Practice nursing is once again being quietly revolutionised, but are we all aware of the changes coming? Are we aware of the policy drivers and contractual arrangements that will govern the future of our work? Over recent years there have been numerous policy changes in the way primary care operates, and these will impinge on our future roles. It is important for general practice nurses (GPNs) to understand the various changes that are starting to happen so we can position ourselves in the best possible place to take full advantage, so we do not get left behind. This article will explore some of the key drivers which could threaten and/or enhance the role of the GPN. Chiefly:
- The roles imbedded within the Additional Roles Reimbursement Scheme (ARRS): the hope is that they will have a direct and positive impact on the Direct Enhanced Service (DES) contract (BMA, 2021)
- The ARRS role of the trainee and qualified nurse associate. The article will explore how this role could fundamentally change the neighbourhood models and structure of the GPN workforce in primary care
- The Investment and Impact Fund and its numerous key performance indicators
- The primary care network (PCN) and how this could create a community of practice and help GPNs embrace reflective practice within teams
- A continued exploration of how the PCN could be used to offer hub and spoke-type placements for pre-registration student nurses and how some approved education institutions (AEIs) are now assigning pre-registration student nurses on traditional degree programmes to PCNs as ‘host trusts’.
These key drivers are a few items that mean the role of the GPN has to evolve to the demands and ever-changing landscape of primary care. Each item will be explored in turn. It is hoped that those reading this article will take the time to consider, reflect and discuss with colleagues, while considering the changes that they as individuals need to make but also how they can make a positive impact in their locality, teams and networks.
The key drivers
The primary care network
The GP contract negotiated in conjunction with the British Medical Association (BMA) allowed networks of GP practices to work together in PCNs on various targets and key performance indicators (KPIs). Networks have been forming since, serving populations of 30 000-50 000 patients, and practices have been rewarded financially to participate. The introduced GP contract has brought numerous new professional roles into primary care under what is known as the ARRS. This has meant that primary care has had new staff groups assisting in the delivery of direct patient care while supporting the achievement of the prescribed KPIs. These staff members are paid for through centrally allocated NHS funds rather than individual GP practices: this differs to the GPNs reading this article who have most likely negotiated their own contract and terms and conditions of employment directly with their employing GP practice. Over the decades this would have resulted in different grades and scales of pay (BMA, 2021).
Over the last 2 years many of the ARRS staff have been embroiled with delivering COVID-related services such as the hot clinics and COVID vaccination services, but as the vaccination work draws to its final stages, these staff are once again focusing their efforts on dealing with the KPIs set under the DES contract and assisting primary care in its ever-growing workload.
Our minds are once again focused on ‘business as normal’, and we might consider how we build relationships in our networks. Dewey (1897) described how individuals learn through life's experiences to enable growth, developing command of self, who is immersed in reflective practice. However, as individuals we are part of the machinery that drives and provides healthcare to our populations; therefore, as our networks grow and cement in our practices, so does our area of shared and common knowledge. This network of shared tacit knowledge, skills and expertise might be known as a ‘community of practice’ (Wenger, 1998). Moving forward with this, we need to continue embracing reflective practices as individuals but also exploit our network of informed and experienced practitioners to maximise the transference of knowledge and use that expertise to enable growth on a population level. This is where we need strong leadership. The author believes the GPN workforce and its outlook, understanding and history in primary care is perfectly placed to lead and assist in the development of such networks. The PCN has been created to enable this, so GPNs need to use the wider team to create a real community of practice for the benefit of patients, colleagues and for the growth of learners on clinical placements.
Additional roles reimbursement scheme
The DES Contract 2020/2021 agreed that the following staff groups could be employed and recruited from central sources of funding. This workforce is known as the ARRS (BMA, 2021). The roles included are:
- Pharmacists: Band 7-8A Agenda for Change (AfC)
- Paramedics: Band 7 AfC
- Social prescribing link workers: Up to Band 5 AfC
- Physicians associates: Band 7 AfC
- Advanced practitioners (clinical pharmacist, physiotherapist, dietician, podiatrist, occupational therapist and paramedic) (NB: this does not include nursing): Band 8A AfC
- Mental health workers: Band 5–8A AfC, depending on the individual clinician
- Care coordinators: Band 4 AfC
- First contact practitioners: Band 7-8A
- Occupational therapists: Band 7 AfC
- Trainee nursing associate: Band 3 AfC
- Qualified nursing associate: Band 4 AfC.
It is important to note that bar the trainee and the qualified nursing associate, the ARRS roles does not include nursing at any level, including the advanced clinical practitioner (ACP). This is important for nurses in primary care to understand, as it will often mean a step change between the ARRS roles that will receive Agenda for Change pay scales and standard terms and conditions of employment and their own self-negotiated contract (Marsden, 2020). The addition of the ARRS roles may or may not help the GPN workforce and their strategy when negotiating employment contracts as nurses in primary care.
It is also important to consider that the above ARRS staff members may be attached to 1 or more practices in a PCN. We must therefore consider this as a potential and evolving model of work for GPNs. Could we use the community to increase and develop neighbourhood level services staffed by our networks staff, even if they are not employed through the ARRS model? In addition to this, it would be prudent to consider how these roles affect our work personally, but also how they can help with workload and how the multidisciplinary approach may benefit patients.
Trainee and the qualified nursing associate
When the first round of ARRS roles and staff members were announced at the beginning of the PCN contract, the role of the trainee or apprentice nurse associate (TNA) and the qualified nursing associate (NA) were not included, but from October 2020 this exciting change occurred (NHS, 2022), meaning primary care can now train and develop its own small section of the nursing workforce. With projected numbers of 7500 each year, this could make a substantial difference to the workforce (NHS, 2022). Given this change, it is important to understand how this bridging role between health care assistant and the qualified nurse can be used. It is also important to understand the potential career pathway of a TNA/NA.
A TNA will have generic training that adheres to the Nursing and Midwifery Council's (NMC, 2018) Standards for Proficiencies for Nursing Associates and once qualified will have been assessed as proficient in the following nursing themes:
- Being an accountable professional
- Promoting health and preventing ill health
- Provide and monitor care
- Working in teams
- Improved safety and quality of care
- Contributing to integrated care.
In addition to these themes of the nursing process, the nursing associates can and will be assessed in various procedures including the administration of medications (NMC, 2018). In essence, the recently qualified NA in primary care is ripe for further development and growth; this is exactly what registration with the NMC allows. It allows access to further education and as GPNs we need to understand this new element of the workforce could become the next, valuable – and cheaper – element of the primary care nursing workforce. As an example, many AEIs allow the qualified NA to enrol on ‘Fundamentals in Practice Nursing’ courses or similar. This means that many NAs will be learning cytology and to give vaccinations including adult and paediatric immunisations using patient specific directions (PSDs). This involvement with our national immunisation programmes has been backed by the Royal College of Nursing (RCN, 2019). We can now see that the NA potentially becomes the treatment room nurse of the future and therefore we must question how the GPN should consider their individual career and career ambitions? In addition to this, there is now a vocational route into becoming a fully-fledged GPN and ACP in primary care (Figure 1).
Some PCNs will currently be actively recruiting TNAs and others NAs. We must consider that the TNA/NA are relatively new roles embedded in vocational training, we need to question how much of this role is understood by primary care and what will happen to workforce development once a critical mass of NAs are working in primary care within PCNs. We might want to envisage NAs offering immunisation, cytology clinics and assisting in the management of long-term conditions for our patient populations.
Investment and Impact Fund
The Investment and Impact Fund (IIF) 2022 has numerous KPIs, which are broadly split into three key themes. It is imperative to have a working knowledge of these KPIs as they will directly impact on the GPN's role. It could be considered that these targets have a similarity to the Quality and Outcomes framework, only these indicators are assessed and rewarded at the network level rather than on the individual practice level (NHS, 2020; 2022b). Ultimately, this means that the ties between practices in the PCN will have to grow, be nurtured and developed for all organisations to succeed. The key areas are identified below.
1 .Prevention and tackling health inequalities
This theme includes targets in vaccination and immunisation, tackling inequalities in our communities and cardiovascular vascular disease prevention.
2. Providing high quality care
This theme includes targets in personalised care (social prescribing), enhanced health care in care homes, anticipatory care (this might have once been called admission avoidance), cancer care, access (online, waiting times, increasing community pharmacy use etc), structured medication reviews and medicines optimisation and respiratory care (increasing inhaled corticosteroid use and decreasing avoidable short-acting bronchodilator agonists).
3. A sustainable NHS
This theme includes targets in improving access to dry powder inhalers (DPIs): this is in line with the quality statement from the National Institute of Health and Care Excellence (2019) who encourage the use of ‘greener asthma inhalers’.
As described, the broad themes will include work that might have historically sat with the GPN, for example immunisations, respiratory care and anticipatory care, but as the new ARRS staff roles take full effect, we must question how this will impact on the GPN and their roles.
Pre-registration student nurses
Over the last few years and especially after the release of the general practice nurse 10-point development plan (Health Education England, 2017) that included one point which stipulated ‘Increase the number of pre-registration nurse clinical placements in general practice’, work began in earnest to increase the student nurse numbers and pre-registration student nurse placements. Alongside this, the NMC in 2018 revised its Standard for Student Supervision and Assessment, the impacts of which in relation to the GPN were examined by Heath (2019). Unfortunately, the author's own experience was that although some headway was made pre-pandemic, the pandemic has had a devastating impact on students experiencing primary care placements.
There are novel placements occurring now in primary care, for example the University of Greenwich with the Southeast London Primary Care Training Hub and Integrated Care System (ICS) have allocated several students to the ICS as their ‘host location’. In practical terms what this means is that students have been allocated a named PCN in the ICS and it will be for the PCN to organise the students' placements from within, allocating learning experiences from the services they provide; the student will remain in their host ICS and PCN for their entire training. This builds on the work carried out by the Capital Nurse project and Southeast London Clinical Commissioning Group (CCG) as described by Heath et al (2021), where a first attempt to place student nurses at the network level was considered and described. Over the 3-year programme the structure of the placements will be as follows:
- Year 1: all three placements will be provided by the PCN
- Year 2: the student will have three placements in secondary care services
- Year 3: the student will return to the PCN and will have their final management placement in their host PCN.
Although not revolutionary, it is hoped the students enrolled in the programme (who are currently coming toward the end of their first year) will become ambassadors and promoters of primary care and be ripe for future recruitment as qualified Band 5 nurses. Some early learning from this programme is that the AEI will need to provide some enhanced assessment using simulation of clinical practice to ensure this group of learners can meet all their proficiencies listed in their Practice Assessment Documents. Further work and analysis of this programme will be needed as the programme progresses; however, in a study from Australia regarding students in primary care settings, they found that continued and repeated exposure to primary care increases the interest in future employment in a primary care setting (Calma et al, 2022). Calma et al's (2022) review of the literature reiterated what was already perceived, in that student nurses are drawn to the high technology environments that health care has on offer; however, this work validates the approach of the university of Greenwich and South East London and the work occurring on clinical placements.
Training hub development: multiprofessional educator faculty
With the development of the ICS, training hubs have been going through a process of change. The hubs have become aligned with the ICS, often with a lead training hub taking charge of the various funding streams, while working with borough or locality-based teams (HEE, 2022). As nurses we should all know who to contact in our training hubs as they will be assisting GPNs to gain access to continuing professional development (CPD) funds and courses.
The way clinical environments are signed off as learning environments is going through a revolutionary process and the days where each individual GP practice is signed up as suitable, appropriate and safe is changing to the PCN being signed off on mass as appropriate educational arenas. The stages of this sign off process have been awarded to the training hubs to oversee. What this means in practice is unfolding and in development; it is important to reflect on the reasons why this process is being progressed and cultivated and this takes us back to the additional roles (ARRS) workforce as described earlier. With the primary care workforce growing, there is a real need for change in the way placements are created, maintained and in the methodology in which learners from all the various primary care professions are supported, coached, supervised and assessed in clinical practice. Much of this is yet to be worked out in detail but as nurses we can expect:
- To see more doctors out in training
- More student nurses being placed in primary care
- More apprentice roles (advanced clinical practice, apprentice nurse associates)
- More allied health care professional trainees, both through traditional routes of education and through apprenticeship programs
- More multiprofessional education and supervision of learners through the entire network.
The groups of learners above are likely to move to PCN placements, rather than placements with individual GP practices.
Discussion and conclusion
Presented here have been several factors that will impact the GPN role as the nursing workforce in primary care and there are advantages and threats to each consideration. It is important to reflect on these as a profession and as individuals. As GPNs we must learn to position ourselves optimally for career and professional development.
- From the perspective of the apprentice nurse associate and apprentice nurse perspective: GPNs could consider becoming supervisors and assessors to support them through their development to qualified nursing associate, placing themselves in a position where they can create, support and develop the workforce from within
- From the perspective of the qualified NA: the NA will need to be supported, developed and clinically assessed in all treatment room level activities; as discussed, cytology and immunisations. As the NA will be able to use a PSD, this means that an independent prescriber will need to authorise each immunisation prior to administration (remember a qualified professional cannot delegate tasks to another member of the clinical team if utilising a patient group direction (NICE, 2017)). Therefore, to be at the forefront of clinical practice it might be prudent for the GPN to consider becoming a non-medical prescriber to authorise those PSDs
- From the perspective of the pre-registration student nurse: these learners need to be encouraged to enhance recruitment into primary care and as the young, energetic newly registered nurses joining the primary care workforce they need to be encouraged and supported to advance their career into strong PCN-focused leadership or advanced clinical practice while facilitating junior staff at all levels and from the multi-professional clinicians
- From the perspective of the IIF: nurses have been at the forefront of delivering our target-based care since the conception of the Quality and Outcomes Framework in 2004 (Jones and Nightingale, 2018). Given the growth of the target culture, it is imperative to engage with the PCN, the contracts and truly understand the GPN's value in achieving delivery
- From the perspective of the multiprofessional educator faculty and the additional roles: once again this leads to the GPN profession needing to increase their skill set in assessment and supervision.
Primary care is clearly going through change. The next few years will see growth in the workforce that may or may not alter the work GPNs perform, the ARRS staff will be supporting us with the management of patients that are living with long-term conditions, and we will see the NA workforce becoming treatment room level nurses. This may feel like GPNs are getting squeezed from all angles; however, GPNs are a resourceful profession, an adaptive profession and through the perspective of the author, GPNs should consider positioning themselves firmly as educators and as leaders in their PCNs. We will need nurses to manage and supervise teams of NAs, and we will need nurses to assist our clinical colleagues from the various professions to develop staff that might not necessarily be of the same professional background. Without change from us and our profession, without the adaption of our roles, could we be in danger of being squeezed out? No one really knows yet, but time will tell. In the meantime, the GPN role should consider how it immerses itself into adaptive educational practices and be ready, willing and engaged with the process of education in the clinical environment to support the ever-evolving workforce and work priorities.
KEY POINTS
- The GP contract has brought numerous new professional roles into primary care under the Additional Roles Reimbursement Scheme (ARRS), this has meant that primary care has had new staff groups assisting in the delivery of direct patient care while supporting the achievement of key performance indicators (KPIs)
- Primary care networks can now train and develop its own small section of the nursing workforce by employing trainee and qualified nursing associates
- It is imperative to have a working knowledge of the Investment and Impact Fund KPIs as they will directly impact on the GPN's role
- Novel pre-registration student nurse placements are now occurring in primary care
- GPNs must learn to position themselves optimally for career and professional development
CPD reflective practice
- How might the addition of the ARRS roles help with capacity issues in primary care?
- What are the pros and cons of these changes?
- How could you help create a community of practice?
- Could you take a more active role in supporting student placements?