GIVEN the continuing growth in chronic disease in the community – driven mainly by an ageing population – the Scottish Government has been busy looking at ways to refocus nursing roles within primary care. A paper published in 2018 featured a new framework* introducing the role of non-clinical Healthcare Support Workers (HCSW) to allow nurses in future to focus less on monitoring of care and more on prevention and management, including self-management and anticipatory care.
These changes sit within a wider agenda designed to support a move in care from hospital to community and primary care settings, with the aims of improving population health, access to services and best value from health and social care services. This is also driven by a refocussed Scottish GP contract which looks to support practices to better understand and meet the differential needs of local patient populations. A total of £3 million has been committed over three years to fund training provision to support changing roles.
MDDUS has been involved in a series of workshops led by GG&C (Greater Glasgow and Clyde) health board, who are working with the West of Scotland Advanced Practice Academy to support practices through this transition. Our role was to highlight the medicolegal issues and regulatory responsibilities in relation to the changes for GPs, PMs and practice nurses, as nursing and HCSW roles in future will require to be more closely aligned with the national framework.
Whilst this is a change particular to Scottish general practice, many of the points below will be of interest to practice managers across the UK in relation to service development.
OBLIGATONS UNDER THE FRAMEWORK
Practice managers will now have a duty, along with the partners, to ensure that they have a clear understanding of the types of services their patient population will require and how this can be supported by practice nurses and HCSW roles.
It may be that roles, along with job descriptions, will require adjustment to reflect local priorities and necessary core competencies, and PMs should be making themselves aware of what options are available to their teams.
From this position, PMs should be planning how the practice can support competency development to close any performance gaps, and this may mean allowing time for training, which can be challenging, particularly in small practices. There will also be a need to risk manage the process by ensuring that supervision and support mechanisms are in place.
Partners within practices have an obligation to "ensure anyone you are delegating to has the qualifications, skills and experience to provide safe care" and to "ensure that all staff you manage have appropriate supervision" (GMC – Good Medical Practice).
In future all advanced nurse practitioners (ANPs) in Scotland will need to hold a master’s level qualification in advanced practice and meet all the required competencies for the primary care role. Existing ANPs will need to evidence that they meet the requirements before they can be recorded as an ANP on a list held by their Board, giving them additional authorities. It is likely that GPs will be required to undertake workplace, clinical sign-off on these competencies, and should bear in mind their regulatory responsibility in relation to honesty and objectivity when appraising or assessing the performance of colleagues.
If a nurse currently working as an ANP does not meet the requirements within the new framework it is perhaps worth knowing that both the NMC and the RCN oppose the use of the ANP title without recognised training or competence. Set against the new framework, this could pose a problem, if only until gaps are plugged.
If the practice is looking to recruit an ANP from outside primary care, they will be required to assess any gaps in that individual’s knowledge and competencies relevant to the primary care role and plan to plug these. Also, if an ANP is recruited from an out-of-hours setting, their competencies are more likely to be closely aligned to primary care than if they trained as an ANP in oncology, for example.
Once future service needs have been established, the nurse should work with the PM and partners to consider where training and development is required.
Any gaps in competencies in relation to the new framework or defined requirements (for example the nurse may fulfil all the competencies required to be classed as a senior practice nurse (Band 6) but may not be a non-medical prescriber) should be addressed with appropriate support and access to training.
It is very important that the nurse, or a HCSW, is not expected to work outside the scope of their current competencies and indeed nurses have a regulatory duty to raise concerns with their employer and to ensure they ask for help.
The nurse’s aspirations should be considered alongside the requirements, and (for example) if an ANP role is to be introduced, it could be that the practice can plan the change over a period of time in order to support the current practice nurse to progress their career to meet this need.
Practice nurses are most likely going to have the lead role in developing HCSWs to learn new skills within the framework – and nurses have similar regulatory duties to doctors in relation to delegation and supervision. By supporting the development of other non-clinical staff in expanded HCSW roles, it is likely that practice nurse time can be released for other activities that require clinical expertise.
It is equally important that both nurses and HCSWs expanding their skills are supported to ask for help at the interface of care or boundary of competence between themselves and other team members. For example, the nurse should feel confident to ask a GP to review a patient for them, and the HCSW should feel they can stop and ask a nurse for advice or support.
TAKE A CONSIDERED APPROACH
Although there are no set timescales for the framework changes to be implemented, there is now a clear direction of travel for GP practice development of nursing and HCSW roles.
I would urge practice managers to take a slow and steady approach to managing the required changes. Ensure you access employment law advice as and when appropriate to risk manage changing roles, as in my experience some HCSWs and practice nurses will be worried about what the changes mean for them and what the practice will expect. They will also perhaps be nervous about new roles or undertaking training, and will need additional support through the process.
If a collaborative approach is taken to understand patient population need and to identify how service development will best meet these needs and benefit patients, our experience is that team members are much more likely to embrace the challenges – and opportunities – ahead.
Liz Price is a senior risk adviser at MDDUS
* Developing the general practice nursing role in integrated community nursing teams. Scottish Government, December 2018