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The role of the primary care nurse lead in practice

Sue Cross
Primary Care
Nurse Lead
NHS Barking and Dagenham

Over the past 50 years, there have been great improvements in healthcare. People are living longer and surviving the diseases that killed them in previous eras. However, the population in most parts of the country has grown by two-thirds and we are much more of a multicultural society than ever before.1

I remember when completing my Nurse Practitioner Diploma at the Royal College of Nursing in the early 1990s, learning about the Black Report and the inequalities in healthcare that occurred; and even with the health improvement of the 21st century these inequalities, I would argue, are still apparent.2
Electoral wards just a few miles apart geographically have life expectancy spans varying by years. For instance, there are 16 stops between Kings Cross and Barking  - so as one travels east, each stop, on average, marks nearly a year of shortened lifespan.3

Why you need one!
There are no minimum standards to become a nurse in general practice in the UK. A nurse can call herself a practice nurse or a nurse practitioner without any relevant qualifications. Having been a practice nurse and nurse practitioner myself, I realise that a majority of nurses in general practice work very hard at ensuring that they have the competence to carry out
their role.

However, these standards are not mandatory, so it can be very difficult for the nurse to appreciate what education and training he or she may need, where to get the funding and how far they can extend their role. Most general-practice employers have not adopted Agenda for Change, so pay, holidays and general terms and conditions may vary from practice to practice.

Some of these factors include employment standards, GP-nurse relationships and nurses' attitudes. Most of these can be influenced positively to create an environment conducive to providing high-quality standards in general practice.

A national survey of practice nurses across the UK, sponsored by the Department of Health-funded Working in Partnership Programme (WiPP), produced data about levels of professional development support in practice.4 A total of 1,160 nurses participated in the online anonymous survey. The findings give an insight into factors that are associated with effective professional development and, therefore, enhance nursing competence and quality of care.
The key findings of this survey were as follows:

  • There are wide variations in employment conditions and levels of professional support for nurses working in general practice in the UK.
  • There are examples of excellent practice and some of unacceptable standards.
  • Appropriate education is not universally available.
  • Some nurses are working with inadequate training and support to maintain competence.
  • There are clear links between good employment standards and nurses feeling well supported in their professional development.
  • A strong working relationship with GPs and, in particular, high-level involvement in decision-making is directly related to nurses feeling well supported.
  • Nurses who feel positive about their role are more motivated and, therefore, likely to seek appropriate support and share responsibility for professional development.4

What the role means
The primary care lead nurse (PCLN) is usually responsible for working with general practices to ensure the high-quality standards of nursing in general practice are maintained; and if high quality isn't already there, making sure that it is achieved.

The PCLN also works with others to achieve nursing redesign and quality strategy to enable the development of a workforce fit for purpose in the delivery of a quality, effective and responsive service to meet the specific primary care trust (PCT) strategic priorities. This will obviously vary from PCT to PCT depending on the economy of the area, social structure, culture of the people living there and the various health and social needs. In these days of Transforming Community Services and shifting appropriate care from the acute services to the community we need to ensure that the infrastructure of general practice is providing the best care possible. The primary care nurse lead is usually responsible for working with others to lead on:

  • Clinical and professional leadership.
  • Service development and modernisation.
  • Standards for better health.
  • Nurse prescribing.
  • Training and awareness.
  • Audit, research and evaluation.

General practice nurses are very isolated and there is often no support to unite these essentially independent private health providers. This can be a very difficult area in which to function, when you may be working without any direct clinical and peer support. Therefore, the PCLN can often bridge this gap and bring these isolated practitioners together.

The day-to-day job
When I started in the role I felt it was important to find out more about Barking and Dagenham and what the population consisted of in terms of culture, age, social demographics and support services (both voluntary and more formal). I was able to gather most of this information from our Commissioning Directorate at the PCT. I then visited each of the nurses and completed a training needs analysis with them to discover what their role was, what training and education they had completed to fulfil that role and from that to determine what their ongoing training needs were. I also tried to discover what their aspirations were for the future and how they intended to reach these. I also wanted to know how they fitted in with the rest of the primary healthcare team and what contribution they made to the direction of the team.

I then produced a report on my findings for the Professional Executive Committee. I meet with them every two months to update them on my progress. I went on to produce a business plan to demonstrate what I felt were the needs for NHS Barking and Dagenham over the next two years. This included:

  • A training timetable.
  • The employment of a clinical supervisor.
  • The development of a primary care nursing bank.
  • A scheme to train the primary care nurses of the future.

One of the main problems with primary care nursing (as in other parts of the country) is an older population of nurses than the national average of general nurses,5 and a complaint from the GPs is that they train their nurses and then they will move practices. We, therefore, need to try to reverse this trend.

By setting up a practice nurse bank, we hope there will be cover from trained practice nurses for holiday, sickness, etc, and by training our own nurses through our apprentice practice nurse scheme, we hope there will be a pool of ready-made nurses to fill any gaps.

We also need to look at why nurses change practices so readily. The introduction of Agenda for Change would help to introduce some uniformity to pay and terms of employment in practice in NHSA Barking and Dagenham. Nurses need to have a feeling of self-worth in their practices and, therefore, allowing them to participate in team meetings and have an equal say in the running of the practice may help here.

Long-term benefits
The WiPP Professional Support Standards for nurses in general practice have now been adopted by all practices in NHS Barking and Dagenham, and have been mapped against the standards of nursing in general practice for the annual review of practices. This means practices have to reach the goal of achieving all the standards. I support them, if necessary, to
achieve these.

We are also employing a clinical supervisor. This person will be an experienced and innovative clinical leader responsible for the assessment of clinical quality by general practice nurses and healthcare assistants. The general practice nursing clinical supervisor will ensure that the primary care workforce is fit for purpose and able to deliver a quality, effective and responsive service to meet NHS Barking and Dagenham's
strategic priorities.

If PCTs are going to achieve their goals for world-class commissioning then supporting general practice to be a mainstay for the new world is a priority. Too often, general practices work independently, and PCTs should support them to become a general practice group to provide the best care for the population and a quality service for Transforming Community Services to be built upon.

1. Office of National Statistics.
2. Department of Health and Social Security. The Black Report. Inequalities in health: the report of a working group. London: DHSS; 1980.
3. Analysis by London Health Observatory using Office for National Statistics data.
4. Crossman S. The WiPP SNAPshot Survey. Supporting nurses and practice: a national survey investigating access and barriers to professional development for nurses in general practice in the UK.
5. Ball J, Pike G. Practice Nurse Review 2009. Results from the RCN employment surveys 2009 and 2003. London: Royal College of Nursing; 2009.

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"I was very interested in this article as I am a Practice Nurse link in the North east and we have a career Start scheme which has been running since 2001 for practice nurses and have never found any information regarding other schemes like ours" - Lesley Young