Primary care trust commissioning responsibilities for general practice nursing

The primary care trust (PCT) commissioning function involves moving from a contract focus towards one that identifies the required service provision based on the health needs of the local population. As a commissioner, the PCT needs to support practice based commissioning cluster to commission a comprehensive and equitable range of high-quality, responsive and efficient services, within allocated resources, across all sectors.1

Prior to establishing the number of general practice nurses (GPNs) with the requisite skills to deliver a service, a review of GPNs' skills and knowledge should be undertaken. For example, before commissioning the delivery of sexual health services within primary care, there is a need to understand the knowledge base of clinicians (including GPNs) to determine whether this would be sufficient to consider shifting provision from secondary care. Similarly, there is a need to review the availability of resources. This is particularly relevant for the GPN workforce as, to date, resources have not been allocated on a basis of need, and nurse development has not followed a structured approach. In addition, the national profile of GPNs identifies a relatively high number of nurses nearing retirement age.

There has been no formal model for succession planning of GPNs because of their predominant direct employment by GPs. This potential lack of succession planning may lead to difficulty in finding an appropriately skilled workforce to recruit from - and this may impact on the ability to safely commission services from general practice. See Identifying workload capacity in Practice Nursing tool. Engagement with general practices and the strategic health authority to consider the future workforce needs could help to address this situation.

Care Pathways

Integrated Care Pathways can also be known as care profiles, care protocols, critical care pathways, multidisciplinary pathways of care.

"An integrated care pathway determines locally agreed multidisciplinary practice, based on guidelines and evidence where available for a specific patient/client group. It forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement" (National Pathways Association, 1998).

A second definition helps to further explain a pathway:

"Integrated care pathways are structured multidisciplinary care plans which detail essential
steps in the care of patients with a specific clinical problem and describe the expected
progress of the patient" (Campbell, et al, 1998).

They are multidisciplinary, locally agreed, evidence-based plans, describing the expected progress of a specific patient group. They form all or part of the clinical record. By facilitating the evaluation of outcome, they can be a quality improvement tool for use as part of clinical governance

See http://www.csp.org.uk for more information

Development of appropriate service specifications

Having considered the service need, a detailed service specification is required. This should identify service outcomes, and set standards by which the service delivery will be measured. This aspect of commissioning offers a real opportunity to measure the impact of the GPN role on health care provision. The key work areas for nursing in general practice are described below.

Long-term conditions management

In order to meet the needs of patients with long-term conditions, there is a requirement for nurses in general practice to address the needs of patients at level 1 and 2 of the long-term conditions pyramid.2 Patients at level 1 and 2 are predominantly mobile and therefore best suited to access nursing care through the general practice environment. This requires GPNs with appropriate skills and knowledge to encourage and support self-management, and manage the disease process as the condition changes. Service delivery must therefore be sufficiently flexible to provide easy access to the GPN. Models of care provision, that include both unscheduled and planned care will support this approach.

Increasing access

In addition to the management of long-term conditions, GPNs have the potential to support the increased access to health care provision. It is estimated that, even without additional training and development, nurses could effectively manage approximately 17% of patients' attendances to general practice.3 This could be increased, with advanced nurse practitioners effectively managing the majority of presenting patients in general practice.4-6

Health prevention/screening

The third focus of work within the general practice setting is health prevention, for example immunisation of children and adults, and cervical cytology. This has been effectively delivered in the past by general practice nurses within the general practice environment.

Defining measurable outcomes of care

GPNs and practices are individually responsible and accountable for the care provided. In addition, commissioners have a responsibility for creating and monitoring standards. Although specific standards for GPN care have not been defined at a national level, these could be introduced through the Standards for Better Health7 domains, current best practice as outlined within national service frameworks and National Institute for Clinical Excellence (NICE) guidance to form a baseline for assessment of care.

Commissioning should also involve support for the development of nurses to deliver a quality service. This can include establishing a safe model of care provision, and the identification of appropriate resources to deliver the service (see Unit: Employment of general practice nurses and Unit: Quality improvement and evaluating practice of the GPN Toolkit). The number of GPNs per head of practice population is disparate and PCTs should adopt a standardised approach to defining nursing need. Identifying workload capacity in Practice Nursing provides a mechanism of calculating GPN hours per general practice, based on practice population and patients with long-term conditions.

They may also look at supporting practices to provide clinical placements for new practice nurses and there are a number of PCTs who have set up successful models in their area. Examples are Liverpool PCTs (contact Lynda Carey Lynda.carey@liverpoolpct.nhs.uk) Multiprofessional Training Practices (contact Diana Moss diana.moss@eastmidlands.nhs.uk) and Essex (Jackie Jones, Jackie.jones@eoe.nhs.uk)

Ongoing monitoring and evaluation

The monitoring and evaluation of service provision is a key component of commissioning. Specific mechanisms to support evaluation will already be in place, such as the Quality and Outcomes Framework (QOF).8 Although this framework is not GPN specific, it does enable a broad proxy measure of nursing care within general practice to be assessed. Specifically, the QOF identifies a number of key areas that are predominantly undertaken by nurses, for example long-term conditions management. The achievement of QOF can therefore, at its basic level, identify nursing input and level of service delivered. However, QOF does not identify the quality of the nurse-patient relationship and its impact on health. This is not an easy concept to measure. Support through reflection, clinical supervision and individual performance review also contribute to the monitoring of standards of service provision.

Clinical leadership to support commissioning

Development of and support for the GPN role is fundamental to high standards of care. While the remit of the commissioning function is clearly identified, this must receive a contribution from local clinicians with a knowledge and understanding of general practice nursing. Clear, credible, clinical leadership from the commissioning arm of the PCT for nurses working within general practice will facilitate access to advice and support that will ultimately facilitate service provision.

GPNs are often perceived as being professionally isolated from other nurses. Although they work daily with other nurses, and generally have close working relationships with GPs, the model of employment for GPNs means that there is frequently a lack of formalised support and advice from a senior nurse. Failure to identify and implement a robust mechanism that provides nurse leadership (with clear negotiation and engagement skills) and support to GPNs has the potential to expose the PCT to clinical risk. Revalidation is also important now. There is a need also to refer to the implications of the White Paper on regulation for GPNs as PCTs will have key roles and may be identified by the Health Care Commission as exposing PCTs to clinical risk. Therefore, development of either a distinct role within the commissioning arm of the PCT, or contracting this work from an external organisation or the PCT provider arm, will both reduce risk and support development of future services.

References

This document is intended as a guide only.
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