The changing face of primary care

Sam McCaffrey takes a look at how primary care is changing and the different clinical roles that can help your practice meet increasing patient demand.

Primary care faces an increasing number of challenges on what feels like continuously diminishing resources. GP surgeries now make 370 million consultations per year - 70 million more than five years ago.

Around a quarter of the population now has a long-term condition and they account for 50% of GP appointments. Additionally, an aging, increasingly co-morbid population is also contributing to the increase in demand. Despite this, GP numbers have remained relatively stagnant. According to the GP Taskforce, the number of GPs per 100,000 population in the UK fell from 62 in 2009 to 59.5 in 2012.

This situation has led to a search for alternative ways to meet the increase in demand and roles that have not traditionally been considered part of the general practice team are now being viewed as viable solutions.

The Government and NHS England have announced plans for roles such as physician associates and pharmacists to increase their presence in general practice, while the skills of paramedics and nurse practitioners are also being used in new and innovative ways.

But what can these different clinical roles do for your practice? We contacted their representative bodies to find out.

Paramedics

Andy Jones
College of Paramedics

Throughout the UK paramedics are working in many GP practices, GP OOHs, walk in centres, community response teams and emergency departments. One of the main benefits of utilising paramedics in these areas is that they are autonomous practitioners.

There are various grades of paramedic currently ranging from emergency care practitioner (ECP), specialist paramedic (SP), advanced paramedic practitioner (APP) and consultant paramedic (CP).

The ECP role has variations in education throughout the UK ranging from a six week internal course to a BSc Hons. Therefore within the College of Paramedics structure this role is no longer recognised.

The specialist paramedic has currently two areas of speciality, Critical Care and Urgent and Emergency Care.

The definition of a SP is a paramedic qualified to a minimum of a post graduate diploma in a subject relevant to their practice. They will have acquired and continue to demonstrate an enhanced knowledge base, complex decision making skills, competence and judgement in their area of specialist practice.

The skill set for SP's include:

• Disease specific management
• Assessment and management of wounds including debridement, skin flap wounds, glue, skin link and sutures
• Assessment of minor illness and injury
• Assessment and management of medical conditions, including chronic, for example;
  • Undertaking an enhanced physical assessment of a patient with a respiratory condition and diagnosing a chest infection. The SP can then provide a course of appropriate antibiotics via a PGD.
• Provide extended analgesic pain relief, such as co-codamol and diazepam, utilising a PGD
• Taking bloods and analysing them
• X-ray interpretation.

An advanced paramedic practitioner is an even further qualified paramedic with a minimum of an MSc in a subject relevant to their practice. They have an expert knowledge base; complex decision making skills, competence and judgement in their area of advanced practice. They can apply advanced clinical history taking skills to receive analyse and interpret highly complex medical information in order to establish a differential diagnosis and develop a care plan for individual patients.

Both an APP and SP can liaise effectively with all members of the multi-disciplinary healthcare and social care teams to achieve a coordinated specialist service for patients.

They can also autonomously develop, implement and evaluate patient management plans for new and reviewed patients using advanced clinical reasoning and decision making skills.

Andy Jones is an advanced paramedic practitioner and the elected representative for Wales in the College of Paramedics.

Physician Associates

Raj Gill
Faculty of Physician Associates

Physician associates (PAs) are dependent medical practitioners who work under the supervision of a named GP. There are currently around 250 PAs practicing in the UK, with one in five choosing to work in primary care. This number is likely to increase over the next few years with a new NHS scheme to recruit 200 PAs from the USA and the Government setting a target of having 1,000 PAs in primary care by 2020.

PA students already possess a life science or allied health degree and undertake a highly intensive full-time postgraduate training program which follows a national curriculum focusing on the common and important medical conditions. Every PA sits a national qualifying examination which insures a minimum standard across the country; this is repeated every six years allowing PAs to remain up to date across specialties.

PAs in primary care are able to: take medical histories, examine patients, request appropriate investigations, formulate management plans, refer to secondary care and conduct relevant follow up.

PAs undertake a variety of appointment types including: on the day acute appointments, chronic disease management, telephone triage, home visits, nursing home visits and minor surgery. PAs will often take the lead on particular QOF areas and can be used to manage complex care and admission avoidance enhanced service. PAs participate in wider practice activities including reviewing bloods and practice correspondence, conducting audits and helping with training and teaching for new staff and students. 

PAs require regular supervision with their named supervisor and need to develop a similar relationship to GP trainer and trainee. The level of supervision is dependent on the individual’s experience and each GP arranges their own system for reviewing patients with their PA. There is currently no statutory regulation for PAs in the UK but there is a managed voluntary register held by the Faculty of Physician Associates at the Royal College of Physicians. This currently limits PAs and they are unable to request ionising radiation, sign prescriptions and complete medical certificates. Recent Government statements calling for the expansion of the number of PAs in primary care point towards regulation in the future and the resolution of these issues.

Raj Gill is a physician associate at a GP practice in London and a member of board of the Faculty of Physician Associates at the Royal College of Physicians.

Pharmacists

Rena Amin
Primary Care Pharmacists Association

There are many challenges facing general practice that a practice-based pharmacist can assist with. These challenges include helping to reduce the 5-8% of hospital admissions that are related to medicines and helping to reduce the amount of wasted prescribed medicines.

A practice-based pharmacist could also help with patients that have concerns about polypharmacy and need help with medicine taking, including the elderly, people with learning difficulties and those with co-morbidities.

NHS England has more than doubled funding for a pilot for clinical pharmacists in general practice due to an overwhelmingly positive response from GP surgeries. The 73 applications that will receive a share of the funding will cover 698 GP practices and include 403 clinical pharmacists.

The NHS Alliance and Royal Pharmaceutical Society have compiled a list of primary care activities that pharmacists could perform in general practice. These may include:

• Clinical services
• Working closely with GPs to resolve day-to-day medicines issues
• Addressing medicines adherence with patients
• Managing and prescribing for long-term conditions in clinics, often in conjunction with practice nurses
• Triaging and managing common ailments
• Responding to acute medicine requests
• Reviewing patients on complex medication regimens
• Taking part in multidisciplinary case reviews
• Carrying out face-to-face or telephone follow up with patients
• Signposting patients to appropriate services and other healthcare professionals (e.g. community pharmacists)
• Prescription management
• Reconciliation of medicines in outpatient and discharge letters — including liaison with hospital, community and primary care colleagues to ensure correct medicines are continued following transfer of care
• Supporting the GPs and other practice staff to deliver on QIPP agenda, QOF and locally commissioned enhanced services
• Working with the practice team to deliver repeat prescription reviews — especially for care home residents, people prescribed polypharmacy and frail older people
• Converting acute medicine requests into repeat medicines, where appropriate
• Point of contact for the practice for all medicines-related queries for healthcare professionals and patients
• Implementing and monitoring a practice’s adherence to a repeat prescription policy
• Audit and education • Conducting clinical audits as part of the multidisciplinary team
• Answering medicine information enquiries from GPs, other healthcare professionals and patients
• Implementing, in conjunction with the practice team, systems for monitoring medicines use
• Contributing to clinical education of other healthcare professionals
• Providing leadership of quality improvement programmes that involve medicines
• Working with GPs and practices nurses to agree, and then manage, practice formularies to improve the choice and cost effectiveness of medicines
• Implementing NICE guidance through audit and feedback, formulary management and educational sessions with the wider primary healthcare team and patient.

Rena Amin is a pharmacist and a partner at a GP practice in London. She is also the joint associate director for medicine management at NHS Greenwich Clinical Commissioning Group.

Nurse Practitioners

Gill Coverdale
Royal College of Nursing

Nurse practitioners are nurses who have experience, knowledge and skills beyond that of first level registration and demonstrate highly specialised knowledge in primary care nursing beyond that of their practice nurse colleagues, increasingly taking on advanced level roles that support their medical colleagues.

Nurse Practitioners will be registered on Part 1 of the Nursing and Midwifery Council (NMC) register and may be registered on other parts as well (midwifery or specialist community public health nurse). Some may have completed the NMC Specialist Community Practitioner Qualification, but all nurse practitioners must have completed a nurse practitioner degree, at either Honours or Master’s level. They will also have completed their Independent and Supplementary Prescribing (V300) qualification, which allows them to prescribe a range of treatments for patients.

The nurse practitioner degree programme prepares nurse practitioners to carry out patient consultations, advanced assessment, use diagnostic reasoning skills and a range of other diagnostic support tools. They will be able to respectfully challenge practice, systems and policies in an objective and constructive manner and proactively develop opportunities to influence national and local policy and strategy. They may have additional responsibilities for education of colleagues within the team and students. These practitioners may also take additional responsibilities for patients with complex, chronic and enduring conditions, proactively promoting health and well-being but also being able to work in a consultancy capacity for complex community nursing interventions.

In addition to nurse practitioners, there will be advanced nurse practitioners who have completed a Masters level programme and whose role may differ to that of their nurse practitioner colleagues, with respect to research, service development and quality improvement. Advanced nurse practitioners do not need to work under supervision from GPs, they are autonomous and have their own professional registration and code of conduct. They are able to work in an autonomous way and they often work in partnership with GPs. In some cases they may be full partners rather than employed by the practice.

Nurse practitioners and advanced nurse practitioners enhance the skill mix of the general practice team and often play a major role in both preventative care and the management of complex and long term conditions, thus enabling their GP colleagues to focus on their specialist interest areas and acute cases, although this varies considerably from practice to practice.

Gill Coverdale is the professional lead for education (standards and professional development) at the Royal College of Nursing.

All healthcare professionals employed by, or contracted to, a practice need to have adequate and appropriate indemnity arrangements in place. For nurse practitioners, advance nurse practitioners, physician associates and paramedics these may be available through Medical Protection, either as an individual member or as part of a Practice Xtra group scheme. Currently we are unable to offer membership for pharmacists, who should contact the PCPA, or their current specialist insurer, for advice regarding indemnity arrangements.