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Challenging the status quo

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It started with a question. 'Why don't more nurses run their own practices?', a delegate at the QNI conference in September asked IN. Unable to provide a comprehensive answer, IN began to investigate the existence of nurse-led practices.

As IN spoke to more and more people, it became apparent that few nurses have set up and run general practices, and that there is no set guidance for nurses wishing to do so.

A small percentage of nurses are flying the flag for nurse leaders in general practice, such as Carol Sears and Julie Belton, the directors of a thriving practice in West London.

When asked, NHS England only knew and of this one nurse-led practice. It doesn't hold data on the number of nurse-led clinics and services across the country but a spokesperson said: 'There are nurse-led clinics happening in every GP clinic, walk-in clinic and many hospitals now also run nurse-led clinics.' There is no obvious reason why more nurses have not taken nurse-led services one step further and opened their own practices.

Many readers contacted IN and expressed interest in setting up their own practices and requested further information. They were unsure of where to go for advice and guidance on business issues, funding and guidelines, so IN decided to explore this for nurses wishing to take general practice into their own hands.

GP-centric

Body text: Historically, general practice was developed by the GP workforce and assisted by practice nurses when they were first introduced in the 1960s. The advanced practice nurse role came into being only in the early 1990s.1

Although the practice nursing workforce has continued to develop both clinically and professionally, general practice is still seen as the GP's domain, says Marina Lupari, the professional lead for primary care and community nursing at the RCN. 'Practices historically developed around GPs; it is very rare that a practice would ever be sold; it is not a commodity in the way that pharmacy's are.

'Even though it is seen as business, it is a business that is often passed on by partners, so it would be difficult for nurses to come in and take over,' says Ms Lupari.

However, there has been an increase in the number of nurse partners. Jenny Aston, chair of the RCGP's general practice foundation nursing group, says that she is aware of approximately 12 nurse partners across the UK. 'Most are with an established GP practice rather than independent,' she says.

'There is no reason why a nurse partner wouldn't go on and take the lead within the partnership,' says Ms Lupari.

'That has never been done because the GP has always been in charge and has employed the practice nurse.'

There is only one practice currently led by nurses in the country. Cuckoo Lane is run by two nurse practitioners and a practice nurse. When they applied to take on the contract for the practice nearly 10 years ago, they illustrated that nurses were capable of seeing two thirds of patients that attended general practice. They secured the tender for the contract, employed two GPs and have been running the practice ever since.

In 1998, Catherine Baraniak, a nurse prescriber, founded Meadowfields practice in Derby, with a proposal for a nurse-led practice. It was initially supposed to be a three-year project that had to prove its efficiency in meeting the health needs of patients and its financial viability. Ms Baraniak oversaw the practice for 14 years.

These two examples illustrate the obvious. Nurses are capable of running successful practices if they want to, so why don't more of them do it?

Stretched resource

Ms Aston says that primary care nurses are currently under a lot of pressure. 'I think the major issue is, who has the time or energy to put the thinking into doing it?' she says. 'You would have to come up with a very clear business plan and consider the whole logistics of setting up a business and how it fits into the new contract.

'There is also the question of whether nurses are able to get a loan, or whether there are local commissioning resources that would enable them to do it.'

General practice handles over 90 per cent of patient contacts in the NHS, yet receives under 10 per cent of the funding. According to a recent analysis by the Nuffield Trust, between 2006-13, the number of GPs increased by four per cent. However, the number of GPs per 100,000 patients in England fell from 60.5 to 60 per cent in the same period of time, meaning that each GP is seeing more patients.2 The number of practice nurses has risen by two per cent between 2010 and 2013, but this is the slowest increase in the last 10 years. Patients are waiting longer and longer for appointments and the number of doctors employed in general practice trails behind the number of consultants being recruited into hospitals.2

But as primary care is lauded as the way to make the NHS sustainable and is expected to offer greater services, the status quo will likely change. 'There is a shortage of GPs, so this is an ideal opportunity for practice nurses to take on ownership and lead practices,' says Ms Lupari.

For nurses wishing to set up their own practices, there is not one clear way for how they can go about doing this or where they can go for guidance or resources.

Anne Moger, practice nurse advisor at NHS England, states that nurses could speak to their director of nursing in their local area team or trust, or the chief nurse in their CCG. Nurses can also go to the the RCN as well as independent business advisors.

Ms Lupari, says: '[The RCN] does not have an off the shelf guide to tell [nurses] what to do. What we would do is work with them to give them the best advice available. We would provide generic information on running a business, which would be available from the nurse leaders network.'

Training ground

Nurse-led clinics and services are widespread across the country and nurses can use their experiences of setting these up as a springboard to set up their own practices.

The QNI supports nurses who wish to run innovative projects through its Innovation fund, which provides nurses with a sum of money to set up clinics or projects in the community. 'This is where nurses can put their ideas into practice. We provide the seed funding and many of those do go on to develop nurse-led services but sometimes somebody has to give them the impetus to approve what they're doing,' says Anne Pearson, director of programmes at the QNI.

Although the charity doesn't provide guidance specifically for nurses wishing to set up their own services, it will provide opportunities for nurses to connect with other nurses that have done it before them.

'The support we offer is networking opportunities, but we do not get involved in the minutiae of helping to actually set up a service,' says Ms Pearson.

One service the QNI signposted IN to was a dementia palliative care service started by Morejoy Saineti, a dementia palliative care nurse in London. In 2008, based on her research, she found there was a gap for dementia services in her area and set up a service to fill that void. She took on a leadership role and worked on training for all of the multidisciplinary teams that were involved, including a number of GPs, community teams, hospice teams and hospital ward teams.

'I took on a big leadership role to the extent that I would influence some of the GPs in terms of their management and gave them confidence in things like medication. I trained many community matron teams, district nurses, GPs, even ward consultants in things like dementia palliative care, pain management and managing challenging behaviours.'

Services such as these where nurses take on a leadership role were highlighted in a number of reports last month and primary care nurses are likely to be at the forefront of this much needed change. Yet this cannot be possible without providing nurses with clear advice on how to combine their clinical skills and leadership to build on the skills they learn from running services.

Senior figures in the healthcare sector are also encouraging community and practice nurses to take on a more entrepreneurial role. Chief executive of NHS England Simon Stevens, urged nurses to take control and enter the NHS Innovation fund, at the QNI Annual Conference in September

Ms Moger says: 'Some of the best innovation in healthcare has come from nurses as they have a unique understanding of what patients, the public and the communities want.'

Encouraging nurses to start innovative projects and schemes is one way of starting the process that could lead to nurse-led practices becoming more common. Making the process and pathway clearer would be another.

'There is a vital role [in primary care] for nurses to help keep well for longer and helping to manage the care and treatment of those people who require more frequent contact.They also have an important role to play in health improvement and prevention; nurses can work with patients to deliver personalised care in the community,' says Ms Moger.

Ms Lupari agrees: 'If it can happen in one place it can happen anywhere.'

References:

1. NHS Reforms Timeline. Nuffield Trust. http://nhstimeline.nuffieldtrust.org.uk.Accessed November 2014.

2. Is general practice in crisis? Nuffield Trust. http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/is_general_practice_crisis.pdf. November 2014. Accessed November 2014.


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