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HS&DR 19/118 - Non-medical workforce in urgent and emergency care settings supporting information



Commissioning Brief – Supporting Information

Closing date: January 16 2020 (two stage – Stage 1 to Stage 2)

The following is intended to provide further information on the background of this call but does not constitute an exhaustive review of the literature in this area.

Non-medical workforce in urgent and emergency care settings

The topic was prioritised in an engagement exercise with a cross-section of users of NIHR research and derived from the James Lind Alliance (JLA) Priority Setting Partnership (PSP) in Emergency Medicine. The topic also supports NICE Guideline 94 (Emergency and acute medical care in over 16s) research recommendation on effectiveness of physician extenders in secondary care [1].

The emergency care workforce is under significant pressure, with increasing demand, rota gaps, trainee attrition and workforce burnout [2]. Evidence about skill mix and new roles in Urgent and Emergency Care (UEC) settings is very complex and diverse with lack of role definition, scope of practice and standardisation of new and advanced roles. There is very limited evidence about skill mix within nursing teams and the wider workforce implications including impact on nursing teams [3].

Several studies have explored the effectiveness of non-medical clinical roles in UEC. A recently published NIHR (HS&DR) mixed method study showed PAs utilised in six hospitals in England positively contributed to the medical team in the ED, patient experience and flow, to supporting the clinical teams’ workload. Further research on the impact of PAs on patient experience, outcomes and service costs is required [4]; Halter and colleagues (2017) reviewed the impact of PAs in acute internal medicine, care of elderly, emergency medicine, trauma and orthopaedics, and mental health. PAs have been deployed to increase the capacity of a team, reducing waiting times, gaining throughput, continuity and medical cover. There is paucity of evidence from a realist perspective considering context, mechanisms and outcomes or process evaluation to clearly describe the intervention and clarify how it will be implemented and the mechanisms through which it will produce change, in a specific context [5].

In a literature review, evaluating new roles within emergency care concluded that non-medical practitioners such as emergency nurse practitioners (ENPs) reduced waiting time in emergency departments (EDs) and led to high level of patient satisfaction. However, the review identified a small but significant percentage of patients would not agree to be treated by an ENP. Several studies also reported that patients seen by ENPs were more likely to follow up in primary care subsequent to their initial ED visit and required further investigation [6]. A small qualitative study (2015) explored how ENPs viewed their role within the ED. The study was single site and included eight ENPs. Further research was recommended to gain better understanding into ENPs practicing in emergency settings and the views and opinions of other healthcare professionals [7].

Evans et al (2014) reviewed the evidence of paramedics trained with extra skills and how this impacted patient care and interrelating services such as General Practices or EDs. Evidence suggested paramedics working with enhanced skills are acceptable to service users and may be a viable means of reducing ED burden, provided referral services have the capacity for the extra referral from paramedics [8].

In 2006, Heart of England NHS Foundation Trust (HEFT) introduced a tailored training programme for senior nurse, paramedics and physiotherapists wanting to become advanced clinical practitioners across three sites: Birmingham Heartlands Hospital (BHH), Good Hope Hospital, Birmingham and Solihull Hospital. Evaluations at these sites showed positive outcomes such as admitting fewer patients to the ED who were subsequently discharged within 12 hours, clearer information on where, when and why senior reviews were required, and prescriptions written by ACPs were more complete and legible. However, there remains a paucity of evidence regarding autonomous non-medical practitioners [9].

The anecdotal evidence from the UK suggests that the deployment of non-medical practitioners in emergency care might have a range of beneficial effects, including: improved patient safety; reduction in cost; improved patient experience and patient satisfaction; improved staff satisfaction; improved learning culture; reduction in unnecessary admissions to hospital. However, there might also be negative effects, such as: adverse effects on patient safety; lower acceptance among patients; diffusion of responsibility and lack of acceptance among senior staff. In order to allow policymakers and health service organisations to evaluate these and other types of impact of non-medical practitioners in emergency care, it is important to examine the available evidence [10].

Relevant NIHR studies


  • HS&DR 10/1007/26 - Clinical Handovers within the Emergency Care Pathway and the Potential for Harm of Clinical Handover Failures. CI: Mark-Alexander Sujan. Published 2014.
  • HS&DR 10/1008/10 - The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care. CI – Joanne Turnbull. Published 2014
  • HS&DR 10/1007/53 – Decision making and safety in emergency care transitions. CI – Rachel O’Hara. Published 2014
  • HS&DR 08/1519/97 - The impact of changing workforce patterns in emergency and urgent out-of-hours care on patient experience, staff practice and health system performance. CI: Valerie Lattimer. Published 2010
  • HS&DR 08/1519/98 - A multicentre community intervention trial to evaluate the clinical and cost effectiveness of emergency care practitioners. CI Suzanne Mason; Published 2009
  • HS&DR 08/1304/063 - Evaluating models – an evaluation of specific acute hospital site reconfigurations in the context of identifying underlying principles for future. CI Peter Spurgeon; Published 2010
  • HS&DR 08/1310/049 - Investigation of organisational factors influencing waiting times in the Emergency Department. CI: Suzanne Mason. Published 2007
  • HS&DR 08/1204/029 - Reducing attendance and waits in A&E departments: a review and survey of present innovations. CI: Matthew Cooke. Published 2005
  • HS&DR 08/1203/031 – Enhanced or extended roles for Allied Health Professionals in the NHS. CI: Kathryn McPherson. Published 2004


  • HS&DR 15/145/06 - General Practitioners and Emergency Departments (GPED): Efficient Models of Care. Active. CI: Jonathan Benger. Start date – 06/2017; End: 05/2020
  • HS&DR 15/145/04 - Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments. Active. CI: Adrian Edwards. Start date – 03/2017; End: 02/2020
  • HS&DR 15/136/12 - Drivers of Demand for Emergency and Urgent CarE (DEUCE). In editorial. CI: Alicia O’Cathain, In-editorial
  • HS&DR NIHR127655 - An evaluation of the impact of online NHS111 on the NHS111 telephone service and urgent care system. CI – Janette Turner. Start date – 03/2019; End date – 06/2020

Other relevant studies


Published Reports

  • NHS Improvement. Safe, sustainable and productive staffing. An improvement resource for urgent and emergency care. National Quality Board 2018, Edition 1
  • RCEM. Guidance on reconfiguring Emergency services. The Royal College of Emergency Medicine 2017
  • RCEM. Securing the future workforce for emergency departments in England. The Royal College of Emergency Medicine 2017
  • Imison C, Castle-Clarke S and Watson R. Reshaping the workforce to deliver the care patients need. Nuffield Trust 2016


  • NICE [NG94] Emergency and acute medical care in over 16s: service delivery and organisation. National Institute for Health and Care Excellence 2018

Journal Articles

  • Schneider A, Weigl M. Associations between psychosocial work factors and provider mental well-being in emergency departments: A systematic review. PLoS ONE 2018; 13(6)
  • Gardner G, Gardner A, Middleton S, et al. Mapping workforce configuration and operational models in Australian emergency departments: a national survey. Australian Health Review 2018, 42 (3); 340-347
  • Crouch R and Brown R. Advanced clinical practitioners in emergency care: past, present and future. British Journal of Hospital Medicine 2018
  • Wold L, Perhats C, Clark A, et al. On the threshold of safety: A qualitative exploration of nurses’ perceptions of factors involved in safe staffing levels in emergency departments. Journal of Emergency Medicine 2017, 43 (2); 150-157
  • Reynard K. A clinical analysis of the emergency medicine workforce crisis. British Journal of Hospital Medicine, Themed Issue on Emergency Medicine 2014


  1. NICE. Guideline NG94 – Emergency and acute medical care in over 16s: service delivery and organisation. National Institute for Health and Care Excellence 2018
  2. NHS England, Health Education England, NHS Improvement and the Royal College of Emergency Medicine. Securing the future workforce for emergency departments in England, 2017.
  3. Dall’Ora C, Pope C, Crouch R, et al. Skill mix and new roles in Emergency and Urgent care: what is the evidence? Health Work: NHS Improvement 2017, Evidence Briefs 4.
  4. Drennan VM, Halter M, Wheeler C, Nice L, Brearley S, Ennis J, et al. The role of physician associates in secondary care: the PA-SCER mixed-methods study. Health Serv Deliv Res 2019;7(19)
  5. Halter M, Wheeler C, Drennan V, et al. Physician associates in England’s hospitals: a survey of medical directors exploring current usage and factors affecting recruitment. Clinical Medicine 2017, 17 (2); 126-31.
  6. Hoskins R. Evaluating new roles within emergency care: A literature review. International Emergency Nursing 2011, 19; 125-140.
  7. Lloyd-Rees J. How emergency nurse practitioners view their role within the emergency department: a qualitative study. International Emergency Nursing 2016, 24; 46-53.
  8. Evans R, McGovern R, Birch J, et al. Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature. Emerg Med J 2014; 31:594-603.
  9. Swann G, Chessum P, Fisher J, et al. An autonomous role in emergency departments. Emergency Nurse 2013; 21 (3), 12-15
  10. Sujan M, Howard-Franks H, Swann G, et al. Impact of advanced autonomous non-medical practitioners in emergency care: protocol for a scoping study.