Implementation of the non-medical practitioner workforce into the emergency and urgent care system skill-mix in England: a mixed methods study of configurations and impact.

The SkillMix-ED Study

This study is funded by the National Institute for Health Research (NIHR Health Services and Delivery Research, NIHR131356 – Implementation of the non-medical practitioner workforce into the urgent and emergency care system skill-mix in England: a mixed methods study of configurations and impact).

The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.

What are we studying?

Increasing demand for emergency care has occurred alongside staffing shortage, particularly of doctors. Re-shaping of the workforce has resulted, including the introduction of non-medical practitioners, such as nurse practitioners and physician associates in Emergency Departments and Urgent Treatment Centres. Non-medical practitioners is a generic term for qualified staff from other health professions who are trained to undertake some of the work of doctors in training grades. Despite 20 years of non-medical practitioners being employed in Emergency Departments, 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.

The aim of this study is to explore the impact of different skill-mix of staff, including non-medical practitioners, in Emergency Departments and Urgent Treatment Centres on patient experience, quality of care, clinical outcomes, activity, staff experience and costs in acute NHS trusts in England. We are investigating the optimal balance of doctors, nurses, and non-medical practitioners in NHS Emergency Departments and Urgent Treatment Centres in order to inform workforce decisions of clinicians, managers and commissioners.

How are we studying these questions and issues?

The study will be carried out in four phases.

Phase One will find out in detail what the staffing models are in Emergency Departments/Urgent Treatment Centres. We will look at published research evidence and at NHS public documents, and we will interview regional and national senior NHS clinicians, managers, commissioners and lay representatives. Then, we will look for patterns in information about staff which is already collected regularly across England. We will look at what non-medical practitioners do and how independently they work in two different Emergency Department/Urgent Treatment Centres.

We will ask a panel of patient and public involvement representatives and a panel of non-medical practitioners to help us to understand these findings. We will develop a system for classifying ‘skill-mix' in each organisation. We will also think of 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. We will look especially at the number of patients who return to the Emergency Department within a week.

Phase Three will involve looking in detail in six Emergency Department/Urgent Treatment Centres. We 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 tell us more detail about skill-mix in the organisations and the outcomes for patients. We will gauge how independently the types of practitioners assess and treat patients. We will also survey and interview patients so that we can understand their experience, and we will interview staff for their views.

Phase Four will pull all the results together. We will ask our panels of patient and public involvement representatives and non-medical practitioners to help us again. We will make recommendations on skill-mix of staff, at what level of independence from senior medical staff that will deliver the best outcomes for patients, for staff and for the NHS. Identifier:


What will we do with our findings?

We will publicise our findings and evidence-based recommendations with professional, patient and public groups. We will use presentations, summaries, web-based video and social media to share our findings with patients, staff and employers. We will regularly update this web page.

How long is the study?

The study is being conducted over three-and-a-half years and started in March 2021.

Who is funding the study?

This study is an independent research project funded by the National Institute for Health Research Health Service and Delivery Research. Our National Institute for Health Research funding number is: NIHR131356.

The NIHR award page is

How are we taking into account the views of the public and patients?

Patient and public involvement representatives have helped design the study. We have formed an independent Patient and Public Involvement panel who can feed in their views and experiences to all parts of the study. The panel is run by a patient and public involvement expert, who is a member of the core study team.

How are we taking into account the views of practitioners?

Throughout this study, we will hold a number of meetings with both our Non-Medical Practitioner panel and Study Steering Committee.

The role of the Non-Medical Practitioner panel is to contribute emergency department/urgent treatment centre non-medical practitioner views and opinions on all aspects of the SkillMix-ED study. Members of the panel were selected from responses to a call for participants circulated on social media by the Royal College of Emergency Medicine Advanced Clinical Practitioner Chair. The professional backgrounds of our Non-Medical Practitioner panellists broadly covers nurses, paramedics, and physiotherapists, from diverse geographic regions of England.

The role of the Study Steering Committee is to provide oversight of the project on behalf of the Project Sponsor and Project Funder. Members of the Study Steering Committee were drawn from a broad variety of professional backgrounds and include: NHS healthcare professionals, members of professional healthcare organisations, Patient and Public Involvement representatives, and experts in emergency and urgent care provision.

Who is the Study Team?

  • Mary Halter, Associate Professor Emergency Cardiovascular and Critical Care Research (joint Chief Investigator), Kingston University
  • Vari M Drennan, Professor of Health Care & Policy Research (joint Chief Investigator), Kingston University
  • Sally Brearley (PPI lead), Kingston University
  • Jonathan Gabe, Emeritus Professor of Sociology, Royal Holloway, University of London
  • Heather Gage, Professor of Health Economics, University of Surrey
  • Heather Jarman, Professor & Consultant Nurse in Emergency Care / Clinical Academic Lead, St George's University Hospitals NHS Trust
  • Dezso Marton, Consultant in Emergency Medicine, Surrey and Sussex NHS Healthcare Trust
  • Francesca Taylor, Research Project Manager and Research Associate, Kingston University
  • Chao Wang, Senior Lecturer in Statistics, Kingston University
  • Sakshi Adhav, Research Associate, Kingston University

How can I find out more about the study and its progress?

If you have any questions or want to find out more, you can contact the core study team directly:

You can follow the study's progress on Twitter @SkillmixE


Mailing list

If you wish to be added to the mailing list for study updates please email with ‘Subscribe to newsletter' in the subject heading.

Presentations and publications

Kingston University data protection privacy notice for the study

In this research study we will use information from you. We will only use information that we need for the research study. We will let very few people know your name or contact details, and only if they really need it for this study.

Everyone involved in this study will keep your data safe and secure. We will also follow all privacy rules.

We will make sure no-one can work out who you are from the reports we write.

What is this privacy notice about?

This privacy notice explains how Kingston University ("we", "our", "us") collects, uses and shares your personal data (information) and your rights in relation to this data. The notice relates to our processing of personal data we hold about you regarding the above-named study ("you", "your").

Kingston University is the data controller of your personal data and is subject to the General Data Protection Regulation (the "GDPR") and the UK Data Protection Act 2018. We are listed on the Information Commissioner's Office (ICO) register of fee payers. A copy of our Data Protection Policy is available online.

This privacy notice answers the following questions:

What is the role of the project?

The study is a National Institute of Health Research funded study exploring what balance – the 'skill mix' - of non-medical practitioners, doctors and nurses is best in emergency departments and urgent treatment centres.

How will we use information about you?

We will need to use information from you for this research project. We will collect in a number of ways, for example:

  • directly from your interview responses should you participate in the research
  • when you communicate with us by letter, telephone or email
  • from your contact details if you informed us you wish to receive study updates.

We will keep all information about you safe and secure.

What types of information do we collect about you?

This information will include:

  • your name and contact information such as work and/or personal email address or phone number (interviews or receiving study updates)
  • information relating to your professional status such as your job title and clinical or managerial expertise (staff interviews only).

How will we use your information?

We use your personal data in different ways depending on the stage of your interaction with us. For example, we process your contact information to arrange a suitable interview time with you. We then process the personal data you choose to provide via the interview and/or for staying in contact for study updates for the purposes of our study.

Further details about the use of interview and/or staying in contact are provided in the information for participants that we have also sent to you.

What legal basis do we have for processing your information?

The legal basis for processing your personal data is "task in the public interest".

We believe that we have a legitimate interest in conducting academic research and have considered the potential impact on you. You can ask us to stop processing your personal data and we will remove them.

Who will we share your information with?

We will share your personal data with a limited number of people internally within our research team where there is a legitimate reason for their receiving the information i.e., to make contact with you.

Please note that no personal data will be passed on to the study funders as any information provided to them will be anonymised.

For how long will we keep your information?

Your personal data will be kept for the time necessary to complete the analysis for the research project. It will then be anonymised. The consent to participate in the research form with your name and signature will be kept in a separate electronic file to the study data for ten years after the end of the study and then destroyed (2034). We will ask for your consent separately for contact details if you wish to receive copies of any published journal article (anytime up until December 2025) and/or the final report (expected to be published by NIHR 2025).

How do you make sure my information remains accurate?

We will hold your data only for a short period of time, which reduces the likelihood that any data will become inaccurate. Furthermore, all personal data will be provided by you.

What are your choices about how your information is used?

You can stop being part of the study at any time, without giving a reason, but we will keep information about you that we already have.

Under the GDPR and the UK Data Protection Act 2018, you have the following rights:

  • to access from us the personal data we hold about you
  • to require us to correct the personal data we hold about you if it is incorrect
  • to require us to erase your personal data
  • to require us to restrict our data processing activities (and, where our processing is based on your consent, you may withdraw that consent, without affecting the lawfulness of our processing based on consent before its withdrawal)
  • to receive your personal data, which you provided to us, in a structured, commonly used and machine-readable format and the right to transmit that data to another controller
  • to object, on grounds relating to your particular situation, to any of our particular processing activities where you feel this has a disproportionate impact on your rights
  • to not be subject to a decision based solely on automated processing, including profiling, which has a legal effect on you.

Please note that the above rights are not absolute and we may be entitled to refuse requests where exceptions apply.

If you have given your consent and you wish to withdraw it, please contact Dr Mary Halter

Where can you find out more about how your information is used?

You can find out more about how we use your information

If you wish to request access to the personal data we hold about you please use the contact above in the first instance. Alternatively, you can use the Kingston University Subject Access Request Form available online.

If you are not satisfied with how we are processing your personal data, you can make a complaint to the Information Commissioner.

You can find out more about your rights under data protection legislation from the Information Commissioner's Office website.

Faculty of Health, Science, Social Care and Education