Steve Williams, London strategic manager for GP practices, explains how to ensure your team is using nurses to their full potential
The General Practice Forward View identified a number of possibilities for using the primary care workforce differently. One clear initiative is to reduce some of the bureaucratic burden on GPs by combining clinical and non-clinical roles.
The process is not about asking staff to do extra duties, but instead to improve and enhance what they currently do.
The NHS Institute for Innovation and Improvement has already looked at productivity in general practice.
A team headed by practice nurse Liz Wilson put together a version of the productive ward,1 based on the successful productive ward programme used by acute trusts. It recognises that general practice is a small to medium-sized enterprise – an independent business that needs to evolve to meet changing demands.
All staff need to be recognised for the contribution they can make. Practice managers already carry out annual appraisals with staff and this is an ideal opportunity to review the job description and consider training needs.
Assessing the nurse role
What do your practice nurses currently do? Do you have an understanding of exactly which clinical procedures they perform? More importantly, do your reception staff know this?
If you want to signpost patients to the most relevant clinician, all staff must be aware of who does what. If patients are educated to understand that certain types of clinics or procedures will be nurse led, then over time they will elect to choose to see the correct staff member – a practice nurse, healthcare assistant (HCA) or associate practitioner (AP).2
As the practice manager, you will already know the goals and objectives of your organisation and this will include improving the overall patient experience. You must be pragmatic and consider your own solutions to your individual organisation’s service demands.
First, define the clinical tasks your nursing team can undertake. Ask them if they have areas of interest or expertise that could be used by sending them on relevant training to update these skills. Remember to consider any clinical administrative tasks that could be incorporated, such as referral letters and medication reviews. Second, ask your GPs which services they would additionally like their nursing team to undertake. Third, discuss these services with your nursing team. Finally, through discussion and agreement, draw up a proposal of how these services can be introduced safely and effectively.
You could use a process mapping tool3 to identify who is involved in which procedure and modify these so that become more effective. For example, you could link all medication reviews with repeat prescriptions. Your nursing team has an ideal opportunity to interact with patients. Make sure they use this relationship to better understand which services they would be happy not to seek from a doctor.
As services continue to move from secondary to primary care, this will provide expanding opportunities for your nursing team, so you need to understand the skill mix you already have. A good way of doing this is to categorise them into levels. This could include:
Level 1 Healthcare assistant.
Level 2 Practice nurse.
Level 3 Nurse prescriber.
Level 4 Associate or nurse practitioner.
Level 5 Nurse partner.
With this matrix, you can provide
a clear pathway for those wishing to contribute more and for those joining your organisation.
Undertaking appraisals with staff
Each year you will undertake an appraisal with your staff. You should link this to the NHS knowledge and skills framework, which highlights the attributes that are needed for certain roles. Each staff member should agree to a personal development plan and review their current job description.
By performing these reviews on a consistent basis, each person’s role can be developed over time for both the benefit of the employee and employer. Training and education are vital to all roles, but clinical skills must be kept updated and reflect current guidance. Resources already exist that can be useful for your organisation, such as the RCGP A To Z Handbook For Nurses In General Practice.4
The following are 10 ways to make the most of your practice nurse:
1. Maximise their use
The average time a patient gets with their GP is eight to 10 minutes. On average, your nursing team will have between 15 and 30 minutes allocated. Find out from your GPs which type of consultations could be signposted to your nursing team.
2. Be specific
Your nursing team will be able to use the extra consultation time to cover everything the patient wants to discuss, including time for a nice chat. It is easier for your nurses with this additional time to engage with patients and build a solid and trusting relationship.
3. Keep to the point
Get your nursing team to identify quickly why the patient is attending. Often patients will present with more than one problem. Let your nursing team triage these requests rather than your GPs.
4. Keep it in the family
As with the point above, sometimes one or more family members may present with ailments. Let your nursing team act as the facilitator in these situations. Again, this will help reduce the number of inappropriate consultations that are booked with your GPs.
5. Ensure they signpost patients to good sources of advice
More patients now present armed with a wealth of information obtained from the internet. There is nothing wrong with patients being informed, and your nursing team can actively promote this by signposting patients to trusted sites for information and advice.
6. Involve them in home visits
Review the number of home visits undertaken in your practice and who does them. Identify those that could be undertaken by your nursing team and agree a visit policy.
7. Give nurses responsibility for providing alternative ways of receiving medical advice
Your nursing team and indeed, your reception staff should be responsible for seeing patients who wish to seek medical advice. This is particularly true for out-of-hours services. Information should be provided about NHS 111 in England, the local out-of-hours service or urgent care centres. Nursing teams can assist in the triage of conditions and refer to a GP or even call an ambulance if necessary. For minor health complaints, the nursing team can provide advice or refer the patient to the local pharmacist, which is a good source of professional advice. And your nursing team will signpost to a doctor when this is necessary.
8. Involve them in medication reviews
Use your nursing team in your medication reviews, especially repeat prescribing. Often, patients with long-term conditions will be on three or four medications at a time. GP consultations do not need to be used for issues of repeat medications or compliance. This type of consultation can be managed by your nursing team.
9. Use the extra time for general patient education
Use the additional time that your nursing team consultations have to explore with patients how to access services in the most appropriate way.
10. Give patients assurance and support
Ensure your nursing team provides appropriate advice to patients and identifies how support can be provided. This also applies to your nursing team. Provide them with assurance and support too.
Getting the best out of your nursing team is not a process of delegating duties or transferring responsibilities. It has to be a two-way process. The first step should be to establish what already exists in your practice. Your nursing team, as with all your support staff, can play an important role in the way care is delivered. Be mindful, though, that this should always be a mutually agreed process. Discuss each step and listen to their feedback. Your nurses will embrace the opportunity and will treat your patients even better.
1. The role of the practice nurse has changed. nursingtimes.net/roles/nurse-managers/the-role-of-the-practice-nurse-has-changed-a-lot/5041108.article
2. Become an HCA or AP. rcn.org.uk/professional-development/become-an-hca-ap
3. Process mapping. kingsfund.org.uk/projects/pfcc/process-mapping
4. General practice nursing. rcgp.org.uk/membership/practice-teams-nurses-and-managers/~/media/Files/Practice-teams/General-Practice-Nursing.ashx
Steve Williams is strategic manager for a group of GP practices in London and co-chair of the Practice Management Network.