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Primary care in the spotlight

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Three different reports published in the last two weeks have highlighted the need to rethink primary care and the role of primary care nurses in order to make the NHS sustainable.

NHS England, the NHS Alliance and The King's Fund all mentioned primary care nurses in their reports as key resources that are currently being underused, but that could be used to tackle the increasing numbers of patient contacts managed in general practice.

Speaking about the Five year forward view published by NHS England, Simon Stevens, chief executive of NHS England, said that the NHS was at a 'crossroads.' However, he went on to say: 'It is perfectly possible to improve and sustain the NHS over the next five years in a way that the public and patients want. But to secure the future that we know is possible, the NHS needs to change substantially, and we need the support of future governments and other partners to do so.'

Prior to the report being published, Mr Stevens was one of the keynote speakers at this year's QNI Annual Conference in September. He urged community nurses to take a greater role in commissioning and running innovative projects. His direct address to primary care nurses, before the report's release, shows they have risen up the NHS agenda.

The NHS Five year forward view looks at how to 'dissolve traditional boundaries between primary care, community services and hospital' to provide patients with individual care tailored completely to their needs. The report outlines three new models of primary care. Two of the three the models affect primary care nurses directly. The first one, The Multispeciality Community Provider, suggests employing senior nurses as consultants or partners working alongside community nurses and other healthcare professionals. The second one, the New Care Model, involves increasing access to general practice to seven days a week to ease the pressures faced by A&E departments. The report states that this will 'partly be achieved by evening and weekend access to GPs or nurses working from community bases equipped to provide a much greater range of tests and treatments'.

The King's Fund report, Specialists in out-of-hospital settings explored how to redesign the primary care workforce. The aim being to ensure that the local population receives care relevant to them. Six case studies from across England were discussed in the report as examples of innovative ways to use the primary care workforce skill mix to improve patient outcomes. These include the Imperial child health general practice hub in London which integrates the roles of GPs, paediatricians, health visitors and community children's nurses, and a dermatology service in Sunderland that hosts nurse-led clinics for severe acne cases and monitoring of prescriptions.

The NHS Alliance report, Think big, act now; creating a community of care, recommended 10 ways of improving primary care services. These included restructuring the workforce, providing easier access to all patients for primary care services and creating new roles that connect general practices across geographical locations.

Two strong themes that were addressed in all three reports, were boosting the roles of nurses to take on more clinically focused care and breaking down the barriers between traditional primary, secondary, community and social care to improve access for patients, increase efficiency and improve patient outcomes.

Expanding Roles

In the case studies presented in the King's Fund report nurses were given new roles in which they could 'work at the limits of their practice.'

The Imperial child health general practice hub encourages GPs, practice nurses and health visitors to attend meetings every four to six weeks with paediatric consultants from nearby hospitals to discuss cases and exchange information.

Hannah Coveney, a health visitor from Central London Community Healthcare, one of the trusts involved in the hub says: 'The multidisciplinary team can discuss a patient's case together and come up with a holistic approach to their care in a more timely manner.

'Also, due to the hub being community-based, should a patient require an appointment with a paediatrician the waiting time should be less and that will likely lead to a better outcome for the patient.'

The Five year forward view says that recruitment of primary care nurses will be required in order to cover the deficit facing the workforce. Think big act now: creating a community of care, identifies that the district nursing workforce has reduced by 40 per cent in the last 15 years and that the practice nursing workforce is mostly over 50.

Heather Henry, co-vice chair of the NHS Alliance, believes that primary care nursing needs to be made attractive to encourage more student nurses and young post-registration nurses into the profession. 'The role is often poorly understood. There needs to be more communication between nurses and practice managers to highlight the role of primary care nurses,' she says.

Breaking down barriers
Having general practice and hospitals functioning as two separate organisations will not alleviate the 'severe pressure from increasing patient demand and recruitment issues,' facing general practice, highlighted in the King's Fund report.

Instead all three reports suggest some variation of removing the barriers between primary, secondary and community care, to provide care that is focused on the patient.
Crystal Oldman, QNI chief executive, says 'The opportunity to develop local solutions for local populations is the way to go forward. We have found that community nurses have valued co-location with GPs.

'In London we are beginning to transform community services. It doesn't matter who is being employed by who, instead we should just take care right back to the patient and ensure that they are kept at the core.'

Mr Stevens says that 'we need to change the way services are provided' to improve the NHS over the next five years. However steps will need to be taken to ensure that the recommendations and examples in these reports are more than rhetoric and that the NHS is made fit for the future.

'The NHS continues to be highly valued by the British people. But what's great about the NHS cannot disguise what needs to change in the NHS,' says Mr Stevens.

1. Five Year Forward View. NHS England: 2014.
2. Specialists out of hospital care. The King's Fund: 2014.
3. Think Big. Act Now. Bringing care back into the community. NHS Alliance: 2014.

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