12

A national evaluation of the clinical and cost effectiveness of Emergency Care Practitioners

Phase two

Final Report

Suzanne Mason, Colin O’Keeffe, Pat Coleman, Richard Edlin, Jon Nicholl

Medical Care Research Unit School of Health and Related Research

University of Sheffield

September 2005

13

Acknowledgements

The authors would like to thank all the participants for their willingness to help in this research by identifying methods for recruiting patients, the recruitment of patient participants and for taking part in interviews. Clive Francis provided administrative support and Kathryn Paulucy and Margaret Flower assisted in transcribing interviews. The MCRU is supported by the Department of Health and the research was developed in association with the NHS Modernisation Agency, who also provided funding for the study. The views expressed are however, those of the authors alone.

©2005 Medical Care Research Unit (MCRU), University of Sheffield

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CONTENTS PAGES

Executive Summary i 1.0 Introduction 1 1.1 Background 1

1.2 Research aims 2

1.3 Objectives 2

2.0 Methods 3 2.1 Controlled observational study 3

2.2 Telephone interviews 6

2.3 Economic study 6

3.0 Data Analysis 10 3.1 Controlled observational study 10

3.2 Telephone interviews 10

3.3 Economic Study 10

4.0 Results 11 4.1 Controlled observational study 11

4.2 Telephone interviews 22

4.3 Economic study 25

5.0 Discussion 28 6.0 Recommendations 33 7.0 References 34

i

EXECUTIVE SUMMARY

This research represents the second phase of a national evaluation of ECPs. The work

builds on that already completed in phase one1 and provides a more in depth account of the

impact of the ECP role on the practitioners and on other health care services.

Methods

Using a mixed-methodology approach we concentrated on three ECP schemes, services 2

and 3 serving predominantly rural areas and service 1 serving an urban population. The

sites were selected purposively for their different models of ECP schemes. At the time of the

study, the number of operational ECPs in the three sites ranged from 7 in service 3, to 33 in

service 2. In the two rural sites, the ECPs were based with other health professionals, in

health care provider settings across the whole of the Trust area. In the area covered by

service 1, the ECPs were operating as independent mobile units in a city within the wider

area covered by the Trust.

In each site, we conducted a controlled observational study of ECP health care compared

with existing emergency service provision. Patients were recruited to the study. We used

several quantitative tools and qualitative techniques to measure patient satisfaction with the

care, acceptability to the patient; safety; subsequent health status and health and social care

use. We also sought to identify criteria of efficiency and effectiveness to measure ECP

services and their impact on primary and secondary care provision. The main surveys were

supplemented by telephone interviews with selected personnel involved in the delivery of

care as ECPs or whose own roles, as clinicians and/or managers were affected by the

service. We also carried out a costing analysis.

Results

Overall the achieved sample was 27 ECPs, 524 patients and 16 interviewees (consisting of

ECPs, other health professionals and stakeholders). The indications are that the models of

ECP care evaluated are providing a safe and effective alternative to urgent and unscheduled

care for patients whose health problem is suitable to be attended by an ECP. Patient

satisfaction with the care received was consistently higher in patients receiving ECP care

than the patients in each of the control groups who received the usual care, although this

result may be influenced by selection bias in how patients were recruited.

Patients seen by an ECP had significantly fewer investigations performed, and more

treatments (including advice) documented than the control group. These patients were

significantly more likely to be discharged to their own place of residence without referral on

to another service. They were also much less likely to require transfer to the emergency

department or for hospital admission. Overall there were no differences found between the

ii

ECP and control group of patients in relation to their reported subsequent use of health

services at 28 days.

Data for the costings analysis were only available in the 999 service, and these data were

quite limited. Based on these limitations, the indications are that the model of ECP service in

that area is cost effective. However the validity of this finding and its generalisability to other

models of ECP care, needs to be confirmed through a larger study.

The ECPs regarded the initiative as enhancing their career options and retaining trained

paramedics and nurses within the NHS, and welcomed the new challenges. Managerially,

the initiative was seen as having a positive effect on other staff such as ambulance

technicians and paramedics who benefited from some of the modules on the ECP course.

Conclusion

In the areas studied, the ECP initiative is moving forward safely and effectively. ECPs were

becoming accepted by other health professionals and patients were satisfied with the service

received. Patients eligible to be seen by an ECP benefit in having fewer investigations, more

treatment and are less likely to be referred on to other services.

There is clear commitment at all levels of involvement to operational success. Some brakes

on development were evident and efforts were focussed in each of the study sites as to how

these might be overcome. However, on all three sites, as the role became more established,

there are signs that professional boundaries are being reconfigured to accommodate the

ECP into the local health care team.

The crucial elements to facilitate future expansion and sustainablility of the role are:

• good leadership,

• political will in the form of effective partnerships between the constituent health

provider organisations, managerially and clinically, committed to changing traditional

ways of working;

• sufficient numbers of trained ECPs, and selection of the most suitable candidates,

• continuing professional development to maximise the utility of the role;

• improved communication and information between ECPs and their host

organisations and other health care providers to promote mutual respect and

understanding of the potential of the ECP to contribute fully to the local health

economy.

• ‘core skills’ and competence to ensure comparability between practitioners

irrespective of previous experience and health service background, and

transferability between areas.

• adequate supervision and support to smooth transition from one setting to another.

ii

1

1.0 INTRODUCTION

1.1 Background

A key strategy to meet the increasing demands for health care in a flexible patient-centred

way is to extend the existing clinical skills of health service staff and develop new ways of

working to maximise the effective use of resources, and improve the efficiency of how health

services are delivered. These challenges are especially present in the area of urgent health

care where a demand-driven service has to be responsive to a fluctuating and increasing

workload whilst ensuring safe, effective and efficient delivery of care in a high profile service.

The background and principal literature relating to the modernisation of the emergency

health services in the UK is contained in the report of phase one of this evaluation1.

An important feature to arise out of the reconfiguration of emergency care, for example,

Minor Injury Units (MIU), Walk-in Centres (WIC) and NHS Direct and changing workforce

initiatives, such as nurse practitioner2 and paramedic practitioner

3, is a significantly

enhanced role for the ambulance service. A recently published report containing the vision

of the ambulance service nationally4 includes “to provide and co-ordinate increasing range of

mobile healthcare for patients who need urgent care” ibid.p17

and “to provide an increasing

range of other services e.g. in primary care, diagnostics and health promotion”ibid.p21

. A key

strategy in realising these goals is the development of the Emergency Care Practitioner

(ECP)5. The ECP is a generic practitioner with extended clinical skills able to respond

flexibly to urgent and non-urgent health care needs in primary care settings or the

community. Working across traditional organisational boundaries, the ECP will work

independently and/or alongside other health care providers in a team-based approach, to

carry out initial assessments and either advise, treat or refer the patient to the most

appropriate care pathway.

This research is the second phase of a national evaluation of ECPs. The work builds on the

initial results reported in phase one1 and examines the impact of the ECP role on the

practitioners through the initial development and implementation, the acceptability of ECP

care to patients, patient satisfaction, appropriateness and safety, and the impact of the ECP

role on the NHS health economy.

2

1.2 Research aims

• To describe the extent to which the ECP role contributed to safe and effective

alternative emergency and urgent care provision in England.

• To share learning to inform the future development and operational context of the

role based on early experiences.

• To identify opportunities and barriers to inform the further development of the role

through a series of interviews held with ECPs and other health care professionals.

• To describe the methodologies applied and tools used to evaluate the ECP role and

its impact to inform future evaluations of such roles in terms of validating appropriate

methodologies for such work.

1.3 Objectives

• To undertake a controlled observational study of up to 4 selected ECP schemes

compared with previously existing emergency service models to evaluate

o Patient satisfaction and acceptability.

o Subsequent health status and health and social care use.

o Appropriateness and safety of care provided.

o Criteria that identify efficiency and effectiveness measures of the current

ECP services and their impact on primary and secondary care provision.

• To describe the attitudes of the ECPs and other health care professionals to the

ECP schemes.

• To undertake an economic evaluation of the ECP schemes.

• To make recommendations for the future development of the role in the light of the

findings from both phases of this study.

3

2.0 METHODS

This study was in 3 parts:

i) A controlled observational study using quantitative methods involving a patient survey of

experiences with the service received following an acute medical event and analysis of

patient routine emergency clinical records.

ii) A series of qualitative telephone interviews with ECPs, other health care professionals

and local key stakeholders in the ECP schemes.

iii) An economic evaluation of the Emergency Care Practitioner schemes.

Setting

The evaluation proceeded in three sites with operational ECP schemes. The sites were

chosen to reflect variation in ECP provision between urban and rural sites and also to allow

comparison of ECP schemes with different operational frameworks working across a variety

of health settings. A fourth site had been selected to evaluate ECPs in the 999 setting.

However during our study the majority of ECPs in this service were required to provide cover

for general practitioners in the out of hours setting. No evaluation was possible in this setting

as ECPs provided 100% cover of patients and therefore no control group was available.

Ethical Committee Approval

The study was subject to MREC approval which was obtained in December 2004 (reference

04/Q1407/281). Following this, research governance approval was obtained in all cases

except for a Hospitals Trust in service 2 where the delay in granting approval for the study to

proceed in their ED exceeded the time period available for data collection such that the study

did not proceed in that setting.

2.1 Controlled observational study

The controlled observational study consisted of a patient survey of experiences with the

service received following an acute medical event and analysis of routine emergency clinical

records. The design was used to assess the acceptability of the service, satisfaction with

service, subsequent health status, health service use and appropriateness and safety of care

for patients seeing ECPs compared with standard emergency services. This was a

pragmatic observational study of different models of ECP care in three sites, which was

designed to be an evaluation of the model of ECP practice which was currently in operation

in that site.

4

Service 1

There were 24 ECPs employed in service 1 at the time of the study operating between 08.00

and 02.00 as a 999 response for eligible patients (identified by an ECP in the ambulance

control room) and also working as an alternative out of hours primary care response.

Nineteen ECPs working in the emergency 999 setting recruited patients to our study. These

ECP patient episodes were compared with standard ambulance response episodes.

Professional background, clinical experience prior to training as ECPs, information about

training, on-going supervision, professional development. N came from a paramedic

background, with experience ranging from n years to n years. N ECPs came from a nursing

background with experience in A&E nursing ranging from n years to n years. In addition of

those with a paramedic background, seven worked for two years as paramedic practitioners.

This was a role similar to ECPs except with a clinical remit restricted to older people and

minor trauma. Clinical supervision and support in Sheffield is provided through a variety of

mechanisms. An ECP Clinical Lead exists (a general practitioner by training) who provides

advice and support. ECps are also able to seek support and advice in the setting they work

in. For example, those who are working in the pre-hospital setting can access support from

A&E doctors. Also newly qualified ECPs spend two months working alongside more

experienced ECPs or until they feel confident to work on their own. Continuing professional

development sessions are held for ECPs once a month by the Clinical Lead, the content of

which is decided by any interests or concerns the ECPs have.

Service 2

At the time of the study the 33 ECPs in service 2 were fully operational in the out of hours

(OOH) primary care setting in the county. They were also operational as part of the 999

service, although they were not able to utilise ECP prescribing protocols in this setting. We

evaluated fully operational ECPs as they worked in the out of hours setting. The ECPs are

based in the out of hours primary care centres in the region alongside general practitioners

and other staff. They were operational between 18.30 and 08.00 hours Monday – Friday

and all day Saturday and Sunday. The evaluation was limited to five ECPs recruited patients

for our study as they saw eligible patients at the out of hours centre, triaged patients over the

telephone and carried out home visits where appropriate. Control general practitioners

recruited patients seen in the same settings.

Service 3

At the time of the study service 3 employed 7 ECPs in three health service settings. All 7 are

employed as part of the ambulance service 999 response, 4 within an Emergency

Department (ED) of a hospital and 3 in a Walk-in Centre (WIC). For our study we evaluated

all 3 ECPs working in the WIC, one of whom had a nursing background and two with a

paramedic background. The control group for the study were patients seen by general

5

practitioners and primary care nurses. The ECPs worked alongside the control professionals

in the WIC, seeing patients within their practice remit exclusively as they presented.

Sample size

The observational study was an exploratory design to examine the implications of ECPs for

patients, professionals and services. There was no primary outcome by which the ‘success’

of the new role could be determined. Rather a multi-dimensional assessment using several

quantitative indicators and patient satisfaction assessments was used. In order to detect any

major changes in satisfaction, time to completion of care or EQ-5D scores, we aimed to

collect information on n=200 intervention and n=200 control patients in total across the

participating sites to give >90% power to detect effect sizes of 0.33SD. It was assumed that

an ECP saw on average around 5 patients per 12-hour shift. Therefore a total of 480 hours

working time would need to be studies to recruit the target. Based on each ECP working a

40-hour week, and assuming that 2 ECPs were on duty per shift led to an estimated 6 week

period of recruitment

Inclusion and exclusion criteria

Intervention

People with a health problem that met the ECP remit in each of the study sites and who were

assessed and treated by an ECP, were eligible for participation. Patients were excluded if

they were unwilling to consent to the study. All calls attended by an ECP whilst the service

was available were eligible for inclusion.

Control

Patients who required emergency assessment and accessed the service via the same route

with a complaint which met the remit of the Emergency Care Practitioners but who did not

see an ECP either because they were ‘busy’ seeing other patients or because they were not

on duty were eligible for recruitment into this part of the study. Patients were excluded if they

were unwilling to consent to the study.

Patient identification and recruitment

Patients were recruited between March and May 2005. In every site staff working in the

sites (mainly ECPs) advised on a suitable method of identifying eligible patients for us. In all

sites, successful recruitment depended on staff on duty asking patients to agree to being

contacted. Eligible patients were initially asked by the ECPs/control practitioners if they

would agree to being contacted by the University of Sheffield. If the patients agreed then the

he/she was sent a consent form, information leaflet and questionnaire directly from the

university with a reply-paid envelope to return information to us. Those patients returning a

consent form and questionnaire were included for the whole of the observational study, while

those refusing were recruited for the analysis of clinical records only.

6

In Service 1 the call-control room is staffed by an ECP who screens calls that would be

eligible to be seen by an ECP. In addition, paramedics may refer cases that they have

attended that they subsequently consider to be eligible to be seen by an ECP, back to ECPs.

In Service 2 calls are received by a central call centre, and allocated to one of five out-of-

hours bases in the locality. [more details…].

In Service 3, patients attend a walk-in centre [how are patients suitable to be attended by an

ECP prioritised/allocated? – more details…]

Information recorded

Eligible patients agreeing to be contacted were sent two questionnaires. The first 3 – 5 days

after the episode for which they were recruited to the study. This collected information on

treatment received and satisfaction with the service (ECP or other health professional) and

documented health status using the EQ-5D (a well validated method of measuring health

status)6. A 28-day follow up questionnaire was sent out to identify all subsequent health and

social care contacts relating to the initial episode and documented health status again with

the EQ-5D. Routine clinical data from patient records was also collected to monitor

presenting complaint, the disposal of the patient after contact with the ECP or other health

professional, diagnosis given and treatments received.

2.2 Telephone interviews

With signed consent from each participant, a series of telephone interviews was undertaken

with a sample of personnel in three broad staffing groups in all three participating sites. The

aim of the interviews was to add context and meaning to the results of the controlled

observational study, and enhance understanding of the direction in which different models of

ECP care are developing.

To elicit the experiences of health care providers and managers involved or affected by the

ECP initiative, the interviewees were recruited purposively from:

i) ECPs

ii) Other Health Professionals, and

iii) Stakeholders

Except one, all the interviews were conducted by the same interviewer (PC), using a semi-

structured interview schedule. The schedule was amended appropriately to capture the

different experiences of the availability of ECPs by respective staffing groups to which the

interviewee belonged. The interviews were tape recorded, transcribed and analysed in line

7

with the principles of framework analysis for applied qualitative data7. Validation was

achieved by ‘triangulation’ whereby the different perspectives of ECP working contributed by

the interviewees working in different roles within and across health care settings were

examined for consistency or divergence.

2.3 Economic study

Resource use for ECPs fall into four major categories: 1) health professional time at first

contact, 2) consumables used at first contact, 3) ED usage and hospital admissions, and 4)

subsequent contact with the health service. Patient recorded data at 28 days provided

details of subsequent contact with the health service, whilst clinical data provided data on

resource usage for the other items. Resource costs were calculated using standard unit

costs where available, and details on methodology in each area appear below. Costs were

assessed in 2004 UK pounds, as these provide the most recent reference costs available.

The health economic impact of ECP provision in each area will depend on the alternative

type and level of care provision available. ECPs are used to substitute for different mixtures

of other health professionals in the three study sites. In service 1, ECPs travel in specialist

vehicles in place of standard ambulance technician or paramedic crews and see patients

who would otherwise be taken to the ED. Within service 2, ECPs are used in place of

general practitioners as out-of-hours cover. Finally, in service 3, ECPs are used in place of

GPs and senior nurses within a WIC. Each of these sites involved a separate comparison

and needed to be considered individually.

Unfortunately, data limitations have prevented the calculation of cost-effectiveness in two of

three locations. Whilst useful as a measure of patient experience, total episode time is

inappropriate as a measure of resource usage, since much of the episode time may be spent

without health professional contact. In the WIC service, contact time was not collected

separately from total episode time, so that it was not possible to collect sufficient information

to estimate resource usage. In the OOH service, whilst the time of face to face contact with

an ECP/GP could be calculated in 25% of cases, travel time could not be assessed because

the point at which the ECP/GP was assigned the case and became free to travel (i.e.

“activation”) was not recorded. Given that travel may be a significant source of staffing

costs, we were unable to estimate costs outside of service 1 (999).

Within the 999 service, we identified a subgroup of 56 patients (31 ECP, 25 control) that had

both quality of life and time data for activation and discharge from paramedic or ECP care.

Data from this subgroup formed the main comparison within the economic analysis and

statistical tests were also used to find any significant differences between the subgroup and

8

the 999 service generally. Differences between ECP and standard care were analysed

using mean effect and standard error of difference, and costs found using unit costs where

available8,9

. The incremental cost-effectiveness of ECP for paramedic substitution calculated

and a probabilistic sensitivity analysis conducted.

Staffing

Paramedic costs were estimated using 2004 Unit Costs, which incorporate the costs of

overheads and management, the building and land used in ambulance services, the physical

costs of ambulances and equipment, and the cost of crew salaries and wages. Published

figures were adjusted by replacing the assumed cost per minute with figures from the current

study.

The mean cost of an ECP contact has been estimated at £24-89 depending on the numbers

of patient contacts assumed per 10-hour ECP shift (from 2-7)1. The methodology here uses

PSSRU overheads for overheads, management, buildings and land (£56,832) equal to those

faced by paramedic units. Phase one of this study produced estimates for the yearly salary

costs of ECPs (£26,475) plus a contribution for setup of the ECP scheme (e.g. training and

placement supervision, purchase of vehicles and equipment, and vehicle adaptation etc,

£1,565). Adding a 12% contribution on salary costs for National Insurance and pensions, the

yearly cost of an ECP is estimated to be £88,049. Cost per ECP contact is calculated

assuming 4.5 patient contacts per 10 hour shift (828 per year), producing an estimate of

£106. This compares favourably with the PSSRU unit costs which estimate a cost per

paramedic journey of £248 (assuming 480 contacts). The main differences in annual costs

are staff costs – since paramedic units include two staff – and the higher cost of

ambulances. Time per ECP and paramedic contact minute is calculated from average

contact time. Upper and lower estimates for costs per contact minute are calculated from

PSSRU estimates (paramedics) and from modelling assuming 2.5 or 6.5 contacts.

Consumables

Clinical data collection typically records whether specific types of consumables, drugs or

tests were used. However, this data often does not allow the identification of which type of

consumable within a class (e.g. dressings) was used in a specific case, nor how many units

were used. Given these difficulties, we are unable to calculate the specific costs of

consumables. However, it should be noted that these figures are likely to be relatively

inexpensive, and are very unlikely to be a crucial factor in the cost-effectiveness of ECPs.

Within the sensitivity analysis, a zero mean difference is assumed but estimates are sampled

from a triangular distribution on

(-10, 10).

Pharmaceuticals, tests and x-rays

9

Whilst we experienced similar problems to those above when costing pharmaceuticals, we

assumed specific types and quantities of analgesics and antibiotics (20xParacetamol 500mg,

21xAmoxicillin 250 mg) were used. A specific tetanus injection (250mg, prefilled) is likewise

assumed. Prices were found from the British National Formulary and reduced by 3% to

deflate from 2005 costs. The number of x-ray sites examined was estimated using patient

diagnosis and costed using standard reference costs (Band A radiography tests). Blood

glucose tests, other blood tests (except blood oxygen tests) and ECGs were costed using

standard reference costs (haematology tests, ECG (12 lead)). Urine tests were ignored due

to a lack of clarity as to which tests were intended.

ED, hospital admissions, and other NHS or social service contacts

ED attendances, GP contacts (both telephone and in person), health visitor/district nurse

contacts, NHS direct, and social/community services were costed using PSSRU unit costs.

Hospital admissions within the 999 service subgroup were costed according to diagnosis and

patient-provided information where available.

Subsequent hospital contacts (indicated by patients as contact with outpatients, MIU or ED)

were costed as first attendance outpatients for trauma and orthopaedics, since most ED

attendances appear to fall within this category. Where patients indicated that they received

five or more of any type of NHS or social service contact, we assume six contacts were

received.

Quality of life assessment

Quality of life estimates were found using self-completed EQ-5D data at 3 and 28 days.

These were transformed into health state utilities using the UK Social Tariff values10

. Given

figures for health state utilities at 3 and 28 days, baseline health is found by assuming a

constant rate of change within the first 28 days post-incident. Quality-adjusted life-year

(QALY) figures are found by adding the difference between estimated health and baseline

health for days zero to 28, and dividing this figure by 365.

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3.0 DATA ANALYSIS

3.1 Controlled observational study

All analysis was conducted in SPSSv.12.0. Analysis of the data was carried out for all

patients together and patients within each study category (intervention and control groups).

These patient groups were analysed across all ambulance services and within each service.

We used the Chi Square tests and t-tests to detect differences (at the p<0.05 level) between

the intervention and control groups and between services on key variables influencing

sample characteristics and appropriateness of care.

3.2 Telephone interviews

The interview texts were analysed thematically under four ‘framework’ headings of

‘organisation’; ‘process’; evaluation; and strategic direction; within area and across area by

staffing group. Within these broad headings, text data were re-grouped to identify triggers

and brakes on development of the ECP role and their contribution towards achieving the

overall strategic visions contained in a recent report4. Data were validated by triangulation of

the data for consistency and divergence in the views of ECP working expressed by

interviewees in each of three staffing groups included.

3.3 Economic study

All analysis was conduced in Excel and SPSS 11.5. All tests were two sided at a 5%

significance level. Tests of continuous data were conduced using t-tests, with equal

variances assumed unless rejected by Levene’s Test for Equality of Variances at a 5% level.

Tests of discrete data are conducted using Chi-Square tests unless cells had expected

sample size below 5, where Fisher exact tests were used.

The incremental cost-effectiveness of ECP substitution in the 999 service was found and

probabilistic sensitivity analyses conducted to form a cost-effectiveness acceptability curve

(CEAC). Where unit costs provide upper and lower quartile figures, these are used in the

sensitivity analysis within a triangular distribution. Where these are not available, a

triangular distribution is used with upper and lower estimates assumed at 75% and 125% of

the central estimate. In the sensitivity analysis, a zero mean cost difference is assumed for

consumables but estimates are sampled from a triangular distribution on (-10, 10).

11

n = 524 Recruited Patients

ECP 245

(46.8%)

Control 279

(53.2%)

3 Day Questionnaire Response Rate

n = 264 (50.4%)

28 Day Questionnaire Response Rate

n = 157 (30%)

n = 524 Recruited Patients

(999) Service 1 = 246 (46.9%)

(OOH) Service 2 = 175 (33.4%)

(WIC) Service 3 = 103 (19.7%)

Control n = 114 (46.3%)

ECP n = 132 (53.7%)

ECP n = 61 (34.9%)

Control n = 114 (65.1%)

ECP n = 51 (49%)

Control n = 52 (51%)

4.0 RESULTS

4.1 Controlled observational study

A breakdown of which group patients were recruited into, and from which sites, is shown in

figures 1 and 2. A key feature of this study was to reflect and compare the work ECPs were

undertaking in different settings and through different services. The sample size calculation

was for 200 ECP and 200 control patients recruited to the study. This number was achieved,

although in differing proportions across the three sites in the study.

Figure 1: Patient recruitment Figure 2: Patient recruitment by service

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Description of patients included in the study

A total of 524 patients were included in the study across the three sites. The study was not

randomised and there were some differences between the ECP and control groups. Patients

seen by ECPs were significantly older (table 1) and twice as likely to have had their incident

outside their own home. When examined by service the patients in the 999 group were

significantly older than those seen by the other two services, were less likely to live in their

own home or to have had their incident in their own home (table 3). This is primarily because

33 patients (16.2%) seen through the 999 service were from a residential or nursing home

and had their incident there, as opposed to none seen through the WIC, and only 4% (n=7)

through the OOH service.

Table 1: Description of participants by study group

Study group ECP

n=245 (%) Control

n=279 (%) Total

n=524 (%)

Female (%) 164 (66.9) 166 (59.5) 330 (63.0)

Mean age (yrs) (SD)* 58.6 (29.8) 49.1 (27.6) 53.4 (29.0)

Living in own home (%) 217 (88.6) 255 (91.4) 472(90.1)

Incident occurred in own home (%)

208 (84.9) 258 (92.5) 466 (88.9)

*, p<0.001;

Non-responder analysis

An analysis of consenting patients not replying to the questionnaires compared with those

who did respond was undertaken to evaluate to what extent those who responded were

representative of the study group.

Non–responders to both the 3 and 28 day questionnaires were significantly younger than

responders and more likely to be male. At 3 days non-responders were also significantly less

likely to be living at home and to have had their incident at home (table 2). However, this

trend was reversed at the 28 day questionnaire.

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Table 2: Non-responder comparison what % of all responded what % didn’t (n

Total 3 Day questionnaire 28 Day questionnaire

Responded Not responded Responded Not responded

n=524 % check figures

% check figures 19.6 43.3

Mean age (SD) (n=498)

56.2 (26.9)* 50.4 (30.8) 57.8 (26.1)* 51.5 (30.0)

% Living at home (n=512)

47.5** 44.7 28.1 64.1

% Incident at home(n=478)

46.4* 42.7 51.6 56.3

*, p<0.05; **, p<0.01

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Table 3: Description of participants by service

Service

999 (Service 1) n=246 (%)

OOH (Service 2) n=175 (%)

WIC (Service 3) n=103 (%)

Total n=524 (%)

Female (%) 160 (65.0) 114 (65.1) 56 (54.4) 330 (63.0)

Mean age (yrs) (SD)

72.1 (18.7) 40.8 (29.2) 34.8 (22.5) 53.4 (29.0)

Living in own home (%)**

205 (86.1) 167 (96.0) 100 (97.1) 472 (90.1)

Incident occurred in own home (%)*

196 (79.7) 174 (99.4) 96 (93.2) 466 (88.9)

*, p<0.05; **, p<0.001;

Figure 3 describes the range of presenting conditions seen by the ECP and control groups.

Figure 4 shows this by service. As can be seen, the commonest presenting complaint was a

fall, with no significant difference detected between the complaints between ECP and control

groups. When broken down by service, it can be seen that the vast majority of the falls

attended occurred through the 999 service, with the WIC and OOH services seeing

proportionately more acute minor medical, ear nose and throat (ENT)/eye and gastro-

intestinal problems.

15

Figure 3: Presenting complaint by study category

0

10

20

30

40

50

60

70

80

90

Fall

Acu

te m

edic

al

Soft tis

sue

proble

m/in

fect

ion

Musc

ulosk

elet

al p

roble

m

Eye/E

NT

GI I

llnes

s

GU/G

ynae

colo

gy

Number

ECP

Control

Figure 4: Presenting complaint by service

0

20

40

60

80

100

120

140

160

Fall

GI I

llnes

s

Soft tis

sue

proble

m/in

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GU/G

ynae

colo

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Eye/E

NT

Musc

ulosk

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roble

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Acu

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edic

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Number

Service 1 (999)

Service 2 (OOH)

Service 3 (WIC)

16

Process measures

Initial episode – investigation and treatment

Tables 4 and 5 show the differences in rates of investigation and treatment between the ECP

and control groups. Data were recorded regarding the types of investigation undertaken at

the initial consultation from the clinical records. Investigations included such things as

electrocardiographs (ECGs), urine testing, blood testing and xrays. Significantly fewer

patients in the ECP group underwent any investigation at all (X2=8.44, df=1, p<0.005). When

this is broken down by type of investigation, significantly fewer ECG or patient monitoring

(X2=7.87, df=1, p<0.01) and fewer blood tests (X

2=15.08, df=1, p<0.001) were undertaken.

Table 4: Investigations received by study group

Study category

ECP n=238 (%)

Control n=269 (%)

TOTAL n=507 (%)

ECG / monitor 2 (0.8) 14 (5.2)* 16 (3.2)

Urine test 3 (1.3) 7 (2.6) 10 (2.0)

Blood test 2 (0.8) 22 (8.2)*** 24 (4.7)

Xray 16 (6.7) 26 (9.7) 42 (8.3)

Any Investigations 20 (8.4) 46 (17.1)** 66 (13.0)

*, p <0.05; **, p<0.01, ***, p<0.001. Table 5: Treatments received by study category

Study category

ECP n=238 (%)

Control n=269 (%)

TOTAL n=507 (%)

Any advice 152 (63.9)* 144 (53.5) 296 (58.4)

Drug treatment 95 (39.9)*** 60 (22.3) 155 (30.6)

Wound treatment 41 (17.2)** 20 (7.4) 61 (12.0)

Any treatment 132 (55.5)*** 91 (33.8) 223 (44.0)

*p, <0.05; **, p<0.005; ***, p<0.001

When treatments administered are compared (table 5), more patients in the ECP group were

recorded as being given a treatment of some description (X2=23.99, df=1, p<0.001). When

examined in more detail, written or verbal advice (X2=5.84, df=1, p<0.05), drug treatments

(X2=16.81, df=1, p<0.001) and wound treatments (X

2=11.44, df=1, p<0.005) were all

recorded as being significantly more frequently provided for the ECP group than the control

group of patients.

17

Table 6: Treatment by service

Treatment Service

999

(Service 1)

n=229 (%)

OOH

(Service 2)

n=175 (%)

WIC

(Service 3)

n=103 (%)

Advice 120 (52.4) 100 (57.1) 76 (73.8)*

Drug 43 (18.8) 64 (36.6) 48 (46.6)**

Wound 47 (20.5)** 0 (0.0) 14 (13.6)

Any treatment 94 (41.0) 67 (38.3) 62 (60.2)*

*, p<0.005, **, p<0.001 When examined by service (table 6), more patients in the WIC group were recorded as

having received any form of treatment (X2=14.09, df=2, p<0.005), general advice (X

2=13.28,

df=2, p<0.005) or drug treatments (X2=26.18, df=2, p<0.000). However, more wound

treatments were administered to the 999 group of patients (X2=39.78, df=2, p<0.000). These

findings reflect the differences in the range of conditions presenting to each of the services

(figure 4). It might be expected that patients with falls (999) would receive more wound

treatments than those with acute and minor medical problems (WIC).

Diagnosis and discharge decisions

The range of diagnoses made within each study group is shown in figure 5. As can be seen

the commonest diagnoses in both groups were soft tissue or musculoskeletal problems.

Figure 5: Diagnosis by study category

0

20

40

60

Soft

tis

sue

Musc

ulo

ske

leta

l

Oth

er

Eye

/EN

TR

esp

Illn

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ynae

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Head

Inju

ryA

ller

gic

React

ion

NumberECP

Control

18

The discharge decisions were recorded from the clinical records and are shown in table 7.

This shows that significantly more patients in the ECP group are discharged to their own

place of residence than in the control group, mainly because significantly fewer emergency

department (ED) or hospital admissions occur in the ECP group (X2 = 47.64, df = 2,

p<0.001).

When examined by service, the 999 service has a much higher utilisation of ED and hospital

services than either of the other two services (X2 = 169.52, df = 4, p<0.001). This reflects the

different presenting conditions and age group of patients being seen and might be expected

(table 8).

Table 7: Disposal by category

Disposal Study category

ECP n=237 (%)

Control n=269 (%)

TOTAL n=506 (%)

Own place of residence

171 (72.2)* 142 (52.8) 313 (61.9)

ED/hospital admission

41 (17.3)* 119 (44.2) 160 (31.6)

Other 25 (10.5) 8 (3.0) 33 (6.5)

*, p <0.001 Table 8: Disposal by service

Disposal Service

999

(Service 1)

n=233 (%)

OOH

(Service 2)

n=174 (%)

WIC

(Service 3)

n=99 (%)

Own place of residence

75 (32.2)* 142 (81.6)

96 (97.0)

ED/hospital admission

134 (57.5)* 23 (13.2)

3 (3.0)

Other 24 (10.3)* 9 (5.2) 0 (0)

*, p <0.001

Patient satisfaction

When asked in the 3-day questionnaire, significantly more patients in the ECP group

reported being ‘very satisfied’ with their consultation than in the control group (n=105

(85.4%) vs. n=85 (66.4%); X2=12.26, df=1, p<0.001). In addition, when asked about future

preference for treatment of similar condition, 77% (n=100) patients from the ECP group said

they would prefer treatment by an ECP in the future rather than a doctor or other health care

professional.

Table 9 breaks down overall satisfaction with the consultation into several components. As

can be seen, patients in the ECP group consistently report higher levels of satisfaction than

patients in the control group.

19

Table 9 Satisfaction with service by study category

Aspects of satisfaction Strongly agree

ECP n=108 (%)

Control n=137 (%)

Staff were polite*** 100 (83.3) 79 (60.8)

Staff were concerned about me*** 80 (66.7) 56 (44.4)

Staff listened to me*** 83 (69.7) 61 (49.7)

Staff answered my questions** 75 (57.3) 56 (42.7)

Staff were thorough in examination** 78 (67.8) 58 (48.7)

Medical treatment excellent** 73 (64.6) 54 (44.6)

Satisfied with advice given*** 84 (68.9) 51 (40.2)

Generally satisfied with care*** 82 (69.5) 55 (43.3)

*** p<0.001, **p<0.005, 28 day outcomes

When asked in the 28-day questionnaire about contact with health services following their

episode, there were no significant differences between the two groups with regard to

whether they made any contact with, or which service they contacted (table 10).

There were also no differences between the two groups with respect to their self-reported

health status at 3 and 28 days after their acute event. This was measured using the EQ-5D6

on both occasions.

When subsequent contact with health services is examined by service (table 11), there are

significant differences, with fewer overall health service contacts being made by the WIC

patients (X2=12.15, df=2, p<0.005). This difference appears mainly to be due to contact with

community and social services rather than hospital services. Significantly more patients in

the 999 and OOH groups contacted community and social services (X2=12.52, df=2,

p<0.005).

Table 10: Contact with services during 28 day follow-up by study category

Type of contact Study category

ECP n= 81(%)

Control n=74 (%)

TOTAL n= 155 (%)

Any health service contact 52 (64.2) 42 (56.8) 94 (60.6)

Contact with community/social services

49 (60.5) 37 (50.0) 86 (55.5)

Contact with hospital services 19 (23.8) 21 (28.4) 40 (26.0)

Hospital admission 5 (25.0) 3 (15.8) 8 (20.5)

20

Table 11: Contact with health services during 28 day follow-up by service

Response Service

999 (Service 1) n=73 (%)

OOH (Service 2) n=52 (%)

WIC (Service 3) n=30 (%)

Total n=155 (%)

Any health service contact 51 (69.9)* 33 (63.5)* 10 (33.3) 94 (60.6)

Contact with community/social services

46 (63.0)* 32 (61.5)* 8 (26.7) 86 (55.5)

Contact with hospital services

22 (30.6) 8 (26.7) 10 (19.2) 40 (26.0)

Hospital admission 6 (28.6) 1 (9.1) 1 (14.3) 8 (20.5)

*, p<0.005 Health care contact time Mean episode time was calculated for each patient episode from routine data. The total

episode time was calculated for the ECP or control consultation from the time of the call

(999, OOH services) or time of registration (WIC) until time discharged by ECP/control. We

did not include any times for subsequent consultations if the patient was handed over to

another service such as ED/MIU. There were large numbers of missing total patient episode

times in the OOH service due to times not being recorded in the out of hours centres.

The mean total episode time was significantly greater for patients seen by ECPs compared

to those seen by control professionals (table 12) (P<0.001, t=6.4, df=372, 95% CI = 0:19:25-

0:36:28). When we looked at total episode times by study category and by service (table 13)

we found that the differences between ECP and control patients were only significant for the

999 service (P<0.001, t=8.1, df=232, 95%CI = 0:32:24-0:53:07). An explanation for this

includes the number of ECP patients initially responded to by standard paramedics crews

and then handed over to ECPs. This created a lag time between time of call and the time

the ECP was activated.

Table 12: Mean total episode time by study category

Response Study category

ECP n= 205

Control n= 169

Mean total episode time (SD)*

01h:29min:39sec (00:49:10) 01h:01min:42sec (00:30:17)

*, p<0.001

Table 13: Mean total episode time by study category and service

Service 999 (Service 1)

n=234

OOH (Service 2)

n=47

WIC (Service 3)

n=93

Study category

ECP n=124

Control n-110

ECP n=29

Control n=18

ECP n=52

Control n=41

Mean episode time

1:46:27* (0:40:35)

1:03min:41* (0:40:35)

1:25:15 (0:36:47)

1:02:57 (0:43:39)

0:52:04 (0:30:37)

0:55:53 (0:33:30)

*, p<0.001

21

Case-mix adjusted comparisons Adjusting comparisons for age, sex, presenting complaint and service made little difference

to the main findings comparing ECPs to controls (Table 14). ECPs were still found to

investigate less frequently (X2=13.6, p<0.001, df=1), give more treatments (X

2=26.0, p,0.001,

df=1) and more advice (X2=8.0, p<0.001, df=1). They were more likely to discharge patients

to their own home than take them to hospital and amongst those followed up by

questionnaire their patients were more likely to be very satisfied (X2=6.2, p<0.001). There

were no differences in subsequent use of health services. We have also used a case-mix

adjusted model to examine whether the conclusions held equally for all three sites with the

different ECP working arrangements. There was some evidence that the effect of the ECP

differed in the 999 service compared to the other services with regard to investigations,

advice and disposal home (Table 14).

Table 14: Odds of processes and outcomes with ECPs compared to controls

Process/outcome Unadjusted Odds

Adjusted Odds (95% CI)

Odds of a difference between each service setting

Any investigation 0.45 0.31 (0.16-0.59) Service 1 (999) = 0.22 Service 2 (OOH) = 3.57

Service 3 (WIC) = Not evaluated

Any treatment 2.47 2.74 (1.83-4.09) No differences between services

Advice 1.68 1.75 (1.18-2.61) Service 1 (999) =5.53 Service 2 (OOH =0.74 Service 3 (WIC) =0.50

Disposal home 2.23 7.69 (4.07–14.5) Service 1 (999) =32.1 Service 2 (OOH) =1.12 Service 3 (WIC) =2.32

Any subsequent health service contact

1.41 1.43 (0.64 –3.22) No differences between services

Very satisfied with care

3.04 2.37 (1.17-4.81) No differences between services

Odds ratio = <0 process/outcome more frequent in control group, odds ratio = >1 process/ outcome more frequent in ECP group.

22

4.2 Telephone interviews

Sixteen interviews were completed altogether. By area, these comprised five from service 1

(999 service), five from service 2 (OOH) and six from service 3 (WIC). By broad staffing

group, the achieved sample consisted of five ECPs, five stakeholders, and six other health

professionals. The stakeholder roles included ECP leads for the ambulance trust, divisional

clinical team manager, general manager, and associate director of primary care. The ‘other

health professional’ participants were general practitioners, nurse consultant in emergency

care, paramedic, lead nurse at WIC and a clinical lead for ECPs.

Descriptive

Predominantly, the ECP interviewees were male and had previously been ambulance

paramedics. Some ECPs also had nursing qualifications.

Within each area, the organisation and processes of ECP activation and referral described

by the interviewees were consistent. Looking across the three study areas, the descriptions

confirmed the distinctive character of each model of care. In the 999 service, the model was

a partnership between the ambulance trust and other health care providers with the ECPs

operating as a mobile unit in a predominantly urban locality with traditional services in the

same area and elsewhere in the county. As well as calls received via 999 prioritising, and

other crews, ECPs were beginning to receive calls direct from GPs, and also from residential

and nursing homes that had established links with the service.

In rural service 2 (OOH), the county-wide medically-supported ECP model was based in GP

surgeries. The ECPs worked a 5 week rota in the out of hours setting and one week as a

standard paramedic. The initial focus on ECPs providing out-of-hours care was extending in

one area of the county to include some in-hours primary care. The other health professional

interviewed in the OOH service regarded this extension of the ECP role into the in-hours

setting as a positive development. It was perceived as necessary for the continuing

professional development of ECPs, giving them experience of the full range of primary care

presentations and enabling ECPs to fulfil what they were expected to achieve.

In service 3 (WIC), the ECP model was rotational based in the ED of a hospital trust in the

north, a walk-in-centre in the south of the county and as a mobile resource. The training in

service 3 followed a different model to the block system of theory-based learning and

placements, operating in the other two areas. In service 3, ECPs underwent an ongoing

process of two days theory followed by three days either on the road or in an ED.

Depending on the rotation, nurses and paramedics provided each other with mutual

supervision. The ECPs gave examples of how new care pathways for referrals were

opening as others working in the health service became more familiar with the role.

Evaluative

23

ECPs and stakeholders perceived the initiative as having a constructive impact on retaining

trained paramedics in the NHS, and offering new career pathways for health care staff from

other backgrounds such as nursing. Benefits had also accrued to other paramedics and

technicians who are able to undertake some of the modular packages designed for ECPs.

The ‘triggers’ to becoming an ECP were cited as new challenges, increased job satisfaction,

being able to retain or offer a clinical focus, to be able to complete a job from start to finish.

From the managerial viewpoint, selection of candidates who would make good ECPs was

regarded as crucial.

“It was about recruiting people that were happy with change, happy to challenge, the pioneers basically. And people that were comfortable with uncertainty.”

Stakeholder interviewee

However, it was observed that the requirement for pre-hospital working may account for fewer nurses than paramedics becoming ECPs.

“I think the ability for nursing staff to transfer to pre-hospital is not as easy as …it is for paramedics to go into a hospital”

Stakeholder interviewee

Similarly ECPs from a paramedic background based in WIC and GP surgeries were

perceived as requiring additional support and supervision to smooth the transition.

Acceptance and integration

The feedback was that the ECP role had been well accepted by some groups of health

professionals, and initial resistance by others was relaxing as the role became more

established, although the extent of this varied across the areas. Triggers to development

were expressed as strong clinical and managerial commitment to the ECP initiative.

“We’ve had an excellent relationship between all the organisations involved…I think that has been crucial…the reason we’ve got such great engagement has been the clinical leadership….with A&E…all those other organisations…also managerially.”

Stakeholder interviewee

‘Brakes’ on the ECP role achieving its potential, were cited as the absence of effective

clinical and managerial links with other health providers across the Trust area, bureaucracy;

a lack of understanding in ‘rank and file’ middle managers about the ECP role, lack of

appreciation of the differences between paramedics and ECPs; insufficient range in the out-

of-hours case-mix for the ECP to gain sufficient experience to deal with cases confidently.

Limited numbers of qualified ECPs also necessarily meant the resource was spread quite

thinly. Failure to use ECP skills fully was raised by the interviewees in two sites as a source

24

of frustration. Reluctance of a few ambulance crews to recognise the new role and to refer

appropriate cases to the ECP was raised in all three sites.

Training

Interviewees in each area regarded the ECP training as sufficient. However, ‘other health

professional’ and ECP interviewees expressed the view that for ECPs to be equipped to

contribute fully to the health care team, they needed to deepen their experience through

regular contact with the usual range of cases presenting to primary care. This was also felt

necessary to develop the ECPs experience of dispensing of clinically diverse drugs and

therapeutics.

Differences in the training packages and the different models of ECP care between areas

were raised as potential ‘brakes’ affecting the transferability and marketability of the ECPs.

Strategic direction

Without exception, the experiences and views of ECP working expressed by the

interviewees were positive. There was clear commitment at all levels of involvement to the

future success of the schemes. There were some barriers to be overcome and strategies

were being developed to address these. There were examples of reflective practice and

innovation with professional boundaries being reconfigured as the ECP role was becoming

more accepted. The ‘crucial’ elements to facilitate future expansion and development of the

role were perceived to be:

• Effective partnership links between provider organisations managerially and

clinically;

• Good leadership;

• Sufficient numbers of trained ECPs and appropriate selection criteria to identify the

most suitable candidates;

• Continuing professional development to maximise utilisation of the role and prevent

de-skilling;

• Listening to staff and fostering a team-based approach.

• ‘Core skills’ and competence to ensure comparability between practitioners

irrespective of previous experience and health service background, and

transferability of role.

• Adequate training and supervision to help ECPs make the transition from one setting

to another.

• Improved information and communication between ECPs and their host

organisations and other health care providers to promote better understanding of the

potential of the ECP role nationally and its contribution to the local health economy.

25

4.3 Economic study

When the 999 patient group is compared with the subgroup used for the economic analysis

(n=56), no significant differences were identified in relation to mean time spent on the

episode, blood tests, ECGs or xrays ordered, treatment prescribed, or discharge decisions

made. It can therefore be assumed that the subgroup is representative of the 999 patient

group for the purposes of analysing costs.

Costs

Staff costs are typically higher for paramedic treated patients compared to ECP-treated

patients (table 15). ECPs typically spend an additional 25 minutes per patient (85 vs 60

minutes; t=7.84, df=200.27, p<0.00), and the estimated cost per minute of ECP and

paramedic contact time is estimated to be £1.25 and £4.34 respectively.

Table 15: Estimated cost differences for ECPs and paramedics

ECP Control

ECP/paramedic costs £106 £248

ED at disposal £13 £83

Hospitalisation £138 £84

Consumables Not measured Not measured

Pharmaceuticals and tests

(including xrays)

£2 £17

Outpatients, MIU and A&E in

follow up

£40 £66

Other NHS and social services

follow up

£60 £154

Total costs £360 £651

ECPs appear to provide less costly treatment than paramedics, saving approximately £291

per patient. This cost saving comes primarily from staff costs at incident , avoided ED

attendances, and lower use of non-inpatient follow-up services. However, the ECP-treated

individuals are more costly in terms of hospital admissions (costing £50 more) and receive a

smaller health gain than those treated by paramedics.

Quality of life

Quality of life figures at 3 days and subsequent QALY benefits at 28 days post incident are

presented in Table 16. Health-related quality of life is not significantly different between ECP

and control patients at 3 days (t=1.05, df=54, p=0.30) and 28 days (t=0.80, df=54, p=0.43).

26

Control patients gained 0.0013 more QALYs over 28 days, but this figure is not significant

(t=0.38, df=38.4, p=0.71).

Table 16: Quality of life and QALY benefit within service 1 (999) subgroup.

ECP, mean (SD)

n=31

Control, mean (SD)

n=25

3-Day Quality of Life 0.42 (0.39) 0.31 (0.43)

QALY benefits 0.003 (0.009)

Cost-effectiveness

Cost-effectiveness is calculated by taking the mean resource differences between ECP and

paramedic-treated individuals outlined above and applying appropriate costs.

Given 0.0013 fewer QALYs per ECP-treated patient, 767 patients would need to be treated

by ECPs rather than paramedics in order to produce one additional QALY. However,

treating these 767 patients could save the NHS approximately £223,500. As this figure is

higher than the standard thresholds for determining cost-effectiveness, the substitution of

ECPs for paramedics appears highly cost-effective on the basis of this study.

Figure 6 shows the cost-effectiveness plane for ECP-substitution and displays the line

representing £30,000 per QALY, which is a standard threshold for cost-effectiveness. All

points to the right of this line suggest that ECP substitution is cost-effective at this threshold.

As the majority of the points lie to the right hand side of this plane, it is likely that ECP-

substitution is cost-effective. As the cost-effectiveness threshold increases this line

becomes steeper and proportion of cost-effective points change. A cost-effectiveness

acceptability curve (CEAC) presents the probability that an intervention is cost-effective at

particular threshold level. Figure 7 shows the CEAC for ECP-substitution on a sample of

200,000 observations. It appears that ECP care is very likely to be cost-effective at both

£20,000 and £30,000 per QALY (p=0.95, p=0.92 respectively) and is likely to be cost-

effective than paramedic care well beyond £100,000 per QALY.

27

Figure 6: Cost-effectiveness plane for ECP substitution (10,000 points)

-£2,500

-£2,000

-£1,500

-£1,000

-£500

£0

£500

£1,000

£1,500

£2,000

-0.030 -0.020 -0.010 0.000 0.010 0.020 0.030

incremental effectiveness

incremental cost

Figure 7: Cost-effectiveness plane for ECP substitution (200,000 points)

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

1.000

£0 £10,000 £20,000 £30,000 £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000

cost-effectiveness threshold

probabiliy of cost-effectiveness

28

5.0 DISCUSSION

Principal findings

In practice, ECPs are delivering an alternative service to standard urgent provision.in the

three sites included in the study. Overall, patients in the ECP group required less

investigating and referral at their initial consultation than the control group. They were also

documented as having received more treatments than the control patient group. They

reported no overall difference in the health care contacts made in the subsequent 28 day

period and no difference in health status. Within the limitations of the study, we found no

evidence that the intervention provided by the ECP service is less safe than in the resepctive

control services.

Some differences were observed. The 999 service displayed a higher utilisation of ED and

hospital services than the other two services studied. This presumably reflects the different

casemix seen by this service when compared with the other two. More patients in the 999

and OOH groups made contact with health services following their initial episode than those

accessing it through the WIC. Again, this finding might be expected given casemix

variations. Patients accessing through 999 in particular are likely to have higher acuity

medical problems requiring investigation and hospital referral. In addition, these patients

were older and therefore more likely to have significant co-morbid problems making

utilisation of resources higher than in the other groups. When we undertook a casemix

adjusted analysis, the odds of being left at home were still higher in the ECP group and

across all three services. However, they were highest for the 999 service.

It is difficult to measure the impact the ECP service has had on the whole urgent and

emergency care service in each site given the limited data we were able to collect. We found

no evidence that the care provided by ECPs for those conditions that ECPs were eligible to

see and treat, was unsafe. Certainly the potential for avoiding ambulance journeys, ED

attendances and hospital admissions appears to be present. The ECPs were shown to

prevent these from happening most of the time, with no obvious adverse effects on the

patient. However, the numbers of ECPs in each site studied was small and the service has

not been active for sufficiently long to have a measurable impact on the overall service. This

is especially the case in the OOH service and WIC.

Differences in the rates of investigations observed between the controls and the ECPs may

be indicative of an under-recognition of potentially significant conditions by ECPs. We were

not able to examine because this study did not have the resources to collect clinical

outcomes data.

Satisfaction of patients with the care received from ECPs was consistently higher than

patients in the control group. Across all three services studied, no difference in satisfaction

29

with care was found between ECP and control patients when adjustment for casemix is

made. Overall, of those patients who saw an ECP, 77% were happy to be seen by one in the

future

A cost-effectiveness analysis of substituting ECP treatment for a 999 ambulance response

and transfer to the ED could be undertaken on service 1 data only. Therefore the results

should be treated with caution. The sample size is small and in some cases, there are very

few data points on which to base estimates of the effect of ECP substitution on resource use.

Further, whilst the subgroup was broadly typical of the cases from the 999 service, there

were some marginally insignificant differences between the subgroup and the service

generally that may be important. This is particularly so where some of the parameter values

implied by the study (particularly NHS Direct usage) lack face validity. However, given the

size of the incremental cost-effectiveness found here, we can be reasonably confident that

ECP for ambulance and ED transfer substitution will remain cost-effective with further data.

The analysis demonstrated a cost saving of approximately £292 per patient seen by an ECP.

Most of these come from staff costs at scene, avoided ED attendances and lower use of out-

patient services.

As the economic evaluation is based on a comparison of ECPs versus ambulance response

and transfer to the ED in one area, they cannot be generalised to ECPs in other areas

fulfilling other functions. It should also be noted that the cost-effectiveness of ECPs may be

affected by whether or not the practitioner was formerly employed as a nurse or as a

paramedic. Even if both groups of ECPs perform identically, the additional training cost

required for ‘equivalent’ competence training may affect overall cost-effectiveness.

Limitations

Generally, the most important limiting factors were that the study was undertaken within a

short timescale and with limited resources.

Patient recruitment

We experienced some difficulties in recruiting patients in each of the schemes for a variety of

reasons. In one site, recruitment of patients in the WIC progressed well, but our plans to

recruit patients and evaluate ECPs in an ED setting were affected irretrievably by a delay of

five months in receiving research governance approval from the Trust.

In the 999 service recruitment of patients for the ECP group was straightforward. The

process was undoubtedly helped as an ECP in the ambulance service control room identified

and dispatched the ECPs to eligible calls. A researcher maintained contact with the ECP in

the control room on a daily basis in order to ensure recruitment rates. However the ECP in

the control room had difficulty in identifying paramedic crews who would invite patients

30

regarding taking part in the study for the purposes of collecting a control group. This may

have been due to the fact that controls had to be recruited from areas within the 999 service

where the ECP scheme was not operational. Paramedics frequently were unaware of the

ECP scheme and the significance of the research or were unwilling to ask patients who had

dialled 999 about taking part in a research study.

In the OOH service, our target of 100 control patients was achieved without difficulty, but

recruitment of the numbers of patients seen by ECPs more problematic due to the small

numbers of ECPs who were operational during the recruitment period.

The recruitment issues mean that the patients included have been highly selected and

although there has been selection of both ECP and control patients it is probable that there

are selection biases in the comparisons reported here. Nevertheless, this should not affect

confidence in these findings that patients who are eligible to be seen by an ECP, were

satisfied with the care received and we found no evidence that ECP care is less effective, or

less safe than standard care..

Data Quality

The baseline clinical data on the patients we recruited was of good quality. Differences

between the 3 services in the way that process and outcome indicators are collected

restricted the comparison that could be undertaken between them.

Time limitations restricted the amount of data we collected. We were not able to collect

routine data from local EDs, hospitals or primary care services which would have allowed us

to have more complete data on 28 day resource use, mortality and nature of the contact. Of

some importance is whether the health contact made after the initial episode was planned or

unplanned. An unplanned contact related to the initial acute health episode suggests that

management at the initial episode was suboptimal. This additional information would assist

us when assessing the safety of care provided within both groups.

The response rates to the questionnaires by patients at both 3 and 28 days, was low. This

may have been as a result of the acute nature of the health care contact. However, for future

studies we may review the method of patient recruitment and design of the questionnaire.

The interviews contributed understanding of the actual and potential benefits of ECP working

from the perspective of the ECP, and other practitioners or stakeholders involved in the

delivery of health care within the same and cross different health setting. It revealed some of

the barriers to ECPs being integrated into the health economy, the stimuli for change, and

the possibility for future strategic development. This understanding may have been

31

enhanced by a larger sample of interviewees, or the addition of other forms of qualitative

enquiry, such as non-participant observation.

Comparability with existing evidence

As part of phase one of this study1, routine data submitted voluntarily by each ECP scheme

was collected centrally and analysed. Data for 8575 first patient contacts were available for

analysis from eleven of the 17 ECP sites. The age of the patients, how they accessed the

ECP service and their disposal pathways were recorded by first contact episodes. Overall in

phase one, 4587 (53.4%) of patients accessing the ECP service via any route were

discharged to their place of residence without immediate or later referral to another health

care professional. Immediate referrals were made in 2260 cases (26.3%)20

. This compares

with the finding in phase two that 72.2% of patients seen by ECPs were discharged to their

place of residence without further referral.

There is a dearth of evidence evaluating the impact of skill mix change in the UK health

services. Most of the published work relates to doctor-nurse substitution in primary and

secondary care11

. Whilst there is evidence that bringing primary care professionals into the

ED may result in costs savings12

, nothing is known about the impact changes to the

workforce in one setting have on other settings.

Studies in the US have discussed the difficulties in identification by ambulance crews of

cases eligible for community treatment13,14,15

16

. In one of the former studies14

, it was

reported that significant expenditure would be required in order to train and equip

paramedics with the skills to triage these broad clinical condition groups appropriately which

may not be cost-effective. With regard to certain medical conditions, studies have shown

that paramedic skills can be enhanced to assess and treat certain conditions in the

community such as wounds17

and hypoglycaemia18

. In addition, the relative merits of a pre-

hospital practitioner have been discussed in certain geographical areas such as rural

locations in fulfilling a broader public health and primary care outreach role in the local

community19

.

Phase one of this evaluation indicated that all actual or anticipated operational settings

involved a vision of ECPs working as independent mobile units, or based in the ED or MIU

and providing Out of Hours or In Hours unscheduled care service. The results of phase two

indicate that an all-encompassing-model has not yet been realised. Each of the study sites

set up their schemes in response to different priorities, and within each model, variation in

the pace of development is evident.

However, the results of phase two confirm the positive commitment to the success of the

scheme at a managerial and operational level found in phase one and expansion of the

service continues.

32

Some ‘brakes’ on the development in all three areas were identified and these need to be

addressed if the ECPs are to fulfil the potential of the role. The principal draw back is the

lack of flexibility that the ECP role presents. It is based on protocols for assessing and

managing specific clinical conditions and situations. This naturally limits the range of patients

that can be managed by the role and hence may limit the extent that the role can be useful to

the health community it serves. However, as the role becomes more established, there are

signs of innovative practice shifting professional and organisational boundaries and re-

shaping how unscheduled health care services are delivered. In particular, these include

more ECPs becoming operational, direct calls to ECPs from GPs, and residential and

nursing homes, ECPs gaining experience by working alongside GPs during in-hours primary

care; and new care pathways opening for ECP referrals.

Methodologies applied and tools used to evaluate the ECP role

This study has provided an excellent opportunity to develop a framework for the evaluation

of other specialist roles within a health care setting. It has taken a patient, workforce and

economic perspective. Indeed this approach is currently being used by the authors in an

evaluation of junior doctors working in the ED and also will be used as part of a more in-

depth and extensive evaluation of the ECP role. The approach has incorporated some mixed

methods using quantitative techniques for the patient surveys and routine data, and

qualitative techniques for evaluating the workforce aspects of the study. In addition, both a

patient and a workforce perspective has been taken ensuring patient satisfaction, outcomes

and health service utilisation are documented and compared, as well as examining the

issues for the ECPs and wider workforce. The measures developed have proved robust and

provided the authors with the data they needed to address the aims and objectives of the

study.

33

6.0 RECOMMENDATIONS

• Utilisation of skills needs to be maximised within each service to ensure clinical

competence is maintained for the breadth of conditions each service treats and to

ensure ongoing effectiveness of the service as shown by this study.

• Links with and integration into existing services is vital if other health care professionals

are to accept the new service and utilise it fully.

• Improving communication and information about the ECP role is an important aspect of

integration into and acceptability within existing services

• Continuing professional development should be a key aspect of each service such that

ECP skill maintenance and development is ensured.

• The differences in service configuration noted make transferability and sustainability of

this role challenging. Accreditation through a central organisation may help to secure

future development and marketability.

• Development of existing national ECP audit collection forms in order to develop a core

ECP clinical dataset facilitating quality control and audit within services over time. This

would also enable differences in development of various ECP models of care to be

monitored.

• Further evaluation is needed to confirm these initial findings through a larger cohort of

sites, ideally with control comparisons and complete clinical outcomes data, to identify

the ingredients that contribute to successful integration of an ECP service into the wider

health community.

34

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