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Leading the way: experiences from a PMS pilot site

Catherine Baraniak
OBE MSc SRN
Fellow of the Queen's Nursing Institute
Practice Lead The Meadowfields Nurse-Led General Practice Chellaston and Upper Moor
Derby
E:catherine.baraniak@gp-c81665.nhs.uk

More than 5 years have elapsed since the Meadowfields Practice opened its doors to patients on 24 August 1998. Meadowfields was one of eight first-wave nurse-led Personal Medical Services (PMS) pilots set up during 1998, and one of just two being led by a nurse who had undertaken self-employed status in order to become an independent contractor. The philosophy of the Meadowfields Practice is that patients should be seen by the most appropriate professional to help them with their problem, and to enable this, the patient is encouraged to see the nurse as a first point of contact. They can also see a GP if they wish - the choice is theirs.

Getting started
In 1998 the notion of a nurse-led general practice earned a certain notoriety, with mixed opinion on the appropriateness of a nurse becoming an independent contractor and being the first point of contact for patients.(1) Several doubts were expressed relating to the proposal, including the clinical ability of nurses undertaking this role, patient acceptability of such a service and its financial viability. However, the fact that 5 years on the Meadowfields Practice has a list of 4,000 patients, has very high patient satisfaction levels,(2) has a cohesive team and has recently opened a second practice in Derby suggests that the model works well. The practice has received many visitors, including nurses, doctors and managers wishing to discuss the Meadowfields model and how they might implement elements of it into their areas of concern. It is interesting to note that many practices have now established nurses as the first point of contact for patients requiring advice and treatment for minor illness, for the management of chronic disease, for health promotional activity, for all screening programmes and for the delivery of NSF requirements. The nurse certainly has a pivotal role in the delivery of primary healthcare services.
It would be untrue to give the impression that the success of the practice has come easily. The path has been difficult, as other studies bear testimony,(3,4) and many challenges remain. Meadowfields now has a sister practice - the Upper Moor Practice - opened on 1 October 2003, which operates along the same lines as the Meadowfields Practice. It has been interesting to reflect on my own feelings about this second venture in light of the experience that I, and the Meadowfields team, have gained over the last 5 years.
Like many initiatives that go against the tide of the traditional establishment, the Meadowfields experience has always been characterised by a pioneering spirit and a very strong sense of mission and purpose. The concept of nurse-led practice was alien within the healthcare environment in 1998, and as a consequence it received criticism or was the object of ridicule from those who had little understanding of what we were trying to achieve. Within the practice there was a driving pressure to achieve financial viability and to have a viable list size, as well as to establish patient satisfaction and acceptance of the service. The Meadowfields team worked long hours and gave over and above of themselves in the delivery of care to the patients. It has been a joy to work with such a team and to be part of something that has had a far-reaching effect on how primary care may be delivered in the future.
The downside of the cutting edge is less palatable. I have had to become accustomed to living with a permanent feeling of knots in my stomach. Regardless of the successes of the practice, there is a constant thought at the back of mind questioning whether I can really do this. It is this thought that frequently deprives me of sleep at night and can cause temporary paralysis if allowed to leave the confines of context. There has also been a constant sense of battle as we have encountered many obstacles, either against nurses having an appropriate higher clinical role in primary care, or opposition to nurses invading territory not considered to be theirs. Battling can be wearying. The learning curve has been, and continues to be, perpendicular for all of us.

Second time around
In contrast, the reflections on my feelings towards our sister practice are very different. While there is an air of excitement and opportunity, experience has enabled me to anticipate the reaction to the practice within our health community and from the public at large. There is less of the pioneer element as the model is well tested now, I know it works well, and I am ­covering ground that I have been over before. I can predict what patients are going to say when the concept of nurse-led services is explained to them. I can predict what the critics will say and I can predict how many hours a week I will need to work as we nurture its success. We are still on a mission, but because of the success of the Meadowfields Practice, this is tempered by an understated acceptance that Upper Moor will be a success too. While I feel convinced in myself that this will be the case, I still have to prove it, and that niggling thought at the back of my mind is now saying, "Can I really do this - again?"
My role of leading these two practices is a new departure for nurses, and while nurse-led services are becoming commonplace in primary and secondary care, the independent contractor nurse is a rare breed. From my own experience, perhaps I can offer some reasons as to why. As an independent nurse, I have feelings of vulnerability and exposure. This is probably to be expected in a pioneering role - a leading mountaineer would not have a rope to climb up but would support their own weight while climbing, establishing footholds and handholds while also securing the rope to the rock face for those behind them to use, making their climb easier. The lead climber has the thrill of reaching the top first, but is probably initially too exhausted to enjoy the view! There is a need for an infrastructure to support nurses who are taking on leadership roles. This is new territory for primary care nurses, and we need to develop the expertise to support our progress. The pioneering element generates uncertainty and cutting- edge adrenaline surges that can be exciting and creative, but also destructive if they are allowed to perpetuate. However, the responsibilities of leadership can be liberating. There are certain freedoms that are challenging and satisfying. Regardless of my fluctuating fickle confidence, I have a reassurance that I have gained the expertise and skills that enable me to do this job and to be able to advise and share this with others. I also have a trophy - no words can express the delight of looking at the Meadowfields project and seeing the fruition of my idea.

The future
Perhaps I should finish this reflection by considering where the development of nurse-led practice could lead in the future. I passionately believe that nurses are a key component of primary care provision and that they are the most appropriate professionals to manage a large percentage of patient problems and difficulties. Perhaps I am a purist, but I do not believe that primary care nurses exist to achieve access targets for general practice, or to address GP workload issues, or to be a substitute for the reducing numbers of GPs across the country. We have always been an operational profession, enabling others to lead and give us instructions, while we try to maintain our nursing principles of caring for our patients. I feel nursing should have a strategic role, particularly in relation to primary care, and be given equal consideration in the planning and design of healthcare services in the UK. Some may suggest that there is no need to have two contracts - GMS and PMS - that nurses can have the opportunity to develop their skills and extend their range of expertise while working under a GMS scheme. This may be true, but the PMS contract offers an opportunity for nurses to rethink the delivery of primary healthcare services and to tailor those services to the needs of their locality rather than to a nationally agreed contract.

Conclusion
In conclusion, the last 5 years have been difficult, challenging, wearying and stressful, and I have probably become hypertensive as a result, but they have also been immensely rewarding and creative, and I have been humbled on many occasions by the way patients have responded to the care we have been able to provide for them. I would challenge and encourage other colleagues who perhaps feel frustrated by the confines of their working environment, or who can see a need that is not being addressed by our traditional ways of working, to consider how things could be done differently, and to consider PMS as a means of achieving change.

References

  1. Comments made in most GP ­magazines dating from July 1997 to December 1998, eg, Pulse, Doctor and GP.
  2. Southern Derbyshire Health Authority. Patient satisfaction survey. 2001.
  3. Lewis R. Nurse led primary care - learning from PMS pilots. London: King's Fund; 2001
  4. Roe B, Walsh N, Huntington J. Breaking the mould - nurses working in PMS pilots [Discussion paper]. Birmingham: HSMC, University of Birmingham; 2001.