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Abstract: New ways of working in critical care are emerging in response to increasing demands for care in the context of a limited critical care workforce. This review appraised the comparative safety, effectiveness and costs of new ways of working in critical care. All papers published in peer reviewed journals during 1990–2003 were utilised. A total of 933 potentially relevant papers were identified. Secondary sources including policy papers, and experts within the field were also used to inform this work. Initially 113 papers met the inclusion criteria. However, 58 of these described policy and secular trends in critical care and were therefore used only to provide background information. A total of 55 papers were then critically reviewed to provide academic focus on the subject area. Examples of comparative empirical research on new ways of working were limited, but the review revealed research activity in the areas of: impact of workload; nursing, medical and organisational factors affecting patient outcomes; and methods to support workforce calculations. The findings suggest that research into longer-term patient outcomes is needed together with a proactive and strategic interdisciplinary approach to practice, policy and research. [Copyright &y& Elsevier]

Objective To establish which generic attributes of general practice out-of-hours health services are important to the public. Methods A discrete choice experiment postal survey conducted in three English general practitioner (GP) co-operatives. A total of 871 individuals aged 20–70 years registered with a GP. Outcomes were preferences for, and trade-offs between: time to making initial contact, time waiting for advice/treatment, informed of expected waiting time, type of contact, professional providing advice, chance contact relieves anxiety, and utility estimates for valuing current models of care. Results Response rate was 37%. Respondents valued out-of-hours contact for services for reducing anxiety but this was not the only attribute of importance. They had preferences for the way in which services were organized and valued information about expected waiting time, supporting findings from elsewhere. Participants were most willing to make trade-offs between waiting time and professional person. Of the predicted utility for three models of care utility was higher for fully integrated call management. Conclusions Greater utility might be achieved if existing services are re-configured more in line with the government's fully integrated call management model. Because the attributes were described in generic terms, the findings can be applied more generally to the plethora of models that exist (and many that might exist in the future). The approach used is important for achieving greater public involvement in how health services develop. Few experiments have elicited public preferences for health services in the UK to date. This study showed valid preferences were expressed but there were problems obtaining representative views from the public. [ABSTRACT FROM AUTHOR]

Objectives To quantify service integration achieved in the national exemplar program for single call access to out of hours care through NHS Direct, and its effect on the wider health system. Design Observational before and after study of demand, activity, and trends in the use of other health services. Participants 34 general practice cooperatives with NHS Direct partners (exemplars): four were case exemplars; 10 control cooperatives. Setting England. Main outcome measures Extent of integration; changes in demand, activity, and trends in emergency ambulance transports; attendances at emergency departments, minor injuries units, and NHS walk-in centers; and emergency admissions to hospital in the first year. Results Of 31 distinct exemplars, 21 (68%) integrated all out of hours call management. Nine (29%) achieved single call access for all patients. In the only case exemplar where direct comparison was possible, a higher proportion of telephone calls were handled by cooperative nurses before integration than by NHS Direct afterwards (2622/6687 (39%) v 2092/7086 (30%): P < 0.0001). Other case exemplars did not achieve 30%. A small but significant downturn in overall demand for care seen in two case exemplars was also seen in the control cooperatives. The number of emergency ambulance transports increased in three of the four case exemplars after integration, reaching statistical significance in two (5%, -0.02% to 10%, P = 0.06; 6%, 1% to 12%, P = 0.02; 7%, 3% to 12%, P = 0.001). This was always accompanied by a significant reduction in the number of calls to the integrated service. Conclusion Most exemplars achieved integration of call management but not single call access for patients. Most patients made at least two telephone calls to contact NHS Direct, and then waited for a nurse to call back. Evidence for transfer of demand from case exemplars to 999 ambulance services may be amenable to change, but NHS Direct may not have sufficient capacity to support national implementation of the program. [ABSTRACT FROM AUTHOR]

Presents information on a study which evaluated whether nurse telephone consultation in out of hours primary care may reduce costs compared to general practice care. Concept of nurse telephone consultation; Methodology of the study; Results and discussion; Conclusions.

Presents a study which examined the effectiveness and safety of nurse telephone consultation in out of hours primary care. Methodology; Data and analysis; Interpretation of results.

Examines the provision of out of hours primary medical care in Great Britain. Demand for out of hours medical care; Cost of night visits; Out of hours care by telephone.

Objective: To examine the implementation of 'Advanced Access' as a means of improving access to primary care. Methods: Qualitative case studies of eight English general practices undertaken as part of a mixed method study. Results: There was considerable variation in the interpretation and implementation of Advanced Access. Practices claiming to operate this system often did not follow its key principles. Differences between practice access systems centred on the use of 'same-day' appointments. The association of Advanced Access with same-day appointment systems was problematic as it both created antagonism to, and diverged from, the Advanced Access model. Practice staff did not necessarily share the conceptualisation of demand that underpinned Advanced Access. Other policies and targets provided further incentives to diverge from the model and these factors were compounded by informal organizational behaviours, notably the exercise of discretion, which led to adaptation. Conclusion: Advanced Access was diluted because it became confused with same-day appointment systems and other incentives and targets. Its guiding philosophy of 'manageable demand' appeared counter-intuitive to staff in the context of general practice, which made its implementation problematic. As a result, the system was adapted and modified. [ABSTRACT FROM AUTHOR]

Objective: Extending the role of allied health professionals has been promoted as a key component of developing a flexible health workforce. This review aimed to synthesize the evidence about the impact of these roles. Methods: A systematic review of extended scope of practice in five groups: paramedics, physiotherapists, occupational therapists, radiographers, and speech and language therapists. The nature and effect of these roles on patients, health professionals and health services were examined. An inclusive approach to searching was used to maximize potential sources of interest including multiple databases, 'grey' literature and subject area experts. An expanded Cochrane Collaboration method was used in view of the anticipated lack of randomized controlled trials and heterogeneity of designs. Papers were only excluded after the search stage for lack of relevance. Results: A total of 355 papers was identified as meeting relevance criteria and 21 studies progressed to full review and data extraction. The primary reason for exclusion from data extraction was that the study included neither qualitative nor quantitative data or because methodological flaws compromised data quality. It was not possible to evaluate any pooled effects as patient health outcomes were rarely considered. Conclusions: A range of extended practice roles for allied health professionals have been promoted and are being undertaken, but their health outcomes have rarely been evaluated. There is also little evidence as to how best to introduce such roles, or how best to educate, support and mentor these practitioners. [ABSTRACT FROM AUTHOR]