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Nurse skills underused in practices

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Making maximum use of existing practice nurses' skills will make general practice more efficient, key nursing figures say as general practice is in the headlines again. Labour leader Ed Miliband recently pledged that, should Labour get elected next year, he will ensure that everyone can access a general practice appointment within 48 hours. The Coalition agenda has for some time centred around greater amounts of care being delivered in the community.

'The question is, how will this be delivered?' says Paul Vaughan, the regional director of RCN West Midlands. 'You need to invest in practice nursing so they can provide access for all the people that contact general practice.'

Mr Vaughan also highlights the need for general practice to become more efficient.

'Ed Miliband is right in that if we don't address the problem there will be continuing issues in A&E, and part of the reason why so many people turn up to A&E wards is because they cannot get access to general practice appointments. We absolutely need investment in this area,' he says.

Tim Curry, the assistant head of nursing at the RCN, believes that general practice is the place to see the majority of patients with long-term conditions. 'We have a diverse and skilled workforce within general practice, but we lack the tools to drive improvement and to make quicker access a reality for patients.'

Inconsistent use of nursing skills

However, despite the need for efficiency in general practice to create better access, there is inconsistency across the country in how nursing skills are used.

Jenny Aston, chair of the RCGP's general practice foundation nursing group, says. 'I think it entirely depends on the attitudes of GPs and practice managers as to how enabled nurses are within general practice.'

'If it's a single-handed GP they may be very happy to keep a clear divide where they do all the doctoring and nurses do all the treatment room stuff. Whereas you get some situations where GPs may want to offload and let nurses have a fairly free reign, and sometimes that can be very risky as [the GPs] may not be making sure that nurses are trained and supported to do that properly.

'It is widely varying and I think that nurses are often put in a difficult position because they are either asked to do things they are not trained to do or are held back from developing and growing.'

One reason for the differences in the way that practice nurses-skills are used in general practice is that practices are still run as independent providers, says Mr Curry.

'Many practice nurses are not released by practices, to carry out basic training, as they simply don't have the funds or capacity to release people.'

Ms Aston says: 'It does depend on the size of the practice, but it also depends on whether the practice has trainee GPs or not. If there are trainee GPs in a practice then they will be given access to the day-to-day patient consultations as the practice has to provide enough training opportunities for GP registrars. Sometimes in these situations nurses are held back because there is an emphasis on training the GPs who need to see all the routine problems and it may mean that, in some instances, nurses have less opportunity to develop,' she says.

In other cases, practice nurses are not able to use the skills they already have. In a survey carried out by Independent Nurse in March this year into the prescribing habits of readers, many respondents stated that although they had gained the non-medical prescribing qualification they did not actively use it. Yet, 92.2 per cent of the respondents said that a greater use of nurse prescribing would increase the efficiency of general practice.

Mr Curry agrees that allowing more nurses to prescribe would be a 'no-brainer' way to increase efficiency. 'There were over 700,000 nurse-led prescriptions last year, and all the evidence shows their value for money in avoiding comorbidities and reducing harm, yet so many practice nurses are prevented from accessing the prescribing course.'

Mr Vaughan says: 'In terms of the skills practice nurses have and the development they could have if general practice employers invested in the educational training of practice nurses, they could do a lot more in terms of managing long-term conditions, as well as some advanced practitioner work to create more capacity in general practice,' she says.

'If all practice staff from healthcare assistants to GPs are up-skilled, far more patients could be seen.'

Jenny Aston

Chair of the RCGP's general practice foundation nursing group

Up-skilling to increase efficiency

Ms Aston believes that increasing general practice efficiency and capacity will also require providing the current workforce with a wider range of skills to be able to provide even more care for patients and maximise the time spent with them.

'If all practice staff from healthcare assistants to GPs are up-skilled then far more patients could be seen and practices can work incredibly efficiently using everyone to their maximum potential, she says.

'If you train up your nurses to the highest possible level, enable healthcare assistants to be appropriately supported and trained, and allow advanced nurse practitioners to take on more of what was traditionally known as GP work, to a level where they feel safe and supported, this would free up GPs' time to take on more of the complex care coming from hospitals. If everyone is up-skilled in an appropriate way with the appropriate support, you can work incredibly efficiently as a practice.'

'We have a diverse and skilled workforce within general practice, but we lack the tools to drive improvement.'

Tim Curry

Assistant head of nursing at the RCN

Using skill mix effectively

An example of this is a nurse-led practice in West London, Cuckoo Lane, where the directors ensure their workforce has the ideal mix of skills to maximise the numbers of patients it sees and the care it delivers.

'In terms of efficiency, the healthcare assistants (HCAs) will carry out initial procedures for patients and then the appointments with practice nurses or nurse practitioners are targeted towards improving the patient's care,' explains Julie Belton, director of the practice and a nurse practitioner.

'For example, if a patient comes in for a diabetes check, the HCA will carry out the preliminary weight checks, take the blood pressure and measure their height. Then the time with the nurse practitioner will be honed in to actually managing their care, in a mutual participation model. This means that the checks are conducted in a more efficient way and staff time is being used better.'

Ms Belton believes that training nurses in specialist areas enables their time to be used in a targeted, efficient way that maximises patient care.

'The practice nurses are highly skilled and have specialisms, such as diabetes, COPD and other things such as family planning. All the nurses will see people within their competencies and also are able to prescribe within their competencies,' she adds.

Continuous training and development for staff benefits the whole practice.

'We encourage all of our staff to go through training, with two conditions. The first is that the training is relevant to expanding their current role. The second is that they then come back to the practice and feedback what they have learnt so that all the members of the staff benefit,' says Ms Belton.

'We also provide in-house and online learning for all of our staff. Every morning we have a five-point huddle, where staff can raise any concerns that they may have had from the day before and then we work to sort those concerns out.' The results are then circulated to all of the practice staff so that everyone remains up to date. 'We have weekly clinical meetings and the practice nurses have monthly clinical meetings. There are also six-weekly practice meetings, ' she says.

A model for efficient skill mix
Cuckoo Lane, is a nurse-led practice in west London serving 4500 registered patients. The team consists of two GPs, six nurse practitioners, four practice nurses and a supporting team of medical administrators and healthcare assistants. The practice has been running as a nurse-led practice since 2005, when the GPs left the practice and the nurses were encouraged to apply for a bid. The practice provides all of the usual general practice services, as well as specialist clinics and services. These include heart disease, hypertension management, diabetes,well woman clinics, baby clincs, inhaler/asthma/lung function clinic antenatal clincs and many more. An article on the nurse-led practice was published in Independent Nurse (21 April-4 May) and can be found at

Standards and career pathway needed

A lack of clear educational standards for practice nurses and no formal career pathway for the profession contributes to the inconsistency in the way nurses' skills are used in general practice.

'I think what's lacking is an understanding of the foundation training that nurses need to enable them to develop,' says Ms Aston.

Anne Moger, programme director for general practice nursing at Health Education Thames Valley and Health Education Wessex, says: 'The problem is that there is a lack of workforce supply because we don't have a clear career pathway into general practice nursing, and there is no national standard for education and training.'

Ms Moger is currently leading a national project for Health Education England (HEE) to consider developing a national education framework for general practice nurses, which will be applicable to the whole non-medical workforce from HCAs to advanced nurses practitioners. The project will also develop professional education standards and an education service specification to create a national template, which can be adapted by employers and commissioners for local need.

Ms Moger also suggests that the way services outside of the hospital are commissioned plays a big part in the way that nurses' skills are used.

'Nurses in general practice are commissioned by NHS England, and they see the same patients as community nurses, such as district nurses and health visitors, who work for community trusts commissioned by CCGs. In an ideal world you'd have a primary healthcare team of nurses working together to manage a practice population. At the moment it's difficult for them to work in this way. There's a real mismatch in where the skills lie and where the work is.

'Due to the lack of joint commissioning these groups of nurses can't work efficiently together to care for the population.'


Nursing figures are in agreement that there needs to be more funding and a clearer educational pathway for practice nurses in order to maximise the skills of the workforce and increase the efficiency and capacity of general practice. Focusing on the practice nursing workforce will ensure that, in the future, general practice is able to provide the care the Government talks about.

'We lack strategic agreement on the future of general practice and there are some real issues surrounding practice nursing that need to be looked at,' says Mr Curry.

'The missing piece is who is going to strategically manage the practice nursing workforce and ensure that all nurses have the same opportunities, not just those working in good practices.'

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