This site is intended for health professionals only

Primary Care Groups - a voice for nurses

Elizabeth Powell OBE
RGN BA(Hons)
Chairperson
St Helen's North Primary Care Group

The emerging change in healthcare - a deliberate swing to a primary care-led NHS - is now providing nurses with the opportunity to formulate health policy. Not only are nurses able to bring clinical skills to their local areas, they are also taking the lead in the way local health services are organised and run. 
Primary Care Groups (PCGs) were established in 1999 with the aim of improving health and health services.(1) This has enabled grassroots staff to be involved in the planning and provision of healthcare for local areas. Many nurses took the opportunity to be part of this change. Two years on, it is worth taking a look at the changes this has meant for nurses at ground level and the implications of policy for practice.

Primary Care Groups - a voice for nurses
Nursing roles in primary care have grown in response to changing health needs and a swing to a primary care-led NHS.(1) The changes that have occurred have been due to developments in healthcare policy, which have attempted to adapt to changing health needs. These include an increased elderly population, developments in medical technology, and, with the advance in technology, people's raised expectations.(2) Another factor that influences the need for change in roles is the present deficit in medical manpower.
The introduction of PCGs in 1999 provided nurses with the opportunity to actively participate in the ­development of primary care health policies and ­development. PCGs have opened the door to a ­population approach rather than a GP-practice focus. It has led to opportunities for community nurses to be involved in, among other things, health improvement of local areas, commissioning and clinical governance.
Nurse involvement at board level provides a ­different view of the old landscape. Patient concerns are ­identified and nurses are able to influence and inform new ­healthcare initiatives at a strategic level. 
The changes enable greater opportunity for ­collaboration by all health and social care professionals. Clinical expertise and local knowledge are influencing and challenging traditional ways of working with the aim of improving local healthcare provision.

Primary Care Trusts
Government policy dictates that PCGs will become Primary Care Trusts (PCTs) by April 2004. This change brings together primary and community care within a single organisation. PCTs are different animals from health authorities and community trusts. There is an opportunity to evolve different working practices, learning from the old while looking to the new. Many of the services provided by community trusts will be provided by PCTs. Opportunities exist to create new links between community and ­primary care by involving staff in the planning of services.
PCTs provide a unique opportunity to foster close working relationships between health and social services.(3) The worst health problems in our country will not be tackled without dealing with their fundamental cause. This means tackling disadvantage in all its forms, including poverty, lack of education, unemployment, discrimination and social exclusion.(3) Community development and public health must be the backbone of PCGs/Ts. Nurses are key to this agenda. Traditionally health visitors and school nurses were the public health nurses. This new agenda requires all health and social care professionals to play their part.

Future employment
While PCGs cannot employ clinical staff, PCTs can, and community staff are likely to transfer to PCTs, keeping their existing pay and conditions of service. Practice nurses, however, can still be employed by their GP but have the option of being employed by the PCT if both they themselves and their employing GP agree. Potential conflict could develop if a nurse and GP disagreed. PCTs will have to work with GPs to ensure adherence to good employment law and be able to provide conflict management regarding difference of opinion about employers, if required, in order to foster a supportive culture. Whether employed by the PCT or by a GP it is ­important that all nurses feel a sense of belonging and ownership of the PCT. Good communication and involvement are necessary to enable this to happen.

[[nip01_box1_55]]

[[nip01_box2_55]]

[[nip01_box3_55]]

New ways of working
The nursing strategy Making a difference provides the framework for nurses to contribute to and influence the strategic development of healthcare services.(4) It proposes new ways of working, increased integration in teamworking in primary care, development of the nurse clinician role and an expanding public health role for school nurses and health visitors. The national plan also sees extension of the role of nurses, with opportunities to work in new ways. PCGs/Ts will lead future nursing strategy in line with health policy. The National Service Frameworks and Health Improvement Programmes are also part of this new agenda.
But how do nurses get the time to focus on this new agenda that aims to improve patient care? Practice nurses and other community nurses are in an ideal ­position to examine their workload. Are there any elements of their role that could be done differently or by someone else? Phlebotomy and treatment room duties are examples of work that could be passed on to enable nurses to develop innovative ways of working that support future change. Skillmix needs to be addressed to enable this to happen. Healthcare assistants are presently employed in the acute and community setting. This needs to be rolled out to primary care to enable practice nurses to fully use their expertise.
Practice nurses have gained great experience and expertise in chronic disease management. These skills are well placed to see nurses as the experts in chronic disease areas, thereby improving care in chronic disease management and focusing on prevention and screening.
Increasingly patients present to practice nurses suffering from minor ailments or minor injuries. Studies suggest that nurses can manage the care of most patients with minor ailments without the help of a doctor.(5) The future sees nurses becoming increasingly the first point of call for acute conditions. Other areas of staff development could include dermatology.
It is important to look to the horizon to ensure that nurses are equipped with the right tools for the job. Personal development plans provide a vehicle to address clinical training needs and look to wider personal development. Leadership skills are just one of the qualities that will be necessary within our ever-changing world.

Enhancing primary and community care
The NHS Plan places emphasis on new forms of service provision.(3) General practice is still central to primary care, but in this ever-changing climate we need to work in synergy with other primary care services. The last three years have seen the changing role of community pharmacists, the advent of walk-in centres and NHS Direct. Nurses need to embrace these changes that give better access and information to patients. There is more than enough work for everyone.

Integrated nursing teams?
The shift to a primary care-led NHS requires a vast range of clinical competencies that should be ­determined by local need.(6) Health needs assessment at local level enables nursing teams to assess the health needs of their practice population, planning their workload accordingly.
The fundamental changes within the NHS and the move to PCGs/Ts should encourage nurses to ­collaborate in care, working together in teams. Work will need to be done to break down and understand culture barriers for this to become a reality.
Working as integrated nursing teams enables community nurses to share the care of a defined ­population aligned to general practice. Flexibility in working practice is required to adapt to meet need. This doesn't mean that nurses should take on each other's roles. Indeed, the expertise of all members is vital to team function; it is more that the team should not be so rigid in its role boundaries. The ability to undertake areas of specialty should be equally available for any member of the team and not restricted to one discipline.

Conclusion
PCGs/Ts are vehicles that aim to deliver health improvement to our population. Making a difference and The National Plan form the frameworks for this change.(3,4) Organisational structures of any kind ­cannot work miracles. It is everyone's responsibility to be a part of this new agenda. PCGs/Ts will have to work differently and listen to and support staff through the changes to enable ownership to be ­maintained and developed.
This is an exciting time for all nurses, and to control your own destiny it is important to match skills to health needs of local areas. Nurses are key in turning this vision into reality. Community development and a public health approach are required to allow true prevention of ill health. In the words of Handy: "We must not let our past, however glorious, get in the way of our future."(7)

[[NIP01_pp_56]]

References

  1. Department of Health. The new NHS: modern and dependable. London: HMSO; 1997.
  2. Ham C. Management and competition in the new NHS. Oxford: Radcliffe Medical Press; 1994.
  3. Department of Health. The NHS Plan. London: HMSO; 2000.
  4. Department of Health. Making a difference. London: HMSO; 1999. (www.doh.gov.uk.nurstrst.htm)
  5. Sum C, Humphreys A, Wheeler D, et al. Nurse management of patients with minor illness in general practice, ­multicentre randomised trial. BMJ 2000;320:1038-43.
  6. Burley S, et al. Contemporary ­community nursing. London: Arnold, Hodder Headline Group; 1997.
  7. Handy C. Beyond certainty. Boston, MA: Harvard Business School; 1996.

Resources
Your Guide to the NHS
W:www.nhs.uk/nhsguide
National Service Framework for Coronary Heart Disease
W:www.doh.gov.uk/nsf/coronary.htm
Information about clinical governance is available at:W:www.doh.gov.uk/pricare/clingov.htm or www.cgsupport.org.uk
Department of Health publications
W:www.dh.gov.uk
NHS responseline
T:0870 600 552

Further reading
Chambers N. Nurse practitioners in primary care.Oxford: Radcliffe Medical Press; 1998.
Elwyn G, Smail J. Integrated teams in primary care. Oxford: Radcliffe Medical Press; 1999.