An innovative nurse-led general practice in West London has been rated outstanding by the Care Quality Commission, offering a successful alternative to GP-led care
This article describes the development of a nurse-led general practice that provides a successful alternative to GP-led care.
Citation: Belton J, Sears C (2015) Nurse-led general practice: a new care model. Nursing Times; 111: 47, 12-13.
Authors: Julie Belton and Carol Sears are directors of Cuckoo Lane Surgery, Ealing.
- This article has been double-blind peer reviewed
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The expansion of primary care services is seen as a way to make the NHS sustainable in the face of growing demand for healthcare (NHS England, 2014). However, a shortage of GPs and increasing pressure on NHS resources means new models of care are needed to make effective use of staffing, as well as to achieve the best patient outcomes (NHS England, 2014).
A recent report on the future of primary care, published by the Primary Care Workforce Commission (2015), found many opportunities to change practice skill mix and staff roles “to help address workload issues, improve the patient experience and sometimes deliver savings”. This included nurses taking leadership roles.
The Five Forward Year Review outlined three new models of primary care, including employing senior nurses as consultants or partners working alongside community nurses and other health professionals (NHS England, 2014). NHS chief executive Simon Stevens has also urged community nurses to take a greater role in innovative projects (Bhardwa, 2014).
Since the development of advanced nurse practice roles in the 1990s, nurse-led clinics and services have become widespread in primary care (Bhardwa, 2014). A small but growing number of nurses are also becoming partners in general practice. Most of these are with established GP-led practices, with few nurses setting up or taking the lead in running practices (Bhardwa, 2014).
Cuckoo Lane Surgery
Cuckoo Lane Surgery in Ealing, west London, has been a nurse-led social enterprise since 2005 and was one of the first general practices run by nurses. It was inspected by the Care Quality Commission in January 2015; as of 29 June, the practice was one of only 3% of the 1,198 inspected by the CQC under its new system of primary care assessments to be rated outstanding (CQC, 2015; Ford, 2015). The Primary Care Workforce Commission also said it showed nurses’ potential to innovate and lead high-quality services (PCWC, 2015).
In 2005, the two GP partners of Cuckoo Lane Surgery decided to retire and Ealing Primary Care Trust put the contract to run it out to tender. Encouraged by the PCT and one of the retiring partners, we (the nurse practitioner, practice nurse and practice manager) submitted a bid to run the practice. We decided to set up a social enterprise, in which profits would be reinvested in the practice, because it was closer to our values than a private business.
We estimated that two-thirds of patients could be seen by nurse practitioners, allowing GPs to focus on more complex cases. We won the bid and Ealing PCT awarded us an alternative provider medical services contract, and the practice has been owned and run by nurses ever since. In its first year, it achieved the highest patient/user satisfaction levels in the local area, according to quality and outcomes framework results.
How it works
Originally the practice served its 4,300 patients from a semi-detached house, but is now located in purpose-built premises, serving 5,000 patients. We employ three part-time salaried GPs, six nurse practitioners (including the nurse directors), four part-time practice nurses, one part-time healthcare assistant, a phlebotomist, pharmacist, practice manager and a range of other non-clinical staff.
The unusual skill mix means patients are seen by nurse practitioners unless they need or request a GP. This depends on the individual staff members’ skills and strengths, rather than the complexity of our patients’ needs. About 80% of patients are seen by nurse practitioners, more than originally envisaged. Most days there are four nurse practitioner sessions and one GP session; each lasts for four hours, including telephone triage/calls and visits. Nurse practitioners also do repeat prescriptions and lab results on rotation, and each day there is a duty nurse practitioner.
Because the practice is owned and run by nurses, the GPs can focus solely on treating patients. They are part of our multidisciplinary team and attend our weekly clinical meetings.
We provide a wide range of services, including clinics for asthma, chronic obstructive pulmonary disease, contraception and child healthcare, as well health promotion services, such as flu vaccination and cervical screening. We also provide services for other GP practices, such as ring pessaries for uterine prolapses and paediatric phlebotomy.
The leadership team
One of the original directors, a practice nurse, has retired, but still works at the practice part-time. Carol Sears is clinical director and Julie Belton, a nurse practitioner and previously Ms Sear’s mentor, joined as director in 2011. She has 11 years’ experience in quality and practice development and is our strategic and operational director. We both maintain a clinical role in the practice, with Ms Sears providing seven sessions and Ms Belton at least one session a week.
One of the biggest challenges we faced when setting up our social enterprise was putting processes in place to ensure the practice runs smoothly. Initially, there was considerable resistance from local GPs, but by developing good external working relationships and an outstanding service, we have overcome this. We have a practice nurse on the board of the local clinical commissioning group and a director on the board of an Ealing federation of 80 GP practices, each providing a nursing perspective in a GP-dominated forum.
Our “outstanding” rating by the CQC shows that with the right leadership and organisational culture, nurse-led general practices can provide a successful alternative to GP-led care.
The CQC said we provided a “safe, caring, effective and well-led service that was particularly responsive to the needs of its local community”, especially more vulnerable patients (CQC, 2015). It praised our “clear leadership structure”, where “staff felt supported by management”, and said our shared purpose and common set of values had led to strong team working, achieving real impact.
Inspectors rated our care as outstanding for a number of key groups:
- Older people;
- People with long-term conditions;
- Families, children and young people;
- Vulnerable groups;
- People with poor mental health, including dementia.
Three areas of practice were highlighted as particularly outstanding (Box 1).
Box 1. Outstanding practice areas
- COPD: Regular spirometry tests, weekly clinics for patients from other local practices and support for patients to maintain self-management plans have improved symptom control and reduced hospital admissions for 25% of patients with lung disease
- Mental health: Targeted treatment and support for local patients has enabled more integrated care outside of hospital settings, leading to 19 patients, who were previously receiving secondary care, being treated directly by their local practice
- Older people: Integrated care, through a dedicated Age UK support worker based at the practice three days a week, provides care for those living alone, including transport to appointments for those who need it
Crucially, we do not aim to provide a cheaper workforce, but to provide high-quality primary care through a different model that maximises numbers of patients seen and care delivered. Resources freed up by using a different skill mix are invested in more staff and better services.
Finding the right people with the right skills has been key, along with robust information and clinical governance. We have a flat management structure and a “no blame” culture, focused on continuous learning and improvement, and ensuring staff feel valued and supported.
Good communication is crucial. Each morning and afternoon we have a “five-point huddle”, where staff gather and flag up the five issues of the day, including those involving particular patients. Action is taken, written up at source and immediately circulated to all staff. A “loving care” board behind reception, only visible to staff, flags up vulnerable patients to staff.
If something is not right, it is immediately acted on. For example, we installed a flexible fabric queuing barrier in reception, so patients know where to wait; this ensures patient confidentiality, without people complaining about being told to stand back.
We follow a coaching style that supports patients and staff to set and work towards their own goals, instead of being paternalistic. This is reflected in excellent retention rates, with most staff having been at the practice for more than 10 years.
The way forward
Since the CQC report, we are registering 20 new patients a week and GPs are sending us their CVs. We must now decide whether to continue growing or franchise out.
Our track record proves that this model of service provision is sustainable; we believe it could be replicated in other areas, with appropriate leadership support and a learning environment, and could help to ease the effects of the GP shortage.
- With the right leadership, nurse-led general practice can be a successful alternative to GP-led care
- An outstanding CQC rating for one nurse-led practice shows nurses’ potential to lead high-quality services
- Up to 80% of patients at the practice are seen by nurse practitioners rather than GPs
- Resources saved by using a different skill mix are invested in more staff and better services
- The model could be replicated in other areas to counter the effect of the GP shortage
Bhardwa S (2014) Primary care in the spotlight.
Care Quality Commission (2015) Cuckoo Lane Practice: quality report.
Ford S (2015) Nurse-led general practice rated outstanding by CQC. Nursing Times.
NHS England (2014) Five Year Forward View.
Primary Care Workforce Commission (2015) The Future of Primary Care: creating teams for tomorrow.