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Can the NHS Long Term Plan stop practice nursing flatlining?

The NHS long-term plan is packed with radical recommendations. Kathy Oxtoby looks at whether any can help primary care

 

Online nursing degree to be established by 2020

What the plan says

To make nursing training more accessible, NHS England will establish ‘a new online nursing degree for the NHS, linked to guaranteed placements at NHS trusts and primary care, with the aim of widening participation’. This could be launched in 2020 ‘depending on the speed of regulatory approvals’. And to minimise student debt and incentivise mature applicants, ‘it will be offered for substantially less than the £9,250-a-year cost to current students’.

Will it help?

A new online degree has the potential to increase the number of people training in nursing – it’s a flexible, convenient and, crucially, cheaper way of qualifying.Online degree courses, such as those run by the Open University, could be templates for delivering this new course. And in the case of the Open University, the blend of online learning and clinical practice seems to be both effective and safe.

However, an online degree course will not solve all nursing recruitment difficulties. Limits on the number that can enrol are not yet known and, even with clinical placements, it may be difficult to reproduce the experience offered by traditional nursing degree courses.

There is also the danger that nurses who qualify through the online programme will be perceived as inferior to their university counterparts. And universities may suffer if aspiring nurses opt for cheaper online training.

The professionals’ views

NHS England spokesperson: ‘The long-term plan sets out a number of specific actions to support growth in the nursing workforce. Details of the online degree will be set out by NHS Improvement In the workforce implementation plan and published later in the year.’

Dr Geraldine Walters, director of education and standards at the Nursing and Midwifery Council (NMC), which will have to approve any online degree course: ‘The NMC is committed to supporting innovative ways of teaching and learning that give students the knowledge and skills to meet our standards, alongside a rich learning experience.

‘While models of flexible and blended learning for nursing already exist, we look forward to exploring new developments for nursing degrees with the Government and education institutions, as well as our partners in the health and care sector in the coming months.’

Dame Donna Kinnair, Royal College of Nursing acting chief executive: ‘As the Prime Minister outlined in her speech on the plan, the NHS’s biggest asset is its staff. So it is strange that this plan offers no money for nurses to develop the specialties and skills patients need. And it is equally worrying that online courses are presented as a magic bullet to solve the workforce crisis. Nursing degrees demand both academic and practical skills, which student nurses learn from contact with professionals and peers, a model not easily replicated online, even with clinical placements.’

Julie Messenger, senior lecturer in nursing at the Open University, which delivers one of the country’s only online nursing degrees: ‘Delivering nursing degrees with an online element alongside clinical practice can widen access to study – particularly for healthcare staff already in work or others who would find it harder to train through a traditional campus-based route.

‘An online blended approach could certainly increase the volume of students. But there might be problems matching students with appropriate clinical placements, and finding suitably qualified practitioners to supervise and assess them.

‘In our experience, the blended model works very well where you have online, largely academic learning supported by local practice placements where safe clinical skills can be taught and practised in real work environments under appropriate supervision.

‘Employers like it too as it means they can develop their own nurses and keep skills local, helping significantly with retention issues – which is a key challenge in rural areas and high-cost locations such as London’.

Making GP practices work together to form primary care networks

What the plan says

The plan proposes the £4.5bn of new investment will fund expanded community multidisciplinary teams in new primary care networks, in which neighbouring GP practices work together, typically covering 30-50,000 people.

Neighbourhood teams will comprise a range of staff including district nurses. The plan points out that in many parts of the country, functions such as district nursing are already configured on network footprints and this will now become the norm. The aim is to create fully integrated community-based healthcare, supported through training and development in primary and community hubs.

Will it help?

The evidence is conflicting. A recent study shows that larger practices don’t save money, partly because it costs more to manage them. However, NHS England recently announced that a primary care network in Luton was saving thousands of pounds on appointments. More evidence is needed. And training and development of multidisciplinary teams, including practice nurses, will be essential to make this scheme work. The recent announcement from the British Medical Association that any sharp rises in inflation could see practice staff funding cut means plans could change.

The professionals’ views

Julie Roye, advanced nurse practitioner at Oakview Family Practice in south London: ‘The move to integrated community-based healthcare is an opportunity to pull together treatments for patients that need a range of disciplines in primary and community health. It can enable a more efficient way of working that will bring consistency for the patients. For practice nurses, I think it will increase opportunities and development. I hope it will provide more improvements in standardised policies and wages, promote team working, add more skills and resources and help manage the workload better.

‘I am excited about these changes. I think there are many benefits for practices and patients. I believe it will enable early diagnosis of chronic diseases, preventing illness, reducing hospital admission and improving chronic conditions. Where practices come together in partnership, they will be able to support each other. This will make more services available to patients across wider disciplines. This kind of joint planning will improve the community and health system.’

Newly qualified nurses to receive fellowship if entering general practice

What the plan says

Newly qualified nurses entering general practice will be offered a two-year fellowship – a scheme suggested by the recent GP partnership review. NHS England says this will offer ‘a secure contract of employment alongside a portfolio role tailored to the aims of the individual and the needs of local primary care’. According to the plan, the move will enable newly qualified nurses to ‘consider primary care as a first destination role’.

Will it help?

The fellowship could help attract newly qualified nurses. Many younger, recently qualified nurses report that they get turned away from general practice posts because of a lack of experience, and instead go to secondary care. Opening spaces in general practice for these nurses will take advantage of their initial enthusiasm upon qualifying and give them a structured environment in which to learn.

But the scheme’s effectiveness will depend on good mentorship, clear terms and conditions for the period after the fellowship, and details of funding. GPs will not necessarily be in a position to finance this extra resource. Nurses will also need a considered plan for career progression so that they will know whether the move offers the potential for further career opportunities.

Also, the proposal also might alienate established nurses in secondary care who are keen to move to general practice.

The professionals’ views

Rachel Viggars, mentor for nursing students at Keele University, specialist nurse practitioner and clinical nurse lead at Ashley Surgery in Shropshire: ‘This is a positive step. It provides the structure to ensure professionalism and standardisation of training, but it requires good, positive mentorship and supportive environments. The employment after the fellowship will also need proper terms and conditions if we are to retain this developing workforce.

‘Thought must be given to the career progression for these nurses after this fellowship.

‘One major challenge is this: many practices are unable to offer full-time posts, which are needed for new staff to achieve and learn. Newly qualified nurses are looking for full-time posts, preceptorship and a career pathway.

‘Targeting younger nurses is fair. Sadly, students are still being told by some tutors and secondary care staff that primary care is not a first-destination career and they shouldn’t consider it until the end of their working life. Young newly qualified nurses are safe as long as they have a mentor, educational support and support from the employing practice. But there might be problems if they are not supported.’

Alexandra Tanner, a third-year nurse studying at Keele University: ‘I had a 12-week practice nursing placement during my degree, but despite that, a keen interest in primary care and good knowledge of long-term conditions, I have not been able to get a practice nurse post, and have now accepted a district nursing post. The two-year fellowship sounds positive, but does it allow for continuing development? As with any other role, training will always be required. An “experienced nurse” who has worked in A&E for 20 years may not have the knowledge of long-term conditions or travel health.’

Dr David Turner, GP partner in Hertfordshire: ‘It raises more questions than answers. Does the two-year fellowship mean they are coming to us as practice nurses, or is the practice going to train them? Who is paying for this? It all depends what skills they come in with. If they are a newly qualified nurse with a lot of training and will sit in with the practice nurse and learn and contribute, then that’s fine. But if they come with no practical skills, the practice nurse has to take the time to train them and we would need funding for that. It would also slow down our current practice nurses.‘Specific training courses would be required for these nurses. Some general practice nursing skills need certified training, which will be expensive.’

Expanding ‘credentialing’ to cover more areas

What the plan says

NHS England says it will ‘expand multiprofessional credentialing to enable clinicians to develop new capabilities formally recognised in specific areas of competence’. This will allow clinicians to ‘shift or expand their scope of practice to other areas more easily, creating a more adaptable workforce’, it says.

With partners, NHS England has developed several credentials, such as the Royal College of Nursing (RCN) advanced-level nurse practitioner credentialing scheme. NHS England plans to ‘accelerate development of credentials for mental health, cardiovascular disease, ageing population, preventing harm and cancer, with the intention of publishing standards in 2020’.

Will it help?

Credentialing is a means of addressing workforce shortages and filling gaps in care. It is also an opportunity for nurses to practise at advanced level and have their additional skills formally recognised. NHS England’s aim to widen the remit of credentialing by publishing standards on areas like mental health and cancer increases the potential for practice nurses to broaden their skills. The RCN’s credentialing scheme is still developing, but the College says that in the future, some GP practices might include a particular credential, such as the advanced-level nurse practitioner award, as a requirement for certain posts.

But while the process will enable nurses to better respond to the complexities of nursing care, it does not mean better pay. Formal recognition does not necessarily equate to a bigger salary, particularly in GP surgeries.

The professionals’ views

RCN head of nursing practice Wendy Preston: ‘Advanced nurse practitioners work autonomously, and the expansion of this valuable workforce has also meant that medical professionals can focus on more complex aspects of care. The skills of practice nurses are constantly expanding to ensure competent clinical responses to the increasing complexity of nursing care. ‘Some areas of practice now include palliative care reviews as well as managing long-term conditions like diabetes and asthma. In some cases, these nurses are the clinical lead, which was a role historically undertaken by doctors.’