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A day in the life of ... a medical centre nurse

Judith Sheppard was one of the first practice nurses to be employed by GPs in Birmingham when she joined the Bellevue Medical Centre 18 years ago. Since then both her role and the nature of the practice have changed out of all recognition.
 
The practice serves a population of 6,150 in an area of the city that suffers some of the highest levels of poverty, deprivation and social need in the UK. Yet this is not a typical inner-city practice. Bellevue Medical Centre is staffed by an unusually high proportion of academics - four professors and five GPs with research interests, three of them seconded from the Ministry of Defence. In addition, four of the partners have high-profile roles in medical education in the West Midlands.

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Many of the 16-strong team of GPs work part-time in order to pursue specialist interests, and this brings a wide range of expertise into the practice and an enthusiasm for adopting change and for new ways of working. The ethos of the practice is to provide the highest-quality patient-focused care.
 
The practice was one of the first to pioneer Personal Medical Services and was involved in preparation and bidding for the Sure Start health and childcare programme when it was launched. Although it has not ended up holding Sure Start status itself, it nevertheless follows the principles of the initiative.

Staff appraisal and team-based learning were adopted by the practice in 1998, long before it became commonplace in general practice. Staff development and CPD is a priority, and everyone in the practice has personal development plans and learning logs.

The academic influence of the GPs has resulted in the nurses becoming involved in a number of research projects undertaken in the practice for the Department of General Practice at Birmingham University. These have included a groundbreaking model of primary care oral anticoagulation management that is now accepted as a credible alternative to hospital outpatient management.

Judith heads a team of four nurses working in a modern purpose-built building opened in 2000. The practice, which is fully computerised, is open all day Monday to Friday and has a businesslike atmosphere. The reception and administration staff are easily identifiable by their uniform - purple blouses and shirts - and the nursing staff wear black trouser suits.
 
Many of the patients suffer health problems related to poverty and deprivation. There is a high proportion of young single mothers, and a number of children are on the at-risk register. The practice has an ongoing problem with "Did Not Attend" rates, which some weeks can be as high as 100.

The nursing team, consisting of Judith, Carmel Hanly, Lisa Curry and Colleen Allen, between them provide clinics for diabetes, dermatology, smoking cessation, asthma, COPD and warfarin management.

"When I first started I would see only a couple of patients in a morning and mainly did just dressings and a few vaccinations. We are now much, much busier and all the nurses are heavily involved in achieving all chronic disease targets."
 
Judith says her expertise progressed naturally as she learned new skills. There were no practice nursing courses when she started working in the practice in the late 1980s, and everything she learned was taught to her by the doctors.
 
"I would go in to see a doctor about a specific issue and would never get out again without them saying, why are you doing this, what else could you do, are there any alternative diagnoses you should be thinking about?" Judith now specialises in asthma and COPD.
 
"Each nurse in the team does her own specialist work and then we share the treatment room work around booked appointments. I run a respiratory clinic and do a warfarin clinic and I also have three sessions when I see anything and everything; people can book in for a blood test, dressings, smears, immunisations, the pill or HRT checks - there is something different each time."

"My experience is now unrecognisable compared with what it was when I first started working here. I have completed diplomas for asthma, COPD and spirometry - I have put quite a lot of work in. There is no doubt that patients now receive a much higher standard of care."

Judith is also responsible for organising the nursing team. She is allocated a few hours of free time on Thursday and Friday afternoons when she can check on the recall systems or catch up on admin. Sometimes, however, she has to take work home.

"When I first started I would do all the letters, put them in envelopes, check them in and check them out; but now we have an admin team who can run the patient lists off the computer and send out the recall letters for me."

The input of the academics and educationists in the practice and their enthusiasm for innovation and change rubs off on the nurses, says Judith.
 
"Most of the time there is a study or something going on. In recent years we have done a study on the causes of and best way of treating indigestion, and we have done one on the prevalence of chlamydia in the community, as well as looking at atrial fibrillation in 65-year- olds. The university doctors set the studies up and then the work for the trial is done by nurses following protocols."
 
The nurses are involved in a lot of the decision-making in the practice. Judith is invited to the partners' meeting if an issue involves the nurses, and practice manager Anne Bishop works closely with her on all aspects of practice work that involves the nursing team.
 
"The doctors do listen to us fairly well. They are open-minded and they allow the nursing team a lot of autonomy. They are very good to me, but then again I work very hard - it is a two-way thing. We have a superb nursing team and work very well together - we cover each other and help each other out if we have problem."
 
"We are very lucky in the way we are treated. We can do our own thing as long as the work gets done. We are very much up for change, and we never say we can't do something; we will always take it on board. I really enjoy the work, otherwise I would not still be here after 18 years," says Judith.