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The Nursing Shift

The Nursing Shift
8 December 2014

NHS Leeds West Clinical Commissioning Group (CCG) is made up of 38 GP practices in the west and parts of outer north west and south west Leeds. We have a budget of around £394 million covering a population of around 350,000. 

NHS Leeds West Clinical Commissioning Group (CCG) is made up of 38 GP practices in the west and parts of outer north west and south west Leeds. We have a budget of around £394 million covering a population of around 350,000. 

Our varied population covers parts of the most affluent and parts of the most deprived areas of Leeds, and includes communities with some of the lowest average life expectancy rates in the city.
In our part of Leeds, fewer children with asthma, diabetes and epilepsy are admitted to hospital as an emergency. However we have a higher than average number of people aged under 75 dying from cancer, cardiovascular disease (heart) and respiratory (lung) disease in our area. In addition, more people in our area are admitted to hospital as an emergency with alcoholic liver disease.
Practice nurses (PNs) have a specialist role delivering differentiated (routine) and undifferentiated (acute) care to patients from the cradle to the grave. They accept self or carer-initiated referrals, patients from GPs or allied health professionals and deliver emergency, acute, short and longer-term care for single, recurring or long-term conditions and co-morbidities.
Feedback from GP practices nationally and locally has made it clear there is paucity in the number of appropriately qualified PNs to help provide key primary care services. We have all heard of the issues affecting general practice, but at times the role of PNs has been forgotten. 
Our local data shows we have an ageing PN workforce with many coming towards the end of their careers, and we just don’t have sufficient numbers coming through to replace recent retirees. We know that these figures reflect national trends. This means we need to recruit and retain a new cohort of PNs to help ease the pressure on already overstretched GPs and wider primary care.
In an effort to address the recruitment crisis facing practice nursing, Leeds 
West CCG has set up a 12-month preceptee practice nurse pilot project. 
We know from our research that nurses want to work in general practice, either as a career change or first destination post qualification, but practices are reluctant to recruit them without general practice experience because they need nurses who can induct quickly, to work at pace and with accuracy – requirements that need time and training. This is an impossible situation without focused investment, so a 12-month program of training has been developed by the CCG. We signed up 10 nurses to the pilot preceptorship programme which started in late September 2014. 
To help get the scheme off the ground we have asked one of our CCG’s member GP practices to act as a hub for the program, offering a link between the preceptee practice nurses and host GP practices who have agreed to take part in the pilot by providing placement opportunities. GPs are now at the centre of NHS commissioning – even if they don’t all feel like they are or don’t want to be – and our preceptee nurses will help member practices to establish closer links with the CCG.
The preceptees will attend identified training and academic courses, embed learning through attendance in differing GP practice placements in a supernumerary capacity and work closely with CCG colleagues. This means they can influence the safe, quality care patients deserve in a forward thinking, credible way by demonstrating desired values, behaviours and by contributing to political discussions informing future healthcare design 
How this has been commissioned and integrated into primary care
In recognition of a need to recruit PNs now, before significant skill and experience is lost through pending retirement, NHS Leeds West CCG used intelligence tools to analyse its workforce demographics, trying to understand and clarify the degree of investment required, coupled with the amount of impact we could absorb. The latter is significant considering the sudden investment in training, as we also recently launched a citywide undergraduate student nurse placement program in partnership with Health Education Yorkshire and the Humber’s Advanced Training Practice Scheme. 
With this in mind our mentorship infrastructure needed to be managed safely, while undergoing further development and taking into context our current staffing levels and demands of new learners within the system.
We recognised the importance of offering quality student nurse placements with an eye to their longer term interest in general practice as a first destination career and realised that in order to make practice nursing an attractive career opportunity we needed to develop and demonstrate the presence of a focused learning pathway; this would enable newcomers to feel supported and valued. It was clear this pathway needed to provide training, knowledge and experience, ensuring a better understanding of working in an environment that traditional nurse education does not fully equip them for. 
Core PN skills, such as cervical cytology and administering vaccinations according to the UK schedule, underpin the public health agenda but are absent from undergraduate curricula. Other aspects are also absent such as ear care, pre-travel risk assessment and vaccination, and management of long-term conditions in a routine context. These are not necessarily skills absorbed by nurses working in secondary care roles, so transferring across from these organisations is equally challenging. This helped us realise that a focused, structured training plan was required that creates a supportive infrastructure allowing good quality learning to happen in practice.
This workforce investment comes at a time of rapid change and challenge for primary and community care, facing demands of the transformation agenda, so the scope of development was discussed within the CCG and extended with an ambition to subtly change the traditional PN role, allowing it to become more community inclusive. 
This is a long-term aspiration that cannot happen overnight as it cuts to the heart of how we currently work, impacting on patient expectations and inclusivity, leadership and whole team working. There is a need to adapt training so that new PNs can function operationally as teams expect. It also gives them the skills to think strategically, questioning the way care is delivered from a patient-centred and economic perspective, making subtle but valuable changes that meet future demands.
Achieving this requires a shift in attitudes at all levels, not only within the practice, community and secondary care workforce, but also with local authority, third sector and higher and further education colleagues and commissioners. Managing and developing these relationships and expectations is a significant challenge regarding success of the program. Alternative placement experience will be the cornerstone of this progression but of fundamental importance is retaining practice team cohesion through changing, challenging and demanding times.
Support from the top
Thirty two years to the day after first stepping out as a student nurse, Philomena (Phil) Corrigan, Chief Executive for NHS Leeds West CCG, went back to her roots at Leeds Student Medical Practice, as she joined the 10o preceptee nurses.
Phil started her career 32 years ago, in October 1982, and has worked in a range of clinical areas such as intensive care, surgical services and older people’s services. She then moved into a research, audit and educational roles before she took up a range of senior director level positions prior to taking on the role of Chief Executive at the CCG. 
Despite the demands of her role, Phil has continued to keep up-to-date with her qualifications and registrations from professional nursing bodies and still commits time every month as a nurse. 

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