Framework for Nursing in General Practice

Framework for Nursing in General Practice

3 Fair and Consistent Treatment

Introduction

The flexibility and responsiveness of general practice as well as the entrepreneurial spirit, which promotes and encourages role development and autonomy are highly valued by practice nurses. Indeed many nurses move into practice nursing because they value working within a small and tightly knit clinical team.

However, some clear messages emerged from the consensus workshop that practice nurses wanted greater standardisation and consistency of employment status with their NHS employed peers. Many were keen to see the development of a career structure that allowed them to progress and rewarded them for taking on new responsibilities. The draft agreement on implementing Agenda for Change in the NHS and the implications for practice nurses has been widely debated and will need to be considered by practices if they are to be able to continue to recruit nurses in an increasingly competitive market.

This chapter is based on standards 1.1-1.3 covering recruitment of new practice nurses, employment of practice nurses and the potential implications of Agenda for Change for practices.

Policies and Procedures

Practices, as employers of often significant numbers of staff will always have developed policies and procedures, written or unwritten, about how they manage their staff. Written policies and procedures, whilst time consuming to produce can prove invaluable in handling HR and employment issues in a fair and consistent way. As small organisations it can often be difficult to access appropriate HR advice or guidance in an area that can be a legal minefield. NHS Scotland's Scottish Partnership Forum has supported the development of a series of PIN (Partnership Information Network) guidelines. These have been developed with the NHS in mind, rather than much smaller practices, however, they are a very useful source for practices. They all start from an understanding of the current legislative and policy position. They have been negotiated and agreed with professional organisations and provide a model policy that could easily be adapted for use within general practice.
The full range of PIN guidelines is available at: http://www.show.scot.nhs.uk/psu/guide.htm

In addition, the Scottish practice managers network are compiling a list of policies in use in practices across Scotland. Sample policies are available from the network's website at: http://www.show.scot.nhs.uk/alhcc/PracticeManagers/Policies-Protocols.htm

Equal Opportunities

Equal opportunities is defined by the Scotland Act (1998) as "the prevention, elimination or regulation of discrimination between persons on grounds of sex or marital status, on racial grounds, or on grounds of disability, age, sexual orientation, language or social origin, or of other personal attributes, including beliefs or opinions, such as religious beliefs or political opinions".

Practices as employers are required by a whole stream of UK and European legislation to treat all staff fairly and equally in relation to recruitment, promotion, redeployment, access to education and career development. The NHS Scotland PIN guideline on Equal Opportunities sets out the legislative base for this as well as a model policy which could be adapted for use within a practice: http://www.show.scot.nhs.uk/psu/documents/equal%20opps.pdf

The recruitment process

A key feature of practice nursing is the diverse nature of the role, so it is seldom easy to simply recruit someone with the full range of necessary skills, even if they are already working as a practice nurse.

Considering filling a practice nurse vacancy provides an opportunity to consider the current and future needs of the practice. There may be the possibility to develop more advanced roles as part of improving access or delivering effective chronic disease management eg nurse consultants. Equally there may be potential to develop staff nurse or health care assistants roles. There may also be opportunities to change the roles and responsibilities of existing team members to enhance their career development.

The skill mix model set out in chapter 5 provides a framework to support decisions about what level of nurse is needed to fulfil the role. The Quality and Outcomes Framework in the new GMS contract rewards practices for developing a job description and person specification for each vacant post. Careful planning and consideration of each new post will help to maximise the benefits and minimise risks to patients, post holder and the practice.

Job Description

The job description should outline the purpose and aims of the post, the main responsibilities, who the individual will report to, and who they may be responsible for. It is important to include appropriate reporting and accountability arrangements and scope of decision making and autonomy. The salary or salary scale should also be included. A set of model job descriptions are included on the CD ROM. These have been drawn up to reflect the four levels of practice outlined in the skill mix model (chapter 5). The model job descriptions have been put together to reflect the full range of roles that a nurse working at each level might take responsibility for and are intended to be tailored to the particular needs of the vacant post.

Person Specification

The person specification is an important tool that the practice can use to ensure they recruit the right person for their post. It identifies the knowledge and skills required for the post. Spending time on the person specification should make every subsequent stage in the recruitment process easier. A model person specification form is available on the CD ROM, which would need to be filled in to meet the specific requirements of each post, based on the job description and the practice's aspirations for the post.

The application process

It is good practice to advertise all vacancies and will help ensure that the practice is not open to accusations of discrimination. The advert should give clear and accurate information in a brief and concise form, which will enable potential applicants to assess their suitability for the post against the criteria to which it refers. Adverts could be placed in local/national or NHS Board media. Applicants should be provided with the job description and person specification along with some details about the practice.

Applications can either be by CV or a formal application form. A model application form is included on the CD ROM. The benefit of using an application form is that the same information is gathered about every applicant, making comparisons simpler. If using CVs, it is common practice to ask applicants to restrict this to a maximum of 2-3 pages and include a single page outlining the particular skills that they would bring to the post and why they are applying.

Whatever method is used, nurses should be asked to provide details of the NMC PIN number and the expiry date, which will be needed to check their registration. They should also be asked to give two referees, one of whom should ideally be their current employer.

The selection process

The final decision on who to appoint to any post will always lie with the practice as employers. However the advice and experience of a practice nurse during the recruitment process would be a valuable asset to practices. The benefit to the practice of engaging nursing input to the process at both shortlisting and interview stage is in questioning candidates on professional matters and advising on the quality of responses. Appropriate professional input will help the practice to make better informed decisions.

Professional nursing input could be sought either from a senior practice nurse within the practice, where a more junior post is being recruited to, or may come from an external source. Practice nurse advisors, where they exist, are well placed to provide this support. Other community nurses attached to the practice may bring relevant local knowledge and expertise in recruitment and selection. Alternatively, professional advice should be available within the Community Health Partnership or the NHS Board primary care division.

The selection process should be transparent, fair and consistent. In particular, interviewers should be aware of the law relating to equality and discrimination. Failure to comply with the law in relation to equal opportunities could result in practices facing expensive litigation claims.

Offering a Post

A job offer should not be made until satisfactory references are received and should be conditional on the following:

• NMC registration check.

• A current Standard Disclosure Scotland certificate.

• Confirmation of identity.

• Satisfactory health assessment.

• Check of relevant certificates.

Disclosure Scotland

The Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2003 sets out those professions and services which are exempt from having to apply the terms of the act and employ people with a criminal record. All health professions are included in this category, as is "Any employment or work which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of that person's normal duties".

The consequence of this is that practices should always make it clear in their application process that nurses applying are required to disclose if they have a criminal record and practices should check via Disclosure Scotland that this statement is correct.

Part V of the Police Act 1997 introduces a new system of disclosing criminal history information to individuals and organisations for employment and other purposes. A new Disclosure Bureau has been established within the Scottish Criminal Record Office (SCRO) for the purposes of issuing certificates under Part V of the 1997 Act. This new service is known as 'Disclosure Scotland' and is responsible for issuing 3 levels of certificates to be known as 'Basic Disclosures', 'Standard Disclosures' and 'Enhanced Disclosures'. The aim of the new Disclosure Scotland service is to enhance public safety and to help employers and voluntary organisations in Scotland to make safer recruitment decisions.

While there is not currently any formal legal requirement on practices to undertake a Disclosure Scotland check, it is standard practice for all such posts in the NHS and practices would be well advised in terms of their own protection and that of patients to follow the same procedure. Nurses should normally have a standard disclosure.

In order to access a disclosure certificate, it is first necessary for the organisation to be registered with Disclosure Scotland. A number of NHS Boards are setting up a single registration for practices, which has a significant cost saving. The cost of the actual certificate would normally be borne by the applicant. Full details of Disclosure Scotland are available at www.disclosurescotland.co.uk.

Nursing and Midwifery Council Registration

Under statutory and contractual requirements, practices must ensure that all health care professionals employed by the practice are currently registered with the relevant professional body on the appropriate part(s) of the register. Practices must therefore ensure that the successful candidate is registered with the Nursing and Midwifery Council (NMC). The NMC professional register has three parts, nursing, midwifery and specialist community public health nursing. Every practitioner eligible to practice will be on the NMC professional register. Practitioners can be registered on more than one part of the register, but as a minimum, applicants for practice nursing posts would need to be on the nursing part of the register.

All registered nurses should be able to produce a card indicating their registration PIN number and expiry date. However, neither the PIN card nor the statement of entry on the register is valid proof of registration. The only way to ensure that nurses, midwives and health visitors have a current NMC registration, and can therefore be employed as registered practitioners, is to check details with the NMC's registration confirmation service. This is a free service, which enables all employers to check the registered status of nurses, midwives and health visitors either by telephone, internet or in writing. Details of how to use these services are available at:

http://www.nmc-uk.org/nmc/main/confirmations/$confirmations. Practices must use the NMC registration confirmation service before employing or re-employing a registered nurse, midwife or health visitor.

Registered nurses are required to renew their registration on a three yearly basis, providing evidence that they have achieved the minimum requirements for continuing professional development and signing a declaration of good health and character. Practices, as employers, should maintain a record of registrations for nurses they employ. When a nurse's registration is due for renewal, the practice should check that she has done so. Failure to maintain a live registration means that the nurse is not eligible to practice and would result in the practice needing to withdraw her from clinical practice until the registration is renewed. When the nurse renews her registration she will receive a new registration card which should be checked by the practice. There should be no need to re-check registration direct with the NMC, unless the practice has some concern regarding an individual's registration status.

It is important to ensure that any locum practice nurses are subject to the same professional registration check as a permanent member of staff. (Bank or agency nurses employed in practice will have had this checked by their employer.)

Enrolled nurses

Enrolled nurses are nurses who completed a two year programme of education leading to a second level registration. Whilst the education of enrolled nurses ended in the mid 90's and many have since taken the opportunity to upgrade their qualification to that of a first level registered nurse, there still many enrolled nurses practicing in Scotland. All enrolled nurses are registered on the NMC's register and are entitled to call themselves registered nurses. All are required to work in accordance with the standards set out in the NMC's Code of professional conduct. This makes it clear that all registered nurses are accountable for their practice. The NMC does not describe a limit to the practice of second level registered nurses but simply the requirements of them at the start of their careers. All registered practitioners have a personal and professional accountability for their own knowledge and competence and for ensuring that they are appropriately prepared for their professional practice. Employers and managers have a responsibility to ensure that all registered nurses whom they employ are competent and up to date in their practice. Practices choosing to employ enrolled nurses will need to ensure that they have access to appropriate education and are competent to fulfil their role, but need not restrict their scope of practice purely on the basis of their second level registration.

Contract of employment

The contract of employment starts as soon as the nurse accepts an offer of employment. Employers are legally obliged to provide to every employee with a written statement of their terms and conditions of employment not later than 2 months from the beginning of that employee's starting date. Legally, this must reflect any terms and conditions agreed informally during the recruitment process. A model contract that practices can adapt for their own use is available on the CD ROM.

Indemnity cover for Practice Nurses - Employer's liability

Under contractual and statutory regulations all professionals working in the practice must be covered by appropriate indemnity insurance. The medical defence organisations have provided clarification on the extent to which GP's membership covers their practice staff. Cover available to members provides indemnity of their own professional acts or omissions, and also provides indemnity for claims made against them in respect of acts or omissions, of non medically qualified staff employed by them. However, indemnity cover for non medically qualified staff, is provided on the basis that individuals work within the boundaries of local /national protocols and guidelines and within their level of knowledge and competency. This is in line with and in addition to the nurses own professional accountability to the Nursing and Midwifery Council. Practices looking to expand the roles of nursing staff should ensure that indemnity cover takes account of any new responsibilities.

Following a consultation in 2002, the NMC in its next edition of the code of professional conduct plan to recommend that all practitioners secure indemnity insurance to cover them against claims of professional negligence.

In the meantime, NMC circular 22/2004 dated 28 July 2004 recommends the following: "a registered nurse, midwife or specialist community public health nurse, in advising, treating and caring for patients/clients, has professional indemnity insurance. This is in the interests of clients, patients and registrants in the event of claims of professional negligence.

Some employers accept vicarious liability for the negligent acts and/or omissions of their employees. Such cover does not normally extend to activities undertaken outside the registrant's employment. Independent practice would not normally be covered by vicarious liability, while agency work may not. It is the individual registrant's responsibility to establish their insurance status and take appropriate action.

In situations where employers do not accept vicarious liability, the NMC recommends that registrants obtain adequate professional indemnity insurance. if unable to secure professional indemnity insurance, a registrant will need to demonstrate that all their clients/patients are fully informed of this fact and the implications this might have in the event of a claim for professional negligence".

Nurses working in general practice may find additional indemnity particularly valuable as they are only covered vicariously through their GP if they are employed and followed the GPs guidelines. Should a claim arise out of the acts or omissions when the nurse has formed his/her own clinical judgement outside of the scope of agreed practice guidelines the GPs indemnifier may be involved but would also be looking for support from the nurses indemnifier. Nurses should seek clarification from their own professional organisations as to what the scope of indemnity cover is and whether any enhanced responsibilities taken on would be covered and by whom.

Dealing with matters of misconduct and poor performance

All employees within a practice are required to perform the duties of their post to an acceptable standard, agreed as part of their contract. Where this standard is not met, the first resort should be to offer support, encouragement, guidance and, if necessary, training to improve their work performance. However it is recognised that this will not always produce the desired results and more formal measures may sometimes be necessary. At this point it is useful to differentiate between a lack of inherent competence or capability to do the job, due to a lack of knowledge, skills or ability and a lack of performance that is attributable to a wilful refusal to work satisfactorily. The latter may be a matter of conduct and may be dealt with under the disciplinary procedure.

The PIN guidelines on Management of Employee Conduct http://www.show.scot.nhs.uk/psu/documents/conduct.pdf and Management of Employee capability http://www.show.scot.nhs.uk/psu/documents/capability.pdf are a useful resource and contain model policies which could be adapted by practices.

Managing issues of capability can be particularly difficult for practices to deal with as there is often not easy access to any professional benchmarks or comparators. One unfortunate side effect of this is that many more cases are referred by practices to the NMC than the Council deem to be appropriate.

In considering whether there is a problem with capability of a practice nurse, practices should consider the following questions:

• What are the indications that the employee is not meeting the requirements of the job?

• Have there been complaints about, or criticisms of, the employee's work from colleagues or patients?

• Are there factual grounds to indicate inadequate performance, such as poor results (e.g. high rate of inadequate cervical smear tests)?

• Does the manager's own observation of the employee indicate dissatisfaction with his/her performance?

• Has the employee requested help to overcome a problem?

The Employment Relations Act (ERA) 1996 states "capability (is) assessed by reference to skill, aptitude, health or any other physical or mental quality". It also states that "incapability must relate to the work or the kind of work the employee was employed by the employer to do". This must be determined in accordance with employees' current contractual obligations.

The PIN guideline on managing employee capability sets out a procedure designed to deal with those cases where the employee is lacking in some area of knowledge, skill or ability, resulting in a failure to be able to carry out the required duties to an acceptable standard. It is intended to be used where there is a genuine lack of capability, rather than a deliberate failure on the part of the employee to perform to the standards of which (s)he is capable.

Lack of capability can be caused by many factors, including:

• Ill health;

• Personal circumstances;

• Skills and competencies;

• Lapse or loss of registration;

• Changes in the workplace environment;

• End of career change;

• Bullying and harassment.

The PIN guideline sets out details of how to respond appropriately to each of these causes. Practices may wish to seek professional nursing advice from the CHP or primary care division where they have concerns about the capability of a nurse.

Referral to the NMC

The NMC's role is to protect the public from registered nurses whose fitness to practice is impaired and whose situation cannot be managed locally. In these circumstances the NMC committee can restrict or remove a practitioner's registration. The NMC has powers to deal with cases of both unfitness to practice and lack of competence, but will only become involved in circumstances where practice is impaired to the extent that public protection may be compromised. The NMC will not normally become involved in a case if you cannot demonstrate that you have already taken considerable measures to tackle the situation at a workplace level.

Before deciding to make a referral for lack of competence, the NMC expects the following steps to have been taken:

• Informal information gathering to establish the facts about a nurse's lack of competence, together with an attempt to identify possible causes. Many cases may be remedied at an early stage if training needs are identified, clear and achievable objectives are established, and support and supervision is provided.

• Exploring other factors that might be causing stress or health problems and identifying solutions where possible, such as an early referral to occupational health

• Determining whether organisational issues have impacted on an individual's performance.

• When serious problems are identified they must be raised formally with the nurse.

The NMC would expect to see written evidence of attempts to address any such shortcomings at a local level including details of the concerns, agreed action plans and reviews of progress. Where issues can be successfully dealt with at local level, there is no need to refer them to the NMC.

Further guidance on reporting impairment to practice is available at: http://www.nmc-uk.org/nmc/main/publications/Reporting-unfitness.pdf

Guidance on reporting lack of competence is available at http://www.nmc-uk.org/nmc/main/publications/lack-of-competence.doc

Maintaining a Healthy Workplace

Health at work is not only about health and safety, although this in itself is a large and complex subject, with a significant range of statutory and legal duties placed on employers.

There are four major components underpinning a healthy organisation:

• health and safety

• promoting access to competent occupational health services

• promoting staff health and wellbeing

• organisation of work

The PIN guideline on Managing Health at Work http://www.show.scot.nhs.uk/psu/documents/health.pdf provides a useful summary of the legislative position in relation to health service employers and sets out a range of model policies that could be adapted and developed by practices.

In addition, the Health and Safety Executive website www.hse.gov.uk is a useful link to guidance and helpful tools.

Agenda for Change

What is Agenda for Change?

Agenda for Change is one aspect of pay modernisation being taken forward by the four UK health departments. It provides a modern pay and conditions structure based on the principle of equal pay for worth of equal value for NHS employed staff. Taken together with the GMS contract, consultant contract and ongoing work on pharmacy and dental contracts the whole stream of work is intended to ensure that employment arrangements for all staff meet the needs of 21st century health care and employment standards. It provides a stronger framework than currently exists to support role development and ensure that salary reflects responsibility

Agenda for Change sets out a proposed new pay and careers package covering the million plus employees who work for the National Health Service across the UK. It aims to harmonise terms and conditions for all NHS staff excluding doctors, dentists and some senior managers, simplifying the current complex and cumbersome systems and introducing a single job evaluation framework linked to a common pay spine. It is proposed, subject to final approval from several staff organisations, that Agenda for Change will be implemented for all NHS staff from December 2004, with payments backdated to October 2004. Not only will the changes impact on pay, grading, terms and conditions, they will also offer greater opportunities for personal development and career progression.

Full details of Agenda for Change and Scottish proposals for implementation are available from: http://www.show.scot.nhs.uk/sehd/paymodernisation/afc.htm .

The main components of Agenda for Change are:

• job evaluation

• new pay bands

• standardised terms and conditions of service

• career and pay progression

Job evaluation

All NHS staff will transfer onto Agenda for Change pay bands via a process of job evaluation. Underpinned by the principle of equal pay for work of equal value, its aim is to ensure that all staff are rewarded fairly. Posts are evaluated using a series of 16 factors and a weighted point score determined that matches a particular job to a pay band. To simplify the whole process, the majority of NHS jobs will be assimilated into these new pay bands using nationally agreed 'job profiles'. The job profiles have been negotiated with professional organisations at UK level and agreed to be fair representations of the post. For practice nursing there are three relevant job profiles: health care assistant (community), nurse working in a general practice and specialist practice nurse. A further profile is being developed for a more highly specialist practice nurse. The job profiles equate to the four levels set out in the skill mix model and to the model job descriptions.

New pay bands

Under Agenda for Change there will be a common pay spine with a series of bands. These are broader than the current Whitley grades. Following job evaluation, every member of staff working within the NHS will be assigned to one of these pay bands. For nurses, this new system will replace clinical grading. Each pay band will have a number of points and it is expected that staff will progress upwards by one pay point each year.

Terms and conditions

Agenda for Change will simplify the current complex and cumbersome system that is based on national and local pay variations. In the future, regardless of their professional or industrial grouping, all terms and conditions will be standardised

Career and pay progression

Under Agenda for Change every member of NHS staff will have an annual development review, which will include appraisal and assessment against the new NHS Knowledge and Skills Framework (KSF). The NHS KSF is essentially a development tool but will also contribute to decisions about pay progression. It is designed to:

• identify the knowledge and skills that each individual needs to apply in their post

• help guide the development of individuals

• provide a fair and objective framework on which to base review and development for all staff

• provide the basis of pay progression in the service.

A summary of the KSF and it's uses is available at: http://www.show.scot.nhs.uk/sehd/paymodernisation/Documents/ksf-related-development-review.pdf The full KSF is available at: http://www.show.scot.nhs.uk/sehd/paymodernisation/Documents/knowledge-skills-framework.pdf

For practice nurses, a KSF profile has been developed matching each of the four model job descriptions and could be used by practices as a basis for personal development planning for practice nurses.

Why should Agenda for Change concern General Practices?

Practice nurses are of course not directly employed by the NHS and practices can choose to pay their staff whatever rate they consider appropriate for the job, so why should practices consider implementing Agenda for Change?

Like the new GMS contract, Agenda for Change has been the subject of lengthy development and ongoing negotiations with the NHS, Health Departments and professional organisations. It provides a uniform package of terms and conditions and should provide a stronger link between reward and the demands of any given job. This new package is intended to replace clinical grading for nurses and the current terms and conditions set out by Whitley Council. This in effect means that practices choosing not to apply Agenda for Change would need to define their own salary scales and terms and conditions as no other benchmark will exist. Indeed for this reason it is understood that many independent sector employers are also working towards implementing Agenda for Change.

Perhaps one of the most powerful arguments for practices in considering whether to implement Agenda for Change will be the impact of market forces. Practice nurse numbers have grown exponentially over recent years and general practice has been viewed by many nurses as a good place to work because of the clinical autonomy that it offers. However, many nurses throughout the development of the framework have commented on lack of access to education and career development in general practice. It seems likely that if career development opportunities and salaries that better reflect responsibilities are developed in the NHS, practices will face an increasingly challenging employment market. In this market, those that have chosen to apply Agenda for Change principles may be more likely to be able to recruit the calibre of staff required to make a success of the new GMS contract.

Implementing Agenda for Change

If practices wish to implement Agenda for Change, they will need to access HR support within the local NHS Board. It will be important for NHS Boards to ensure that the necessary support and resources are made available to practices to enable this.