1. The Changing Face of General Practice Helene Irvine Nurse Adviser, Wessex LMCs RCGP - Deputy Clinical Lead for Practices in Special Measures CQC Specialist Adviser Advanced Nurse Practitioner
General practice never seems to stand still but there are major changes coming!
Many of you will be familiar with the 5 year forward view but thought I would be useful to refresh ourselves with a snapshot look at the proposals and how this may impact on us as nurses now and in the future

2. Five Year Forward View A snapshot!
Investment £500 million pounds over 5 years
Workforce – see later
Workload – £10 million for vulnerable practices + £40 million for resilience programme
Practice infrastructure = £900 million (£45 adopt online consultations and £40 million practice resilience programme)
New Models of Care (improving access £2.4 million by 2020/21)
The 60-page plan also contains specific, practical and funded steps to strengthen workforce, drive efficiencies in workload, modernise infrastructure and technology, and redesign the way modern primary care is offered to patients.
Wrapping services around GP practices – however at greater scale – population based commissioning 30,000 – 200,000!
Massive financial investment over the next 5 years
Compounded by increase demands on general practice
Ageing population with co-morbidities
MCPs
An MCP is what it says it is - a multispecialty, community-based, provider, of a new care model. It is a new type of integrated provider. It is not a new form of practice-based commissioning, total purchasing or GP multi-fund, or the recreation of a primary care trust (PCT). An MCP combines the delivery of primary care and community-based health and care services – not just planning and budgets. It also incorporates a much wider range of services and specialists wherever that is the best thing to do. This is likely to mean provision of some services currently based in hospitals, such as some outpatient clinics or care for frail older people as well as some diagnostics and day surgery; it will often mean mental as well as physical health services; and potentially social care provision together with NHS provision. The building blocks of an MCP are the ‘care hubs’ of integrated teams. Each typically serves a community of around 30-50,000 people. These hubs are the practical, operational level of any model of accountable care provision. The wider the scope of services included in the MCP, the more hubs you may need to connect together to create sufficient scale. All 14 MCP vanguards now serve a minimum population of around 100,000.
STPs
NHS England has created 44 STP areas - or 'footprints' - each of which brings together five CCGs on average, covering populations of between 1m and 2m people. The groups will incorporate all health and care systems within each area.
Each area's STP will set out how the local system will improve health and wellbeing for the population, improve service quality and deliver financial stability and balance.
An MCP or a PACS? Multispecialty community providers (MCPs) and integrated primary and acute care systems (PACSs) are both population-based new care models that aim to improve the physical, mental and social health and wellbeing of their local population. Both are based around the general practice registered list, and apply a new model of enhanced primary and community care. They encourage diverse communities to look after themselves by supporting self-care and connecting people to community assets and resources. They support staff to work in different ways, with a focus on team-based care, and harness digital technology to achieve their goals. Both MCPs and PACSs are provider models that will ultimately need to be commissioned using new contractual mechanisms and funded using a whole population budget. However, MCPs and PACS will differ in scope and may differ in scale. On scope, both models include primary, community, mental health and social care services. A PACS also provides most or all local hospital services. An MCP may provide some services currently provided in a hospital setting, including outpatient or diagnostic services, as well as extending access to urgent care services in the community. Under an MCP model the remaining hospital services will continue to be provided by the local hospital, under a separate contract. Both models have the potential to transform where and how traditional hospital services are provided. The PACS model offers the prospect of achieving this transformation across all hospital services. The other difference may be one of scale. The natural unit of both the MCP and the PACS model is the neighbourhood population of 30,000 to 50,000. At a minimum an MCP will need a population of 100,000, but could be much larger. At a minimum, a PACS will provide care for all the population served by its acute trust, generally at least 250,000. Local commissioners may initially aim to commission a PACS but instead commission an MCP. This could happen where, for example, it turns out that there is insufficient desire amongst general practice to fully integrate with the local hospital. Or the local acute trust may be happy to be able to ‘dock’ with a newly established MCP, without wanting to run it; and instead focus more of its energies on wider acute and specialist collaboration.
GP recruitment and retention
Exhaustion

3. Access
Improved access to in hours and OOHs. Integration of extended access with out of hours and urgent care services, including reformed 111 and local Clinical Hubs
Easier and more convenient access to GP services, new roles. Over 5m consultations a week. The front door of the NHS.
A 1% reduction in capacity in general practice, can lead to a 15% increase in attendances at A&E.
This includes appointments in the evening and at weekends by 2020.
7 day services remains an important issues
Can’t be delivered at the level of a practice
Can’t be delivered without additional funding
Commissioning and funding of services to provide extra primary care capacity across every part of England, backed by over £500 million of recurrent funding by 2020/21.
Joining up NHS 111, GPs extended hours, oohrs service
Vanguards trialling this in different ways and Kerie will talk about this is more detail later
For us in primary care it may be a different way of working e.g 7 day service evening and weekends
If you ask nurses why they came into primary care it was the variety, small team working, personal continuity of care and favorable hours
Reduction in the GP workforce, retirement, pressure on general practice, mergers, closures new providers may have implication for contacts and the future
Can also see this as an opportunity
GPNs a very valuable part of the workforce and we can be part of this transformational agenda but we need to speak up rather than having some changes imposed upon us
With new providers taking over general practice

4. How many?
The numbers
The future
31% > 55yrs old
32.6% prescribers
66% covered by employers indemnity
98.6% Female 1.4% Males
51% no formal GPN qualification
33.4% GPNs due to retire by 2020
NURSING WORKFORCE FACTS
3405 NURSES RESPONDED to QNI survey (stats reflect studies by RCGP/RCN and Deloite) 3000 from England
HIGH NUMBER OVER 55yrs old
RETIREMENT – not dissimilar to other professions in agriculture 50% are over age of 50yrs
NUMBER OF MALES 1%
CLINICAL SUPERVISION NOT AVAILABLE %
ONLY 11% IN WESSEX
HOME VISITS - 38%
Lack of educational training underpinning role of ANPs – moving to care certificate for HCAs to standardize educational standards and competencies - regulation
Key:
GPN = General Practice Nurse
ANP= Advanced Nurse Practitioner
Source:
The Queens Nursing Institute (2015) General Practice Nursing in the 21st Century QNI: London
RCGP. (2014) The future of General Practice. RCGP: London

5. Workforce to increase by 2020/21
5000 doctors in general practice £21,000 incentive for GP trainees in 109 areas
3000 fully funded practice based MH therapists by F/T for every 2-3 GP practices
1000 physician associates
£112 million investment to provide a pharmacist per 30,000 pts =1500 co-funded clinical pharmacists by 2020
£15 million pounds for GPN development
£6 million pounds for PM development + £45 million for admin & clerical staff
Workforce of the future
Pas – expand on this later
New roles see this as a sportive step forward
Need to retain and recruit new nurses into primary care issue around parity in terms of salaries, AL, CPD

6. Mind the (generational) gap
25% of NHS
40% of NHS
35% of NHS
<5% of NHS
Jones K., Warren, A & Davies, A. (2015) Mind the gap: Exploring the needs of early career nurses and midwives in the workplace Summary report from Birmingham and Solihull Local Education and Training Council
WHO ARE THE NEXT GENERATION? WHAT ARE THEIR NEEDS? WHAT MOTIVATES THEM?
BABY BOOMERS – dedicated, loyal, work long hours, hard working, experienced, skills – use these skills and knowledge leadership roles
GENERATION X – EMBRACE CHANGE
THEY WILL NEED – opportunity for training, advice, to change roles, get feedback and coaching
BOTH MAKE UP 65% OF NHS WORKFORCE - 30 YR AGE GAP!!!
MENTORSHIP - PROVIDED BY BABY BOOMERS & GENERATION X – we need them!!
GENERATION Y & Z
AMBITIOUS, HIGH CAREER EXPECTAIONS, NEED MENTORSHI, DIRECTION, SUPERVISION & REASSSUREANCE
Us of TECHNOLOGY – the way forward
MILLENIALS - MAINTAIN WORKLIFE BALANCE
TECHNOLOGY – very good at accessing/using
OPEN CULTURE, WANT DIRECTION, MENTORSHIP
REGULAR FEEDBACK THERE AND THEN +VE AND CONSTRUCTIVE Vision & reqrd for outcomes
91% STAY IN JOB FOR 3 YEARS
Baby Boomers
Generation X
Generation Y
Generation Z
Motivated and hard working; define self-worth by work and accomplishments.
Practical self-starters, but work-life balance important.
Ambitious, with high career expectations; need mentorship and reassurance.
Highly innovative, but will expect to be informed. Personal freedom is essential.

7. INDEMNITY – HIGHER UP HIGHER RISK
Level
Role
Qualifications 8
Advanced Nurse Practitioner
Registered with the Nursing and Midwifery Council. Master’s degree
Postgraduate diploma meeting ANP requirements and to include level 8 high intensity interventions (see
NICE guidelines for descriptors of behaviour change interventions)..
Independent and supplementary prescribing – V300.
NMC Mentorship or practice educator qualification 7
Senior GPN
Registered with the Nursing and Midwifery Council.
First degree and working towards postgraduate level qualification.
NMC Mentorship qualification
Independent and Supplementary prescribing – V300.
NMC Mentorship qualification. 6
GPN
Registered on Part 1 of the Nursing and Midwifery Council register.
Degree level qualification/equivalent experience.
NMC Specialist Community Practitioner Qualification – Practice Nurse/relevant experience. 5
Registered on Part 1 of the Nursing and Midwifery Council register 4
Assistant practitioner
Higher Care Certificate (currently under development).
Hold or working towards Foundation degree at level 5. 3
HCA
Care Certificate (highly recommended) to include, or have as an addition, training for working alone in community settings and specific skills needed for the role Level 2 brief intervention training (see NICE guidelines ),
Level 3 apprenticeship or QCF level 3 diploma in clinical healthcare support or the equivalent, Maths and English functional skills qualification 2
Care Certificate (highly recommended) to include, or have as an addition, training for working alone in community settings and specific skills needed for the role .
Hold or working towards Level 2 QCF Diploma in Clinical Healthcare Support or equivalent. Maths and English functional skills qualification – some of the requirement may change when new NOS are published 1
Pre-employment
Examples: work experience, traineeship, pre-employment programme, cadetship
This is taken from the HEE District Nurse & General Practice Nurse Career Framework 2015
Fits in with the RCGP/RCN Competency Framework 2015
Sets out a clear career pathway from HCA to ANP and the qualifications required to practice at each level, including Master’s Degree for most senior roles.
INDEMNITY – HIGHER UP HIGHER RISK
Crown indemnity larger scale working
MDU
2015 – 25 negligence claims against NPs
2005 – 2 complaints
40% for delayed diagnosis
Delayed referrals
Prescribing errors
Importance of clinical supervision/competencies
Cost effectiveness NOT ONE SIZE FITS ALL

8. What will this advanced practice look like?
Defines level of practice and not necessarily the role
Is it a level of practice rather than a specific role?
Advanced Nurse Practitioners
Physician Assistant
2 year MSc
2 year PGDip / Masters
Qualified nurse / Allied Health Professional, minimum 3 years post registration
Science related degree
Nursing model
Medical model
Work autonomously
Work under supervision
Prescribe
Don’t prescribe
Admit, discharge & refer without consulting with GP
Supervising doctor always maintains ultimate responsibility
Accountable through NMC annually
Voluntary registration – nothing formal yet
Revalidate every 3 years
Re-take exam every 6 years
Pregnant women
Unclear
Value for money?
Lots of the reports mention the Physician Assistant and when discussed with colleagues where are the nurses – reply taken as granted.
General Practice Forward View April 2015 – 1000 more PAs!
Need to consider what sort of workforce you as a practice need. Not one size fits all depends on need of your practice population also consider role on current non clinical staff
What is the best fit for your population focus on outcomes
ANYONE can call themselves an ANP!
Absence of evidence in not evidence of absence!
Advanced practice – 4 domains
Clinical practice 2. Education 3. Research 4. Leadership
Advanced Practtioners work at interface between their own profession and medicine (Uni of S’Hpton) Higher risk – needs regulation. This is a challenge as brings with it a mandate for meeting a minimal educational standard. Masters academic level

9. What has to be different?
Wellbeing & empowerment
Lifestyle & health
Self care
Community pharmacist
Care & support
Active signposting
Click
Call
Come in
Consultations
Online
Phone
Group
Access hub
Face to face
Workforce
Collaborative working
Self care
Broader workforce
Technology
Right place
Access
Right time
New ways of working for us
New ways for patients
Education at all levels re self care
Social prescribing
Right care
Right person
The General Practice Forward View england.nhs.uk/gp

10. Benefits
For patients
Easier access at the right time with the right people
New services, broader expertise, less medicalised
For practices
Wider workforce
IT improvements
Collaboration
More appropriate use of clinical skills
Wider picture
Transformational change in primary care
14% reduction in A&E minors
The General Practice Forward View england.nhs.uk/gp

11. Solutions? Promote General Practice as a place to work
Student placements – only 25% offer student nurse placements
Opportunities for new ways of working
Parity between secondary and primary care & transition
Establishing minimal educational standards/competencies
Mentorship- to facilitate training/learning (33% in Wessex)
Why primary care?
Primary Care Workforce 2020 – 5000 more staff GPs. PAs, GPNs, Pharmacists, Paramedics, Mental health, Psychologist, Dieticians, health coaches
WHY GENERAL PRACTICE
Like flexibility Hours Challenge
Variety of role Working environment
2. STUDENT PLACEMENTS – look at funding e.g Yorkshire and Humber rise from 30-88% of nurse choosing primary care as an option.
38% of funding into primary care this may not just mean General Practice!
3. New ways of working – leadership, utilize their skills and knowledge advance their roles – LTC/HCA H/Pton/prevention/co-ordination/share skills FLEXIBILITY
4. MENTORSHIP - NMC Guidelines
WESSEX 33% ACCESS TO MENTOR
5. PARITY - salary, AL, training
6. ESTABLISH MINIMAL EDUCATIONAL STANDARDS- Safe staffing and workload doing it for HCAs, why not PNs/ANPs and regulation of the role.
15 million pounds to improve training and capacity in general practice

13. References
Department of Health. Transforming Primary Care. 2014
NHS England (2014). Five Year Forward View NHS England.
NHS Wales (2010) Framework for Advanced Nursing in Midwifery and Allied Health Professional Practice in Wales
NHS Education for Scotland (2012) Advance Nurse Practice Toolkit;
NHS Health Education England. Oct Developing people for health ad healthcare. District Nursing and General Practice Nursing Service. Education and Career Framework
RCGP/RCN November General Practice Advanced Nurse Practitioner Competencies. Updated GPN Standards.
Royal College of General Practtioners The 2020 GP. A vision for General Practice in the Future NHS
The 2022 GP (2013) RCGP
Wills P (2015) Raising the Bar. The Shape of Caring Review. Health Education England and the Nursing Midwifery Council.