In Liverpool, nurses working in general practice are actively engaged in the drive to improve care and reduce unwarranted variation, using the NHS England RightCare programme
The NHS England RightCare programme can help tackle the challenge of local unwarranted variation in the care provided at general practice level. Liverpool Clinical Commissioning Group is using the RightCare approach to engage nurses working in its 92 GP practices, prompting them to discuss what can be done to improve care and reduce variation. This article describes this approach, in which the use of relevant and meaningful data is key. It is published in parallel with an overview of RightCare and the role of nursing, midwifery and care staff in exploring unwarranted variation.
Citation: Poll S, Lloyd K (2018) Using RightCare to engage general practice nurses in Liverpool. Nursing Times [online]; 114: 1, 31-33.
Authors: Sharon Poll is primary care clinical advisor; Kerry Lloyd is deputy chief nurse and deputy head of quality; both at Liverpool Clinical Commissioning Group.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
- Also read our article Exploring unwarranted variation through the RightCare programme
There has never been a greater need for nurses to make the best use of resources while addressing unwarranted variation and focusing on prevention. This article discusses how using the NHS England RightCare programme can help tackle the challenges. It describes the approach adopted by Liverpool Clinical Commissioning Group (CCG) to engage nurses working in general practice, as well as the benefits of using meaningful, relevant data to promote appreciative inquiry, reduce unwarranted variation and improve health.
Challenges in general practice
Wide variation exists in general practice nursing, as highlighted in a report published by the Queen’s Nursing Institute (2015), with survey responses from over 3,400 general practice nurses indicating some major challenges and opportunities:
- 53% reported their employer always supports their professional development;
- 22.8% of nurses in general practice have two jobs;
- 74.7% indicated they there were no specific days allocated for professional development.
The current independent employer model of general practice means many nurses often work in isolation. This is especially relevant for smaller, single-handed practices who are unable to invest in a wider nursing team skill mix. NHS England’s Five Year Forward View (NHS England, 2014) has crystallised a consensus on why and how the NHS should change. It describes three gaps – a health gap, a quality gap and a financial sustainability gap – that provide opportunities for improvement.
As nurses, we are committed to providing high-quality care to the population we serve while making the best use of finite resources. As the leading health professionals working with individuals to plan and deliver care, nurses are without doubt best placed to reduce unwarranted variation and improve health. With their diverse skill set and generalist approach to managing complex comorbidities, nurses working in general practice have an opportunity to drive the improvements described in the Five Year Forward View and influence the redesign of care.
The financial pressures faced by local health systems mean the need for general practice nurses to make the best use of resources, drive reduction in high-cost activity (secondary care) through high-quality management of long-term conditions, and focus on prevention and early intervention has never been so great.
The case for change in Liverpool
Liverpool CCG has 92 GP practices serving a population of around 505,000 in three localities (North, Central and South). The practices range in patient list size from 1,541 to 36,611 and work in 12 neighbourhoods comprising between 30,000 and 50,000 people.
A highly skilled general practice nursing workforce offers a large amount of first contact and continuing care, managing long-term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), asthma and cardiovascular disease, and delivering key public health initiatives such as immunisation, vaccination and cancer screening programmes.
The case for change in Liverpool is compelling. The city has some of the highest levels of poor health and the greatest health inequalities, both within itself and compared with the rest of country. In Liverpool:
- 30% of people have one or more long-term conditions;
- 86% people are not active enough to maintain good health;
- 25% of adults smoke;
- Over half of adults are overweight or obese;
- The difference in life expectancy between different areas can be more than 10 years.
How can RightCare help?
The changes needed to implement reforms in the NHS must happen at scale and pace. This requires organisations to cultivate a strong culture of engagement, as organisations with more engaged staff achieve better patient outcomes and experiences (King’s Fund, 2012).
To become engaged, nurses in general practice first need to be able to engage with each other so that they collectively understand the local challenges. They also need a high level of trust and shared purpose, so that they can collectively take responsibility, not just for the individual in the consultation but for the whole practice population. Strong engagement and a shared purpose will help to get them talking about the important things.
Headspace for change
Increased workloads and competing priorities make it difficult for many nurses to find the headspace needed to make change happen. Allowing them to come together outside the busy clinical environment is vital, so they can think about how things can be done differently. Allowing time away from the workplace to think creatively about improving care is incredibly effective.
However, while giving staff headspace is seen as key to making change happen (Allcock et al, 2015), constraints and demands can make it a rare opportunity. Smaller practices tend to rely more heavily on nurses, which means that freeing up their time is a real challenge. Creating headspace for nurses in general practice requires a climate of collaboration built on trust, understanding and mutual respect between GPs, practice managers and nurses.
Leadership is a key skill for nurses at all levels, as it allows them to exert influence positively, clearly and confidently. It is essential to strengthen nurse leadership from frontline to board level to drive up standards of excellence, support an open organisational culture and deliver high-quality, safe patient care (Francis, 2013). Truly enabling nurses to exert influence to improve care across general practice requires an organisational commitment.
Using data positively
The way data is used has been known to bring about negative judgements. For some, it feels like finger-pointing, while for others, it lacks meaning or relevance. Helping nurses understand how data can be used more positively, for learning rather than for judging, requires a different conversation, one that focuses on understanding where improvements can be made. This also helps nurses make sense of the multiple layers of NHS performance measures.
Providing nurses with meaningful and transparent data helps promote change and improvement. Presenting local data to nurses in a clear yet meaningful way helps them understand where improvements can be made and fosters learning and appreciative inquiry.
Liverpool CCG’s approach
Liverpool CCG has set itself ambitious targets in its ‘Healthy Liverpool’ strategy (Liverpool CCG, 2015). This sets out a new model of care, transforming the health and social care system and leading to new ways of working and improved outcomes for the population. Liverpool CCG is committed to transforming health and so has invested in the development of clinical nurse leadership across primary care. We now have:
- A full-voting clinical practice nurse on Liverpool CCG’s governing body;
- A general practice nurse lead in each of the three localities;
- An assistant practitioner lead supporting the non-registered nursing workforce.
Alongside engaging the wider workforce using a bottom-up approach, Liverpool CCG has ensured that nurse leadership is evident at a strategic level: senior nurse leaders play an active role in shaping how we implement the RightCare programme. This involves the deputy chief nurse at programme level, which ensures that the role of nursing is central in how we reduce variation and improve health outcomes.
Visible nurse leadership at all levels has enabled strong general practice nurse involvement in the design of care pathways and brought strong clinical nursing influence in commissioning decisions. Through regular engagement with the CCG strategic nurse leaders, our clinical commissioning reflects a multidisciplinary model, rather than a purely medical one.
In Liverpool CCG, strong clinical engagement with nurses is supported through:
- Individual practice visits to connect and support nurses;
- An intranet page dedicated to nursing in general practice to share information;
- A twitter page for nurses in general practice (@Liverpool_CCG);
- Specific workshops for healthcare assistants and advanced nurse practitioners;
- Quarterly city-wide meetings providing networking opportunities.
Initially, the quarterly meetings were held for two hours over lunchtime to allow more nurses to attend. The meetings had a clear purpose, which made it easier for nurses, but also for the practices employing them, to understand what they were about. Placing value on the contribution of general practice nurses meant that there was an increase in the release of nurses from approximately 30 initially to over 70. Meetings now run for two and a half hours every quarter from 12.30 until 3pm and can attract in excess of 100 nurses. They provide a focus on the transformation of primary care (NHS England, 2016), offer peer support and networking opportunities, increasing the drive for improvement.
Engagement has allowed a two-way communication between the CCG and frontline nurses, and has helped create the headspace for nurses to think differently about how to improve care. It is also helping to inform commissioning decisions and pathway redesign.
Using local data
Figs 1 and 2 show local data that was presented to nurses at a recent quarterly meeting, showing variation between the three localities for indicators relating to specific aspects of care for patients with diabetes (Fig 1) and COPD (Fig 2). Some variation is expected and normal – it can be due, for example, to the fact that different people choose to manage their conditions in different ways. However, when discussing the data, nurses agreed that some of the variation could not be explained and needed further exploration.
Presenting indicators taken from a locally commissioned general practice quality improvement scheme has allowed nurses to compare their practice with neighbouring ones. The indicators relate to core nursing responsibilities, which help nurses focus on areas where there is the greatest opportunity to drive prevention and early intervention. Presenting information in that way gets nurses talking about opportunities to improve, using best practice, removing barriers and optimising processes to make sustainable improvements in practice. It prompts nurses to explore questions such as those listed in Box 1.
Box 1. Questions for nurses prompted by discussion of local data
- Did we know we were different from our peer practices? What are we able to learn from the information shared? What are our admission rates in comparison with other practices in our locality?
- Do we know where and how to access data? Is training and support required for this?
- Who are the people we are not seeing? What approach is needed to identify them?
- What can we learn from our peers? How can we share best practice?
- Do we understand where improvements can be made? What are our current processes?
- What change can we make? How do we engage our colleagues? How will we know change is an improvement?
Using data that is simple, transparent and relevant to nurses’ daily work promotes appreciative inquiry; engages nurses in a meaningful way; fosters the ownership of treatment and care for individuals; and contributes to learning and development. Actively engaging nurses and getting them to talk about the same things helps trusting and credible relationships emerge. Bringing nurses together helps create headspace, enabling them to think creatively about the way care is delivered so that variation can be explored and unwarranted variation can be addressed. Strong clinical and strategic nurse leadership ensures the role of nursing in quality improvement remains central to how nurses deliver on reducing variation and improving health outcomes.
- In Liverpool, the NHS RightCare programme helps engage nurses working in general practice
- Practice nurses need to be able to engage with each other to understand the local challenges
- Bringing nurses together outside the practice allows them to think creatively about improving care
- Strong nurse leadership at all levels allows nurses to influence commissioning decisions and care pathways
- Discussing local data that is relevant to nurses helps them to tackle unwarranted variation
Allcock C et al (2015) Constructive Comfort: Accelerating change in the NHS.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
King’s Fund (2012) Leadership and Engagement for Improvement in the NHS: Together We Can.
Liverpool Clinical Commissioning Group (2015) Healthy Liverpool: The Blueprint.
NHS England (2016) General Practice Forward View.
NHS England (2014) Five Year Forward View.
Queen’s Nursing Institute (2015) General Practice Nursing in the 21st Century: A time for opportunity.