title: A review of effective methods of delivery of care: skill-mix and service transfer to primary care settings.
abstract: OBJECTIVE
  Health policy in England is seeking to minimise hospital use and provide access to services in a primary healthcare setting and maximise skill-mix, driven by issues such as cost and access. The aim of this review was to determine the effectiveness of increased use of skill-mix and service transfer within general and oral healthcare. Secondary outcome measures were related to cost, quality, access, health outcomes and satisfaction.
  
  
  METHODS
  Data sources were the Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination DARE, British Nursing Index, CINAHL, EMBASE, MEDLINE, and PsycINFO from 1996 to August 2008. The reference lists of relevant papers were scanned to identify additional studies.
  
  
  METHODS
  A rapid appraisal of systematic reviews, randomised controlled trials, controlled trials and service evaluations in relation to specialist services, practitioners with a special interest, medical and dental, nursing and dental care professionals, together with evidence of service shifts from secondary to primary care was undertaken.
  
  
  RESULTS
  A total of 206 papers were reviewed. All titles and abstracts of articles and papers found were extracted and validated according to predefined criteria. They were screened for relevance by two researchers, who assessed trial quality and extracted data. Twenty-six papers met the inclusion criteria. The literature demonstrated limited evidence of the cost-effectiveness and health outcomes associated with changes in setting and skill-mix. However, there was evidence of improved access, patient and professional satisfaction.
  
  
  CONCLUSIONS
  There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.
authors.affiliation: Research Associate in Oral Health Services Research and Dental Public Health, King's College London Dental Institute, London, UK.
authors.forename: David M
authors.initials: DM
authors.lastname: Williams
authors.forename: Jibby
authors.initials: J
authors.lastname: Medina
authors.forename: Desmond
authors.initials: D
authors.lastname: Wright
authors.forename: Kate
authors.initials: K
authors.lastname: Jones
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Gallagher
mesh_terms: D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000458:organization & administration*; D003727:Dental Auxiliaries / Q000706:statistics & numerical data*; D005792:General Practice, Dental / Q000458:organization & administration*; D006291:Health Policy; D006302:Health Services Research; D006801:Humans; D009722:Nurse Practitioners / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care; D013039:Specialties, Dental / Q000458:organization & administration; D013218:State Dentistry / Q000458:organization & administration*; D006113:United Kingdom