Better performing GP practices are more likely to have “invested in, and valued, their nursing teams”, according to a major new report on primary care performance.
The Care Quality Commission found better performing GP practices also tended to invest in training and developing their nursing teams, and make use of advanced nurse roles.
“Those rated as ‘good’ or ‘outstanding’ tended to have invested in, and valued, their nursing teams”
However, the review also warned that nurses working in general practice could become “isolated” and that many practices were experiencing recruitment problems.
In what it claims is the most detailed analysis yet of general practice in England, the CQC has pulled together the results of its first complete round of inspections of the sector – though some of the individual trends identified have been noted before by the regulator in previous reports.
The regulator’s inspectors rated 7,365 general practices – about 98% of the total – over the last three years. It rated 4% as “outstanding”, 86% as “good”, 8% as “requires improvement” and 2% as “inadequate”.
The CQC’s report highlighted that geneal practice nurses (GPNs) had a “crucial and expanding role” in delivering high-quality care, particularly in long-term conditions, wound care and childhood immunisation.
“The role of GPN can sometimes be isolated, and we found that a larger nursing team presented several advantages”
It drew a link between its inspection results and how the nurse role was used and valued, with more highly rated practices found to have put resources into their nursing teams.
“From our experience of general practice inspections, we found that those rated as ‘good’ or ‘outstanding’ tended to have invested in, and valued, their nursing teams,” it said.
But there was a warning from the regulator for those with small nursing teams. “The role of GPN can sometimes be isolated, and we found that a larger nursing team presented several advantages,” noted the report, published today.
“For example, in a larger team it is easier to develop expertise in specific areas and divide responsibilities that would often be the sole responsibility of a single GPN,” it said.
The CQC suggested that, where one nurse had sole responsibility, practices could “perform poorly” on safety metrics, for example, in the governance systems for monitoring medicines, equipment and infection control.
“Findings from our interviews suggest that in a larger practice it is easier to have staff with defined roles, and there is a greater likelihood that there will be well-functioning nursing teams where nurses focus on particular areas, such as diabetes or chronic obstructive pulmonary disease, and junior nurses take on task-oriented roles,” said the CQC.
“Some providers could not always demonstrate sufficient clinical oversight and support for this advanced level of practice”
It added: “We found the role of nurse manager was more common in large practices and is valuable in developing the nursing team with professional support and appraisal, including for Nursing and Midwifery Council revalidation and skill mix.”
Overall, the regulator concluded that, while the size of a GP practice “does not dictate whether it can provide good quality care” or be more highly rated, there “was a link”.
The report also highlighted that the best practices used non-traditional roles such as advanced nurse practitioners, care co-ordinators or healthcare assistants to support GPs and reduce referrals to secondary care or avoidable hospital admissions.
Using a multi-disciplinary approach was having a “positive impact on care” in the best performing practices, said the CQC in its report – titled The State of Care in General Practice 2014 to 2017.
“Our qualitative analysis found that a larger team size, with a mix of skills encompassing staff from a range of professional backgrounds, contributed to high-quality care,” it said. “In these practices, roles were clearly identified, and can include for example nurses, phlebotomists, counsellors, pharmacists, occupational therapists and physiotherapists.”
The report concluded that general practices with the highest ratings were those that demonstrated strong leadership that was non-hierarchical in nature. Staff also needed to have an understanding of everyone’s responsibilities in the practice team and a knowledge of the different needs of their patient groups.
“GPs, practice managers and other primary care staff should be commended for their efforts”
Meanwhile, it suggested that more training and the expansion of more advanced roles for primary care nurses might also help alleviate the “widespread” recruitment problems in the sector.
The CQC noted that the Health Education England’s General Practice Nursing Workforce Development Plan – sitting alongside NHS England’s overall General Practice Forward View strategy – aimed to address nurse recruitment problems by “improving training in GP practice settings and raising the profile of the role to help retain and expand the general practice nursing workforce”.
However, the regulator sounded a note of caution on the introduction of more advanced nursing roles by practices without sufficient staff or resources to support them.
“Although we found a growth in the role of nurses providing care for patients with acute conditions, some providers could not always demonstrate sufficient clinical oversight and support for this advanced level of practice,” it said.
The CQC also highlighted the need for practice nursing staff to share learning to improved professional development, which was linked to better team performance.
“For example, a nurse who was designated ‘nurse lead’ may attend meetings and forums to share learning and reflect and maintain their clinical knowledge. They would then bring back ideas that could benefit patients by applying their learning to practice,” it said.
- Nurse-led GP practice rated ‘outstanding’ by CQC
- Smaller GP practices fared worse under inspections, CQC finds
- CQC emphasises ‘important wider role’ of practice nurses
Overall, the CQC acknowledged that GP practices were “facing ongoing pressures around capacity, patient demand and workload and at a time of service redesign”.
But it said the best general practices were “driving change and embracing innovation” to make sure they were able to deliver even better care into the future.
Regarding its own impact, the CQC highlighted that 82% of the practices that were first rated as “requires improvement” or “inadequate” improved their rating following their most recent inspection.
However, the regulator admitted that its ratings could sometimes compound a practice’s existing problems with trying to attract sufficient clinical staff.
“Difficulties in recruiting staff from all professional backgrounds – not just GPs but nurses – particularly following a rating of ‘inadequate’, limited practices from improving because of a perceived poor reputation,” it said.
“However, the interviews identified that some practices had overcome this challenge through having nurse-led services and creative recruitment strategies,” it added.
Commenting on the report, Professor Steve Field, the CQC’s chief inspector of general practice, said: “We have found that the clear majority [of practices] are safe and of a high quality.
“Where we identified concerns, most practices have taken action and improved,” he said. “GPs, practice managers and other primary care staff should be commended for their efforts.”
Dr Richard Vautrey, chair the British Medical Association’s GP committee, said: “This report shows that general practice consistently receives the highest ratings for the quality and safety of care delivered to the public.
“The number of GP practices obtaining the highest grading continues to grow, with nine out of ten rated as either good or outstanding,” he noted.
“These positive results are undoubtedly down to the hard work of GPs and practice staff, but many are in an environment where they are increasingly struggling to deliver effective care to their local communities,” he said.
The inspections began in October 2014 when the CQC formally introduced its new regulatory regime for primary medical services. An initial programme of inspections was completed in January 2017.
Under proposals that CQC consulted on earlier this year, practices rated as outstanding or good will be re-inspected at intervals of up to five years, while those rated as inadequate and requiring improvement will continue to be re-inspected by CQC after six months and 12 months respectively.