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Exclusive: GP practice averts crisis after adopting Alaskan primary care model

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A primary care model being tested in Scotland, involving nurse practitioners taking over some tasks currently done by GPs, has boosted the quality of care and reduced strain on resources.

The model, which is based on the Nuka primary care system developed in Alaska, sees practices broken down into small teams made up of a GP, nurse case manager, healthcare assistant and administrator who care for a defined population of patients.

“We have shown ANPs can deal with a good 90% of the daily workload”

Maxine Jones

Features are being tested at the Academy Medical Centre in Forfar, Tayside. Six months into the trial, the participants feel “a sense of crisis has been averted” at the centre, where previously increasing demand was leading to unprecedented strain on GPs, said project consultant Maxine Jones, an associate with the International Futures Forum.

In addition, the new way of working has been shown to have multiple benefits, including better co-ordination and continuity of care, more satisfied patients and less strain on GPs, she said.

The Nuka system, developed by healthcare provider Southcentral Foundation, which is based in the Alaskan city of Anchorage, sees co-located small teams work with just 1,400 patients.

“It is really exciting in terms of a shift of power and career opportunities for nurses in general practice”

Maxine Jones

The Forfar version – which is being supported through the Scottish Government’s primary care modernisation programme and is known as the Forfar Headroom Initiative – has five teams each working with a slightly larger patient list of 2,300 per GP whole-time equivalent.

Advanced nurse practitioners (ANPs) have a central role in the care model in Alaska, Ms Jones told Nursing Times.

“Instead of a bottleneck happening through the GP co-ordinating everything, the role of the co-ordinator goes to the nurse case manager who we’d call an advanced nurse practitioner [in the UK],” she said.

“In Alaska, she is the first point of contact for all patients. She’ll give advice, signpost patients to the appropriate providers, make the appointments, organise the screening and follow-ups, manage the results, make the referrals, monitor the target performance and do the prescription refills,” said Ms Jones.

The Forfar pilot is using a mix of nurse practitioners and general practice nurses, who are also currently training to function at an enhanced level.

“We have been training all the nurses up over time to develop a broad range of clinical expertise, so they can deliver generalist care at at enhanced level, and some can now manage acute minor illness,” said Ms Jones.

“The message is these nurses are the nearest thing to a GP… so they really are a robust and viable alternative”

Maxine Jones

She said: “The nurses who are already nurse practitioners can practice autonomously, with very little involvement of the GP and that has meant GP contacts have reduced generally and booked appointments for GPs have reduced by 48%.”

She told Nursing Times that trials across the country had demonstrated that ANPs could provide a “robust alternative to the GP recruitment crisis”.

“We have shown nurse practitioners can deal with a large proportion of their daily workload, because they are able to asses, diagnose and treat in line with GPs,” she said.

“In Alaska, this has shifted the balance away from the GP as the main holder of the burden of care to the nurse effectively being the main person,” she said. “It is really exciting in terms of a shift of power and career opportunities for nurses in general practice in the UK.”

Initial findings suggest the approach has led to “vastly improved” continuity of care for patients, said Ms Jones.

Care was better co-ordinated and patients were now able access the treatment or support they needed on the same day, instead of having to come back to a separate clinic, she added.

International Futures Forum

Scottish pilot suggests ANPs ‘viable’ alternative to GPs

Maxine Jones

“It has led to a better patient experience – they like the continuity, only have to tell their story once and feel it is helpful to deal with the same team of care providers,” said Ms Jones.

Other benefits included better team relationships and the reduction in GP workload, which meant doctors could offer longer consultation slots if necessary and spend more time on other key tasks.

Under the Nuka system, groups of small teams are supported by a wider team that includes behavioural health psychologists, a dietician and pharmacists with a range of other services available to patients on site.

Ms Jones said work was under way to recruit an extended team in Forfar including a behavioural psychologist and social prescribing co-ordinator, and put in place services such as physiotherapists to run musculoskeletal clinics and pharmacists to run pain management clinics.

She said the pilot had not been without its challenges, not least the fact some GPs had left before it started, meaning the patient lists for each team were larger than they had hoped.

But they had gone onto recruit more nurses as a result. The practice started off with 7.1 whole time equivalent GPs and now has 4.5, while nurses have gone from 3.2 whole time equivalents to 5.5.

Other challenges included a shortage of skilled primary care nurses in the market. Training up the nurses had taken longer than expected, said Ms Jones, and it would have been better if all had been at an advanced level already.

Nuka system

Scottish pilot suggests ANPs ‘viable’ alternative to GPs

Academy Medical Centre in Forfar, Tayside

“Nationally, practices, generally, recognising the value of advanced nurses, so there aren’t really enough to go round any more,” she said.

“In Scotland, they are looking to increase the number of ANPs by 500 before 2021 and in my opinion there needs to be ten times that number,” she told Nursing Times.

She added: “I believe that, when fully trained, these nurses can be the nearest thing to a GP – so they really can be a robust and viable alternative.”

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Readers' comments (1)

  • Sounds interesting.

    Not all ANPs are educated adequately in terms of Advanced Decisions and their legally binding status. Perhaps in a small community they would do better?

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