Nursing in General Practice

The Toolkit for Nurses and Health Care Assistants

Pam Campbell, Anne Longbottom, Alison Pooler

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315347141
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This indispensable toolkit is full of practical hints and tips to enhance and develop the role of nursing in general practice. The user-friendly, straight-forward style makes it great for quick reference, bringing together all the basic information required to find a clear career path. This toolkit, along with the linked on-line material, prepares readers for adjusting their roles in accordance with patient needs, personal and professional aims and career aspirations. It is ideal for all nurses and health care assistants in general practice, including healthcare students wanting a career in general practice. Practice managers, PCT managers, health care educators and general practitioners will also find it of great interest.

1

The development of nursing
and health care assistant roles
in general practice

This chapter provides an introduction to the role of the nurse and the health care assistant working in general practice. It identifies the unique position for the roles and outlines the value of skill mix within general practice. It draws on national policy changes to demonstrate how the roles are changing and moving forward, and sets the context for the remaining chapters.

Contents

Introduction

Nursing in general practice

Defining nursing roles

Regulation

Complementary nursing roles: working together

Looking ahead

Progression of the nursing role in general practice

Summary

Introduction

General practice nursing is a relatively new branch of nursing that makes a unique contribution to patient care and has a significant part to play in the development of primary care. Nationally there are around 18,000 general practice nurses,¹ with only a small minority being employed directly by an NHS trust, and the majority being directly employed by practices. It is not known how many health care assistants work in general practice, but it thought to be a relatively small number in comparison. However, this number is likely to increase significantly in future as the importance of their role becomes recognised.

The Government White Paper entitled Our Health, Our Care, Our Say² states that ‘When people are asked about their local NHS, they probably think first of their GP.’ More than 90% of all patient contact takes place in primary care, and general practice offers patients and carers a point of contact for acute, routine and continuing care, and helps them to navigate through other parts of the health care system. Increasingly this includes consulting registered nurses such as nurse practitioners and practice nurses, as well as other health care professionals including physiotherapists, mental health counsellors and therapists, and non-registered staff such as health care assistants (HCAs).

General practice is facing a constant wave of new innovations, reorganisation and developments. As the number of general practitioners (GPs) and practice nurses due to retire in the next 10 years increases, new ways of working for the whole practice team will need to be considered. Across the country nurses are already developing new skills and taking on new responsibilities.³ The nursing role in general practice already encompasses services such as health promotion, family planning, treatment room care, minor illness and the management of chronic and long-term conditions such as coronary heart disease, asthma and diabetes. As the role expands still further, it is anticipated that nurses working in extended roles will:

• complement the quality of services provided by doctors
• safely substitute for doctors in a wide array of services
• reduce the direct cost of services.

A study by Walsh and colleagues in 2003⁴ examined the roles of practice nurses and found that they had:

• extended their clinical role to include diagnosis of simple and/or chronic conditions, plus their treatment and management
• developed a variety of innovative services and clinics to meet the needs of their local population
• developed a nurse triage service with a system tailored to suit the needs of the population that they serve.

The NHS Plan contained the Chief Nursing Officer’s 10 key roles for nurses,⁵ and these provided significant motivators for nursing in general practice to develop many new expanded roles, including nurse prescribing, diagnosis and assessment. Modernising Nursing Careers⁶ emphasises the increasing scope for nurses to develop a structured career progression.

Registered nurses will need to relinquish some of the more task-orientated roles that they have been used to undertaking in order to take on new expanded roles. With appropriate training, health care assistants can take on many of these activities. Well-trained and supported HCAs can bring huge benefits to patient care in general practice, especially when they are well integrated within the practice team.

Nursing in general practice

The NHS Plan recognised that patients’ expectations of the NHS and general practice are rising. Patients and carers want more convenient, quicker access to advice and treatment in health-related matters, and nursing has a key role to play in the delivery of patient-centred care. Many people are living longer and often have long-term or chronic illnesses that need to be managed. There is also a growing awareness among nurses of the need not only to respond to illness but also to prevent disease and promote health. Nurses working in general practice are in a position to help both opportunistically and, through planned intervention, to influence the health status of the estimated 98% of the general population who are registered with a GP.

National policies such as The NHS Plan,⁵ Liberating the Talents,⁷ National Service Frameworks, Commissioning a Patient-Led NHS⁸ and the management of long-term conditions have all had an impact on the general practice role. The NHS Plan suggests that ‘… it is about working smarter to make the maximum use of the talents of all the NHS workforce.’

The changing role

There is a clear Government commitment in Our Health, Our Care, Our Say² to move what have traditionally been seen as secondary care services into primary care settings. This will have major implications for primary care teams in terms of the services they will be able to deliver. Nurses working in general practice will be critical to the success of these reforms, as they take up expanded roles in nurse prescribing, increased clinical specialisation, providing out-of-hours services or partnership responsibilities.

The primary purpose of nursing is to provide holistic health care for patients, families, carers and communities. Nurses seek to maintain all aspects of the health environment, so that it is conducive to improving health, facilitating recovery from illness or rehabilitation and, where appropriate, achieving a dignified death.⁹ As nursing roles extend into areas of clinical competence that were once reserved for the medical profession, the essence of the nursing role that includes nurturing and caring could easily be lost. Health care assistants are ideally placed to provide additional support for patients in this way. The flexibility and responsiveness of general practice promote and encourage role development and autonomy which are highly valued by nurses. Indeed many nurses move into this area because they value working within a smaller clinical team. In 2002, the Wanless Report¹⁰ emphasised that services should focus on prevention and early intervention in health care, and that people should take more responsibility for their own health and that of their families. Nurses within general practice already have, or with training and support can gain, the knowledge and skills to help to achieve this through the management of long-term conditions and encouraging self-care and self-management by patients.

Defining nursing roles

General practice nurses

The range of work performed by nurses in general practice is getting broader, and historically has developed in an ad-hoc way depending on the needs of the practice. The plethora of job titles and variety of roles is well recognised, and poses a challenge to both the profession and the NHS in terms of defining jobs and levels of practice.

The Nursing and Midwifery Council (NMC) is working to provide transparency about the standards and qualifications that are required for nursing and has, for example, agreed that higher levels of practice should constitute a recordable qualification.¹¹ An NHS career framework promoted by Skills for Health¹² has identified advanced practitioners as a distinct category (on Band 7 of the Agenda for Change pay structure), and as the Department of Health’s Modernising Nursing Careers Review¹³ emerges, it is expected to provide formalised guidance for career progression to identify recognised routes to advanced practice status. The Working in Partnership Programme (WiPP)¹⁴ is striving to ensure that there is a recognised career and educational pathway for nurses working in general practice, from HCA to advanced nurse practitioner.

Blurring of medical and nursing boundaries

A study by Laurant and colleagues in 2005¹⁵ evaluated the impact of doctor–nurse substitution in primary care by patient outcomes, process of care and resource utilisation, including cost. It found that in general there were no appreciable differences between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. However, patient satisfaction was higher with nurse-led care, and nurses working in general practice tending to provide longer consultations, to give more information to patients and to recall patients more frequently than doctors. The impact on GPs’ workload and direct costs of care was variable. The findings suggest that appropriately trained nurses can provide care of equal quality to that provided by GPs within defined areas and achieve good health outcomes for patients. However, GPs’ workload may remain unchanged either because nurses are deployed to meet previously unmet needs, or because nurses generate a demand for care where previously there was none.

As primary care services develop, the need for high-quality, suitably qualified general practice nurses will continue to grow, and developing a good mix of skills at all levels within the team will be important for the safe delivery of patient care.

Health care assistants

Health care assistants (HCAs) have been in existence for many years,¹⁶ and they represented 17% of the 1.3 million NHS workforce in 2004. HCAs work in a variety of health and social care settings, undertaking direct patient care as well as doing non-clinical work. This is most common in secondary care settings in hospitals, although HCAs are also used in community services (district nursing), and increasingly are being used in general practice. As health services move away from traditional secondary care to primary care settings, and the age of the primary care workforce continues to increase, general practice will need to consider alternative ways to cover the day-today work that will arise from these changes. By reviewing the skill mix and workload of their staff, practices could develop the role of the HCA, resulting in a wider range of staff with a diversity of qualifications and skills providing hands-on care for patients.

The Wanless Report 2004¹⁷ estimated that 12.5% of the nurse’s workload could be undertaken by HCAs (across all sectors), with nurse practitioners taking on 20% of the work normally undertaken by general practitioners or junior doctors. By 2020 another 144,000 HCAs will be needed to undertake tasks previously performed by practice nurses. With increased competition between health care sectors for HCAs, general practice will need to ensure that it provides a rewarding and progressive career structure for HCAs.

Information and experiences identified in the Working in Partnership Programme (WiPP) Web-based toolkit for HCAs (www.wipp.nhs.uk) have shown that HCAs play an important role within the practice team in delivering patient care. Increasingly, appropriately trained, developed and integrated HCAs are undertaking work previously done by registered health professionals in order to meet patient and practice needs.

In the face of recent shortages, qualified staff have seen HCAs fill the gaps, providing the care that patients desperately need. More than ever, health care assistants are an essential part of the team.¹⁸ The development of the HCA role and integration into the practice team is vital to ensure that practices are ready to participate in the service redesign and modernisation of the future primary care sector.

Scope of the HCA role

An HCA is defined as ‘someone who works under the guidance of a qualified health care professional.’¹² However, this definition does not describe the variety of roles and activities undertaken by HCAs in general practice across the country. The title ‘healt...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• The Working in Partnership Programme
• Acknowledgements
• List of tools
• About the Authors
• Chapter 1 The development of nursing and health care assistant roles in general practice
• Chapter 2 Employment of nurses and health care assistants in general practice
• Chapter 3 Competence of nurses and health care assistants working in general practice
• Chapter 4 Education and training for nurses and health care assistants in general practice
• Chapter 5 Professional development and career planning for nurses and health care assistants
• Chapter 6 Working together: integration of nurses and health care assistants working in general practice with other health care professionals
• Chapter 7 Quality improvement and evaluating practice
• Index