Skill-mix and service transfer to primary care settings

Abstract

Data sources

British Nursing Index, CINAHL, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects), EMBASE, Medline, PsycINFO and the reference lists of eligible papers were searched.

Study selection

Studies that focused on practitioners with special interests (PwSIs) or roles clearly created/defined to be practising with special interests, detailing innovative ways of working with a special interest with evidence of formal evaluation of changing role of location of service from systematic reviews or interventions were included. Surveys of views on changing skill-mix or location of services, studies that did not concern dental or medical professionals, dental care or nursing professionals were excluded. Only studies in English and with a UK focus were included.

Data extraction and synthesis

All titles and abstracts identified were screened for relevance. Two authors assessed quality and extracted data, queries were reviewed by a third author and a narrative synthesis was presented.

Results

Twenty-six papers met the criteria with a strong bias towards the medical literature. Five categories emerged:(i) specialist outreach; (ii) general practitioners with a special interest; (iii) nurse practitioners with a special interest; (iv) dental care professionals; (v) out-of-hospital services. Evidence showed specialist outreach clinics to be effective in relation to access and patient satisfaction with some having a higher quality of care but higher cost. However there may be cost-benefits associated with this care, particularly when part of a multifaceted intervention. There is controversy and a limited evidence as to whether the services provided by medical PwSIs are effective, and whether the benefits outweigh the risk and the cost. From the evidence obtained through early innovation, it appears that these services can increase access and are more satisfying for patients, and that these roles have the potential to bring more work satisfaction to the practitioners. Overall, the findings do support the view that moving specialist care into the primary care setting via appropriately trained nurse practitioners is an effective use of resources, but with the caveat that nurse practitioners in primary care are not necessarily cost-effective. There is evidence that professionals complementary to dentistry (PCDs) are able to diagnose a range of conditions and, with appropriate training, complete a wide range of dental procedures as well as dentists, but much of the evidence for other aspects of substitution was of lower quality, weak or insufficient.

Conclusions

There was limited evidence of the cost-effectiveness and health outcomes associated with changes in setting and skill-mix. However, there was evidence of improved access, patient and professional satisfaction. There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.

Commentary

This is a very interesting, if broad review of skill mix and service transfer, with a specific focus on the potential implications for NHS services in England in light of current policy directions. That said, as the review points out, the desire to move some specialist services to primary care is not new. The review itself highlights some of its potential limitations, and the search strategy although pretty comprehensive, only focuses on papers published between 1996 and 2008 although it does include a number of systematic reviews which take in a longer time-frame. The review does show there is some potential for benefit for the transfer of services from secondary to primary care but it is clear that the nature has not been fully identified, and improvements in cost-effectiveness may not be one of these, although as the authors point out this should not be the only reason for determining primary-care skill-mix.

The number of papers that could be included is small and may be understandable given the UK focus of the review. However it could be argued that a wider search of the literature may have provided studies of relevance from health services provided in other developed countries, different payment models notwithstanding. Having been involved with the one dental systematic review that was included,¹ we did find relevant information from other countries in terms of overall cost-effectiveness in relation to dental services. While the review highlights some more recent papers on skill-mix usage in dentistry, it is disappointing that as that review is now nearly 10 years old there are so few new studies addressing either health outcomes or cost-effectiveness of skill-mix in dental services, despite that fact that there are increasing numbers of dental care professionals being produced within the UK. Consequently I agree whole-heartedly with the authors' call for robust formal evaluation of their effectiveness, together with best models of service delivery.