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Share more of GP workload with practice nurses, say researchers


More of the primary care workload should be done by nurses, according to experts responding to the findings of a major new study into UK general practice.

The study by researchers from Oxford University found the overall workload in general practice has increased by 16% over the past seven years.

“The GP or nurse will eventually have to consult throughout the booked clinic length, with no break”

Study authors

However, when this was broken down into consultations by GPs and practice nurses, the analysis showed GPs bearing the brunt.

The research – said to be the largest analysis of primary care consultations to date – prompted some experts to call for a move away from a “doctor-centric” model of primary care to one where more work is shared with other professionals like nurses.

The findings, published in The Lancet, are based on more than 100 million consultations at 398 practices in England between 2007 and 2014.

The researchers, led by Professor Richard Hobbs, used data from the Clinical Practice Research Datalink, a national database where GPs and nurses record all face-to-face, telephone consultations and home visits.

University of Birmingham

Practice nurses should ‘carry out more consultations’

Richard Hobbs

The results show that, during the period studied, rates of GP consultations rose by 12.36% per 10,000 person-years compared with 0.9% for nurses.

A moderate 5.2% rise in rates of face-to-face consultations by GPs was overshadowed by a near 100% increase in telephone consultations.

For practice nurses, face-to-face consultations increased by about 3%, while there was a near 10% decrease in telephone consultations and home visits decreased by about half.

The figures show the average length of face-to-face GP consultations increased by about half a minute from 8.65 minutes in 2007-08 to 9.22 minutes in 2013-14, while face-to-face nurse consultations had also steadily increased in length to 9.72 minutes.

The authors said the findings appeared to suggest the system was “approaching saturation”, given that most practices offered patients 10-minute appointment slots with the expectation that some consultations will be shorter than others or people will not show up.

“Because the mean face-to-face consultation time is now approaching 10 minutes, the GP or nurse will eventually have to consult throughout the booked clinic length, with no break,” said the study authors in their paper.

“This situation will be undoubtedly demanding, in view of the various clinical problems being dealt with,” they added.

Meanwhile, they pointed out their figures were likely to be an under-estimate, because they do not encompass other professionals activities such as teaching or continuous professional development –believed to account for as much as 40% of workload.

While increased use of shorter telephone consultations may be one solution, the authors said this gave less opportunity for prevention work.

Instead, it was important for the NHS to focus on ways of reducing the number of people seeking appointments and increase “self-management”, they concluded.

Other academics also said it was time to move away from a “top heavy” primary care model, where there were about three times more GP consultations than nurse consultations.

Cambridge University

Practice nurses should ‘carry out more consultations’

Fiona Walter

“We believe that a major shift is also needed in general practice, away from a doctor-centric model to one that is a truly shared care model, in which more and varied types of clinical support staff work in collaboration with GPs,” said a comment piece on the research, which was also published in the same journal.

This would mean more work being done by professionals such as nurses and pharmacists, wrote Dr Matthew Thompson, a former NHS GP and now a professor in the Department of Family Medicine at the University of Washington in Seattle, and Dr Fiona Walter, principal clinical research associate at the Department of Public Health and Primary Care at the University of Cambridge.

“Expansion of the roles of different types of clinical support staff rather than simply employing more GPs is an underused approach in the UK, leaving GPs to bear the burden,” they wrote.


Readers' comments (8)

  • Laha78

    In order for this to happen, they need to start offering full time contracts for Practice Nurses as opposed to the usual 15 hours per week posts often advertised. From my experience, Practice Nurses aren't always on every day and when they are, it's for a very limited time.

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  • I agree with the above. I have always had to make specific appointment times if I wanted to see the practice nurse. Although I do have a bigger problem with increasing services to nurses. Practice nurses dont have the same level of protected study clinical nurses have and GPs are rarely willing to pay for further study - how are practice nurses going to become more competent in making independent decisions without the education. Also our local gp nurse can prescribe, refer, diagnose and have their own pts which I think is great, but they still receive a upper band 6, lower band 7 pay. I personally would not do a doctors job, for a nurses pay.

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  • i could not agree more pippi you seem to have hit the nail on the head and some of us practice nurses are still on band 5 with no wage rise for a few years and little chance of one in the future, i see 6 to 8 patients in an hour unless there is a problem then I'm afraid we spend a lot of time waiting outside a doctors office waiting to get confirmation of treatment which can only be issued by the GP. I spend most of my spare time doing on line courses and days off going to courses too, to enable me to keep up to date, there have been times when i don't even get the chance to grab a drink or eat lunch, if i do i usually do this whilst filling in paperwork!

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  • I'm so disappointed to hear that anon 12:46. Band 5 for the work you do is a disgrace, and are you not able to refer patients to clinic/hospital services rather than wait for GP confirmation? I thought most practice nurses now had the autonomy to do so.

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  • I have to say, having in the last 2 yrs experienced the NHS as a user rather than staff it reinforces my opinion on highly experienced nurses. In that they are so undervalued. My Mcmillan nurse continues to be incredibly supportive as well as very informative on any question I ask. The same for general practice my consultations for myself and my children are always clearer, more organised and informative with the nurse practitioners/practice nurses. Yes we need more GP's or assistants but more importantly we would benefit from a huge injection of community nurses to deal with primary care increase. Much of which is parents requiring reassurance I know we don't need GP's on 100k a year to carry out much of the minor issues they see in the surgery.

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  • In GP land I never get a break except have been frowned on for taking my unpaid hour lunch in a 10 hour day.
    Because the first GP I worked for in 1999 did not support any training, I quickly paid and attended modules I felt would help me in the patients I was seeing. A few years later, I was invited to do the Specialist Practitioner degree so I asked what content would be involved. I realised I had already done much of it at a higher level, but typical in nursing, the uni concerned expected me to not only repeat the modules with them, but also to disregard the ones I had at a higher level.
    Now I am nearer to retirement, I look back, and think in contrast to the popular view, nurses should not be always expected to be the same, except for the core RGN/Diploma/Degree. This does not help nurses who wish to be pioneers, proactive, amidst some who as a lead nurse once said, "We have a lot of G grade phlebotomists!"
    I also resent the assumption that if employed by GPs, nurses have to ask their employer to do things like prescribing which I was blocked from doing, simply because I needed a medically qualified person to supervise me. This is ridiculous because so many GP's do not even know what their nurses can do, they do not know about HCA accountability and would be quite happy for a HCA to "just do a few flu's!". Only this week, my lead GP asked me what a PGD was as I asked him to sign me off on some new ones.
    I still choose to attend probably more GP updates than the GPs themselves do. I do not think for a minute I could work as a GP with no core medical training, but over the years I have acquired many skills where patients have needed my help and I have enjoyed the challenge of researching how to help, often when GPs have not done so.
    For the first time, I have not had a pay rise in 3 years and I was top level 6 when I arrived in 2004, though I do get 6 weeks leave and have always insisted if I need to learn something I will do so and take leave for doing it, within reason.
    I am not planning to retire just yet, but I do wish primary care would start to see that they already have what they need under their noses without yet introducing more confusing titles. All we need is a flexible structure to allow proactive nurses to flourish without jumping through more and more hoops when many of us already have a couple of degrees worth of modules but not necessarily in the format that pleases each institution.

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  • cant see how many more pateints we can see, some days I se 50 pateints in a day with no break

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  • If Practice Nurses are expected to professionally keep pace with the growing needs of Primary Care, then they need to be trained properly/given time to study and pass all appropriate exams. There are some GP practices out there, that will do everything as cheaply as possible as long as it does not impact on their wallet (It is mean of me to say this but I cannot think of any other reason).
    I was working as a Nurse Practitioner within Primary Care - only without the qualifications.

    Would the GPs have supported me if anything had gone wrong? I seriously doubt it.

    Did I ask for further training and qualifications? All the time, but the GPs did not agree.

    There needs to be some professional obligation placed upon all GPs that if they ask their Practice Nurse to work in a certain role within the practice, that the Practice Nurse is trained and supported to achieve that role.
    Surely there is a duty of care in there somewhere? Not just to the patient but to the nurse?

    Whilst this need for further training is 'optional', I cannot see there being many GP surgeries out there that will train their nurses properly.
    If GP practiced were made to train their nurses properly, it would make it safe for everyone and be an investment in the future.
    There must be somebody, somewhere, with the power, that could sort this lamentable situation out.

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