1. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros MUNROS is funded by the European Commission FP7 programme, HEALTH-F3-2012-305467EC. Project co-ordinators Prof Bob Elliott, r.elliott@abdn.ac.uk and Prof Christine Bond, c.m.bond@abdn.ac.ukr.elliott@abdn.ac.ukc.m.bond@abdn.ac.uk www.abdn.ac.uk/munros New Roles for Health Professionals: Findings from the MUNROS Project Professor Robert Elliott, University of Aberdeen Professor Matt Sutton, University of Manchester Professor Christine Bond, University of Aberdeen

2. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Project Background and Design 1 Spending on workforce largest single item of health care expenditures in EU member states (around 2/3rds of total) New technologies and new protocols changing the way health care is delivered New professions and extended roles require changes to workforce planning models New and extended roles offer opportunities for enhancing delivery and containing costs MUNROS Partners chosen to capture health care systems which differ between: Bismarck and Beveridge In focus of delivery between primary and secondary care; In composition of health workforce; In levels of per capita health care expenditure;

3. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Project Design 2 System-wide comparisons of health outcomes and costs are challenging can offer only limited insight Health system heterogeneity due to differences between populations health status, health systems structures, use of drugs, and different technologies Detailed data required to enable like-for-like comparisons not available MUNROS FRAMEWORK Focus on three clinical conditions: – high prevalence in all partners; – all associated with significant morbidity and mortality; – all employ national guidelines and clinical protocols to determine treatment; cover a condition with high prevalence among >65’s, – and involve acute and chronic management and surgical procedures Heart Disease; Breast Cancer and Type 2 Diabetes Hospitals covering teaching; large general; other general; located in densely populated urban and small towns/rural

4. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Structure of Research Project PhaseWork Packages 1. Mapping health system integration, skill mix and competencies WP 1 Understanding health systems WP 2 Mapping skill mix 2. Methodology and study design WP 3 Case studies WP 4 Questionnaire design 3. Data collection, management and analysis WP 5 Impact on clinical practice and organisation of care WP 6 Outcomes: the patient experience WP 7 Outcomes: process, productivity and clinical effect WP 8 Changes in costs and benefits 4. Translation into policy: delivering impact WP 9 New professional roles and the integration of care WP 10 Management of human resources and successful workforce planning WP 11 Scientific structure, policy engagement, impact and dissemination 5. Scientific coordinationWP 12 Scientific co-ordination

5. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Consortium

6. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Understanding health systems & mapping skill mix Nine partner countries representative of different systems Workforce polices: regulation of junior doctors’ hours (England, Scotland, Netherlands) Payment systems: payment for clinical treatment conditional on physician delivering treatment (Germany) Technological advance: new roles for nurses as technology changes chronic disease management (Italy) New approaches to care: shift from secondary to primary care Professionalisation of non-medical health care professionals: degree-level entry requirement changes expectations of professions

7. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros WP2 findings: Mapping skill mix Three main groups of countries: o New professional roles have legal power and authority (England, Netherlands, Scotland and now Germany): Nurse Practitioners and Advanced Practice Nurses – New Professions o New professional roles are focussed on specialised care within the medical domain (Czech Republic, Germany, Italy, Turkey): Extended roles for established professions o Marginal development of new roles (Norway, Poland) Literature review revealed new professions produced improvements in o Access o Patient knowledge and satisfaction, o Clinical outcomes. Employed in many clinical areas: cancer, diabetes, other chronic diseases

8. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros WP3 findings: Case studies Impact of new professional roles is small but significant o Few new care professionals in new roles o Established professions set the rules o Tasks undertaken vary within countries and between local teams o Health care organisations are creating more new roles Contribution of new professional roles: o Increased throughput without increasing costs o Increased transparency of recording of procedures o Offered more patient centered care Tasks undertaken depend on attitude and flexibility of established professionals o Often a single individual – the team leader o Necessary to establish new professionals are knowledgeable and competent o Extension of roles results from assuming additional tasks to “get the job done”

9. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros MUNROS is funded by the European Commission FP7 programme, HEALTH-F3-2012-305467EC. Project co-ordinators Prof Bob Elliott, r.elliott@abdn.ac.uk and Prof Christine Bond, c.m.bond@abdn.ac.ukr.elliott@abdn.ac.ukc.m.bond@abdn.ac.uk www.abdn.ac.uk/munros Work Package 5: Survey of Health Care Professionals and Managers

10. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Questionnaire content Demographics Educational qualifications Hours worked Perceptions of integration and specialisation Drivers and barriers Factors influencing decisions Performance of tasks

11. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros 3,043 completed questionnaires All PathwaysManagersProfessionals Scotland56393 Germany41272 The Netherlands18105 Italy129134 Czech Republic182451 Turkey194494 Norway46126 England49304 Poland049* Total7152328

12. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Diversity of professional respondents on the pathways Consultant Junior Doctor General Practitioner Physician Associate Advanced Nurse Specialist Nurse General Nurse Health Care Assistant Pharmacist (Hospital) Pharmacist (Prescribing) Pharmacist (Community) Radiologist Advanced Radiologist Psychologist Physiotherapist Occupational Therapist Dietician Echocardiogram Technician Social Worker Medical Technician Laboratory Technician Medical Assistant Documentarist Data Controller Midwife GP Auxiliary Staff Angiogram Technician Podiatrist

13. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Average weekly hours worked (all countries) Professional Group Breast CancerHeart DiseaseType 2 Diabetes Total On pathway Total On pathway Total On pathway Medical 44.450%47.061%43.931% Nursing (Advanced/Specialist) 33.873%33.880%37.949% Nursing (General/Auxiliary) 37.962%37.685%39.071% Pharmacist, AHP, Other 37.241%40.241%39.235%

14. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Managerial decisions on staffing

15. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros How managers decide ‘who does what’ on breast cancer pathway

16. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros MUNROS is funded by the European Commission FP7 programme, HEALTH-F3-2012-305467EC. Project co-ordinators Prof Bob Elliott, r.elliott@abdn.ac.uk and Prof Christine Bond, c.m.bond@abdn.ac.ukr.elliott@abdn.ac.ukc.m.bond@abdn.ac.uk www.abdn.ac.uk/munros Work Package 6: Questionnaire survey of patient experience and satisfaction

17. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Questionnaire content 1.Patient’s health state – date of diagnosis, co-morbidities, health-related quality of life 2.Care received – professionals giving assistance at each treatment stage 3.Experience of care – perceived organisation of care and satisfaction 4.Use of healthcare services – type, quantity and quality of care received in each setting 5.Value placed on care received – willingness to pay for the “ideal visit” 6.Demographic and socio-economic characteristics

18. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros 3,307 completed patient questionnaires Type2 DiabetesHeart DiseaseBreast Cancer SCO128166153 GER-4199 NED-6299 ITA289395150 CZE9912272 TUR161145194 NOR196457 ENG83114194 POL94199163 Total87313081126

19. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Perceived organisation of care

20. Patient perceptions of organisation of care: breast cancer Mean values; 1 = strongly disagree, 5 =strongly agree

21. Average patient satisfaction: breast cancer Mean values: 1 = extremely dissatisfied, 7 = extremely satisfied

22. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Exploring skill mix: the task list We asked each healthcare professional: Do you personally undertake this as part of your normal duties for [pathway] patients? 92 tasks for breast cancer 51 tasks for heart disease 55 tasks for Type2 diabetes

23. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Examples from the task list (heart disease)

24. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Summary measure from the task lists Average proportions of tasks that doctors and nurses report undertaking Nurses do no tasks Doctors do no tasks Nurses and doctors do same number of tasks 0.00.51.0

25. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Nurse share of breast cancer tasks

26. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Nurse share of heart disease tasks

27. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Distribution across sites (breast cancer) Scotland Germany Netherlands Italy Czech Rep Turkey Norway England Nurse share of tasks

28. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros WP7: Processes, Productivity and Health Outcomes Objectives: to assess the impact of differences in skill mix at different sites (within and between countries) on: – Patient health outcomes (e.g. EuroQoL measures) – Patient experiences (e.g. satisfaction) – Processes and outcomes (e.g. readmissions) Data sources: – Patient questionnaires – Medical records – Register data : Scotland, Norway, England

29. Patient health and nurse share of tasks: site level variation Nurse share of tasks Patient health (difference from mean)

30. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Next steps Compare costs of delivering care in different ways Consider effect on integration of care and team composition Develop work force planning tools suitable for use in all European countries Provide information on key facilitators and barriers to involving different health care professionals to support workforce strategy

31. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros How much does care cost? Use data collected on health service utilization, productivity costs, and informal care to analyze the effects on costs of differences in skill mix Preliminary results: breast cancer past 3 month costs – HEALTH CARE COSTS: average €2,350 Lowest costs in Scotland (€1,140), highest costs in Germany (€6,040) Differences associated with differences in rate of hospitalisation and treatment procedures – SOCIETAL COSTS: average €2,570 220 Euros is mean productivity costs plus informal care – Multilevel, multivariate modelling suggests shifting tasks from doctors to nurses may reduce costs of breast cancer care

32. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Costs of BC care, all countries Mean health care costs over past three months: €2,350 Mean societal costs over past three months: €2,570 Cost category Mean Median Min Max SD% Visits to professionals 34 62 0 2,113 22682% Hospitalization 791 0 0 27,800 2,30232% Diagnostic procedures 141 88 0 3,168 22867% Treatment procedures 1,210 0 0 9,727 1,83244% Medication 76 19 0 1,169 12767% Total health care costs 2,353 911 0 37,995 3,38797% Productivity losses 190 0 0 1,740 45929% Informal care 31 0 0 1,512 13923% Total societal costs 2,574 1,234 0 38,193 3,54398%

33. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Costs of BC care, per country CountryN Mean Median Min Max SD% Czech Republic72 1,750 483 - 10,171 2,32099% England169 1,495 377 - 12,643 2,05996% Germany99 6,042 5,331 116 21,506 4,267100% Italy150 2,020 1,857 - 22,626 2,45899% Norway56 1,333 440 10 11,464 2,069100% Scotland153 1,138 99 - 21,048 2,50190% The Netherlands99 2,630 1,717 - 18,896 3,05594% Turkey191 2,815 1,472 - 37,995 4,35799% MUNROS total989 2,353 911 - 37,995 3,38797% Lowest costs in Scotland: €1,140 – Less hospitalization (-€460) and treatment procedures (-€550) Highest costs in Germany: €6,040 – More visits to professionals (+€380), hospitalization (+€1,490) and treatment procedures (+€1,760)

34. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Selecting the optimal team Comparing European and national guidelines for core team/wider team Deliver care according to skills and competencies The ideal team Survey data Case studies Map ‘ideal team’ to actual team The actual team Our data Cost effectiveness-clinical effectiveness Identify ‘gaps’ -country specific advice Identifying optimality

35. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Selecting the optimal team Comparing European and national guidelines for core team/wider team Deliver care according to skills and competencies The ideal team Survey data Case studies Map ‘ideal team’ to actual team The actual team Our data Cost effectiveness-clinical effectiveness Identify ‘gaps’ -country specific advice Identifying optimality Develop optimal models for team composition to deliver integrated care which gives best results for patients and is financially sustainable

36. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Management of human resources and successful workforce planning Develop a workforce planning tool – Multi-professional not uni-professional – Based on what needs to be done Projected disease prevalence and health care need Tasks needed to provide care to a patient with a particular disease – Combined with who can do it Information on which professional can deliver those tasks effectively Information from Regulators

37. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Bringing it all together What is known already Review of health systems Literature review 9 countries Primary data collection Case studies Questionnaires Routine data >100 hospital sites and primary care Using the data Health economic analysis Optimal models Workforce planning tool Applying theoretical approache s

38. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Bringing it all together What is known already Review of health systems Literature review 9 countries Primary data collection Case studies Questionnaires Routine data >100 hospital sites and primary care Using the data Health economic analysis Optimal models Workforce planning tool Applying theoretica l approach es Effective and Effficient Accessible Resilient

39. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Dissemination International National Local CMO/CNO meeting Luxembourg Munros conference Edinburgh Report to EC Special Issues Individual papers Clinician meetings Published output Meetings Summaries of findings/ peer comparisons National conferences Clinical meetings National briefing papers Professional journals

40. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Acknowledgements We thank o European Commission for funding this research programme ‘Health Care Reform: The iMpact on practice, oUtcomes and cost of New ROles for health profeSsionals (MUNROS), under the European Community’s Seventh Framework Programme (FP7 HEALTH-2012-INNOVATION-1) grant agreement number HEALTH-F3-2012-305467EC. o All those who supported and guided this work both within the MUNROS research project team and as external associates. o All the MUNROS research and project partners for their continuing collaboration in this research.

41. MUNROS is funded by the European Commission FP7 programme www.abdn.ac.uk/munroswww.abdn.ac.uk/munros Thank you-questions please The MUNROS partnership The team The health care team of the futureThe patientA MUNRO