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General practice under pressure

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General practice capacity and clinician recruitment must be addressed urgently, or the service will become unsustainable. This is the conclusion of an extensive review of primary care, undertaken by Deloitte's UK Centre for Health Solutions.

According to Primary Care: Today and Tomorrow - Improving general practice by working differently the crisis is fuelled by rising life expectancy, patients' increasingly complex long-term health conditions and the NHS' financial challenges: investment in general practice is stalling, while workload spirals. General practice must therefore adapt to the evolving health landscape, or buckle under the weight of demand.

Soaring number of consultations

Numbers of general practice consultations have soared over the past decade, from 171 million in 2001 to 300 million in 2008. During this period, practice nurse consultations rose by almost 150 per cent, while GP consultations increased by only 11 per cent.

If the trend continues, annual general practice consultations could total 433 million by 2035. Of these, patients age 65 and over would make up 180 million consultations.

'It is imperative that new ways of working are identified and adopted,' the report says. 'Particularly as previous solutions, such as increasing supply or paying staff more for existing ways of working, are unlikely to be sustainable given the unprecedented efficiency challenges facing the NHS over the next four years.'

While patient numbers are increasing, the general workforce is on the decline: around 22 per cent of GPs are age 55 or over, compared with 17 per cent in 2000 and the BMA's 2011 national survey of GP Opinion reveals that 10,000 GPs have expressed an intention to retire within five years.

Practice nursing has similar demographics: one in five current practice nurses are over 55. Deloitte cites an RCN review claiming that a disproportionate number of primary care nurses are expected to retire within five to 10 years. 'The challenge of replacing those who retire is likely to become an increasingly prominent issue over the next few years,' the report concludes.

Attracting more nurses into the discipline of general practice by means of a standardised career pathway is the key to maintaining services, argues Cambridgeshire practice nurse and chair of the RCN Advanced Nurse Practitioner Forum Jenny Aston.

'This isn't a new problem,' she says. 'The Working in Partnership Programme in 2008 identified similar trends. It said 33 per cent of practice nurses would be retiring in the next five years, so it is something that we have known about for a little while. One problem we have is that we don't have detailed information on the number of practice nurses. RCN figures say there are 15,000, while the DH puts it at more than 20,000.

'Also, we don't have enough practice nurses coming through,' she adds. 'Student nurses do not get general practice experience when they are training, so they don't see it as a career option.

'There's no incentive for GPs to offer training places to student nurses. We need to introduce a national, standardised career pathway for practice nursing.'

Standards for practice nurses

Ms Aston points out that 'the NMC has no standards outlining what a practice nurse should be'.

'The Royal College of General Practitioners has some standards, but they are fairly basic,' she says. 'We need national standards and solid guidance from the top on how to go about shifting care from hospitals to primary care.'

Director of Deloitte's Centre for Health Solutions and report author, Karen Taylor, agrees more needs to be done to encourage nurses into practice nursing, earlier in their careers.

'It is often viewed as a branch of nursing to go into towards the end of your career,' she explains. 'A student nurse might look at a job in a hospital and see the potential to progress to higher bands and build a career. Primary care lacks that structure.'

The last three years have seen a reduction in the number of pre-registration nurse training places. At the same time, NHS Information Centre statistics show new entrants and returners to general practice employment have fallen.

Because of the time it takes to train GPs and practice nurses, many immediate recruitment shortfalls can only be met by qualified practitioners from abroad. However, even this short-term staffing solution will be undermined by changes to employment regulations designed to limit recruitment from other countries comes into effect.

From 2016, under proposed changes to UK immigration policy, nursing staff from non-EU countries earning less than £35,000 per year will have to leave the UK. The RCN has described the change as 'deeply concerning', stating that around half of nurses from outside the EU would not be eligible to remain in the UK if the plans became law.

'The general reduction in supply is likely to limit the number of nurses who might consider a career as a practice nurse,' the Deloitte report says. 'This in turn could limit the scope for GPs to delegate work to practice nurses.'

Ms Aston believes that unless a strategy is put in place to encourage more nurses to consider a career in primary care, GPs could look for a 'quick fix' solution.

'My concern is that we will end up taking what could be called the easy option and employ healthcare assistants (HCAs) trained to do lots of different tasks,' she says. 'HCAs have a role to play, but they must be supported by a workforce of good practice nurses.'

Cornerstone of the NHS

Ms Taylor describes general practice as 'the cornerstone' of the NHS since its inception, but warns it must adapt to survive.

'While important, the traditional ways of working, which rely on face-to-face consultations between the patient and the GP and, increasingly, the practice nurse, are no longer sustainable,' she argues.

'Additionally, rising life expectancy is bringing about increasingly complex long-term health issues requiring frequent GP visits.'

In her report, she recommends GPs adopt new models of care, using new technology and other practice staff more effectively, working closely with patients to provide more care in the community. Solutions may involve practices 'employing - or developing formal partnerships with - health visitors and district nurses'.

'While the different funding streams for general practice and community nursing may present a barrier, the new commissioning regime, with its aim of developing a more co-ordinated and integrated approach to care within the local health economy could be a solution,' the report says.

However, Ms Taylor warns there is resistance to change within the primary care community.

'People are comfortable working in the way that they have always worked and doing things the way they have always done them,' she asserts. 'But the old way simply isn't sustainable and although a lot of people do want to see their doctor face-to-face, many do not need that type of contact.'

Ms Aston agrees, and points out that clinicians must ensure they make optimum use of consultations in order to reduce the number of appointments patients feel they require.

'Patients do need face-to-face time, but we need to look at how well we are using that time,' she explains. 'If you use it well, you can win patients' trust and support them to do more for themselves. Self-care is the key to reducing pressure on general practice.

'It is also important to ensure that patients are seeing the right person, be that a doctor, nurse, or someone else like a health coach. That way you can spread the load more effectively.'

The report warns recent NHS reforms, which will transfer responsibility from PCTs to clinical commissioning groups, could place general practice under huge strain.

'GPs will need to maintain their role as providers of safe, good quality care in the face of this new commissioning challenge, new regulatory and performance management systems and a requirement to provide more care with less money,' says Ms Taylor.

'GPs need to adopt new models of care, using new technology and other practice staff more effectively, working closely with patients to provide more care in the community, with an emphasis on shared decision-making and self-management. They will still need to act as gatekeepers, but also, increasingly, as care navigators.'

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