Emergency Care Practitioners, Case for investment
Keywords:
A national programme had the ambitious intent to reduce A&E attendance by 1 million. They had already identified Emergency Care Practitioners (ECP), which is an experienced paramedic/nurse/AHP who receives additional training so that they can diagnose, treat, or refer directly to an appropriate service avoiding A&E.
ECPs are expensive to train (£40,000 each) so the program needed to identify who makes the saving, and how do they know that they've made it. The evaluation and economic modelling, involving extensive stakeholder engagement, showed an ROI of 2 to 3 years through: a single responder in a car instead of two crew in an ambulance to appropriate calls (Ambulance Review 2005: Taking Healthcare To The Patient); reduced A&E attendance (offset against the increased cost of use of other services); and use of additional skills of the ECP in other environments eg Out of Hours. PCTs were able to benefit from the money saved, so PCTs agreed to fund 800 places for training with ambulance trusts (£32 million).
Other outcomes: –
- a cultural shift towards measuring outcomes (for patients, for the service) not just activity
- working with the rest of health economy
- career progression for ambulance men whose previous choices were management or training
- patients treated at home instead of "scoop and run"
Benefits Management - how to deliver ECPs
ECPs are an excellent example of a really successful new form of advanced front-line clinician. They were developed from the ground up, harmonised across the country by sharing benefits and picking the best from each site. I was initially involved with the 17 pilot sites the national team encouraged local innovation, my work was twofold:
- to coach the sites so that they reported what they had achieved, and just as importantly the lessons learnt, so that others could steal with pride and converge on a single model
- to justify investment by PCTs and Ambulance Trusts in 800 of these advanced practitioners.
ECPs continue to remain a distinct and homogeneous new profession, one of very few widely adopted new professionals in 15 years, and I continue to serve on the national panel steering the profession to registration.
Some of the key publications to emerge are listed in the child pages to this page (below)
The ECP Report: Right Skill, Right Time, Right Place
This was one of the defining reports for the Emergency Care Practitioner. Launched by Prof Sir George Alberti in October 2004, it explains what ECPs are (or can be), where they were at the time, how much they cost to develop and what the Return on Investment is (these two were my bits). In essence, RoI is between 2 and 3 years based on the savings made by reduction in attendance at A&E (as we didn't have figures for the impact on admissions) recognising fewer cases per year than a traditional paramedic, which on the basis that an ECP costs around £40,000 per year to train is a pretty good result! Download the report from http://minney.org/Publications/The_ECP_Report_Right_Skill_Right_Time_Rig...
ECP Competence and Curriculum Framework
The Competence and Curriculum Framework defines what an ECP is and what training they require. At present (July 08) the title is not a restricted title so anyone can, technically, use it; this is being taken through the long process to help it become a restricted title. As this document is quite large the link to the document is here http://minney.org/Publications/SfH_ECP_88pp_CCFW.pdf
Measuring the Benefits of the Emergency Care Practitioner
"Measuring the Benefits" looks at the evidence for urgent care practitioners caring for patients effectively. It compares paramedics and advanced paramedics (in research from USA, Canada, Australia and Europe) with advanced nurse practitioners and ECPs (in UK pilots). The evidence is overwhelming - there are no shortcuts to delivering better care. Paramedics and advanced paramedics don't have the confidence nor training to diagnose, treat and refer a significant number of patients away from Accident & Emergency safely; result is they aren't cost-effective. More highly trained practitioners can provide immediate care and reduce the further care that patients require (as well as reducing the number of times a patient is asked the same questions, time in the system getting nothing done, transport, etc) to such an extent that they pay for their extra training in 2 years. This report also presents the first evidence that ECPs reduce admissions to hospital, which dramatically changes their cost-effectiveness from an RoI of around 2 years to one closer to 18 months on the basis of two common conditions. Download the report from http://minney.org/Publications/SfH_ECP_32pp_Measuring_the_Benefits.pdf
The future for the Ambulance Service - July 2005
2005 saw the publication of "Taking Healthcare to the Patient: Transforming NHS ambulance services" by Peter Bradley CBE. I carefully researched the impact that differently trained paramedics could have for patient quality of care, and for the use of follow-on services. My specific brief was to determine whether it was possible (at that time) that 1 million emergency attendances (attendance at hospital A&E) could be avoided. I concluded (brought out further in "Measuring the benefits of the Emergency care practitioner" Sept 2004) that alternately trained paramedics could not provide the necessary care for patients but that fully trained emergency care practitioners could provide this, though to avoid 1 million attendances would require 11,000 ECPs to be trained. Remarkably coincidentally, Prof Sir George Alberti had asked how many ECPs could be delivered within 10 years, and I'd worked out a similar number based on the availability of (mainly nurses) willing to make the move, the pace of training vs need to keep staff on the front line, and the benefits that could be achieved vs need to spend only when the money is available. Download "Taking Healthcare to the Patient" here.