GP leaders warned last month that general practice is in crisis and called on the government to deliver an emergency funding package to avert service cuts and longer waits for appointments.
The call came just as NHS England launched a consultation paper seeking views on how general practice should develop in the coming years. The paper, Improving General Practice - A Call to Action1, is frank about the pressures on the service: squeezed NHS budgets, an ageing population with increasing rates of co-morbidity, public dissatisfaction with access to appointments, persistent inequalities between rich and poor areas, and difficulties in recruiting and retaining staff. 1
Against this background, the paper asks how key objectives can be met: co-ordinating care of patients with long-term conditions, preventing emergency admissions and A&E attendances, preventing ill-health and better involving patients in their own care. It also calls for a more 'holistic' approach combining people's physical, mental health and social care needs.
Practice nursing boomed in the 1990s and early 2000s. Between 1995 and 2008 the proportion of consultations undertaken by practice nurses grew from 21 to 35 per cent.
Numbers of practice nurses employed similarly rose by 37 per cent in England between 1999 and 2006, when there were 14,616 whole time equivalents in English general practice. But the boom ended there. Last year there were 14,695 practice nurses employed - little change in six years. 2
It is a similar story in Scotland. After expansion in the 1990s, the number of practice nurses remained static - with 1,211 in 2003 and 1,215 in 2009. 3
By contrast, the GP workforce has grown continually, increasing by a total of 25 per cent in England in the decade up to 2011, while other practice staff grew by 20 per cent in the same period. Qualified nurses are being squeezed between the growing numbers of the medically trained and often unregistered healthcare assistants.
Buried in these statistics is the contribution of nurse practitioners, whose additional training enables them to lead clinics for chronic conditions and hold consultations for minor ailments, while generalist practice nurses perform more routine tasks such as cervical cytology, immunisations and travel clinics.
'General practice has changed quite a bit over the last few years,' said Sara Richards, a nurse member of Slough CCG and former chair of the RCN Practice Nurses Association. 'There are a lot more salaried GPs than partners now.
'We used to bang on about having the right skill mix, and they have done that to a certain extent. There are now lots of healthcare assistants and nurse practitioners and salaried GPs who come in, do their job and then go home. But they don't have quite the same interest in the practice as GP partners do.'
She continued: 'It's quite difficult to get a good skill mix because we are all the time fighting for appointments. You can try to be innovative, starting up new clinics, etc, but there isn't enough time for just seeing patients for everyday things.'
Nurturing practice nurses
A key issue in the paper is inequality in general practice services between deprived and prosperous areas, with a two-fold difference in the numbers of GPs and practice nurses per head of population between the best- and worst-served areas.
For example, in 2006, there were 124 GPs and practice nurses serving 100,000 people in Cambridge compared with just 64 in Barking and Dagenham. In all, 38 PCT areas - all in deprived inner cities - were identified as having the most need for general practice development.4
The consultation paper highlights 'persistent inequalities' in access to and quality of primary care between rich and poor areas, including the two-fold variation in GP and nurse provision.
There have been some successful initiatives to improve recruitment in more deprived areas. The Open Doors programme in Tower Hamlets, east London, (see pages 34 - 35) has trained 31 practice nurses since 2008, providing over half of the practices in the area with a nurse.
'Nurses who want to work in a GP practice found that they have to have experience as a practice nurse to be employed as one,' explained Vicky Souster, one of the two experienced practice nurses who runs the programme.
The course covers diabetes, asthma, chronic, immunisations, cervical cytology screening and long-term conditions like COPD. Academic evaluation found it an 'effective and innovative' programme.5
Some would like to see an overhaul of training across the country to boost practice nurse numbers. 'We have to look at the way that students are trained so people can choose practice nursing at university,' said Margaret Briggs, former chair of the RCN's Scottish Practice Nurses Association and a practice nurse in Falkirk.
'Most practices want someone with some experience. You will need a lot of training practices - like you have GP trainees and registrars - so that the practice will take on a nurse for a year and nurture her.
'Quite a lot of experienced practice nurses will be retiring in the next few years,' she added. 'The workload has increased. There can be some very stressful times, trying to get through all the things required in the GP contract, and there is no allowance being made for the extra work.'
The ageing nature of the practice nursing workforce was emphasised in a survey carried out by the RCN's Eastern Region last year. Of 90 practice nurses in the region, 98 per cent were aged over 40 and 56 per cent were over 50.
Improving access to general practice was also a recurring theme under the previous Labour administration, but as the consultation paper identifies, the public remains dissatisfied.
The difficulty of resolving this problem at a time of squeezed NHS budgets remains profound.
A recent survey of 202 GPs for the Royal College of GPs found that more than 70 per cent are forecasting longer waits for an appointment within the next two years. Almost half said they had cut the range of services offered to patients, while 39 per cent had cut practice staff.6
Ms Richards lays the blame on the GP contract, which ties practice income to targets under the Quality and Outcomes Framework (QoF).
'The problem is there are not enough appointments because we are being told we have to hit this target or that target. Targets are the problem,' she said.
'We are always fighting to get all our QoF points, so a lot of time is taken up with admin. They are just tickbox exercises. I don't think it's improved the patient experience at all.
'We are not giving patients the time they need to be looked at properly. In seven to ten minutes, what can you do? You haven't got time to do some investigations.
'Care needs to be more coordin- ated,' she continued. 'What's the point of calling someone in for a blood pressure check when they are diabetic and receive one anyway? We are all the time reactive and not proactive.'
Margaret Briggs says there is often a 'mismatch' between the funding the QoF provides and services that patients need. 'The QoF keeps changing - new things are added and GPs are not always recompensed for changes.
'You don't want to withdraw a service that's good for patients even though the money has been taken away or reduced. If you have estab- lished some very good clinics and might have seen changes in patients' behaviour, it's a shame if they are discontinued or downgraded.'
Open all hours?
| NHS Priorities |
- Proactive co-ordination of care, particularly for people with long-term conditions and more complex health and care problems.
- Holistic care: addressing people's physical health needs, mental health needs and social care needs in the round.
- Ensuring fast, responsive access to care and preventing avoidable emergency admissions and A&E attendances.
- Preventing ill health, ensuring more timely diagnosis of ill health, and supporting wider action to improve community health and wellbeing.
- Involving patients and carers more fully in managing their own health and care.
- Ensuring consistently high quality of care: effectiveness, safety and patient experience.
- Consultation ends on 10 November 2013.
Source: Improving General Practice - A Call to Action (NHS England, August 2013)
Easing the pressure on A&E is another key goal identified in the consultation paper. One nurse well placed to correlate the difficulty of accessing primary care with increases in A&E admissions is Sister Soozi Cooper, who runs the Tracker Project at the Cranborne Practice in Dorset.
She and a colleague are tasked with preventing admissions of vulnerable, mostly elderly patients. It is an example of the co-ordinated, holistic care which takes in the social dimensions that the consultation paper aspires to.
'We get weekly A&E printouts, and from a wad half an inch thick there tends to be one of our patients admitted - and that tends to be at weekends. A lot of people at week- ends end up in A&E,' said Ms Cooper.
I don't see any reason why general practice opening hours should not be changed. As nurses we are used to working all hours on shifts in a hospital setting. There should be a way to do that in primary care.'
Ms Cooper and her colleague now have a caseload of 500 patients, mainly because it has proven difficult to discharge frail elderly people whose circumstances can rapidly change.
The eight-year-old programme has been so successful that it is now being rolled out across Dorset. 'We need to be looking ahead and supporting patients to stay in the community,' said Ms Cooper. 'District Nurses have such a high workload-when they see Mrs Jones about her leg ulcers they don't have time to ask if they are getting their meals or their benefits.'
| The challenges for general practice |
- An ageing population, growing co-morbidities and increasing patient expectations, resulting in large increase in consultations, especially for older patients. The number of people with multiple long term conditions set to grow from 1.9 to 2.9 million from 2008 to 2018.
- Increasing pressure on NHS financial resources, which will intensify further from 2015/16.
- Growing dissatisfaction with access to services. The most recent GP Patient Survey shows further reductions in satisfaction with access, both for in-hours and out-of-hours services.
- Persistent inequalities in access and quality of primary care, including twofold variation in GPs and nurses per head of population between more and less deprived areas;conditions.
- Growing reports of workforce pressures including recruitment and retention problems.
A key problem identified by many practice nurses is the wide variation in nurse training between surgeries. Fiona Ross, Professor of Primary Care Nursing at Kingston University, London, said this was subject to the 'vagaries' of individual employers: 'Some of whom support, train and develop their staff and others who don't - to the extent that in many places nurses are undertaking activities for which they have not been trained, kept up to date or receive supervision for.
'Also despite well-meaning government policy to develop prim- ary care and the emergence of many new initiatives, the role of generic nursing staff in the community has largely not been a priority.'
The variation in training affects chronic disease management, says Liz Wilson, an advanced nurse pract- itioner from the Bartley Green Sur- gery, Birmingham and nurse adviser at Birmingham Crosscity CCG.
'Some surgeries have nurses with diploma or degree level modules in disease areas and some surgeries have nurses who have received no or very little training,' she said.
'Patients should be able to expect the same standard of care in every surgery in England and this can only be achieved if minimum educational standards for practice nurses are introduced.'
Her CCG has developed a practice nurse network for asthma and COPD with monthly meetings.
'High standards of evidence-based chronic disease management delivered by well-trained practice nurses who help patients to achieve self management has to be one of the ways of addressing the increasing burden on A&E,' said Ms Wilson.
'It is the responsibility of CCGs to ensure that their practice nurses are adequately trained to deliver chronic disease management. But there needs to be a national initiative to agree on what minimal standards are.'
1.Improving General Practice - A Call to Action (NHS England, August 2013)
2.NHS Staff 2001-2011 Overview (NHS Health and Social Care Information Centre)
3.General Practice and GP workforce and practice population statistics to 2012 (IDS Scotland)Scotland)
4.Select Committee on Public Accounts, Question from Austin Mitchell MP and Ian Davidson MP, October 2008 (www.parliament.uk)
5.Journal or Nursing Education and Practice 2013;10:110-119
6.Full results at www.comres.co.uk