Primary Care Networks: What About Nurses in PCNs? Q&A

Nurses and PCNs – Welcome to our Primary Care Networks: What About Nurses in PCNs? Q&A.

Today we are extremely lucky to have Millie, a Specialist Practitioner practice nurse for a North London practice supporting more than 5,000 patients. Mille’s practice is an active member of their PCN. So, Millie, thanks for speaking with us today and sharing your experience and thoughts about the voice of nursing in a PCN.

Millie, I know how passionate you are about your career in nursing but was this something you always wanted to do?

When I was about 10, I was set on becoming a vet so I could keep my budgie well and alive forever! My budgie eventually died of old age and so did my dream of becoming a vet. That said, I guess I had an early inkling of wanted to keep animals well and healthy and this simply moved on to people.

So, with that feeling of wanting to keep your animals healthy what attracted you specifically along the nursing routes?

I had never thought of going into nursing until I had a small operation when I was 21. I got on really well with the nurses, we chatted a lot and their stores and their passion encouraged me to look into nursing as a career. Plus, they said I would be good at it and I do love a compliment! At the time, I had a mortgage and other adult things you accumulate in your 20’s and I liked the idea of being paid to get a qualification. I considered a business focused degree but instinctively knew I would be happier working directly with people and the opportunity to make a difference. Cliched I know and an aspiration we often have as youngsters. But in nursing, that feeling never leaves you.

We have seen so many changes in health and social care and particularly General Practice. What’s your experience of the many changes that have taken place?

Can I remember that far back? Well, I do remember typing notes on paper records, trying to read the doctors scribbles and no computers. Yes, younger people, that was how it was in the “old days”. Patient notes are critical, so it was a real challenge back then. I remember QOF being introduced and while new things are always a worry, I was encouraged by the fact it would bring some equality to patient care.

General Practice has always worked closely with whatever commissioning bodies are in place from PCTs, PCNs, CCG’s, GP Federations ta name a few.  We are very much looking to the future with our PCN. I do sometimes wonder if we have gone full circle. By that I mean similar commissioning bodies using different names, the “new” services being offered, population demographics, increasing elderly population growth and “new” ways to manage health.

The models of care need to move forward to adapt to changing circumstances and to build on what we have had before. For example, in the days of PCTs, the ambition was to implement super-surgeries and now primary care has created PCNs to have larger groups of practices. But on the whole, I have seen a lot of changes and yet, there is not a day that goes by when I have regretted becoming a practice nurse.

So, do you feel the new arrangements for nurses and PCNs have taken from what’s worked well and what hasn’t from previous incarnations?

I have always welcomed improvement and the benefits to patients is always articulated as the priority. New models of care may not provide instant patient improvement but coupling new ways of working with regulatory rigour, training and development, they will transform primary care and the way we go about our work.

Moving to ICT based improvements was a relief! Painful sometimes but now patients can book online, our websites enable signposting, a lot of patient information is available which provides clear information to patients and saves resource time within the practice. So today it’s just the norm for most of our patients.

That’s not to say patients don’t feel unable to call us. I do also think there’s lots to be learnt from what didn’t work well in the past. For example, how we engage patients, partners and stakeholders in change. General practice is the heart of the health service and our community and has a special place both emotionally and on a practical level. But we must keep changing, and we must deliver.

We all know there needs to be improvements and with that comes change. With the introduction of the NHS 10-year plan and the PCN contract where do you think nursing in the PCN fits into the expected health transition plan?

I think there is still a way to go for the Aims, Ambitions and Strategy’s of PCNs to be translated into an operational plan that engages all practice staff, stakeholders, partners and patients. Tackling shortages and retaining staff is an ongoing struggle across General Practice and some areas have more challenges than others. Much like other disciplines, nursing has struggled with recruitment and retention.

There seems to be no single answer to this. I see plans for a multidisciplinary workforce will enable more patients to be seen both in and outside of practice. I think more practice nurses may be asked to work across the various surgeries within PCNs which I imagine some may not want to do.

I can also see delivering specialist services across a wider population will encourage development in these disciplines and support recruitment and retention. I also have big hopes for the success of the out of hospital care agenda.

My biggest fear is the possible loss of that feeling of a ‘family’ practice. General Practice, in particular, is often at the heart of communities and generations of families. The likes of the TV show Doc Martin portraying that very heart of the community service. There is a very personal trusted relationship between patient and nurses whereby patients often disclose other issues that impact their health and wellbeing. But the big question is how do we retain this and meet the demands and challenges of the current health landscape? That’s a big question and not one I have an easy answer to. Ask me again in two years.

We are all aware of the recruitment, retention and general resource issues across health services, what do you think has impacted nursing services and how is this being tackled? Is this working?

I am pleased to say we have an excellent practice nurse and HCAs training programme that has been crucial to managing our resources. It’s exactly how we have been able to recruit one of our students. That and the great colleagues, of course! So yes, I would say it worked for us, but perhaps less so for practices that do not have students and cannot recruit from this pool of resources.

There are many projects and initiatives focusing on workforce, leadership and the RCN are key advocates of these initiatives. Trying to make all those elements work together so we don’t dip in and out of is a major issue. We all have day jobs, but we all recognise that much as our patient’s needs are never static we need to constantly seek ways we cannot just meet the patient needs but plan, in advance for the needs of our population.  Recruiting and retaining staff with such uncertainty is challenging.

We have seen the introduction of Clinical Directors and Leads, but what about Nurses in PCNs? Is the voice of the nursing team present in PCNs yet?

Interesting question right now. As I mentioned earlier, I believe that the PCNs are still determining their Aims, Objectives and Vision and these are not yet fully developed in a way that has been articulated to the majority of staff in practices.

There have been some none-GP staff who have taken up the lead roles within PCNs, but these seem to be few and far between. I do believe early engagement is important and staff want to feel they are part of the journey, not simply being discussed in a room somewhere.

There’s lots to read online and social media about the new arrangements, the contract, the deliverables and knowns and unknowns, but the wider clinical staff seem not yet engaged. That said, I would struggle to see how we can be part of the development whilst our resources are so stretched so I do hope we are included in the set up stages of PCNs. Its always good to have the nursing voice at the strategy table.

STP’s and ICS’s are looking to PCN’s to drive transformation within population-based health. What transformation initiatives do you feel will most impact patients that the nursing teams can drive and deliver and play an active part?

I believe nursing teams will step up to an active role in driving and delivering services but more importantly to support the design, be a voice at the table. The new models of working that involve greater use and allied health professional rather than just GPs is the way of the future. I have been lucky enough to have met many great and inspirational nurses in my career and I do believe we can have an active role in supporting and delivering leadership within PCNs.

There are risks however as new roles are being developed within PCN development, for both new services and reconfigured roles will need governance and structure and rigour and testing. Our greatest asset is the trust patients place in our qualifications, experience and passion. If patients are being treated by different new health professionals every time they visit the practice, they may struggle to positively embrace these changes and feel they are improving their care.

There is space for both continuity and change and the key to success is knowing how best to blend that together. There is always a hierarchy to any change process. General practice is no different. You would expect any business owner (the partners) to have a vested interest but is this is particularly interesting in the case of PCN development.

For example, who will be responsible for operationalising PCNs, workforce and service redesign and engagement? Will this be a whole team approach where are those skills found or grown or developed? Has that even been thought through?

I don’t know, I am merely asking the question, but I believe there’s both further work and more dialogue required. And done quickly so we take the staff with us on the journey. I hope nurses will play an active part in the development of population-based health. We are experienced at delivering complex change, are adaptable, versatile, passionate and have both a vested interest in our careers, our workplace and of course our patients.

And finally, what advice would you give colleagues who are reticent about how PCN’s will really make a difference and what advice would you give to ensure practice nurses have a voice?

Ahhh this is a difficult one!!! I know it may be a big ask from colleagues and fellow nurses but we need to stay ahead of the game, We need to have a loud voice and a voice just as important at set up and development as it is in delivery.

I suggest you find out who your PCN Leads are, engage with your Clinical Directors, find out what’s happening, where, and who with. There are lots of meetings, webinars, WhatsApp chat groups – check out the noise on social media, lobby your local nursing leads, find out what’s going on at nurse professional level.

It’s a big ask as nursing time is fully engaged but take a breath and seek out who and what. Remember above all else, nurses are exceptional at managing change. We are passionate about our patients so let’s keep an open mind and embrace change to help shape change.