Sunday 18 May 2008

Case Study - funding for training ECPs

In olden days, physicians delivered care in hospitals, and primary care was delivered by witches. OK very olden days, but it took a long time before it was acceptable for a doctor to deliver care in the patient home (Edinburgh Medical School 1760s), and certainly the 'scoop and run' ambulance service originally designed to recover the wounded from the field of battle in the Crimea has no intention of delaying a patient reaching the safety of the hospital right up until now.
But things have changed. Hospital A&E began filling up due to a number of factors, the principle ones being a maximum 4 hour wait (access to care) and less easy access to GPs (new GMS contract). In rural areas where hospitals are often distant from the patient need another factor contributed - ambulances could be tied up taking a patient to hospital which played havoc with response time targets.
What was needed, so Warwick Univ, East Anglia Ambulance Trust (EAAT), Joint Royal Colleges Ambulance Liaison Committee (JRCALC), and just about everyone else but completely independently, decided, is a practitioner who can
  • respond to a request for unscheduled care at the scene of the accident or need
  • treat minor injury or illness on the spot and discharge the patiet fully treated (or stabilised to see their GP in due course) or refer the patient to a non hospital pathway
  • thus saving both attendance at A&E and possible admission
EAAT put a community nurse and a paramedic into the same car to see how it would work. Warwick Ambulance Trust designed a training course to teach paramedics the bits of nurse training and nurses the bits of paramedic training - both resulted in an advanced practitioner (single person) with years of experience delivering health care and the minor injuries, minor illness and referral bits of a nurse and trauma and live sustaining bits of a paramedic. A few arguments later and the name Emergency Care Practitioner or ECP was born.

How much benefit did they bring (and how much did they cost)?
I embarked on a detailed exercise to find out how many patients the average ECP would divert from A&E by treating at home or referring to another pathway, and how valuable this would be. At the same time both Sheffield Univ (ScHARR) and I researched how much the average ECP cost to train, including equipment, car, backfill, etc.
The results are published in "The ECP Report: Right Skill, Right Time, Right Place" (Sept 2004). Each Whole Time Equivalent ECP saved around £26,500 overall whilst working on emergency responses, taking into account the number of saved ATTENDANCES at A&E, their higher salary and cost, the times they had to call an ambulance for the patient, etc. We had no idea how many admissions they would save so we didn't include it in the calculations (this came later, ramping the benefits up in "Measuring the benefits of the emergency care practitioner" (July 2007).
Each ECP cost around £40,000 to train including backfill whilst on training, uniform, equipment, medicines, etc. This means it takes less than 3 years (allowing 1 year whilst they qualify) to get your investment back.

The explosion in numbers
With clear numbers, ambulance trusts began training ECPs and there are now (4 years later) nearly 1000, which indicates an investment by tens of NHS Trusts of £40million.

Difficulties encountered
It hasn't been plain sailing.
The benefits (A&E avoidance is given above, but they also worked in Out of Hours and A&E or Walk-in Centre settings) didn't benefit the ambulance trust who paid for the savings, they benefitted the Primary Care Trust. Ambulance Trusts either had to swallow a considerable sum in training, or negotiate for a paymet from the PCT.
At the same time ambulance trusts were hit with a new response time target and perceived that experienced paramedics spending perhaps 2/3 of their time on non-ambulance duties starved them of staff to meet this target (I modelled London's response times and showed they could do even better by training up a critical mass of ECPs - but see next)
Politics got in the way. Driven by a few people who hadn't invented the ECP, ambulance trusts began to clamour for an "advanced paramedic" who could avoid A&E admissions but not do any of the other ECP things like Out of Hours or Walk-in Centre. Research showed that it was the rotation (especially time spent in A&E) that really caused the change of behaviour but this was politics, not evidence.

Where are we now?
In spite of the above ECPs are providing care in large numbers throughout England, employed by ambulance trusts, primary care trusts, GP surgeries and private companies. The title isn't yet regulated because this is a long and drawn out process, but the evidence is there that this new practitioner, the first successful really new practitioner for decades, really is a cost-effective solution delivering excellent patient care. Of course none of this could have happened if it hadn't been an excellent solution, but without clear numbers it would have been difficult for trusts to justify putting ££millions into training up ECPs to deploy them.

With massive and heartfelt thanks to my friends on the ECP national team who made the ECP happen in the first place and gave me the support I needed to prepare the benefits case: Chris Wintle, Belle Connell, Mark Bilby, John Gosnold, George Alberti, and so on; and at Changing Workforce Programme and Skills for Health who kept on supporting ECP programme.

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