Developing the general practice nursing role in integrated community nursing teams

Developing the general practice nursing role in integrated community nursing teams

This series of brief papers on the Transforming Roles programme aims to update stakeholders on the professions' contribution to the wider transformational change agenda in health and social care in Scotland. The sixth paper defines the refocused general practice nursing role.

Background

The Chief Nursing Officer (CNO) is committed to maximising the contribution of the nursing, midwifery and health professions (NMaHP) workforce and pushing the traditional boundaries of professional roles. The Transforming Roles programme aims to provide strategic oversight, direction and governance to:

• develop and transform NMaHP roles to meet the current and future needs of Scotland's health and care system; and
• ensure nationally consistent, sustainable and progressive roles, education and career pathways.

Phase 1 of Transforming Roles focused on nursing roles.

Integrated community nursing teams

Shifting the balance of care from hospital to community and primary care settings at or near people's homes aims to improve population health, increase quality and safety, and secure best value from health and social care services.

Delivering on these aims requires a different approach that enables community nursing staff to develop new and innovative ways of working to provide safe, effective, person-centred care and clinical interventions tailored to need. Health visitors, family nurses, district nurses, general practice nurses, community children's nurses, school nurses and their wider teams, working as integrated community nursing teams, would provide a seamless interface and reduce any boundaries between their practice and place of care.

Integrated community nursing teams within health and social care partnerships will play a key role in prevention, early intervention, supported self-management, reducing inequalities, and planning, providing, managing, monitoring and reviewing care. They will build on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings.

Role of general practice nursing

General practice nurses are mainly employed by general practitioners (GPs). They provide nursing services in general practice settings and have extended roles in health protection, urgent care and supporting people with long-term conditions.

The number of consultations for general practice nurses relative to GPs increased from 28% in 2003/04 to 33% in 2013, illustrating the continued shift of chronic disease management from GPs to nurses.^[1] The growth in chronic disease prevalence means that a refocused general practice nursing role is needed to ensure more effective disease prevention and management, including self-management and anticipatory care.

Developing a general practice nursing role for the future

A short-life working group was established in 2017 under the auspices of the Transforming Roles programme to refresh the role and educational requirements of general practice nurses. The main tasks of the group were to scope the current role across NHS boards and identify areas for developing a refocused role.

Nurses working in general practice can be employed by health boards and (more commonly) employed by general practice. This framework applies to all nurses working in general practice.

Key features of the refocused general practice nursing role

Nurses working in general practice at all levels of the career framework will play a pivotal role in integrated community nursing teams. Different models will exist and develop according to local population needs, but core areas of the role will include:

• focusing on public health, including primary and secondary prevention and addressing health inequalities;
• care and support planning, including anticipatory care;
• assessing illness and injury;
• supporting management of long-term conditions;
• supporting people with complex conditions or who are frail as part of integrated community teams;
• promoting mental health and wellbeing; and
• providing nursing care across the life cycle.

Nurses working in general practice must demonstrate an appropriate level of competence, according to role, within four pillars of practice – clinical practice, leadership, facilitation of learning, and evidence, research and development (Annex 1^[2]).

Role definitions for nurses working in general practice have been agreed to ensure consistency and sustainability, with the equivalent Agenda for Change (AfC) banding for nurses working in the NHS presented as a guide^[3] (Table 1).

Table 1. Role definitions and equivalent AfC banding

Level of practice	Job title	Definition	Equivalent AfC banding
2–4	Healthcare support worker	Works across individual healthcare disciplines under the direction and professional accountability of registered practitioners.	2-4
5	General practice nurse	Responsible for delivery of general practice nursing services, within the professional competence of the post holder, to the whole practice population.	5
6	Senior general practice nurse*	Has a higher degree of clinical decision-making, autonomy and responsibility than general practice nurses in the clinical environment and has completed the appropriate level of education.	6
7	Lead general practice nurse	Has advanced skills in long-term condition management. Involved in the delivery and planning of safe and effective nursing care to the whole practice population. Leads and manages a nursing team working closely with the practice manager and GPs to deliver practice priorities.	7
7	Advanced nurse practitioner	The Transforming Roles programme has set out a nationally consistent approach to advanced nursing practice. ANPs are competent to work at advanced level as part of multidisciplinary teams across all clinical settings, dependent on their area of expertise. They are clinical leaders with the freedom and authority to act and accept responsibility and accountability for those actions. The role is characterised by high-level autonomous decision-making, including assessing, diagnosing and treating (including prescribing for) patients with complex multidimensional problems.[4]	7 (minimum)
8	Consultant nurse	Consultant nurses work at a very high level of clinical expertise and have responsibility for contributing to national, as well as local, developments in their recognised area of expertise.	8a–8d

* Level 6 role description has been developed in conjunction with the Queen's Nursing Institute/Queen's Nursing Institute Scotland to ensure consistency across the UK (see: https://www.qni.org.uk/nursing-in-the-community/practice-standards-models/general-practice-nurse-standards/gpn-voluntary-standards-for-web/).

Box 1 presents a case study example of how NHS Greater Glasgow & Clyde and the West of Scotland Advanced Practice Academy are working collaboratively to meet the standards for advanced practice set by Transforming Roles.

Box 1. Case study: NHS Greater Glasgow & Clyde and the West of Scotland Advanced Practice Academy working collaboratively to meet the standards for advanced practice set by Transforming Roles

NHS Greater Glasgow & Clyde (NHS GGC) is collaborating with the newly formed West of Scotland Advanced Practice Academy to support GP practices and advanced nurse practitioners (ANPs) through guidance, support and continuing professional development (CPD) opportunities for ANPs. The Academy is an alliance of the NHS boards and universities that educate ANPs in the west region.

The Transforming Roles guidance on advanced practice^[4] states that a new ANP in Scotland should hold a master's-level qualification in advanced practice and meet all the required competencies for her/his area of practice. Existing ANPs who meet the ANP definition and have been practising at this level should need only to evidence that they are continuing to meet the required competencies of their role.

NHS GGC is introducing a final sign-off process for new ANPs and those who are not yet recorded by the board as ANPs.^[5] This process will be led by the ANP's line manager who, together with the ANP's clinical supervisor, will review the ANP's NHS Education for Scotland (NES) TURAS ePortfolio for evidence of formal ANP-related qualifications and evidence that all agreed competencies are being met: for general practice, this would usually be the Royal College of General Practitioners/Royal College of Nursing ANP competencies, and for out-of-hours services, the NES competencies.

Nurses who can evidence that they meet these requirements will be recorded as an ANP on a list held by the board. An internal and external moderation process will be put in place by the board and the Academy. Arrangements will be in place for those who have been practising before 2017 (when the requirement changed to a master's-level qualification in advanced practice) or before 2010 (when evidence of master's-level learning was required).

Nurses who are not able to demonstrate that they have met all the required competencies will be supported to develop their ePortfolio through a series of board-provided portfolio workshops, masterclasses, eLearning opportunities and supervised practice provided by their GP practice/employer. This may include those who trained many years ago or who are transitioning from ANP roles in acute care.

Regular CPD events arranged by the Academy will support qualified and trainee ANPs. Membership of the Academy will also support employers within the region to meet the standards for advanced practice set by Transforming Roles.

Accountability

In conjunction with the Scottish Executive Nurse Directors and the Royal College of Nursing, the Transforming Roles General Practice Nursing Group will develop a professional framework for nurses working in general practice that includes principles for professional, clinical and care governance.

Key areas for evaluation of workforce impact include the need to demonstrate that services remain safe and effective, and are reducing unwarranted variation. Baseline data should be collected prior to implementation of the refocused role with reviews post service-change conducted through, for example, activity and adverse events analysis, measures of service stability (such as access), and patient and staff experience.

Impacts on the quality of care should be evaluated as part of the supervision model, with patient-record review and direct supervision being used to evaluate each nurse's competence and effectiveness.

Advanced nurse practitioner and lead general practice nurse

Much discussion and debate has taken place on the differences between advanced nurse practitioner and lead general practice nurse roles. As both roles have developed, differences and similarities have come to the fore. It is therefore recognised that within general practice, these two roles can exist within the same post.

Advanced nurse practitioner and lead general practice nurse roles should not be viewed as sitting within an hierarchical structure, with one more senior to the other. Both roles reflect high levels of practice, but with different (although equally valued) clinical focuses.

Educational preparation and support for general practice nurses

Nurses working in general practice require effective clinical supervision and support through competency frameworks and locally agreed supervision models. The combination of academic preparation, clinical competence development and effective supervision supports a tripartite approach to training and education.

The professional development of nurses in general practice requires significant educational commitment and investment to underpin the provision of high-quality, safe and effective nursing practice. The key to this is associated levels of learning against the Scottish Credit and Qualifications Framework (SCQF)^[6] (Table 2).

Evaluation

The wider impacts of the refocused role will be aligned to the Excellence in Care programme to ensure consistency of measurement and quality across the nursing workforce in primary care settings. Evaluation of impacts locally should be considered in relation to workforce impact and quality assurance.

Table 2. Associated levels of learning

Level of practice	Level of learning (SCQF)	Job title
2–3	6	Healthcare support worker
4	7 or 8	Senior healthcare support worker
5	9 or 11	General practice nurse
6	11	Senior general practice nurse
7	11	Lead general practice nurse
7	11	Advanced nurse practitioner
8	11/12	Consultant nurse

The National Health and Social Care Workforce Plan Part 3^[7] committed £3 million over three years for training and education needs in general practice nursing. The Scottish Government has commissioned NES to manage this significant investment. A three-year plan that offers education and development opportunities spanning all stages and career levels within the general practice nursing workforce is in place. This includes strengthening the learning experience in general practice for undergraduate student nurses, supporting newly qualified nurses in general practice nursing training places, increasing leadership capacity and capability through a clinical fellowship model, and funding a range of continuing professional development short courses and university-accredited modules.

Established nurses working in general practice will have completed relevant recognised courses and be able to demonstrate appropriate knowledge, professional values and competency. For those nurses new to general practice, adherence to the Transforming Roles Education and Career Development Framework^[8] is expected.

Professional development for advanced nurse practitioners in general practice also requires significant educational assurance and investment. Key to this is the requirement for a master's-level qualification, with a core educational focus on the development of competence in: clinical assessment; clinical reasoning, judgement and diagnostic decision-making; anatomy and pathophysiology; non-medical prescribing (V300); leading, delivering and evaluating care; and practice learning/transferable work-based learning processes.

The Transforming Roles General Practice Nursing Group will continue to oversee the funding of training for general practice nursing. This will enable ongoing development of the workforce, particularly during the three-year transition period for GMS Contract implementation in the context of Primary Care Service Redesign.^[9]

Future work

Employers of nurses in general practice should review their nursing workforce and use this guidance to revise job descriptions to reflect local priorities, specifically in relation to the definitions, education and supervision requirements, core clinical competencies and the four pillars of practice. This will be recorded appropriately as a requirement of the 2018 GMS contract and will support future workforce planning.

The refocused role for general practice nursing comprises phase one of a fuller programme of review of general practice nursing, with further consideration being given to:

• agreeing a professional framework for nurses working in general practice;
• exploring cluster models and their implications for nurses working in general practice;
• scoping opportunities to improve ways of working as part of integrated community teams with district and care-home nursing colleagues;
• developing a modular post-graduate programme with a focus on interdisciplinary learning;
• managing investment to support continuing professional development of the current workforce to support the refocused role;
• linking with higher education institutions to further develop the research base on service impacts of general practice nursing developments;
• improving succession planning;
• supporting career development and clearer career pathways for nurses working in general practice;
• exploring how to embed professional accountability infrastructures for nurses and employers across all general practice settings;
• further engaging with key stakeholders, such as nurses working in general practice, GPs and others, through a series of national events; and
• progressing to phase 2 of this workstream.

The Information Services Division should continue to influence and develop datasets for nurses working in general practice to support workforce planning.