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Time's up

GPs are certainly making much of the noise around the government's promise of seven-day access to healthcare, due to frustration over the idea of an increased workload when they are already overstretched. But what of the impact on the community and practice nursing workforce upon whom much of the additional work is likely to fall?

Prime Minister (PM) David Cameron says seven-day access offers, “a vision of a modern NHS working for you - when you need it, where you need it… and that begins with a transformation of primary care.

"We simply can't aspire to be the safest health system in the world without this commitment. While our hospitals are working hard Monday to Friday to get patients better, sometimes it can feel as though Saturdays and Sundays are more about just somehow getting through to Monday. Diseases don't work weekdays 9am to 5pm. And neither can we”.

These words have caused a wave of frustration through general practice. Dr Joe McGilligan, former chair of NHS East Surrey Clinical Commissioning Group, reflects much of the worry GPs have been expressing.

He says: "We keep asking the wrong question when determining access to GPs. Patients don't want any GP; they want their GP. The government knows GPs are the most cost effective part of the NHS.

“They hope by opening seven days a week it will save money and resolve all the issues in A&E, such as long stays, it won't. I worked in a 24/7 service in Australia and I was the wrong GP up at 4am! There is no system that will satisfy everyone and in the UK we don't have the workforce to fulfill political promises.”

But he does point out that not every practice needs to be open so long as the records can be shared easily.

As for practice nurses, he says this could be a real opportunity for the profession but seemingly only if practice nurses are collectively prepared to work in the evenings and on weekends.

“I think practice nurses could come into their own to help provide the long-term continuity of care for patients with multiple co-morbidities. They could run their own clinics to satisfy the small number of patients who couldn't get in during the working week, and nurse practitioners could easily provide a triage, and see and treat clinics during evenings and weekends, so long as the resources followed the patients."

Dr Nadim Fazlani, chair of Liverpool CCG, says: “It is about practices working together to provide a service. This is not just GPs but includes practice nurses and other disciplines as well.”

It is clear from GP leaders that the primary care nurse workforce will be impacted if the proposal for seven day access is put into action but exactly how will likely depend on how individual practices choose to tackle this latest plan.

The Royal College of Nursing (RCN), representing practice nurses, has put forward its view. Dr Peter Carter, chief executive and general secretary of the RCN says: “The RCN supports moves to make the best care available when it is needed, whether it is 9am on a Tuesday or 9am on a Sunday. However, this will require complex planning and enough nurses to make an already stretched system work. Practice nurses are employed directly by GPs rather than by the NHS, so it is not yet clear how they would be affected by moves towards seven-day care. It is possible that there could be considerable variation in the level of care provided by GP surgeries over the weekend, with some opting to use their practice nurses more and others less.

“Either way, it is important that serious consideration is put into how GP surgeries can employ enough nurses for the level of demand seven days a week [requires]. Many practice nurses choose to work for GPs because of the hours, which many feel allow them to carry out parenting or other caring responsibilities, and the NHS must be careful not to lose these nurses and their skills altogether. There is a general shortage of nurses in the UK at the moment and there could be serious issues in training and developing a workforce with a wide variation in what they do and who employs them,” says Carter.

As the RCN has said, “serious consideration” needs to be taken into account regarding employing and training nurses if the proposal goes ahead.

Jane Levine a practice nurse at Beaconsfield Medical Centre, Brighton, works additional shifts as part of the extended hours service. She feels if the proposal was put into action then she may feel pressured to work more, “In essence, because [working extended hours now] is voluntary and offers flexibility, it is a very enjoyable way to earn extra money. It really helps that the rate of pay is considerably higher than the normal rate due to weekend/evening working time. If this was to become compulsory however I would feel very pressured as it would take away my work-life balance,” Levine says.

Fiona Daziel, co-lead of for the Royal College of GPs General Practice Foundation for practice managers says: “Practice nurse teams are already operating under pressure and many parts of the country are experiencing a dearth of experienced nurses in general practice. It is unclear to me how GP practices will be able somehow to find additional hours to cover weekends, and continue to cover during the week as well.”

As expressed by Levine and Daziel a major concern around the proposal for primary care nurses is whether they will be pressured to work more. The PMhas assured that extra working is not expected saying: “Let's be absolutely clear. This isn't about NHS staff working seven days a week. It's about different shift patterns, so that our doctors and nurses are able to give that incredible care whenever it is needed.”

Heather Henry, co-vice chair of NHS Alliance's Practice Nurse Network doesn't seem convinced that seven day access is possible for the current workforce: “We don't even know how many general practice nurses there are in this country, so how are we going to move to a 24-hour primary care when we are short of five thousand GPs and we are not training general practice nurses, 64% of whom are over 50 [years of age].

“We've seen [the secretary of state for health] Jeremy Hunt announce a new deal for the primary care workforce, but how will it be paid for? I think the financing needs working through. I also have concerns about whether unregulated physician associates are a better option than advanced nurse practitioners, therapists and practice pharmacists.” 

Nurses, as Henry says, are already overworked and the new plan for a seven day service will only add more pressure to the job.

Dr Sarah Schofield chair of NHS West Hampshire CCG says: “I believe we have a seven day, 24 hours a day GP service already - made up of in hours and out of hours (OOH) services. The current discussions should focus on improved OOH provision with the clinicians having access to the GP records, which would make care a lot safer and easier. 

“With the current strains in general practice it is not feasible to suggest that every practice will open seven days a week providing their 'normal' service. I believe that the only way to provide a seven day week service that is different to that of the here and now, would be for groups of practices to work together to provide urgent and routine care with access to patient records. Just extending week day general practice is not possible with a strained workforce and burgeoning workload.”

So it's not necessarily about working longer but working smarter. More flexible shift patterns and improving on what already exists in terms of out of hours care. Both of which could provide new opportunities for practice and community nurses if there are enough to fill new posts.

Back to the PM's vision. “It's about key decision makers being around at the weekend”, he says: But how can this be achieved if the workforce is already spread thin?

Will practice nurses become managers to healthcare assistance if they are working at the top level of their competency?

Ursula Gallagher, commissioning network lead at NHS Alliance sees nurses working to the top of their skill set as an opportunity rather than a pressure.

She says: “If there is going to be a small team in a practice you are going to want people to be as flexible as possible, and therefore actually it is more likely to be nurse practitioners and nurse prescribers working alongside a GP at the top area of their skill set, rather than the whole discussion about creating larger factors. I think there are larger opportunities for nurse led models or model for which nurses play a bigger role at the top of there skill set in terms of the seven day discussion.”

Gallagher thinks the move can have positive outcomes for nurses if there is proper planning and they grasp the opportunities presented. She says that while it's recognised that access is important to patients, particularly out of hours, there needs to be more thought on how it's delivered.

“What people want from Saturdays is very different to what people want on Sundays, because most people don't think of Sundays as a day they make a routine visit to their GP.

“But all in all we have an opportunity to plan how we make services more accessible to patients across the seven days. But then I don't think it's a one size fits all answer and if you're in a rural community it will be different to being in the middle of the city.

“I think for nurses it provides a number of exciting opportunities. I think it may also increase employment opportunities for nurses who wish to work part time… but making sure nurses are included in the discussions about how this is planned and what the models are is really important. “Therefore it's a really important issue for nurses in a leadership role already working in general practice to get stuck in, in terms of being part of those discussions and volunteering their thoughts about what would work for their patients.”