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Healthcare assistants: a threat or an opportunity?

Janet Gear
RGN CHCN (General Practice Nursing) CPT
Professional Lead Practice Nursing
Blackwater Valley & Hart PCT
Aldershot
E:janet@the-gears.freeserve.co.uk

My practice nursing career, along with many others, began in response to the new ways of working outlined in the 1990 GP contract.(2) I joined a practice team with five part-time PNs and five GPs working from three surgery sites. The practice brochure proudly announced: "We have a practice nurse at each of our surgeries who can advise you on travel vaccinations, test your urine and check your blood pressure if you wish."

The branch surgery had been open for a year and served around 2,000 patients. Patients waiting to see the nurse joined an orderly queue. By 11.30am, morning surgery would be over and the GPs would be out and about on house calls. I would join the two receptionists for coffee and a piece of cake, usually provided by grateful patients, before cleaning and stocking the consulting rooms. Other tasks included filing letters and results and summarising notes - all of which I enjoyed because I learned so much about the patients' medical histories. Each Friday I would take the fluffy towels and pillow cases across the road to the launderette! Remember the days?

As time went on, the number of patients grew and the PN role expanded within the primary healthcare team. The 1990 contract had introduced some novel tasks, such as "new patient health checks", "over-75 checks", the concept of "health promotion" and chronic disease management clinics.

I undertook the cervical screening course and quickly realised that I needed more family planning knowledge to cope with the range of questions women asked when they attended for a smear. Next was diabetes management in primary care, the PN course, and a teaching and assessing qualification.

Major changes at practice level followed, such as:

  • Practice nurse appointments.
  • Practice nurse-led clinics, such as diabetes, ­asthma, coronary heart disease and travel health.
  • Fundholding.
  • Computerised patient records.
  • Computerised appointment systems.
  • Protocols.
  • The paperless practice.
  • More patients … more GPs … and more nurses.

And there were changes at organisational level too - Health Commissions became Health Authorities, which turned into Primary Care Groups, which evolved into Primary Care Trusts and Strategic Health Authorities.

Despite the changing role and increasing workload, when the idea of employing a phlebotomist in practice was mooted, I was adamant that this was not the best way forward. Practice nurses had spent the past 10 years moving away from task-oriented patient care to provide a holistic approach. It was impossible to quantify, but we knew that when a patient attended for a blood test we could also offer a diverse range of advice, support and health education during the consultation.

In an attempt to see whether a nurse-led phlebotomy clinic would work, I introduced one myself with 5-minute appointments. It soon became clear that this wasn't going to work. I remember one of my first patients, attending for a blood test, announced that her diabetes was out of control and showed me a makeshift dressing that her husband had put on her leg that she'd gashed at home … 20 minutes later she left the treatment room!

However, as time went by, we were struggling to meet demand, and audits of PN activity supported claims for extra nurse hours. Quite rightly, questions began to be asked about the appropriateness and cost-effectiveness of our expanding role. There was a definite need to focus our specialist skills, especially around chronic disease management, and advances in evidence-based medicine were impacting greatly on the provision of care. For example, the increase in the use of statins and the benefits of tight glycaemic control in diabetes and treatment of hypertension all warrant regular blood tests to monitor progress and titrate medication levels.

Gradually I was beginning to relent. Around this time I was asked to work with a PCT-employed healthcare assistant (HCA) to develop the role of the HCA and identify future training needs. This project raised awareness of the potential opportunities and threats for all key ­stakeholders:
For GPs and PNs:

  • Letting go of parts of our role we enjoy.
  • Feeling our role was disintegrating.
  • Allowing others to see our patients.
  • Understanding the needs of unqualified ­colleagues.
  • Providing a varied role.
  • Teaching and assessing skills.
  • Holding accountability for aspects delegated.
  • Understanding the support and development needs of a larger team.
  • Developing leadership skills.
  • Ensuring protected time for all aspects.

For HCAs:

  • Joining an established team.
  • Acknowledging role boundaries and core ­competencies.
  • Committing to training (eg, NVQ Level 3 Care).
  • Learning and developing new knowledge and skills.
  • Accepting the potentially isolated role and ­accessing peer support.
  • Recognising a possible career pathway.

For patients:

  • Meeting and trusting new members of the team.
  • Understanding the role.
  • Receiving holistic care.
  • Being assured of confidentiality and privacy.

For practice teams:

  • Getting team consensus.
  • Managing change.
  • Increasing size.
  • Ensuring personal development and support needs were being met.
  • Understanding role boundaries.
  • Identifying logistics of room space and computer access.

This led to the development of a job description for HCAs. The job description we developed aimed to ensure a varied role with opportunities for developing clinical skills alongside the more mundane aspects of the HCA role (see Table 1).

[[NIP16_table1_51]]

As with any new member of staff, initial induction, training and support were very time-consuming, but 18 months on my initial concerns about the HCA role appear to be unfounded. The post is for five sessions (25 hours) per week, and PN time has been released in two key ways as reflected in the job description. First, new clinical skills enable the HCA to hold regular phlebotomy sessions, to undertake annual reviews of patients with impaired fasting glycaemia, and to prepare and assist the GPs during minor operation sessions. Building on the HCA's previous knowledge and skills from working both in hospitals and the community allayed my fears about reverting to task-oriented care. Second, it does not need a highly qualified PN to undertake the time-consuming and essential organisational duties needed in a busy general practice environment, such as daily equipment checks, ordering stores and stocking consulting rooms. Our team audit figures demonstrate that, as the HCA role has expanded, the PNs have been more able to use their specialist skills with additional appointments for triage, chronic disease management and women's health clinics. Patient access to a wider range of appointment times has also improved.

Difficulties over the past 18 months have included adjusting to working with nonqualified staff, altered team dynamics, finding time to teach and assess NVQ coursework, and a logistical lack of room space (to be alleviated by current building work).

Overall, planning and implementing the HCA role in general practice has been a positive experience.The skill of phlebotomy is easily taught, but the additional knowledge and skills relating to informed consent, record keeping, data protection, diversity, equality, health and safety, communication, and holistic awareness of patients' needs potentially cause challenges and threats to providing safe and effective patient care. Access to relevant training and professional support is paramount. HCAs are encouraged to gain a nationally recognised qualification (NVQ Level 3 Care), which ensures assessed learning and sets a standard across the PCT. A valuable peer support group has been introduced to provide a forum for updating skills and sharing knowledge and experiences.

This article has touched on many aspects of meeting the demands of the quality agenda and further expanding patient access to a range of services in the ever-changing field of primary care. I now accept that reviewing roles and introducing skillmix has the potential to provide golden opportunities for all stakeholders … provided the potential threats are also recognised and addressed ­effectively within the primary healthcare team.

References

  1. Baulcomb S, Burley S. Teamwork and skill mix. In: Burley S, Mitchell EE, Melling K, Smith M, Schilton S, Crumplin C. Contemporary community ­nursing. London: Arnold; 1997.
  2. Department of Health. General ­practice in the NHS. The 1990 contract. London: HMSO; 1990.

Further reading
Liberating the talents: helping PCTs and nurses to deliver the NHS plan. London: Department of Health; 2002
The new GMS contract - delivering the benefits for GPs and their patients. London: Department of Health; 2003