1. Transforming Roles in Integrated Adult Nursing Teams
Jennifer Wilson, Professional Nurse Advisor, Primary care Division, Scottish Government
Maria McIlgorm, Professional Advisor, Chief Nursing Officer Directorate Scottish Government

2. s Policy Aspirations Right place, right time
More care and treatment at home or in the community
Maximising all contributions
Integrated teams working with people and communities
A focus on Prevention, Early Intervention and Supported Self Management
A focus on reducing fragmentation
The policy ambition’s have a clear focus on providing more care in the home or community (2020 Vision). A National Clinical Strategy places a emphasis on primary
Care with supports for health and social care. There is evidence that produce overall better outcomes for people, better experience of managing will illness and disability and
Lower and more proportionate use of resources. Nurses and AHP’s play a pivitol role in helping the SG achieve their policy ambitions.

3. We are more informed and empowered when using primary care
NATIONAL PERFORMANCE FRAMEWORK OUTCOME
We start well
We live well
We age well
We die well
Our vision is of general practice and primary care at the heart of the healthcare system.
People who need care will be more informed and empowered,
will access the right professional at the right time and will remain at or near home wherever possible.
Multidisciplinary teams will deliver care in communities and be involved in the strategic planning of our services.
PRIMARY CARE VISION
HSCP OUTCOMES
People can look after own health
Live at home or
homely setting
Positive Experience
of Services
Services improve
quality of life
Services mitigate inequalities
Carers supported to improve health
People using services
safe from harm
Engaged Workforce Improving Care
Efficient Resource Use
We are more informed and empowered when using primary care
Our primary care workforce is expanded, more integrated and better co-ordinated with community and secondary care
Our primary care services better contribute to improving population health
Our experience as patients in primary care is enhanced
Our primary care infrastructure – physical and digital – is improved
Primary care better addresses health inequalities
PRIMARY CARE OUTCOMES

4. TRANSFORMING ROLES – Phase 1
Aims
Strategic oversight, direction & governance to the development & transformation of nursing roles to meet current and future needs of Scotland’s health & care system
Ensure nationally consistent, sustainable & progressive nursing roles & career pathways
Priorities – Phase 1
Community nursing teams – adults and children
Advanced nursing practice
National approach to postgraduate education and development
Supporting Health and Social Care Integration at the point of contact
Principles:
Responding to population need
Tackling inequalities
Maximising public health approach
Prevention & early identification
Outcomes focused
Promoting independence
Relationship based care – ‘good conversations’
Promoting choice, continuity and control
Promoting personalised care
Approaches that encompass health, social care, wellbeing.
Build on individual and community assets
Aim of Part 1 - was to provide strategic oversight, direction and governance to the development and transformation of nursing roles to meet current and future needs of Scotland's Health and Care system. To Ensure nationally consistent, sustainable and progressive nursing roles and careers in care. The principles guided the process. The first phase included, Advance Practice – for Acute, Paediatric/Neonatal, Mental Health and Community and Primary care. Community nursing roles included, Health visiting, a refocused District nursing role, General Practice Nursing, School Nursing, community paediatrics and looked after children’s nurses. We have recently embarked on Phase 2 of the programme and this has widened to include AHP’s and Healthcare Scientists. Advance Practice – will be extended to AHP’s, Midwifery and Clinical Scientists. Other programmes of work include the Physician Associate role, specialist nursing, and we are reviewing applying this process to Nursing in care homes. As part of Phase 2 an integrated nursing group will be set up to over see the implementation of integrated community nursing roles. The work of this group will contribute to work around integrated multi-disciplinary teams. A change process has evolved through transforming programme this process of change which is now applied to all change programmes in various degrees (more detail on next slide).

5. Methodology and Process
2 Phases 1st Phase – Advance Practice (Acute, Children/neonates, Mental Health and community and primary care) Community Nursing including Health visiting, District Nursing, General Practice, School Nursing 2nd Phase – Widened to include Advance Practice for AHPs, Midwives and Healthcare Scientists, Physician Associate Role Specialist Nurses Role of Nursing in Care homes (Under discussion)
Change Process:
Clarify role definition and practice
Agree role parameters and competence level
Agree education levels and requirements
Scope baseline numbers current and projected future
Undertake service and education needs analysis
Engagement with stakeholders
Financial Modelling
Implementation and evaluation

6. Transforming Roles Publications CNO Directorate
There have been 5 publications from the work, 1 setting the vision for transforming roles, 2 Advanced Practice, 3 a refocused district nursing role, 4 School Nursing and 5 An Education framework to support the education and development needs of staff to attain the skills and competence to undertake the refocused role. The GPN paper will be published later this year.
Transforming Roles Publications CNO Directorate

7. General Practice Nursing
Jenny Wilson, Professional Advisor

8. The Role of the General Practice Nurse
“General Practice Nursing will continue to have a vital role under the proposed new contract.”
Need for highly skilled General Practice Nurses
Need to invest in GPN Education and training
The introduction of the proposed 2018 contract will increase the need for highly skilled practice managers with wide ranging, adaptable and versatile skills. In addition to continuing to manage the practice employed team, they will work more with the wider primary care system including GP clusters, NHS Boards, HSCPs, and emerging new services.
Alongside the changing role of practice managers, the roles of receptionists and other non-clinical staff in the practice have also evolved.
Practice receptionists have an important role supporting patients and enabling practices to run smoothly.
Opportunities to develop the skills of practice receptionists to support patients with information on the range of primary care multi-disciplinary team services available, or to increase their role in the management of practice documentation and work optimisation, are currently being explored with Healthcare Improvement Scotland (HIS). HIS will be working with GP clusters to develop training and resources to support these staff.
There is also a wide range of practice administrative staff carrying out a diverse number of tasks from prescription management, medical secretarial skills and IT management including call and recall, to documentation management, health and safety monitoring, and finance management. These staff are a highly skilled and adaptable workforce who will continue to have an important role in general practice in the future.

9. Projected prevalence of Chronic Disease

10. Primary Care Workforce Survey

11. Primary Care Workforce Survey
Over half of nurses (55%) are over the age of 50 years

13. Core areas of the General Practice Nursing Role
Public health including primary, secondary prevention and health inequalities.
Care and support planning including anticipatory care
Assessment of illness and injury
Long term conditions management
Complexity and frailty within integrated community teams
Mental health and well-being
Nursing across the life cycle

14. Level of Practice
Job Title
Definitions
Level of Learning
2-4
Health Care Support Workers
Work across individual healthcare disciplines under the direction and professional accountability of registered practitioners.
Level 6 / 7 5
General Practice Nurse
Responsible for delivery of general practice nursing services, within the professional competence of the post holder, to the whole practice population.
Level 9 or 11 6
Senior General Practice Nurse
Have a higher degree of clinical decision making, autonomy and responsibility than general practice nurses in the clinical environment.
Level 11 7
Lead General Practice Nurse
Have advanced skills in long term condition management. Involved in the delivery and planning of safe and effective nursing care to the whole practice population. Leads and manages a nursing team working closely with the practice manager and GPs to deliver practice priorities.
Advanced Nurse Practitioner
The Chief Nursing Officer’s Transforming programme has set out a nationally consistent approach to advanced nursing practice. ANPs are competent to work at advanced level as part of multidisciplinary teams across all clinical settings, dependent on their area of expertise.  They are clinical leaders with the freedom and authority to act and accept responsibility and accountability for those actions.
The role is characterised by high-level autonomous decision-making, including assessing, diagnosing and treating (including prescribing for) patients with complex multidimensional problems.  8
Consultant
Nurse
Consultant nurses work at a very high level of clinical expertise and have responsibility for contributing to national, as well as local, developments in their recognised area of expertise. The role is structured around four key themes clinical/professional leadership, expert practice, policy and service development, research and evaluation; and education and professional development.
Level 11/12

15. Summary of Key Recommendations
Nurses working in general practice must be embedded into existing nursing governance structures, with clear lines of responsibility and accountability leading through the professional nursing line, up to the Executive Nurse Director. This responsibility may be delegated as appropriate.
For those established practitioners within general practice and NHS Boards, it is recommended that their role is mapped to the refocused role descriptions and levels of practice with local arrangements agreed to meet any gaps in competence and capability.
It is recommended that the impact of the refocused role of nurses working in general practice is aligned to the Excellence in Care programme. This will ensure consistency of measurement and quality across the nursing workforce within the primary care setting.

16. District Nursing
Maria McIlgorm

17. s District Nursing - Key Roles and functions
Person centered care
Continuity of care
Anticipatory care planning
Supported early discharge
Public health and well being
Effective Long term conditions management
Intermediate care support
Home based urgent care management
Effective Palliative and end of life care
Care home in-reach
Effective outcome focused case management
The policy ambition’s have a clear focus on providing more care in the home or community (2020 Vision). A National Clinical Strategy places a emphasis on primary
Care with supports for health and social care. There is evidence that produce overall better outcomes for people, better experience of managing will illness and disability and
Lower and more proportionate use of resources. Nurses and AHP’s play a pivitol role in helping the SG achieve their policy ambitions.

18. Understanding Quality in District Nursing Services District Nursing (Kings fund 2016) (Findings)
What matters to staff, service users and carers?
Caring for the whole person
Continuity of care
Personal manner of staff
Access to district nursing staff between appointment times
Nurses as co-ordinators of care
Involvement of family/carers
Clinical competence/expertise
Reliable and predictable visiting times
Service Challenges and Impact
Growing gap between capacity and demand
Increasing need to prioritise
More focus on task
Missed opportunities for prevention
Limitation in National Data
Indications of growth in demand and complexity

19. Refocused District Nursing Role in an Integrated H&SC system
Key leadership role in:
Public Health
Anticipatory care planning
Prevention –promoting health and well being
Early intervention
Supported self-management
Complexity/frailty
Intermediate care
Palliative and end of life care
Complex
Care Needs
Intermediate
Care needs
Lower care needs
Spectrum of care

20. District Nursing (all bands) Headcount & WTE - Mar-15 to Mar-18
Headcount down by about 470, and WTE down by about compared to original ISD data for Mar-18.
amended HB data

21. Skill Mix District Nursing – National Profile
Agenda for change Band
% Skill Mix
Band 7
5.8%
Band 6
20.8%
Band 5
57.8%
Band 2 – 4
15.8%

22. District Nursing age breakdown: as at Mar-18 (amended HB data)
The WTE figures for each age cohort are estimated by applying the age band proportions for the original ISD data to the amended HB data.

23. District Nursing – average age of band 5 joiners: 2016 to 2018

24. 32% increase in population over 65
58% increase in population age 90

25. Based on CHAD data for Boards making up 55% of the Population in 2016/17
Nearly 45% females & 41% of males aged 90+ would require DN services
5% of those aged
<1% for ages <45

29. Opportunities with H&SC Integration?
Maximising workforce capability
Reducing fragmentation
Working across traditional boundaries
Better alignment of teams
Shifting the balance of care
Increasing care in community
Improving continuity and reducing fragmentation
Sharing of skills/competencies
Reducing duplication and inefficiencies
‘One team’

30. Buurtzorg Onion Model