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Nurse-led triage in general practice

VOL: 102, ISSUE: 13, PAGE NO: 42

Kathryn Godfrey

A general practice in Doncaster has developed a nurse-led focus with such commitment that the nurse team at the pra...

A general practice in Doncaster has developed a nurse-led focus with such commitment that the nurse team at the practice now manage three-quarters of patient care.

The practice first started developing nurse-led services six years ago. Becoming a pilot for the personal medical services contract allowed the practice to think creatively about developing the role and responsibility of the nurse. Difficulty in recruiting the fifth GP partner was another factor.

The changes that have taken place mean that the nurse team has grown from three to nine. The practice now runs a total nurse triage system, has nurse-led disease-specific and minor illness clinics, and a nurse partner. The development of the nurse role has meant that the time for each GP appointment has doubled. The GPs can therefore now focus on patients with more complex needs.

Chris Simmonds, practice manager at the medical centre, says: 'This system has not been introduced as a cheap alternative. It is a better way of looking after patients, as they get to see the person who is most qualified to take on that particular case.'

The starting point of the change was having the nurses run minor illness clinics every morning. Disease-specific clinics were also developed, and these now cover diabetes, asthma, chronic obstructive pulmonary disease, hormone replacement therapy, hypertension, sexual health and aural care.

But it was bringing in the nurse triage system for patients who ring in for an urgent appointment that had the biggest impact on the way the practice runs. The system was introduced three years ago for three mornings a week. It proved successful, as one in five of the patients was dealt with by talking to the nurse so that the individual no longer needed to see a doctor. Spurred on by these results the practice introduced total nurse triage two years ago.

A team of at least three nurses now run the triage service from 8.30am to 6pm. Patients ring in and speak to the receptionist, who passes on the individual's details to the nurse team, one of whom will ring back within 10 minutes (see box). There are some exceptions: patients with chest pain are put straight through to the nurse; parents who have children with a fever will be asked to bring them in that day, and patients who want to make an appointment to see a GP for a follow-up appointment do not need to go through the triage system.

Since running total nurse triage it has been shown that almost 50% of the patients who ring in have no need to make an appointment, as they are helped by telephone advice or by advice and a prescription. Of the remaining patients who do make an appointment, half of these make it with a nurse, either in a disease-specific or minor illness clinic. It is only the remaining 25% who see a GP or the nurse partner.

The reduction in pressure on the GPs has meant that appointments with them or the nurse partner have been extended from seven-and-a-half to 15 minutes. Appointments with the nurses are only 10 minutes, as they are seeing patients with less complex needs.

Since the total triage system has been introduced, waiting times for an appointment have been reduced from an average of 3.75 days to 1.45 days. In fact, most patients are seen on the same day they request an appointment unless they wish to see a specific GP.

All nurse training for the extended role has been fully funded and supported by the practice. A significant amount of the training has been in-house and led by one of the practice GPs, Dr Pat Barbour. Each of the nurses has spent around 10 practice sessions with Dr Barbour and attended a series of 10 two-hourly education sessions over a six-month period. In addition, the nurses receive ongoing mentoring and are able to consult freely and easily with a GP during nurse-led sessions.

Members of the nurse team hold a variety of qualifications. At least two are qualified in each of the disease areas covered by the clinics, to allow for holidays and staff sickness. One member of the nurse team is a health care assistant who has extended her role. She carries out phlebotomy, spirometry, fits 24-hour ambulatory monitors, and sorts test results that have been sent electronically, ringing patients where necessary.

Ellie Armitage has been a nurse at the practice for the past 16 years and leads the nurse team. A year ago the GP practice partners asked her to become a nurse partner. Ms Armitage was delighted at this opportunity for her and the team.

'The ethos of the practice is to be nurse-led, so having a nurse partner gives more power and voice to the nurse team,' she says.

Like the other partners, Ms Armitage is self-employed, receives a percentage of the practice partnership, has a partner's vote, a caseload, her own practice room and parking space. She is an extended and supplementary nurse prescriber and refers patients to secondary care.

She is also involved in training medical students allocated to the practice. She explains: 'I act as a mentor for some of the medical students, which means that they leave here with a whole new vision of what nurses can do.'

Despite the fact that the nurse-led triage system is delivering so many benefits it is not being taken up across the country. It, and other allied developments, are being held back, says Ms Armitage, by GP conservatism. 'Many GPs,' she says, 'are scared and want to hold on to what is traditionally theirs. They don't like nurses encroaching on their role. A lot of scaremongering has come from the BMA, which has tried to put a block on nurse prescribing. Even here in Doncaster there is still a lot of distrust.

'It is hard,' she adds, 'to get across the benefits to GPs. It seems bizarre that doctors train for seven years to end up seeing a child with a runny nose when there are so many excellent nurses who can take on this extended role.'

However, she emphasises that certain elements have to exist within a practice for it to be a success. 'Everyone has to be pulling together,' she says, 'from receptionists, to nurses through to the doctors. We are all good friends; there is trust between us. The team approach is the key to making a system like this work.'

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