Practice Nurse at 30!

Practice Nurse was launched 30 years ago in 1988, and goodness, how things have changed since then. We look back at the past three decades of general practice, while contributors share their memories general practice nursing and look to the future

It was 1966, The Beatles were at the top of the charts with the double A-side, Day Tripper/We can work it out, and much of south east England lay buried in up to a foot of accumulated snow. But 1966 was also the year that really launched general practice nursing.

The ‘GP Charter’ in 1966 provided, for the first time, consistent reimbursement for general practitioners’ practice staff and premises. GPs could claim 70% of their staff costs, and 100% of the cost of premises.¹ This encouraged more practices to employ nurses, and the ‘cost rent scheme’ allowed practice premises to be upgraded to accommodate them. This period was hailed as a golden age, and laid the foundation for general practice as we know it today.

During this period, the number of practices employing their own nurses increased. An early ‘experiment’ is described in a paper in the BMJ in 1967, Extended use of nursing services in general practice,² when a two-handed rural practice decided to take on ‘an experienced nurse to help in the clinical work of the practice for about 20 hours weekly, with the following duties:

• The reception and assessment of requests to visit and other messages
• Visiting new calls after consultation with the doctor in those cases where there was doubt about whether a visit by doctor (sic) was necessary
• Immunisations and desensitization procedures during surgery
• Assistance at the antenatal clinics
• Routine visits to elderly and disabled people.

‘From the beginning we decided… to pay her top salary scale and a car allowance.’

The doctors soon realised what a treasure their nurse was. ‘We found there are a surprising number of duties apart from immunisations and routine injections for a nurse to do…’ and very soon the practice had started a weight loss group and a smoking cessation group.

By 1988, the general practice nursing workforce had developed and mobilised to such an extent that it was deemed worthy of its own journal – and Practice Nurse was launched – a peer reviewed journal that aimed to support and educate nurses in their burgeoning careers. We have been in continuous publication ever since, and have been recognised in repeated readership surveys as the leading journal in this sector.

Practice nursing gained another significant boost in 1990 when the ‘New GP Contract’ introduced targets for childhood immunisations, cervical screening, and formalised the concept of health promotion. Furthermore, in a bid to bring all practices up to the standard of the best, GPs were remunerated for providing chronic disease management services for patients with diabetes and asthma. Substantial sums of money were available to practices who met the targets, and running health promotion clinics was seen as money for old rope – but with GPs still providing their own out of hours coverage, and home visiting a common feature of daily practice, it soon became clear that the practice nurse workforce needed to be expanded to take on this additional ‘new’ work. The chronic disease management clinics became the foundation of today’s management of long term conditions which is the bread and butter of the present GPN role.

Non-medical prescribing also became a stepping stone for the transformation of the role: in the early days, nurses often used to recommend treatments – especially for their patients with diabetes or asthma – but it was the GP who signed the prescription. In some cases, that was all they did, and in all other respects, it was the nurse who was the prescriber. To formalise this ad hoc arrangement, non-medical prescribing was introduced in 1992 – initially allowing community nurses to prescribe from a formulary within the context of a care plan. By 1999, an extensive review of prescribing arrangements allowed other groups of nurses to become independent prescribers – although still from a restricted formulary. It wasn’t until 2006 that nurse prescribers were able to prescribe any licensed medicine for any medical condition, extending their accountability for the assessment of patients and their clinical management.

The 1990s also saw the introduction in the UK of the first nurse practitioner university courses, transforming nurses from the doctor’s handmaiden to an autonomous practitioner able to diagnose and treat patients, freeing up GPs to deal with more complex cases. Through most of this time – from 1988 onwards – Practice Nurse has been here to support readers. Our content reflects their responsibilities and – we hope – interests. Sections in the journal have been introduced over the years to cover the essentials of general practice nursing for new entrants (and, increasingly, healthcare assistants), nurse prescribing and advanced practice. With the relaunch of our website, practicenurse.co.uk, in 2014, we launched the Practice Nurse Curriculum – at first to help readers prepare for annual appraisal, and subsequently to help with revalidation.

Practice nursing may be heading for rocky shores as a result of an ageing (sorry!) workforce – a third of GPNs are due to retire within the next two years.³ However, it is hoped that the Government’s recent and long-overdue recognition of the value of practice nurses will help to boost recruitment and retention, and that eventually there will be an injection of resources into general practice to secure its future.

Whatever the future holds, Practice Nurse plans to be here for all of you.

RELISHING THE AUTONOMY OF GP NURSINGI started working in general practice in 1984 not long after completing my training, writes Beverley Bostock.I knew the autonomy of general practice nursing was for me and I relished the idea of having my own list and working with patients on an equal footing. I’d worked on a GP unit as my last hospital job and really enjoyed the camaraderie the nurses and GPs shared so when a job came up in a surgery I leapt at the chance. It was very forward looking, as even in 1984 we had a full cohort of practice nurses delivering care for old and young alike and I learnt by doing, supported by these very experienced and wise professionals. I did a lot of summarising of records too, something that was a brilliant learning tool for later on in my career when I started to deliver ‘on the day’ care.As time went on I went from summarising and practice nursing to becoming a qualified practice manager for a fundholding practice, and worked with a very innovative GP who taught me about the business of general practice. I continued with my clinical role too and completed a project on implementing quality standards in general practice – quite a new idea in 1990!Eventually I moved on to work with the GP who had the most profound impact on my career and whose focus on evidence based clinical care was way ahead of its time. He taught me so much by constantly asking me, ‘What do you think? What would you do? What does the evidence say?’ and expecting thoughtful responses to his questions. We were one of the first practices in the area to bring in nurse-led acute care. I’ll be forever grateful to Dr Ian Bayman for making me the nurse I am today.So where do I find myself now, 34 years since I started in GP-land? Working in a wonderful practice, supported by a fabulous extended team of doctors, nurses, our HCA, pharmacists, dispensers and superb reception and admin staff, that’s where! Don’t get me wrong, it hasn’t all been plain sailing – there have been some duff practices and uninspiring colleagues from whom I have parted company – and not all of the changes that have happened in general practice have been good ones. However, there are so many doctors, nurses and patients I remember from over the years who have taught me so much about what it means to be a general practice nurse. I’ve truly relished the past 34 years in general practice and the experience never ceases to inspire and excite me. I’m already looking forward to the next 30 years, and the way things are going I may yet be needed!

FROM RAW BEGINNINGS TO EXPERT PRACTITIONERKate Hunt recalls: ‘My first, very brief, foray into the life of a practice nurse was in 1988. I was in the middle of my midwifery training and was asked by the local GP if I could provide a couple of days help while their practice nurse was away. With the confidence of youth I leapt at the chance with little knowledge of what was expected of me. The ‘Primary Care Nursing Team’ at that time comprised one part-time practice nurse who also provided cover for reception and dispensary as part of her role. The first half of my morning consisted solely of taking blood samples. At the end of the morning, the whole practice sat down together in large, not necessarily comfy, armchairs for coffee, recounting the day’s work so far. The day progressed to simple dressings (anything more complicated was seen by the district nurse), childhood vaccinations and attending to anyone walking in with a minor injury – a fairly common occurrence in this rural, agricultural community. I also learnt to use the large and cumbersome silver ear syringe, an instrument that should now only be seen in a medical museum! I wrote, by hand – there was no sign of a computer – in the Lloyd George notes and was responsible for finding and replacing each patient’s notes at the beginning and the end of each day. And had the time to do it.In 1992, I had my first ‘proper job’ as a practice nurse. The role had grown significantly with five part-time nurses, both registered and enrolled, employed at the practice. Nurses had responsibility for patients with long term conditions as well as offering clinics for the ‘well woman’, ‘well man’ and ‘the over 75s check’. I especially remember the Health Promotion clinics where you had to see a magic number of at least 10 patients for weight, blood pressure or dietary advice, in order to receive payment under the ‘new’ GP contract. It was not uncommon for any receptionist who was registered at the surgery to have their blood pressures taken or be asked to jump on the scales to make up the numbers. Travel clinics were conducted by looking at a poster, detailing which vaccines were needed for every country, on the back of the door. Malaria advice was through a national helpline number where the same doctor answered the phone, whatever time of day you rang, to tell you what the patient needed for their particular destination. All the metal instruments – speculae, forceps, scissors – were washed up then sterilised at the end of each day in a tabletop autoclave, and woe betide you if you forgot to top it up with water before switching it on!Computers, and EMIS, had arrived although we continued to complete the Lloyd George notes for immunisations as for some reason it was deemed necessary to double up. The NHS cervical screening programme was in full swing and although contraceptive advice was part of the practice nurse’s remit, intrauterine contraception was very much still the doctors’ domain. However, training and professional development opportunities were aplenty at this time and I was fortunate enough to benefit hugely from this, as were my colleagues. It was certainly a time of growth and development.After a break of 7 years specialising in Sexual Health, and having children, I returned to practice nursing in 2003. I had thought it would be like putting on a pair of old slippers thinking it would be comfortable and familiar but soon realised things had changed so much those old slippers were no longer up to the job! Huge change had occurred in the intervening years. Wound care had improved in leaps and bounds together with the quality of dressings that were available. Knowledge of Long Term Conditions (or ‘Chronic Disease’) was far more extensive with PNs having an even greater role in managing patients with diabetes, asthma, COPD and heart disease. It was clear I had a lot of learning to do. Nurse practitioner roles were flourishing and HCAs were supporting the nursing team, taking on many of the tasks that had previously been the bread and butter of a practice nurse’s daily routine. In addition to treatment room skills, GPNs specialised into areas previously the domain of doctors such as minor illness and diagnoses. Back in the 1990s, GnRH analogue implants were only ever inserted by the GP under a local anaesthetic, with the practice nurse merely standing by and dabbing with a piece of gauze.But things have changed, as has the treatment. Introducing a comprehensive contraceptive service, encompassing intrauterine and sub dermal contraceptive techniques, into my rural practice is one of my proudest achievements – a far cry from the very brief pill checks and ‘depot’ appointments of the early years. And the days of the autoclave are long gone. Instead of looking at the poster for the latest travel advice, GPNs became skilled at taking a thorough risk assessment for all travellers and with patients going a bit further afield than the Costa del Sol, consultations and travel health advice became much more in-depth. And the more we know, the more we have to impart. There also came a plethora resources to inform our practice, and NICE guidance has become embedded in all that we do. Our work has became more and more evidenced-based, and with such increases in our knowledge and skills have come greater demands on our abilities and time.Patients started to see practice nurses as expert all-round practitioners in their own right but they also felt we had far more time, in their eyes, than our over-stretched medical colleagues. Back in 1988, the one part-time practice nurse who also did a bit of reception and gave out the pills was sometimes perhaps viewed with a bit of suspicion compared to that of the Family Doctor high on his or her – in truth less frequently 30 years ago – pedestal, or maybe that was how it was seen in rural Suffolk. Now, instead of a brief exchange on the weather during a 10 minute appointment for the game keeper’s tetanus booster, we are trying to deal with a young woman’s asthma check at the same time as being asked about chlamydia screening and what we would recommend for a sore throat and tickly cough all in one consultation, and with no more time to do it! Both patients and our employers seem to want more and more from us, and it begs the question, have we unwittingly become the victims of our own professional development and success?And so practice nursing has continued to develop at an astonishing rate. We are highly skilled in our incredibly varied and autonomous role. We now have specialist roles, manage long term conditions independently, triage, diagnose and prescribe. In 2018 we see more patients, we deliver more care, we have targets to meet and our employers are breathing down our necks to ensure we achieve it all.I have experienced at first hand a role that has progressed and evolved to the benefit of both patient and practitioner and that has served me well as a career within the heart of a community. Nowadays we do more, so much more, than we did 30 years ago but there is a huge risk that we are becoming overwhelmed with the sheer volume of work and administrative demands of present day general practice nursing? I positively believe that we are more fulfilled practitioners, but, it has to be said, few of us have time to sit down for coffee and reflection on the day’s work with colleagues.

THE GP’S VIEWNurses and GPs worked together long before practice nurses became plat du jour, writes Dr Ed Warren. When I started there were District Nurses (now Community Nurses) with an office in the surgery, so they were available for advice and wound care (which GPs never get taught), and helped with the Baby Clinics. This was such a good idea that it had to be stopped through a re-organisation.The 1990 GP contract brought in financially incentivised targets for all manner of health promotion data: smoking, weight, blood pressure and the like. But it had to be done in an organised way, and there had to be Health Promotion Clinics to get at the money. We panicked and got a GPN, and then several GPNs. We were not alone: the number of GPNs in the NHS surged.At first I wondered if being employed would alter the GP/nurse relationship, but true to form it did not. Even as another new contract in 2004 segued us into the fetid morass that is the Quality and Outcomes Framework (QOF), it was increasingly obvious that general practice could not survive without GPNs. I think we are very lucky with our practice nurse team. However, I have yet to meet a GP who did not think that ‘their’ practice nurse was special. This says an awful lot about the skills, commitment and character of the average GPN (if there is such a thing).The days of the ‘doctor’s handmaid’ are long gone. During the early years, at the end of a long day I was doing an IUCD (coil) replacement, and inadvertently ended up with two coils in situ. The GPN helping me never said a word, and assumed that I knew what I was doing (always a mistake). I can’t imagine the present generation of GPNs letting a GP get away with such a bungle.When evidence-based and properly recorded chronic disease management became fashionable, GPNs were the obvious people to take charge: if you want an important job doing, get a nurse to do it. The QOF reinforced the financial need for such developments as much as the clinical imperative.What of the future for GPNs? The General Practice Forward View promises a four-year programme of support and development for general practice nursing. But just extrapolating from current trends scarcely does justice to the contribution of GPNs (though I hate to think what it would be like if GPNs stopped doing triage and CDM clinics). Practice nurses are the CDM experts now, but face increasing issues with multimorbidity. What if the academic arm of GP nursing were expanded through our great university and professional institutions, and GPNs were give the time and resources in their contracts to do the research required to work out how to best manage patients who have more than one chronic disease? Wouldn’t that be something special?

REFERENCES

1. Kmietowicz Z. A century of general practice. BMJ 2006;332:39-40 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325136/

2. Weston Smith J, Mottram EM. Extended use of nursing services in general practice. BMJ 1967;4:672-674. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1749220/?page=1

3. Queen’s Nursing Institute. General Practice Nursing in the 21st Century, 2015. https://www.qni.org.uk/wp-content/uploads/2016/09/gpn_c21_report.pdf