General Practice Nursing: foundational principles

Organization

Introduction

The role of the General Practice Nurse (GPN) has changed rapidly over the past few decades. GPNs now play a key part in primary care, relieving General Practitioners of much of their previous workload (Baird et al. 2016). Predicted changes in the GPN workforce have also led to much interest in – and financial support for – this branch of nursing across the UK.

This book is written for nurses who want to work in primary care and for those who are new to the GPN role or returning to it after a long gap. The content aligns with the Queen’s Nursing Institute (2015) and Health Education England (2017) competency framework. Across the different countries in the UK, the existing framework is being revisited to ensure that these competencies also match each local area’s requirements. For instance, in Northern Ireland nurses are employed as treatment room staff as well as GPNs.

This book aims to support the student who is learning the foundational skills needed to develop into a confident and competent primary care nurse. It therefore provides relevant information about clinical skills and knowledge, health promotion and screening, and the management and assessment of long-term conditions. Some topics have been omitted or only mentioned in passing because the GPN will require additional training in order to tackle them properly. For instance, some aspects of women’s sexual health are discussed in Chapters 4 and 5 but further reading will clearly be required to gain an in-depth knowledge of this complex subject.

Scattered through the text, you will see boxed reader’s activities, which are designed to reinforce the content. These activities may require you to draw a timeline or make notes, for instance. You should therefore keep a notebook close at hand so that you can complete the activities and check your answers when they appear, later in the text.

References

Baird, B., Charles A., Honeyman, M., et al. (2016). Understanding pressures in general practice. London: King’s Fund.

Health Education England (2017). The General Practice Workforce Development Plan.

Queen’s Nursing Institute (QNI) (2015). District Nursing and General Practice Nursing Service Education and Career Framework. https://www.​hee.​nhs.​uk/​sites/​default/​files/​documents/​Interactive%20version%20of%20the%20framework_​1.​pdf (last accessed 5.2.2019).

Chapter 1

The role of the GPN: Political, professional and economic drivers

Deborah Duncan

Introduction

In all corners of the NHS, work is currently being undertaken to develop a robust competency framework for both treatment room nurses and general practice nurses. This chapter looks at how the GPN role has changed since the 1960s.

Historically, GPNs contributed to the delivery of the GP contract to the whole spectrum of the practice population. Now GPNs work as part of a multi-disciplinary team (MDT) within GP surgeries, assessing, screening and treating patients of all ages. They also offer health promotion advice in areas such as contraception, weight loss, smoking cessation and travel health. Their role now also embraces expertise in long-term conditions (LTCs), preventative services, sexual health and advanced clinical skills (QNI 2015). There is a specific skill set to manage uncertainty and risk when supporting people who may have undifferentiated diagnoses. All this has to be delivered according to guidelines and protocols, adhering to the Quality Outcomes Framework (QOF) within general practice. Nurses will be central to the delivery of the new care model set out in the NHS’ Five Years Forward View (NHS 2014) so that they can meet the needs of an ageing population, many of whom have comorbidities and long-term conditions (Goodwin et al. 2011).

In 1948, when the NHS was created, GPNs were responsible for all personal medical care. They became the gateway for individuals to access hospitals, specialist care and social care. In the early days of the NHS there were few explicit standards for general practice, and few incentives for medical professionals to take on the GP role (Godwin et al. 2011). There was also a rapidly growing demand for services (Collings 1950). Many GP practices employed nurses to support them with these challenges.

The 1960s to the 1980s

The role of the GPN then saw significant financial support and development in the 1960s. The first contract between General Practitioners (GPs) and the NHS was formalised in 1966 and this covered funding for ancillary staff, including nurses (QNI 2015). Initially, nursing staff were mainly working as treatment room nurses (Cartwright & Scott 1961). The 1966 contract for GPs included additional payments to cover the costs of practice staff and premises as well as the responsibility of providing 24-hour care, 365 days a year. However, this still did not really affect the work of the GPN.

In 1972 the Royal College of General Practitioners (RCGP) was created, giving GPs their own official representative body for the first time. In 1976 a three-year postgraduate training programme became mandatory for GPs. Finally, in 1978, the WHO’s Alma Ata Declaration on Primary Health meant that disease prevention and health promotion increasingly started to be seen as a central part of general practice. GP practices recruiting GPNs would advertise these posts indicating that the role included a significant long-term care component, disease prevention and health promotion, and some treatment room work (such as dressings). They also offered GPNs some support to gain competencies for cervical smears, travel health and child immunisations (While & Webley-Brown 2017). However, many GPNs did not feel they received the training they were promised (While & Webley-Brown 2017).

In the 1980s the RCGP Quality Initiative was launched, in response to increasing evidence of variation in clinical practice. Early attempts to measure quality in primary care and provide incentives for improvement were met with increasing resistance. There was no significant change for GPNs until the early 1990s and the introduction of the ‘internal market’ (the GP fundholding system). At this point, for the first time, GPs were given budgets to commission services for their local populations. The new GP contract included chronic disease clinics and incentives to meet the population target rates for vaccinations and cervical screening. GPs therefore responded by employing nurses to provide these services (McGee & Castledine 1999). By the time this system was disbanded by the Labour government in 1998, only 33 per cent of practices were participating.

This change did, however, have a huge impact on the role of the GPN because general practice was now being seen as less curative and reactive and more preventive and proactive. The management of long-term conditions and health promotion was largely delegated to GPNs and, as a result, the numbers of nurses employed increased, as did the need for further specialised education. Research showed that, although nurses needed longer consultations for these patients, they did provide effective care (Laurant et al. 2005, Woodroffe 2006). A later Cochrane review (comparing GP and GPN consultations) showed that there were no consistent differences in problem recognition, examination, prescribing, and referral or diagnostic test rates or patient satisfaction (Wilson et al. 2006). This extended role became an important consideration when employing new staff. GPNs were also shown to offer effective services for patients with minor illnesses or ailments and those requiring same-day appointments (Shum et al. 2000).

Also, in the 1990s the Royal College of Nursing (RCN) Practice Nurse Forum lobbied for specialist practitioner recognition from the United Kingdom Central Council. This was achieved in 1994 (UKCC 1994) although there was not yet a recognised qualification.

Changes from 2000 to 2010

In 2004 the General Medical Services (GMS) contract was renewed and the GMS introduced the Quality and Outcomes Framework (QOF), a voluntary scheme giving GPs an incentive to provide services in addition to their core essential services. For the first time, GPs began to employ healthcare support workers or healthcare assistants (HCAs) in order to release the GPNs to focus on this specialised work. HCAs were shown to make an increasingly useful contribution to the skill mix in general practice (Bosley & Dale 2008). Not only was the HCA role reviewed, but there was a continuing incentive to educate and encourage the GPN in general practice (Sibbald, Laurant et al. 2006). However, it can be difficult for nurses to fulfil such a varied role when they come from a piecemeal educational background.

Alongside the changes in the contractual arrangements with general practice, there was the 2000 NHS Plan which stated that ‘the future of the NHS Plan rests on the strength of its primary care services’ and this required the introduction of new models of general practice (DH 2000). In 2005 the Chief Nursing Officer introduced the Liberating the Talents paper which set out 10 key roles for nurses in extending and advancing their clinical roles (DH 2005). The Darzi review also encouraged the use of quality indicators at all levels in the NHS, including general practice (DH 2008). The response was the establishment of stronger regulatory and governance mechanisms, including annual appraisals for GPNs.

Changes from 2010 onwards

Within a decade, following the change from a Labour to a Conservative government, the primary care landscape had changed again – with the arrival of new Clinical Commissioning Groups (CCGs). Health Education England (HEE) and the Local Education and Training Boards (LETBs) were also formed (DH 2012a, 2012b). The Health and Social Care Act (2012) introduced comprehensive changes to the way the NHS operates, as the aim was to see more than 80,000 people with complex needs receiving community-based, GP-led, personalised care by 2014 (DH 2012b).

GPs were expected to take a lead role in independent CCGs and have greater influence over the design and delivery of local healthcare services, which included 60 per cent of the £110 billion NHS budget. The central tenet of the reforms was ‘no decision about me without me’ which means increasing choice and service integration, delivering care closer to home and highlighting patient involvement. This required better communication between GP practices and other services such as community nursing services, A&E, ambulance services, care homes, and mental health and social care teams (DH 2012b).

The principle that ‘All UK residents are entitled by law to access primary care services, which are free at the point of need‘ was key to the establishment of the NHS in 1948 and was restated in the 2012 NHS Constitution for England (DH 2012c). Again, the workload of the nursing team increased in response to these demands. Nurses were seen to play a greater role in general practice, with the number of full-time equivalent nurses employed in general practice rising by 37 per cent between 1999 and 2006 to 14,616 (Goodwin et al. 2011, p. 1).

Patients’ have also become more demanding in terms of what they expect from general practice; they want greater responsiveness from GP practices, better coordination of services and a focus on health promotion (RCGP 2007). These changing demands have led to the employment of more GPNs and HCAs. This is reflected in the fact that, between 1995 and 2008, the proportion of general practice consultations undertaken by nurses increased by 14 per cent (Hippisley Cox & Vinogradova 2009).

In 2015, in a response aimed at standardising some aspects of the nursing team training, the framework for a Care Certificate was published by Health Education England (HEE) to replace the National Minimum Training Standards (NMTS) and the Common Induction Standards (CIS) that had historically provided the framework for healthcare assistants working within health and social care.

The Five Year Forward plan from NHS England (2016) makes a variety of suggestions to respond to ever-changing demands in general practice. One such suggestion is that CCGs, local authorities and NHS England will be able to pool budgets to jointly commission expanded services, including the hiring of additional nurses in GP settings to provide a coordination role for patients with long-term conditions (The King’s Fund 2015). It is also suggested that a GPN development strategy should include improving training capacity in general practice, increasing the number of preregistration nurse placements, improving retention of the existing nursing workforce and supporting practice nurses to return to work (NHS England 2016).

Such a radical plan will require the investment of an additional 15 million pounds and a review of the previous piecemeal GPN training (NHS England 2016). This plan recognises the problems that will potentially occur within the next five years and mirrors the 2015 Queen’s Nursing Institute report which suggested that 33.4 per cent of the GPN workforce will be due to retire by 2020 (Bradby & McCallum 2015).

The Queen’s Nursing Institute is a registered charity established in 1887. It is dedicated to improving the nursing care of people in the home and community. The institute has an established national network of Queen’s Nurses, who are committed to the highest standards of care and who lead and inspire others. The institute also offers education grants to fund nurses to improve patient care by supporting them to develop their skills through leadership and training programmes, publishing research, influencing government, policy makers and employers, and campaigning for investment in high-quality community nursing services.

For more information go to https://www.qni.org.uk

Box 1.1: The Queen’s Nursing Institute

The 2013 HSCIC Workforce and Development Census showed that there were 23,833 GPNs, an increase of 375 (1.6 per cent) since 2012. There were also 14,943 full-time equivalent (FTE) nurses, an increase of 248 (1.7 per cent) since 2012. Although GP practices are apparently still recruiting GPNs, the level of recruitment does not reflect the scale of the need and there are concerns that they are still not recruiting many men to this career pathway. The problems with GPN recruiting may be partly due to the fact that GPN employment structure is unlike that of other community nurses, such as District Nurses or Health Visitors, where rates of pay can vary between £14.60 and £22.00 per hour (Bradby & McCallum 2015). These long-standing issues need addressing in order to maximise GPN retention and reduce attrition (While & Webley-Brown 2017).

The QNI report also shows that many GPNs find it difficult to access ongoing education and training (Bradby & McCallum 2015). In total, 47 per cent of respondents stated that their employers did not necessarily support additional training or even offer regular appraisals. This is a real concern, bearing in mind that many GPNs have had a piecemeal journey through education to get to where they are now. In response to some of these issues, Health Education England (2015a) also launched a district nurse and general practice nursing framework developed in partnership with nursing stakeholders to standardise roles and provide a pathway to plan and develop careers. Previous frameworks were mapped against the NHS Knowledge and Skills Framework with no specific nationalised descriptions of practice nursing roles (RCGP 2012). This framework sets out the core and specific competencies and skills needed to make the change from acute to primary and community care. The main aim is to provide a much-needed career framework for GPNs, healthcare assistants (HCAs) and advanced nurse practitioners (ANPs) like the RCGP GPN Nursing Service (Fitzmaurice et al. 2015).

In 2017 Health Education England published the General Practice Workforce Development Plan in an NHS landscape awash with strategic plans and frameworks. This document was produced in response to the Five Year Forward plan and the proposed investment of at least 15 million pounds in the NHS in England (Bradby & McCallum 2015, The King’s Fund 2015). Large funds were ringfenced to develop the UK’s nursing workforce and this document offered clear guidance on how to increase recruitment, retention and return to practice , with examples of coherent workforce solutions for sustainable and transformational planning. Its key messages were about entry into the profession, establishing the role, enhancing it and expanding the HCA role (HEE 2017).

There are five sections in the document, with a total of 17 recommendations. The first section is about entry into general practice nursing for pre-registration nursing students and the recommendations include raising the profile of the GPN’s career path, by increasing the number of pre-registration nursing placements and use of the HEE quality framework. The second section outlines recommendations for the newly qualified GPN, including strategies to increase employment of nurses on completion of their pre-registration training, preceptor programmes and GPN educator roles. The third section is about enhancing the GPN role and maximising the professional development of the workforce, by providing access to accredited training, having GPN leaders in all CCGs and supporting nurses who wish to return to practice. The fourth section covers expanding workforce support, including the recommendation that all HCAs hold the care certificate, to increase the number of HCAs in general practice and that their training is aligned to the RCGP framework (RCGP 2012). The fifth and final section recommends a sustainable and accessible tool kit to support GPs to implement these recommendations.

The General Practice Workforce Plan is peppered with examples of innovative practice and delivery of educational programmes. In addition, the Queen’s Nursing Institute is currently involved in a consultation process, reviewing the education and practice standards for experienced GPNs (QNI 2017b). Like all competency frameworks, these standards will seek to guide GPNs, their employers and higher education institutions in forming expectations of the role of the GPN. As GPNs, we have seen huge changes in our role and educational requirements since the 1960s. Our hope is that these reports will shape and help our profession as we move forward into the next decade. Certainly, across England, Scotland, Ireland and Wales, the GPN’s role has been reviewed and several of the countries already have draft