Since the Francis Report in 2013, staffing has been an area of concern for the NHS. With the recent revelation around the spend on agency staff, the looming retirement crisis in primary care nursing and the lack of specialist roles, the nursing profession is on a knife edge.
As patient contact in general practice will escalate over the next few years, many believe that the primary care workforce must be transformed to deal with the demand. As a result Health Education England (HEE) has commissioned 205 places for physician associates (PAs) to ease the workload on GPs and act as preliminary contacts for patients.
However, PAs and advanced nurse practitioners (ANPs) both work at Band 7, so why have two types of practitioner working at the same level? Some believe that the NHS should invest in as many different workforces as possible to plug the gap.
Others have questioned the need for funding new workforces, when ANPs can do the job, and many of them can also prescribe. In an opinion piece in IN ANP Ghislaine Young questions why ANPS are not being actively recruited and trained when, as a workforce, they have been around for a quarter of a century. If 'we are to keep patients out of hospital and manage them in the community, we need more staff. ANPs will work autonomously assessing, treating, medicating and discharging patients,' says Kirsty Armstrong, ANP and senior lecturer at Kingston University, London.
'ANPs fit seamlessly into this clinical area and many others,' she adds.
Confusion over advanced practitioner role
One of the biggest issues around the ANP workforce is the lack of recognition and understanding of what an ANP does.
'I think the Royal College of Nursing (RCN) probably needs to do more to make the role visible and I think nurse practitioners themselves often find themselves as an isolated group within the workforce,' says Dr Michelle Drage, chief executive of Londonwide LMCs, which describes itself as the professional voice of general practice in London. 'I think they have a huge amount to offer that is not made clear to everybody else.'
The RCN published a document in 2008 and updated it in 2012, outlining the key training, duties and pathway of an advanced nurse practitioner.1
Marina Lupari, the RCN's professional officer for primary and community nurses, says that it recognises ANPs are a workforce of extreme importance and is working on a career framework that clearly sets out what it means to be an ANP at Band 7. 'We are carrying out a lot of work to raise awareness of the ANP role, from working with the Royal College of General Practitioners (RCGP) to produce competencies as well as creating a career framework for general practice nursing, which includes ANPs.'
Yet, the NMC still does not recognise ANPs and has not yet made the decision to regulate the role.
Melanie Rogers, an ANP and committee member of the International Council of Nurses' advanced nurse practitioner network' says: 'In terms of countries with the developed role, Britain is the only country that hasn't regulated it. Around 10 years ago, it was definitely going for regulation but then for some reason the NMC decided against it. We need standardisation across education institutes to deliver the same training for ANPs,' Ms Rogers adds.
Ms Lupari says that the NMC is moving away from the concept of recordable qualifications. 'The NMC says there is no requirement for the ANP qualification to be recorded so they deem the framework a valid way to ensure the profession is working to the most suitable level,' she says.
One thing these frameworks could help to address is the fact that some nurses are often given the ANP title without having carried out the appropriate training. In the 2012 RCN competencies, it is advised that all nurses with the ANP title should undertake an advanced nursing practice programme. It also states that the UK health departments agree that ANPs will have completed masters level education.
'The RCN and the NMC should make the expected criteria more transparent,' says Dr Drage. 'This criteria already exists for nurse practitioners and the RCN and the NMC should open the window for nurses who are employed and want to progress. Most patients and even other nurses, unless they have been mentored by a nurse practitioner, don't know what one does.'
Recent surges in alternative workforces could threaten to diminish the ANP role further. One of these is PAs.2
PAs are a branch of healthcare worker that work alongside doctors. They can do many things such as deliver test results, manage chronic disease and carry out consultations. One of the things they cannot do is prescribe.
They are also an unregulated workforce, although the RCGP will be setting up a faculty of PAs to regulate the workforce, due to be completed by summer 2015.
During health questions in parliament on 1 June, Ben Gummer, the minister in charge of the nursing workforce, was asked whether he had plans to make greater use of PAs. He answered 'yes', he did.
When pushed for further detail a Department of Health spokesperson later said: 'Individual organisations can best decide what mix of staff suits the needs of their patients. Our job is to make sure that the workforce is in place to support these choices, which is why we have committed to 10,000 additional staff in primary and community care, including ANPs and PAs by 2020.'
But is investing in multiple professions a good idea?
Dr Drage doesn't think so. 'What the government should be doing is putting the funding that it is allocating to support the training of physician associates into sustaining and developing nurses who want to advance their role,' she says.
Not everyone agrees. An article printed in The Guardian on 2 June3 stated that Ian Cumming, the chief executive of Health Education England (HEE), said that a new body of staff would be created to help nurses cope with growing workloads. He said the new staff would do some of the tasks currently done by fully qualified nurses and could become known as 'nurse associates.' He told The Guardian that they would 'care for patients under the supervision of registered nurses. So they would have an expanded skill set compared to the healthcare support worker, but they wouldn't be a registered nurse'.
However, nursing unions have expressed their concern over creating further workforces instead of supporting the current nursing service.
Evidence for investment
Growing evidence has proved that ANPs can provide safe and effective care. Horrocks et al4 found that 65% of patients preferred to see a nurse in a nurse-led clinic and very few needed referral back to the GP.
Cuckoo Lane, a practice managed solely by nurse practitioners in West London, recently received an 'outstanding' in its latest CQC inspection. 'If you look at things like our results from the Friends and Family test and patient feedback there is enough hard data to prove that we are providing a good service,' says Julie Belton, the practice manager and ANP. 'I would say that we are demonstrating that the work ANPs do is comparable to that of a standard GP. It is about demystifying the medical model. Nurse practitioners provide something that is complementary to primary care and, as the evidence suggests, our patients are satisfied with that,' she adds.
Ms Lupari says that there needs to be more up-to-date and varied research to properly depict the value of ANPs in general practice.
Updated research could demystify the role of ANPs in general practice. It might stop CCGs following the lead of Leicester CCG, which recently recruited 10 PAs from the US. The CCG spent £600,000 to bring them to the UK. Professor Farooqi, GP and chair of Leicester CCG, says that the PAs role will be similar to that of a nurse practitioner, except they will be more specialised. 'We are recruiting from the US purely because there are not sufficient PAs in the UK – currently there are only around 250 of them – whereas there is a ready supply of these staff available to us from the US.'
When asked why Leicester CCG did not recruit nurse practitioners he says: 'We have found in Leicester that it is increasingly difficult to recruit nurse practitioners in primary care – there is a shortage, as there is with GPs. This is why we have chosen to recruit PAs from the US.'
HEE has said that it has increased the number of nursing training places by 13.6% over the past two years. This will see over 13,000 additional nurses available for the NHS, hospital or community, by 2019.5
Shortages in the workforce proves that there needs to be better recognition of ANPs and that funding needs to be set aside to expand the workforce.
'It doesn't need to be PAs versus ANPs, I'm sure that each can have a role in general practice,' says Ms Belton. 'This appears to be a kneejerk reaction to try and look at some of the recruitment and retention issues around general practice and obviously things are going to get harder and harder,' she adds.
A spokesperson from HEE East Midlands reinforced the importance of a balanced workforce: 'We need the right people with the right skills, values and behaviours now and in the future so that patients know that NHS staff will always be there for them.' IN
1.RCN Competences: Advanced Nurse Practitioners. 2012. The Royal College of Nursing. https://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003207.pdf
2.Bhardwa S. Physician associates plough same furrow as advanced nurse practitioners. Independent Nurse. 2015. http://www.independentnurse.co.uk/news/physician-associates-plough-same-furrow-as-advanced-nurse-practitioners/82350/
3.Campbell D. NHS may create new tier of health worker to help registered nurses cope. The Guardian. 2015. http://www.theguardian.com/society/2015/jun/02/nhs-new-tier-health-worker-help-registered-nurses
4. Horrocks et al. Can nurse practitioners provide equivalent care to GPs? BMJ. 2002. http://www.bmj.com/content/325/7356/166