Skill-mix interventions with a focus on transitional care

Improving the transition from one setting to another is critical for patients with acute conditions, as there is a risk of disruption in service delivery. Transitional care is defined as the various points where a patient moves to, or returns from, a particular physical location or makes contact with a health care professional for the purposes of receiving health care. This includes transitions between home, hospital, residential care settings and consultations with different health care providers in outpatient facilities (World Health Organization, 2016).

Skill-mix interventions to improve transitional care were analysed in 20 systematic reviews emanating from the overview of reviews. All reviews evaluated interventions before, at, or immediately after discharge from hospitals to ambulatory care services. The skill-mix interventions were clustered into transitional care roles performed by various professions. These reviews did not differentiate between the professions that performed the role of coordination or case management. Four and five reviews, respectively analysed the effects of transitional care roles led by pharmacists and nurses, whereas two reviews specifically analysed patient navigator roles for older people (Table 5.1). Although the skill-mix interventions varied across the reviews, they all had in common that the main tasks were to improve the coordination and transitioning of care between the inpatient and outpatient sectors.

The reviews evaluated the effects of several, often bundled, interventions. These included discharge planning, care coordination, home visits, shared care plans, multisectoral care collaboration across social and health sectors, as well as care coordination between hospital and ambulatory care providers.

• Nine systematic reviews focused on transitional care roles and pre- and post-structured discharge interventions. Case management was central to all reviews, but interventions in one review combined health and social care to collaboratively provide primary care-based follow up for stroke patients post-discharge from hospital. The interventions comprised medication reviews, assessment of disability and caregiver needs. It also included the provision of information and linkage with other services provided by social workers, stroke support workers, care coordinators, case managers, GPs and caregivers (Reference Allison, Shelling and DennettAllison et al., 2011). Seven reviews covered a range of different interventions such as home visits or rehabilitation in addition to case management delivered by nurses, pharmacists, family physicians or case managers (Reference Domingo, Reyes and ThompsonDomingo et al., 2012; Reference Feltner, Jones and CenéFeltner et al., 2014; Reference Hansen, Young and HinamiHansen et al., 2011; Huntley et al., 2013; Reference Langhorne and BaylanLanghorne & Baylan, 2017; Reference Rennke, Nguyen and ShoebRennke et al., 2013; Reference Vedel and KhanassovVedel & Khanassov, 2015). Multiprofessional teams were introduced in the transition from paediatric to adult care settings for patients with juvenile onset rheumatic and musculoskeletal diseases. Transitional care teams that focused on the care transitioning across the two different phases of life (paediatric to adulthood) encompassed at least a transition coordinator, paediatric and adult rheumatologist trained in adolescent rheumatology and a clinical nurse specialist as well as several other professionals (Reference Clemente, Leon and FosterClemente et al., 2016).

• Pharmacist-led transitional care focused primarily on medication reviews and reconciliation and patient counselling at the hospital–home interface (De Oliviera et al., 2017; El Hajj et al., 2014; Reference Ensing, Stuijt and van den BemtEnsing et al., 2015; Reference Mekonnen and McLachlanMekonnen, McLachlan & Brien, 2016). Nurse-led transitional care interventions often covered more interventions compared with pharmacists, including discharge planning and coordination, home visits and patient assessments, among others (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015; Reference Huntley, Johnson and KingHuntley et al., 2016; Reference Joo and LiuJoo & Liu, 2017; Reference Verloo, Chiolero and KiszioVerloo et al., 2017; Reference Zhu, Liu and HuZhu et al., 2015). However, pharmacists were unique in providing expert medication reviews and reconciliation services.

• Two reviews covered patient navigator roles performed by different professions. The reviews included a wide range of interventions, but most of them focused on the role of patient navigation providing discharge planning and follow up, education and multiprofessional collaboration (Reference Le Berre, Maimon and SourialLe Berre et al., 2017; Reference Manderson, Mcmurray and PirainoManderson et al., 2011).

Skill-mix interventions focusing on the relocation of care

Four reviews summarized the evidence on skill-mix interventions resulting from re-location of care settings (Table 5.2). All analysed hospital-at-home services.

Table 5.2

Summary of reviews: skill-mix interventions and relocation of care from hospital settings to patients’ homes

Abbreviations: CI: confidence interval; COPD: chronic obstructive pulmonary disease; ESP: extended scope-of-practice physiotherapists; GP: general practitioner; RR: relative risk.

Country abbreviations: AU: Australia; CA: Canada, DK: Denmark; ES: Spain; IT: Italy; NO: Norway; NZ: New Zealand; RO: Romania; SE: Sweden; UK: the United Kingdom; USA: the United States of America.

Sources: [1] Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al. (2017); [2] Reference Qaddoura, Yazdan-Ashoori and KabaliQaddoura et al. (2015); [3] Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al. (2017); [4] Reference Jeppesen, Brurberg and VistJeppesen et al. (2012)

Three reviews, including two Cochrane reviews, analysed the effects of shifting care location from hospitals to home in which various professions were involved, a concept referred to as hospital-at-home, in which a specialized team provides active treatment in the patient’s home for a disease that usually would require hospital inpatient stays. Randomized controlled trials covered different patient groups: stroke, mixed conditions, elective surgery (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017), heart failure (Reference Qaddoura, Yazdan-Ashoori and KabaliQaddoura et al., 2015) and acute episodes of chronic obstructive pulmonary disease (COPD) (Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017). The interventions comprised several new team and skill-mix models, including teams working in hospital outreach services, community-based teams, as well as teams enhancing coordination of care across the settings. The professions covered a range of both specialists and lay workers, including specialist physicians and social care workers, various therapists (speech, etc.), care assistants, home helps and volunteers (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017; Reference Qaddoura, Yazdan-Ashoori and KabaliQaddoura et al., 2015; Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017).

Another Cochrane review focused on hospital-at-home skill-mix interventions. This time delivered by a specialist respiratory nurse under guidance of a medical hospital team targeting patients with acute exacerbations of COPD (Reference Jeppesen, Brurberg and VistJeppesen et al., 2012).

Skill-mix interventions focusing on new division of work for (minor) acute illnesses

New division of work for acute, often minor, illnesses was the focus of four reviews (Table 5.3). The triage of patients with acute musculoskeletal conditions was shown to be as effectively performed by physiotherapists with extended scopes-of-practice as by physicians. The role of physiotherapists with extended scopes-of-practice in the triage involved assessments of patients, undertaking diagnostic procedures and onward referrals to other departments, surgery or community services such as rheumatology and orthopaedic services (Reference Oakley and ShackladyOakley & Shacklady, 2015).

Table 5.3

Summary of reviews: skill-mix interventions and new division of work for (minor) acute illnesses

Abbreviations: ESP: extended scope-of-practice physiotherapists; PMAS: pharmacy-based minor ailment schemes.

Country abbreviations: AU: Australia; CA: Canada; CN: China; IE: Ireland; HK: Hong Kong; NL: the Netherlands; NZ: New Zealand; SE: Sweden; UK: the United Kingdom; US: the United States of America.

Sources: [1] Reference Oakley and ShackladyOakley & Shacklady (2015); [2] Reference Paudyal, Watson and SachPaudyal et al. (2013); [3] Reference Wright, Graham and HayesWright et al. (2013); [4] Reference Dasanayake, Brar and MattaDasanayake et al. (2012)

A systematic review that covered studies in the United Kingdom found that pharmacy-based and pharmacy-led minor ailment schemes were effective in the management of minor acute illnesses. It resulted in generally high patient satisfaction and improved GP satisfaction, as well as reducing costs of prescribing by 25% (Reference Paudyal, Watson and SachPaudyal et al., 2013).

Two reviews analysed the effects of extending the role of mid-level dental care workers by taking over tasks that have traditionally been performed by dentists. One review focused on caries treatment for patients with acute dental health care needs as a means to expand the dental care workforce in primary care and reduce dentists’ workloads (Reference Wright, Graham and HayesWright et al., 2013). The other review assessed interventions such as irreversible procedures or local anaesthesia performed by dental hygienists and assistants (Reference Dasanayake, Brar and MattaDasanayake et al., 2012).

Transitional care

All 20 reviews (Table 5.1) on transitional care skill-mix interventions found them to be associated with improvements in at least one patient-related or health-system-related outcome measure. There was no evidence on profession-specific outcomes.

Positive effects were found with transitional care roles performed by various professions for patients with stroke and heart failure. Skill-mix changes focused on improving transitional care reduced mortality in stroke patients (Reference Langhorne and BaylanLanghorne & Baylan, 2017). Moreover, home visits and clinic-based interventions focusing on easing transitions were associated with a decrease in mortality in patients with heart failure (Reference Feltner, Jones and CenéFeltner et al., 2014). Other positive effects ranged from improved knowledge about the condition (Reference Allison, Shelling and DennettAllison et al., 2011), improved self-management (Reference Manderson, Mcmurray and PirainoManderson et al., 2011), adherence to appointments (Reference Clemente, Leon and FosterClemente et al., 2016) and medication (El Hajj et al., 2017; Reference Verloo, Chiolero and KiszioVerloo et al., 2017) and increased patient satisfaction (Reference Zhu, Liu and HuZhu et al., 2015). Several positive benefits were also identified for caregivers (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015; Manderson et al., 2012).

Pharmacist-led transitional care was found to significantly reduce medication errors in one review (De Oliviera et al., 2017), whereas a second review showed mixed results on adverse drug events (Reference Ensing, Stuijt and van den BemtEnsing et al., 2015). Nurse-led transitional care was associated with improved treatment and medication adherence (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015).

Overall, there were mixed effects on mortality. In two studies, mortality was significantly reduced for patients receiving transitional care, based on meta-analyses (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015; Reference Le Berre, Maimon and SourialLe Berre et al., 2017) and one showed improved mortality rates (Reference Feltner, Jones and CenéFeltner et al., 2014). One review showed a non-significant reduction (Reference Langhorne and BaylanLanghorne & Baylan, 2017), one review showed mixed results (Reference Ensing, Stuijt and van den BemtEnsing et al., 2015) and one showed no significant difference for all-cause mortality (Reference Mekonnen and McLachlanMekonnen, McLachlan & Brien, 2016).

Regarding health-system-related outcomes, transitional care was shown to reduce emergency department visits in the pharmacist-led models (De Oliviera et al., 2017; Reference Ensing, Stuijt and van den BemtEnsing et al., 2015; Reference Mekonnen and McLachlanMekonnen, McLachlan & Brien, 2016), and with mixed results emanating from the reviews analysing nurse-led and mixed-profession-led transitional care (Reference Huntley, Johnson and KingHuntley et al., 2016; Reference Le Berre, Maimon and SourialLe Berre et al., 2017) and case management and structured discharge (Reference Allison, Shelling and DennettAllison et al., 2011). In the case of nurse-led transitional care, hospital readmissions and hospital length of stay were reduced (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015; Reference Huntley, Johnson and KingHuntley et al., 2016; Reference Joo and LiuJoo & Liu, 2017; Reference Zhu, Liu and HuZhu et al., 2015). Transitional care interventions delivered by various professions showed a significant reduction in readmission rates (Reference Vedel and KhanassovVedel & Khanassov, 2015) or mixed results (Reference Rennke, Nguyen and ShoebRennke et al., 2013). Several reviews analysed the costs and efficiency of transitional care interventions, of which one found lower costs in nurse-led case management across care settings for patients (Reference Huntley, Johnson and KingHuntley et al., 2016), one demonstrated reduced costs for nurse-led transitional care for at-risk pregnant women and low-birthweight newborns (Reference Bryant-Lukosius, Carter and ReidBryant-Lukosius et al., 2015), one reported cost savings associated with the difference in readmissions in the pharmacist-led intervention (El Hajj et al., 2017). Inconclusive (Reference Manderson, Mcmurray and PirainoManderson et al., 2011) or mixed (Reference Joo and LiuJoo & Liu, 2017) evidence on costs was also shown.

Skill-mix and relocation of care

Meta-analyses showed that hospital-at-home skill-mix models were associated with a reduced risk of living in an institutional setting for stroke patients at follow up (for example at 6 months) and for patients with multiple medical conditions, as well as slight improvements in patient satisfaction (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017). Reduced likelihood of living in residential care was also found in Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al. (2017). Hence, there is some evidence to suggest that hospital-at-home may delay admission to residential care and nursing homes. In all three patient groups reported in Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al. (2017), the length of inpatient hospital stay was significantly reduced, but mixed results were found in Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al. (2017). The two Cochrane reviews on hospitals-at-home showed no or little difference on mortality (Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017) at 3–6 months for stroke patients (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017). Little or no difference on hospital readmission was reported in two reviews (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017; Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017). Mixed results on costs were reported in one review (Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017). The third systematic review on hospital-at-home for patients with heart failure reported improved quality of life, decreased readmissions and a reduction in the total costs (Reference Qaddoura, Yazdan-Ashoori and KabaliQaddoura et al., 2015).

The Cochrane review that focused on hospital at home interventions for patients with COPD delivered by a specialist respiratory nurse showed a small significant reduction in readmission rates and a non-significant effect for mortality rates. Mixed results on patient satisfaction and a significant reduction in direct costs were found in the review (Jeppesen et al., 2017).

New division of work for minor acute illnesses

Only one review highlighted profession-specific outcomes in terms of satisfaction of GPs with the skill-mix intervention (Reference Oakley and ShackladyOakley & Shacklady, 2015). The review on triage performed by extended scope-of practice physiotherapists showed high patient and physician satisfaction with their overall performance in terms of diagnostic accuracy. The evidence was based on a total of 14 studies in six countries assessing the correctness of the diagnoses, after physiotherapists were trained in performing triage functions. This review states, however, that there may be a lack of robustness to the evidence making it difficult to generalize findings to all extended scopes-of practice in musculoskeletal triage, especially in terms of the different aspects of satisfaction. There is also insufficient evidence concerning the content and length of training for triage purposes. Extended scopes-of practice have a variety of clinical roles; these need to be clearly described and updated with current extended scope-of practice clinical practice/competencies to allow findings to be of relevant clinical value (Reference Oakley and ShackladyOakley & Shacklady, 2015).

In the review by Reference Wright, Graham and HayesWright et al. (2013), all studies with mid-level dental hygienists performing expanded procedures for acute dental conditions (such as caries) were associated with reductions in caries over time, less untreated caries and mixed results in the treatment of caries severity, suggesting that mid-level providers can take care of minor, routine caries cases and expand access to services. Reference Dasanayake, Brar and MattaDasanayake et al. (2012) demonstrate that tasks performed by dental hygienists show equal quality compared with dentists, and they also find high success rates in giving local anaesthesia and in carrying out reversible and irreversible procedures. Increased productivity, reduced waiting times and patient satisfaction were also reported.

Results of pharmacy-based minor ailment consultations by pharmacists suggest that these are being managed well and are less costly than by a general practitioner. Moreover, the review’s findings show significantly fewer GP consultations and an overall satisfaction or positive attitudes among patients, GPs and pharmacists (Reference Paudyal, Watson and SachPaudyal et al., 2013).

Education and training of professions involved in the skill-mix changes

While the majority of reviews provided information on the professions involved in the skill-mix changes, few reported details on the education, competencies and skills they acquired. Also, when comparator groups were mentioned, their education was not reported.

Overview of recent trends across Europe and internationally

Recent trends in skill-mix innovations in acute and transitional care across Europe and internationally have focused on discharge and transition from hospital to ambulatory community care and home settings; relocating care to the lowest level (hospital-at-home) and new forms of division of work for minor acute illnesses in primary outpatient care. New models of care have emerged, involving the utilization of new skills of existing providers. The expanded roles of two key professions, nurses and pharmacists, are emphasized in the literature, but there are also expanded roles of physiotherapists (particularly in the triage function), radiographers and physician assistants, and of team-based interventions more generally. We highlight some of the key trends below.

Transitional care

Expanded roles of nurses and pharmacists are two of the more recent innovations to ensure smooth discharge and transition from acute care.

Expanded roles of nurses

In several countries, the role of nurses in care coordination from acute to community settings has been expanded. Having nurses and other clinical staff involved in transitioning care can help in both identifying patients at high risk and focusing interventions to reduce readmissions and improve quality of care.

In the Netherlands, recent transitional care interventions include the Transitional Care Bridge programme for acutely hospitalized older patients, combining a Comprehensive Geriatric Assessment, an integrated care plan and a transitional care programme, including visits during hospitalization and soon after discharge by a community nurse (Reference Buurman, Parlevliet and AlloreBuurman et al., 2016). Another intervention in the Netherlands, coordinated by nurses and directed at outpatients with a recent coronary syndrome included guidance on lifestyle factors, biometric risk factors and therapy adherence (Reference Jorstad, von Birgelen and AlingsJorstad et al., 2013). The nurse-coordinated Cardiac Care Bridge transitional care programme aimed to reduce unplanned hospital readmission and mortality in older hospitalized cardiac patients at high risk of readmission and mortality. In this programme, a cardiac research nurse develops an integrated care plan with the patient, is involved with a community nurse in handover and discharge, and a community nurse visits the patient four times after discharge. Participating nurses followed a 5-day training course on case and disease management (Reference Verweij, Jepma and BuurmanVerweij et al. 2018).

In Germany, secondary prevention after acute hospital episodes is provided by a number of actors, including GPs and nurses. However, no home-based early post-discharge programmes are available. Several intervention trials explored whether a post-discharge nurse-based case management could improve health outcomes and reduce readmissions. The KORINNA (“Coronary infarction follow-up in the elderly”) study, for example, evaluated the effects of nurse-based case management for older patients discharged after an acute myocardial infarction from a tertiary care hospital. The intervention consisted of a nurse-based follow up for 1 year including home visits and telephone calls (Reference Meisinger, Stollenwerk and KirchbergerMeisinger et al. 2013).

In the United States of America (USA), the Centers for Medicare & Medicaid Services are implementing a range of policies to reduce readmissions. This includes penalties for hospitals with 30-day readmissions above their expected rates and support for demonstration projects aimed to improve the transition from hospital to the community (Reference Linden and ButterworthLinden & Butterworth, 2014). Hospitals have responded with a range of transitional care interventions, including in some cases an expanded role for nurses (Reference Jones, Lawrence and LadebueJones et al., 2017). A nurse-driven intervention in an acute care hospital in California, for example, aimed to reduce readmissions through a multifaceted approach during hospitalization with pre-discharge planning and post-discharge follow up (Reference Dizon and ReinkingDizon & Reinking, 2017). The intervention involved the hiring of a nurse outpatient care manager for those patients discharged home who performed home visits and follow-up phone calls, follow-up phone calls by a nurse practitioner for high-risk patients discharged to a skilled nursing facility, a review of discharge instructions for high-risk patients by a pharmacist, and medication reconciliation by pharmacist technicians.

Skill-mix and relocation of care

Several countries have implemented or are evaluating new skill-mix models that are also linked to the re-organization of care. One frequently mentioned example is hospital-at-home. However, other models are specialized clinics (for example, heart failure clinic) or new roles and locations, such as intermediate care, all aiming at reducing hospital admissions and stays and providing care as close to patients’ homes as possible.

While hospital-at-home service delivery has been adopted in the USA and Australia, the idea has also been taken up in some European countries such as the United Kingdom, Germany and Switzerland as an alternative to standard hospital care. Highly specialized and experienced health professionals are required to provide quality care. A hospital-at-home programme to avoid hospital readmissions involving advanced practice nurses is described in Box 5.2.

A United States-based study examined the effect of a multiprofessional team-based specialized Heart Failure clinic on 90-day readmission rates or all-cause mortality (Reference Jackevicius, de Leon and LuJackevicius et al., 2015). The team consisted of a physician assistant, clinical pharmacist specialist and case manager, with care overseen by a cardiologist. Prompt outpatient follow up was identified as specifically important in the case of heart failure because of a high risk of hospital readmission and mortality.

A Canadian study involved an advanced practice nurse (specifically a nurse practitioner) in an intermediate care role for patients discharged from an acute care hospital to home who were at high risk for acute care readmission (Reference Neiterman, Wodchis and BourgeaultNeiterman, Wodchis & Bourgeault, 2015).

This intervention, which involved the nurse practitioner completing a personal health record with patients outlining and reconciling their medication, laboratory tests and primary care visits, helped to effectively triage patients by attending to their medical as well as social needs during post-discharge recovery.

An expanded role for pharmacists to help avoid hospital admissions or readmissions has also emerged as a trend internationally. Countries in which the role of community pharmacists has been expanded in recent years include Australia, Canada, England, the Netherlands, Scotland, and the USA (Reference Mossialos, Courtin and NaciMossialos et al., 2015). There are notable divergences in scope of practice across the United Kingdom. England has defined different tiers of community pharmacist roles in terms of the effective, safe and efficient use of medicines and the prevention and management of chronic conditions. Not all pharmacies provide all services, and many are commissioned locally. In Scotland, provision of the majority of extended services is a core contractual requirement; that is, every pharmacist will provide them. In Canada, the scope of practice of pharmacists has also expanded in recent years, shifting from more traditional functions such as medication dispensing towards services such as minor ailment prescribing, medication reviews, immunizations and strategies to promote medication adherence (Reference Kelly, Young and PhilipsKelly et al., 2014).

The roles of physiotherapists in triage at emergency departments to avoid acute care admissions have been expanded in recent years in several countries, including the United Kingdom, the Netherlands and Australia. In the above-mentioned, nurse-coordinated Cardiac Care Bridge transitional care programme in the Netherlands, for example, physiotherapists provided two home-based cardiac rehabilitation sessions per week during the first 6 weeks post-discharge in older hospitalized cardiac patients at high risk of readmission and mortality (Reference Verweij, Jepma and BuurmanVerweij et al., 2018).

In Australia, an expanded role of physiotherapists in emergency departments has been extensively funded since 2012. A study on the implementation of an expanded scope-of-practice physiotherapist role in a regional (that is, rural) hospital emergency department found that this role included increased autonomy in management and discharge of patients treated in the emergency department and independent ordering and interpreting of plain film X-rays (Reference Goodman, Harvey and CavanaghGoodman et al., 2018). For sustainability in rural areas, a larger advanced-level physiotherapy workforce with easier access to expanded scope training was recommended (Reference Bird, Thompson and WilliamsBird, Thompson & Williams, 2016).

Finally, physician assistants, a profession established in the USA in the 1960s, are now also being introduced in Europe, especially in the United Kingdom (since 2003), but also in Germany (since 2005).

Early studies of their implementation in the United Kingdom suggest that they are being deployed in primary care and out-of-hours centres as well as in hospital settings. A current limitation to their role is that they are not a regulated United Kingdom profession and therefore are not allowed to prescribe, but expectations are that this will ultimately be addressed. Observational studies suggest that patient satisfaction is high and outcomes are good (Reference Farmer, Currie and HymanFarmer et al., 2011). One study in 12 English general practices for same-day consultations included 2086 patients and showed that processes and outcomes of physician assistants and GP consultations were similar, but physician assistants cost less per consultation (Reference Drennan, Halter and JolyDrennan et al., 2015).

Treatment of minor, acute illnesses in primary and ambulatory care settings

Skill-mix innovations in the treatment of minor acute illnesses in primary, community and ambulatory care also involve the use of new and expanded roles. This is perhaps most extensive in the case of nursing and community pharmacy.

A number of countries have implemented programmes in which the unscheduled acute care of patients with minor illnesses is delivered by nurse practitioners. These programmes are based on extensive evidence that indicates that nurse practitioners can provide patients who have minor illnesses with a high standard of care similar to that provided by GPs. Some countries, such as the United Kingdom, Canada and the USA, have also allowed nurse prescribing in primary care (Bhanbro et al., 2011).

There have also been initiatives in a number of countries to expand the role of community pharmacists, for instance in Switzerland (see Box 5.3). Swiss pharmacists in community pharmacies are providing care and triage for patients with minor acute conditions. In the United Kingdom, far-reaching reforms have taken place. There, contractual frameworks recognize new roles of community pharmacies, including the provision of advice on and administration of vaccines, the provision of a minor ailment service, a chronic medicine management service including repeat dispensing, and many public health services, the most important of which is the provision of smoking cessation advice. Especially in Scotland, community pharmacy staff are responsible for the vast majority of successful quit attempts. These extended roles are further enhanced by the granting of prescribing rights to pharmacists (and nurses) who undertake a short (25 days of study, plus 12 days supervised practice) post-qualification, university-based course. This has enhanced the ability of pharmacists to manage a wider range of minor ailments, such as a urinary tract infection, whereby antibiotics can now be prescribed by an independent prescribing pharmacist according to an agreed local protocol or through an alternative arrangement called a “patient group directive”.

Research evidence underpinned these developments. Early work (Reference Sinclair, Bond and LargueSinclair et al., 2006) showed that pharmacist-led care for rhinitis resulted in good outcomes, which were similar to those of a group of patients who had seen their GP. Most recently, the Minor Ailment Study (MINA) programme of work has looked at the real-world evidence for this service after national roll-out (see Box 5.4).

In the United Kingdom, pharmacists are also increasingly employed in settings other than the hospital or community, and there have been government initiatives to increase pharmacy capacity within both GP surgeries and care homes. Pharmacists regularly run patient clinics for patients with diabetes, coronary heart disease, diabetes, asthma, COPD and sexual health services, and provide advice to GPs on their medicine management. As in the management of minor ailments, research suggests that pharmacists with prescribing rights can manage patients effectively, with outcomes as good as or better than those from GPs, at least in certain defined conditions such as chronic pain (Reference Bruhn, Bond and ElliottBruhn et al., 2013). Studies in Canada have also confirmed the success of pharmacist prescribing interventions (Reference Famiyeh and McCarthyFamiyeh & McCarthy, 2017).