This is the latest updated volume in a well-established series bringing together information from a variety of sources to estimate national unit costs for a wide range of health and social care services. This report consists of tables for more than 130 types of service which, as well as providing the most detailed and comprehensive information possible, also quotes sources and assumptions so users can adapt the information for their own purposes. This year we have included a guest editorial on ‘Big Data’: increasing productivity while reducing costs in health and social care and three short articles on The cost of integrated care; Shared lives – improving understanding of the costs of family-based support and the costs of providing a group intervention to people with dementia and their family carers:SHIELD: RYCT & CSP intervention costs (Remembering Yesterday Caring Today and Carer Support Programme). There are also several new schema providing the costs of: advocacy for people with learning disabilities; a hospice rapid response service; the early years classroom management programme; residential parenting assessments; independent review officers; time banks; dentists and care home costs for people with dementia. The 2014 edition is also available in full, free of charge, at the PSSRU website www.pssru.ac.uk/unit-costs/2014/ as an Acrobat file.

Unit Costs of Health and Social Care 2014

Objective: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting. Design: Systematic review of randomised controlled trials and prospective observational studies. Data sources: Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies. Included studies: Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care. Results: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations. Conclusion: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care. What is already known on this topic Nurse practitioners have existed in North America for many years An increasing number of such nurses are being employed in the United Kingdom in general practice, emergency departments, and other primary care settings Reviews suggest that nurse practitioners are equivalent to doctors on most variables studied, but the relevance of this in the context of the NHS is unclear What this study adds Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes Nurse practitioners provide longer consultations and carry out more investigations than doctors Most recent research has related to patients requesting same day appointments for minor illness, which is only a limited part of a doctor9s role

https://www.bmj.com/content/bmj/324/7341/819.full.pdf

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

Background
Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care.

Objectives
Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.

Search methods
The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix).

The searches for this review were conducted in 2002 and are now out-of-date and therefore the review findings should be used with caution. The review is currently being updated and the updated version should be published before the end of 2014.

Selection criteria
Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses.

Data collection and analysis
Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes.

Main results
4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable.

In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

Authors' conclusions
The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.

While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.

Substitution of doctors by nurses in primary care

This is the twelfth volume of a series designed to improve unit cost estimates over time, drawing on material as it becomes available, including ongoing and specially commissioned research. It brings together information from a variety of sources to estimate national unit costs for a wide range of health and social care services.

The costs reported always reflect, to a greater or lesser degree, work in progress, as the intention is to refine and improve estimates wherever possible, drawing on a wide variety of sources. The report consists of sets of ‘schemata’ or tables, which as well as providing the most detailed and comprehensive information possible, also quote sources and assumptions so users can adapt the information for their own purposes. Also included are: an editorial discussing current and new developments; brief articles providing background to user services, descriptions of cost methodology or use of cost estimates; price indices; a reference list of key studies; a glossary; and indexes.

New in this edition: This volume includes a considerable expansion of information about the costs of child social care services, based largely on the results of a series of studies commissioned under the Department of Health's Costs and Effectiveness of Services for Children in Need research initiative. Also included is information on the cost-effectiveness of screening and referral to an alcohol health worker in alcohol-misusing patients attending an NHS accident and emergency department. Information about the costs of a nurse practitioner in primary care is also included for the first time.

There are five brief articles: description of the methodology used and resulting unit costs of the adoption process and of supporting families; a brief article identifying the processes involved and the costs to social services of carrying out core assessments for children and their families; a description of the processes undertaken by social services and the factors associated with the variation in costs of child care; description of the evaluation of the costs and outcomes of Home-Start — a well-established national and international organisation offering support to families with young children experiencing difficulties; and information about a detailed study of family interventions and the costs of services used by families requiring support.

/pdf/unit-costs-of-health-and-social-care-2004-4g2t0zmosb.pdf

Unit Costs of Health and Social Care 2004

In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.

Can health care teams improve primary care practice

Objective: To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care. Design: Multicentre randomised controlled trial of patients requesting an appointment the same day. Setting: 20 general practices in England and Wales. Participants: 1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations). Main outcome measures: Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs. Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28). Conclusions: The clinical care and health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners.

https://www.bmj.com/content/bmj/320/7241/1048.full.pdf

B Leese.

Papers

Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

Provision of services for patients requesting a ‘same-day appointment’ in primary care: A comparison of nurse practitioners and general practitioners