An observational study in Emergencies, sponsored by Kingston University. Completed at 2 sites in United Kingdom. Per ClinicalTrials.gov, last updated 2025-09-22.
Sponsored by Kingston University · Observational
This study will explore the result of different skill-mix in ED/UTCs in England, to make recommendations about the best balance.
Patient and public involvement (PPI) representatives have helped design the study. There will be an independent PPI panel who can feed in their views and experiences to all parts of the study. The panel will be run by an experienced patient and public involvement expert, who is a member of the core study team.
The study will be split into four phases over two-and-a-half years.
Phase One will find out in detail what the staffing models are in EDs/UTCs. The investigators will look at published research evidence and at NHS public documents, and will interview regional and national senior NHS clinicians, managers, commissioners and lay representatives. Then, information about staff which is already collected regularly across England will be analysed for patterns. What non-medical practitioners do and how independently they work in two different ED/UTCs will also be examined. The panel of patient and public involvement representatives and a panel of non-medical practitioners will help interpret these findings. The study will develop a system for classifying 'skill-mix' in each organisation and a way to measure how much support and supervision non-medical practitioners need.
Phase Two will look at figures regularly collected from all NHS Trusts in England between 2017 and 2021, to assess whether different skill mixes lead to different patient outcomes. The number of patients who return again to the ED within a week is the primary outcome.
Phase Three will involve looking in detail in six ED/UTCs. The investigators will collect in depth local data to add to the national data we looked at in Phase Two. This will include looking closely at staff records and patients' clinical records to illustrate more detail about skill-mix in the organisations and the outcomes for patients. The study plans to gauge how independently the types of practitioners assess and treat patients and to also survey and interview patients so that their experience can be understood, alongside the views of staff who will also be interviewed.
Phase Four will pull all of the results together. The panels of patient and public involvement representatives and non-medical practitioners will help with this synthesis. The study aims to make recommendations on skill-mix and levels of independence that will deliver the best outcomes for patients, for staff and for the NHS.
Primary research question
What is the impact of different non-medical practitioner skill-mix in Emergency Departments (ED) and Urgent Treatment Centres (UTC) in acute hospitals on patient and service processes and outcomes?
Background
Increasing demand for emergency and urgent care has occurred alongside staffing shortage, particularly of doctors. Re-shaping of the workforce has resulted, including the introduction of non-medical practitioners (NMPs), such as nurse practitioners and physician associates. Despite 20 years of NMPs in EDs, there is limited evidence of effectiveness of individual roles, and none as to appropriate skill-mix of staff, at what level of independence from senior medical staff.
Aim
To explore how NMPs are being deployed and the impact of different skill-mix including NMPs in EDs and UTCs on patient experience, quality of care, clinical outcomes, activity, staff experience and costs in acute NHS trusts in England, in order to inform workforce decisions of clinicians, managers and commissioners.
Methods
A mixed methods study will be conducted in three phases.
Phase One (months 1-12) aims to describe the rationale for, and configurations of, the NMP workforce in EDs/UTCs in England, and to develop analytical tools.
Phase two (months 13-18) aims to utilise the analytical tools to assess the impact of skill-mix ratios on national ED/UTC indicators of quality.
•The investigators will conduct and publish a quasi-experimental study of associations of skill-mix ratio classifications with our primary outcome (rate of unplanned return to the ED/UTC in seven days, a proxy for clinical safety), secondary outcomes (national indicators of ED/UTC quality and performance), and cost-effectiveness. (WP4)
Phase three (months 13-24) aims to explain the effectiveness and acceptability of skill-mix ratios through investigation in six local-level case study sites.
In Phase four (months 25-30) the investigators will prepare a synthesis of findings, using the logic model, for structured discussion at a stakeholder event to prepare recommendations and outputs.
Timelines for delivery
The study will take place from March 2021 to August 2023.
Anticipated impact and dissemination
The research will generate new knowledge and understanding of optimum/most effective/impact of different skill-mix outcomes to translate into workforce models with our NHS partners. Commissioners, clinicians and managers will be able to assess their local skill-mix in relation to the guidance on (optimum) skill-mix outcomes. Dissemination throughout the study will include policy briefings, academic outputs, bite-size findings, conference presentations and social and mainstream media routes accessible to stakeholders.
Kingston University is the lead sponsor of 8 studies on the registry; none are open to participants now.
Counted across the registry records on this site, refreshed daily.
The study population varies for each of the study components, but is encompassed within the following:
Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.
Exclusion Criteria:
Doctor-in-training and non-medical practitioner volunteers
Other: Non-medical practitioners
Patients attending the Emergency Department of one of six NHS trusts participating in the research as a case study
Other: Non-medical practitioners
NHS organisations with an Emergency Department participating as a case study site
Other: Non-medical practitioners
NHS Trusts whose Emergency Department (n=183) records data is held by NHS Digital and will be provided anonymously/without individual patient consent (these anticipated hundreds of thousands of records are not included in the enrolled patient numbers)
Other: Non-medical practitioners
Patients attending the Emergency Department of one of six NHS trusts participating in the research as a case study and volunteering to take part in an interview following completion of the patient questionnaire
Other: Non-medical practitioners
Staff working in the Emergency Department of one of six NHS trusts participating in the research as a case study and volunteering to take part in an interview
Other: Non-medical practitioners
Senior NHS clinicians, managers, commissioners and lay representatives with roles and interests in the non-medical practitioner workforce
Other: Non-medical practitioners
All observational research activity in each cohort is related to the exposure of non-medical practitioners in the Emergency Department or Urgent Treatment Centre
Re-attendance
Re-attendance at the Emergency department following the index event
Time frame: 7 days
Left without being seen
Left Emergency Department before being seen for treatment
Time frame: up to 8 hours
Time to initial assessment
Time from patient arrival to being assessed by a clinician
Time frame: Up to 8 hours
Time to treatment
Time from patient arrival to being treated by a clinician
Time frame: Up to 8 hours
Total time
Time from patient arrival to leaving the Emergency Department
Time frame: Up to 8 hours
Clinical investigation
Clinical investigations recorded by the attending clinician in the Emergency Department
Time frame: Up to 8 hours
Treatment code
Treatments recorded using a code by the attending clinician in the Emergency Department
Time frame: Up to 8 hours
Onward referral /treatment complete
Patient's next destination recorded in the Emergency Department
Time frame: Up to 8 hours
Cost
Staff unit costs
Time frame: 1 hour
Stakeholder perspectives
Qualitative exploration of the factors and rationale influencing current and future ED/UTC workforce configurations and the inclusion of different types of NMPs
Time frame: Up to 6 months
Staff perspectives
Qualitative exploration of views of staff closely related to working with NMPs
Time frame: 3 months
Patient satisfaction
Quantitative measure of patient experience of being attended in Emergency Departments with differing skill-mix ratios
Time frame: 1 and 28 days
Patient perspectives
Qualitative exploration of views of patients attended in Emergency Departments with differing skill-mix ratios
Time frame: 28 days
Plan to share: No
No publications or documents are linked to this record.
This study is completed, as verified in Sep 2025. You cannot join it, but the record below documents what was studied.
Get an email when the registry record changes — status, dates, results — or when someone posts here.
Sign in to followQuestions and observations about this study, from anyone following it. Not medical advice, and not a channel to the study team — their contact details are on the registry record.
Sign in to join the discussion. Reading takes no account; posting does. You choose a display name, and a pseudonym is the default.
Nothing here yet. If you are running this trial, taking part in it, or weighing whether to, this is the place to say so.
Kingston University