference
Lattimer 1988
Nurse cheaper
Lewis 1967
No difference
Spitzer 1973
No difference
Venning 2000
No 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