Evaluating NHS workforce innovations in urgent and emergency care (UEC) settings 


by Colin O’Keeffe and Suzanne Ablard

New or extended staff roles are an innovative response to the complex challenges facing the NHS, such as increasing demand, staff burnout, staff retention and declining service performance. (1) (2)  This is no more the case than in urgent and emergency care (UEC) settings, where sustained patient pressures require a committed workforce that can meet patients’ needs appropriately and safely, whilst reducing the current excessive and costly dependence on hospital services. (3)

Key examples of the new roles are:

  1. Advanced paramedic practitioners (APPs). APPs train as paramedics and then receive additional education (including to Masters level) and clinical training to operate as autonomous practitioners in a range of UEC settings. Paramedics working in extended roles were originally introduced to improve the patient experience in UEC, working across traditional care boundaries and limiting unnecessary journeys to hospital. (4) 
  2. Advanced Clinical Practitioners (ACPs). ACPs come from a variety of health backgrounds including nursing, pharmacy, paramedics and occupational therapy. Educated to master’s level they are characterised by an ability to work autonomously, undertaking complex tasks such as assessing patients, making diagnoses and discharging patients (similar level to a mid-grade medical staff). They are able to work in any healthcare setting including UEC. (5) 

It is crucial that health service research evaluates these new roles to see if they are delivering on their potential to improve the working lives and careers of staff and contribute to better, more patient focused experiences. The Centre for Urgent and Emergency Care (CURE) at ScHARR (6) has undertaken large-scale national evaluations of paramedic practitioners (PPs) and Emergency Care Practitioners (ECPs). Both of these roles were the forerunners of the current Advanced Paramedic Practitioner role.  

Two large controlled trials evaluating PPs/ECPs were carried out from 2003-2013, to measure their impact on patient care, safety and the staff themselves across different UEC and geographical settings. (7) (8)  The two trials demonstrated that PPs/ECPs were operating as safely as established staff (such as GPs) and were as acceptable to patients as the staff they were substituting.  There was variation however in the benefits to patient care, depending on the UEC setting in which they operated.  7 8  Both studies underpin the evidence for NICE clinical guidance on the use of Advanced Paramedic Practitioners. (9)

Within one trial design (7), we also carried out surveys and interviews with ECPs, to understand their expectations and experiences in the roles and job satisfaction.  Meeting role expectations and associated satisfaction varied in the different geographical study sites. For example, in some sites ECPs filled gaps in local UEC provision that their training had done little to prepare them for, such as paediatric urgent care. In such instances, they had little positive impact on patient care, affecting their job satisfaction negatively. Career pathways after achieving ECP status were also limited. (10) 

ARC YH Advanced Care Practitioner (ACP) evaluations

CURE is continuing its workforce research, evaluating the ACP role as part of the ARC YH UEC theme programme. (11)

The first ARC YH evaluation is exploring ACP’s experience of developing clinical competence and opinions on role identity. Using a qualitative study design we are conducting focus groups with trainee and qualified ACPs working across primary, secondary and mental health care to find out:

  • The factors that have influenced their clinical competence achievements (e.g. training experience both in clinical practice and external education opportunities; experience of educational and clinical supervision; self-identified knowledge gaps; opportunities to undertake clinical placements in different departments; and availability of supernumerary time).
  • Views on the role identity of ACPs as part of the multi-disciplinary team and NHS workforce going forwards.
  • Views on the long-term career progression of ACPs. 

To date, we have conducted 4 focus groups. Formal analysis has not been undertaken yet, but preliminary findings suggest ACPs are highly ambitious and keen to seek out opportunities for self-improvement. Specifically, many ACPs said they were attracted to ACP training because it provided them with an opportunity to develop their clinical skills to a more advanced level without having to move into a nursing management role, therefore maintaining high levels of patient contact: 

“I wanted a bit more clinical contact and that’s why I didn’t want to go back onto the department at my level cos I would be a manager and I didn’t want to be managing and sat behind a desk doing planning and things that like I wanted to be patient contact.”

Early findings also show there is significant variation in the experiences of ACP training with some ACPs experiencing a very structured training programme, whereas others less so. ACPs on structured training programmes appear to be more satisfied and have clearer goals and objectives with regards to their training compared to those on less structured programmes:

“They are responsible for organising their own placements, their own education so to speak, outside of University arranging their own placements, arranging who they are going to work with, there is no structure to that program at all.”

The second ARC YH project is evaluating a Health Education England South West (HEESW) NHS training programme for trainee Emergency Care ACPs. The training programme aims to create greater standardisation of ACP training between different EDs. (12) (13)  Initially the training programme is being piloted across 5 EDs in the South West but it is hoped this will expanded in the future. As part of the training programme, trainees are expected to work towards credentialling against the Royal College of Emergency Medicine (RCEM) ACP curriculum. The credentialling process confirms that the ACP has reached a specified standard of clinical care, by the presentation of evidence of delivering that standard in practice. 

Through the ARC we have been commissioned to undertake an independent evaluation of the new HEESW training programme to:

  • Explore ACP experiences of undertaking the new HEESW pilot training programme compared with non-pilot trainee ACPs, including views on career progression.
  • Identify barriers and facilitators to the implementation of the new HEESW pilot training programme and how the pilot training programme could be improved in the future

The evaluation will involve administering surveys and undertaking one-to-one interviews with trainee Emergency Care ACPs enrolled on the HEESW pilot training programme, as well as those who are undertaking an alternative Emergency Care ACP training programme. We will also conduct one-to-one interviews with strategic leads who were involved in the set-up and running of the HEESW pilot training programme. 


The landscape of the emergency care workforce has undoubtedly changed in the UK over the past 15-20 years.  Introducing and integrating innovative roles such as the ACP successfully into different healthcare settings is challenging but can bring many benefits. CURE’s past workforce evaluations and the current ARC YH ACP research helps assist the understanding of how new roles operate in practice towards making recommendations on how they evolve in the future.


  1. Sibbald B, Shen J, McBride A. Changing the skillmix of the healthcare workforce. Journal of Health Services Research and Policy 2004;9 (Suppl 1):28-38.
  2. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database for Systematic Reviews 2005;18 (2): CD001271.
  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. NHS Modernisation Agency. The emergency care practitioner report—right skill, right time, right place. London: Department of Health, 2004.
  5. Royal College of Nursing.  Advanced Level Nursing Practice – Introduction, 2018.  Available from: https://www.rcn.org.uk/professional-development/publications/pub-006894 (Accessed 06/07/19)
  6. Centre for Urgent and Emergency Care, University of Sheffield: https://www.sheffield.ac.uk/scharr/research/centres/cure
  7. Mason S, Knowles E, Colwell B, Wardrope J, Dixon S, Gorringe R, Snooks H, Perrin J, Nicholl J. Paramedic Practitioner Older People’s Support Trial (PPOPS): A Cluster Randomised Controlled Trial. British Medical Journal, Nov 3;335(7626):919, 2007. https://www.bmj.com/content/335/7626/919.long
  8. Mason S, O’Keeffe C, Knowles E, Patterson M, O’Hara R, Campbell M, Bradburn M. A pragmatic quasi-experimental multi-site community intervention trial (NEECaP) evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways. Emergency Medicine Journal, Emerg Med J. 2012;29 (1):47-53
  9. National Institute for Clinical Excellence (NICE). Emergency and Acute Medical Care in over 16s: Service Delivery and Organisation. NICE guideline NG94, 2018.
  10. 10. Mason S, O’Keeffe C, Coleman P et al. A Multi-Centre Community Intervention Trial to Evaluate the Clinical and Cost Effectiveness of Emergency Care Practitioners. Report for the National Institute for Health Research Service Delivery and Organisation programme, 2009.
  11. ARC Yorkshire and Humber. Find at: https://www.arc-yh.nihr.ac.uk/what-we-do/urgent-care.
  12. NHS Health Education England, Advanced Clinical Practise.  Available from: https://www.hee.nhs.uk/our-work/advanced-clinical-practice (Accessed 25/08/19)  
  13. Royal College of Emergency Medicine, Royal College of Nursing, NHS Health Education England. Emergency Care Advanced Clinical Practitioner Curriculum and Assessment, Version 1.0, April 2015.

Related Blogs

Overflow in Urgent Care: Are Non-Urgent Patients the Culprit?

Read about the research we conducted to try to answer this question by using a detailed dataset, the Emergency Care Dataset (ECDS), and how we tried to understand the post-pandemic urgent care attendance trends.

Is “Winter pressure” on urgent and emergency care now seen all year?

As we head into Winter, urgent and emergency care services in the NHS prepare for additional demand associated with the colder months. But recent research funded by the NIHR and HDRUK suggests that the highest levels of demand previously only seen during Winter are now affecting urgent care services year round.

Creating the CUREd dataset – a real world linked data for Urgent and Emergency Care 

In this blog, our Urgent and Emergency Care theme look at real world linked dataset ‘The CUREd Database’ and its potential to provide solutions to the challenges facing urgent and emergency care.