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The Francis report: what does it mean for primary care?

With its focus on acute hospitals, the Francis report may seem a million miles from primary care nursing. But its recommendations and the government's response to them will affect everyone working in healthcare.

Much of what Robert Francis wrote will resonate with practice nurses and others working in primary care such as health visitors, community and district nurses. The “relentless focus on the patient's interests,” the obligation to protect them from substandard care and the need for a “compassionate and caring culture” are unlikely to be quibbled with by nurses, many of who would say this is at the core of their professional practice anyhow.

“The key recommendations - such as the duty of candour - will go across healthcare,” says Jane Beach, a professional officer in Unite the Union's health section - which includes the Community Practitioners and Health Visitors Association. “The professional issues around not tolerating poor standards will apply just as much within the community.”

Jenny Aston, nursing lead at the Royal College of General Practice's General Practice Foundation, agrees: “There is a lot that can be mapped across to general practice.” The key message of having competent capable staff who are able to do the job applies across healthcare, she says.

So how will this affect the lives of nurses working in practices and other parts of primary care? RCN assistant head of nursing Tim Currie says there are many elements of the report which will affect practice beyond the acute sector, such as the desire for seamless communication and joined-up working.

One of the key recommendations is the duty of candour on staff to be open with patients and those around them, as well as informing their employer when something goes wrong which causes, or could have caused, death or serious injury - even if the patient is unaware of it. This raises questions about what action should be taken if this does not happen and how whistleblowing can be supported.

Yet this is in the context of a cultural shift in the NHS towards a more open and transparent system, which admits and hopefully learns from mistakes. Ms Aston points out that significant incidents are inevitably much more personal in a general practice. “If you sit down and discuss a significant incident in general practice you are talking about the people in the room,” she says. The complaints system is also much more accessible and immediate, she points out - though sometimes patients may be reluctant to complain about people they intend to have an ongoing relationship with.

The challenge for practice nurses in particular will be how this translates into the much smaller world of general practice - and what they do if they feel the thrust of this duty of candour is not being followed within the surgery. Heather Henry, a nurse who sits on the NHS Alliance's national executive, points out that in the hospital sector nurses will have several levels of management to go through which may offer them some degree of anonymity.

But in a practice they may be working alongside the person whose performance or behaviour they are concerned about; and in some cases that person will also be their employer and can identify who has raised these concerns. “It is the very close nature of the working relationship that you have with employers that is the difficulty,” she says.

Many nurses working in small teams in the community may also find it difficult to raise concerns and will be concerned about who to go to. Ms Beach points out that nurses working in care homes are also in a very difficult environment and risk being sacked it they speak out. “But as a health professional you have a professional responsibility to raise concerns,” she says.

Ms Henry points out that practice nurses often have a long-term relationship with patients who may be more open with them about issues with both the practice and the NHS more widely. “That gives you quite a burden about what to do,” she says. Francis flagged up the importance of complaints as an underused source of account- ability and basis for improvement.

In extreme cases, where practice nurses feel the need to raise performance issues outside the practice, they are likely to end up in an uncomfortable position and many will chose to leave, suggests Ms Henry. They may also feel uncertain about where to go to with information.

But practice nurses are often lone workers or have limited contact with their peers - and the same can be true for other nurses working in the community. This can make it harder for them to recognise when their own work needs improvement or to discuss common problems. Francis suggested peer-review would be helpful in achieving some of the cultural and behavioural changes he wants to see, and it should be a key part of the delivery and monitoring of any service.

Yet primary care nurses still find it hard to get protected time for contact with their peers. Ms Henry says social media can be helpful in this as an alternative way to connect. It is often the nurses who are not involved with peer groups who may have problems, she says. The report recommends revalidation for nurses, similar to what is being introduced for doctors, along with a requirement for appraisals. This may help make the case for protected CPD time.

The report also recommended regulation of healthcare assistants (HCAs) - a move many nursing organisations would welcome, although it is uncertain whether the government will take his forward. As HCA numbers in primary care grow and more work is delegated to them, this may offer a way for nurses to do so with greater confidence. However, Ms Henry warns that it may not completely relieve the registered nurse of the responsibility for the delegated work.

Practices could also take on a greater role in monitoring patients after discharge from hospital; something which has already drawn some warnings from GPs about additional workload but might be done by practice nurses. A recognition that patients - especially the elderly - need continuity of care and long-term oversight of their health rather than just undergoing “episodes of care” would fit into the philosophy of many primary care nurses.

Nurses who sit on or advise clinical commissioning groups could also have a role to play in improving care in the acute sector. Prime Minister David Cameron, who responded to the report in Parliament, said he hoped clinical commissioning groups (CCGs) would assist by being able to have clinical conversations with the acute sector. Nurses - especially those with experience of both primary and acute healthcare - will be well-placed to do this. However, Ms Aston questions how realistic it is to expect ordinary GPs to monitor hospitals more than they do at present.

What impact Francis will ultimately have on nurses will largely depend on how the government, the profession and other organisations respond to it. Many, such as the RCN, are still working through it and will respond in more detail later. Implementing even a fraction of the 290 recommendations will take time; and changing the culture of the NHS even longer.

But Mr Currie says that every nurse should read the 120 pages of the executive summary. “Some of it will impact, some of it won't but we all need to be able to say we have read it.”