1. Supporting Practices nurses in the new world of General Practice
Dr Marina Lupari
Professional Lead for Primary & Community Care
Royal College of Nursing

2. Dramatic Changes in Health Care
Aging population
Growing diversity
Global health care system
Bio-medical advances
New areas of knowledge, i.e. genetics, environmental health

3. Where are we now?
An alternative guide to the new NHS in England by KingsFund

4. The news:

5. Primary care workforce/infrastructure:problems
ageing population and changing consumer expectations>increase in demand for GP appointments.
45 million more appointments every year compared to 5 years ago
The number of people unable to get an appointment has been rising and public satisfaction with access to GPs is falling.
People finding it too hard to see their GP and GPs are finding it harder to give the kind of personal care that is the hallmark of their profession.

6. Solutions
Increasing the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice, as well as more practice nurses, district nurses, physicians’ associates and pharmacists
A new deal on infrastructure
BUT…a new deal on access with a seven-day NHS

7. Innovative Experiments:
1965: Duke University PA Program
Charles Hudson
Thelma Ingles

8. 5YFV/Vanguards – new care models

9. Nursing is integral to the 5YFV
Prevention
Empowering Patients
Engaging Communities
Local Leadership
Aligned National Leadership
Modern Workforce
Use of Innovation
Exploit Info. Revolution
Drive Efficiency
New Models of Care

10. What does it mean for Nursing?
Focusing on prevention
Empowering patients
Engaging communities
Incentivise healthier individual behaviours
Strengthen powers for Local Authorities
Targeted prevention programmes – starting with diabetes
Additional support people to get and stay in employment
Create healthier workplaces – starting with the NHS
Staff as role models
Staff as expert in behaviour change
Improve information: personal access to integrated records
Invest in self- management
Support patient choice
Increase patient control including through Integrated Personal Commissioning (IPC)
New relationships
Sharing the leadership space with patients
Support England’s 5.5m carers – particularly the vulnerable
Supporting the development of new volunteering programmes
Finding new ways to engage and commission the voluntary sector
NHS reflecting local diversity as an employer

11. GP Nurses
Competent, confident nurses for the 21st Century Practice Setting.

12. Making Room in the Clinic….
Modern health care depends upon:
Nurses, physicians, and patients working together
finding common ground
putting patients first
knowing how to use the skills and knowledge of providers across time and place

13. Clinically significant questions focused on health policy issues :
How do we decide who provides particular types of care at particular times and places?

14. “nurses…particularly effective at improvisation, invention….”
In 1950s and 1960s as at the turn of the 2oth century, nurses were particularly good at doing what had to be done.
night shift
rural areas
public health
home care
Able to use skills and knowledge to meet patient needs
NY VNA, circa 1900, VNA Coll.

15. What do PNs do? “Patient Centered”
Assessment
Diagnosis
Treatment
Case Management/coordination of care/integration
Continuity and secure transmission across the health system
Emotional support
Access
“Whole Person”…Family and Community focus

16. PN Managed Clinics
History of nurses managing health care independently and interdependently:
In home during child birth and plagues
In wars caring for the soldiers
In public/community health during epidemics

17. Some of the challenges for PNs
Care need is changing more quickly than workforce development producing huge capacity and capability pressures
Models of practice are very variable;
Availability of specialist practice and leadership education and training is decreasing;
Profile of DN & PN is low
Young people are not given adequate careers advice
Undergraduate student nurses can’t access placements easily
Qualified nurses often use DN & PN post as a default position
Historical education commissioning methods
Ageing workforce
Indemnity

19. Limitations to PN progression
Scope of practice
Payment
Competition vs.. Collaboration
Nursing & Midwifery Council
Autonomy
Prescriptive authority

20. Some of the challenges for PNs
Care need is changing more quickly than workforce development producing huge capacity and capability pressures
Models of practice are very variable;
Availability of specialist practice and leadership education and training is decreasing;
Profile of DN & PN is low
Young people are not given adequate careers advice
Undergraduate student nurses can’t access placements easily
Qualified nurses often use DN & PN post as a default position
Historical education commissioning methods
Ageing workforce
Indemnity

21. Nursing contribution to strengthening Primary Care
Transforming Nursing for Community and Primary Care
Revalidation for nurses
Accountable clinician
Compassion in Practice/ 6Cs
Supporting New Care Models
CQC inspection of general practice
Workforce review
All the above programmes have or will have a focus on community and primary care nursing

22. Focus on developing more general practice, district and community nurses to:
Play an enhanced role in the community
Enable healthy lives and managing self care
Enable whole-person coordinated care
Addition of a community care field to encourage more nurses to see specialised community care as a future career - field could include district nurses, GP practice nurses, health visitors and school nurses
Develop more practice placements in primary care

23. What about the new NMC Code?
Revised Code comes into force from 31 March 2015
Contains the professional standards that all registered nurses and midwives must uphold
The Code will be central to revalidation process as a focus for professional reflection
The Code will be central to revalidation process as a focus for professional reflection.
According to the NMC this will give the Code significance in registrants’ professional lives, and raise its status and importance for employers.
The NMC hopes that through revalidation, registrants will provide fuller, richer evidence of their continued ability to practise safely and effectively when they renew your registration.
Registrants encouraged to reflect on the Code in relation to feedback they receive and training and learning and development undertaken
The NMC states that the revalidation model aligns to the four themes of the Code:
• Prioritise people by actively seeking and reflecting on any direct feedback received from patients, service users and others to ensure that you are able to fulfil their needs.
• Practise effectively by reflecting on your professional development with your colleagues, identifying areas for improvement in your practice and undertaking professional development activities.
• Preserve safety by practising within your competency for the minimum number of practice hours, reflecting on feedback, and addressing any gaps in your practice through continuing professional development (CPD).
• Promote professionalism and trust by providing feedback and helping other NMC colleagues reflect on their professional development, and being accountable to others for your professional development and revalidation.
The Code also sets out various requirements to fulfil registration requirements including:
- meet any reasonable requests so we can oversee the registration process
- keep to our prescribed hours of practice and carry out continuing professional development activities, and
- keep your knowledge and skills up to date, taking part in appropriate and regular learning and professional development activities that aim to maintain and develop your competence and improve your performance.

24. What is revalidation?
From 31 December 2015 Revalidation will be the process by which all registered nurses and midwives will demonstrate to the NMC that they continue to remain fit to practice
Revalidation will take place every three years at the point of renewal of registration and will replace the existing Prep standards
To revalidate, registrants must declare that they have met a number of requirements over the three year period
Every year the NMC will select a sample of nurses and midwives to audit
Revalidation is the new process by which nurses and midwives will demonstrate to the professional regulator - the Nursing and Midwifery Council (NMC), that they continue to be fit to practise and to remain on the NMC register. Revalidation is planned to come into force from 31 December 2015 onwards.
In the three years preceding the date of your application for renewal of your registration, you need to meet a range of revalidation requirements designed to show that you are keeping up to date and actively maintaining your fitness to practise.
Each year the NMC will select a sample of nurses and midwives to provide further information to verify the declarations that they made as part of their revalidation application. If selected, it doesn’t necessarily mean there is any problem with your application, but you need to send the requested information quickly and within the specified timeframe.

25. What are the revalidation requirements?
Minimum 450 hours practice over three years
Minimum 40 hours of CPD, 20 of which ‘participatory’
Obtain at least 5 pieces of practice-related feedback
Record at least 5 written reflections on feedback, CPD and/or the Code and discuss these with another NMC registrant
Have an indemnity arrangement in place
Confirm your good health and character
Obtain confirmation from an appropriate third party that you have met the revalidation requirements
Every nurse and midwife must confirm that they have met the following requirements:
Have completed at least 450 hours practice over the three years since their last registration, 900 hours for a nurse who is also a practising midwife
Have undertaken a minimum of 40 hours Continuing Professional Development (CPD) in the three year period. At least 20 hours must have been ‘participatory learning’, learning with others (e.g. workshops, conferences, peer review activities, coaching and mentoring, group or practice meetings). Accurate records of CPD also to be undertaken
Have obtained a minimum of five pieces of practice-related feedback in the three year period preferably from a range of sources including patients, colleagues, students and service-users
Over the three years to have recorded a minimum of five written reflections on the Code, feedback they have received or on CPD undertaken, reflecting on how they used this to improve their practice.
Have a professional development discussion with a fellow NMC registrant and ensure that they complete the relevant documentation to confirm this.
Demonstrate that they have or will have when practicing an appropriate professional indemnity arrangement in place
Confirm that they are of good health and character (e.g. no criminal record)
Finally that they have obtained confirmation that they have met all the revalidation requirements from an ‘appropriate third party’

26. Revised Code: key areas of change
Delegation
Fundamentals of care
Raising concerns
Social media
Patient & public expectations
Revalidation
Cautions, charges & formal complaints
Medicines management
Leadership & time management

27. Current developments
Response to HEE Primary care workforce commission call for evidence
RCN/RCGP statement on principles for primary care
Launch of GPN Career Framework  
Primary care themes within the RCN response to the Five Year Forward View
Primary care themes within the RCN response to the State of Caring Recommendations
CQC GPNurse inspection regime
Revision of GPN toolkit
Production of HCA toolkit

28. It’s change that I can’t stand…
So change is on its way…?
I’m all for progress—
It’s change that I can’t stand…
Mark Twain