NEW ROLES IN GENERAL PRACTICE RAJ GILL PHYSICIAN ASSOCIATE SWISS COTTAGE SURGERY

NEW ROLES IN GENERAL PRACTICE RAJ GILL PHYSICIAN ASSOCIATE SWISS COTTAGE SURGERY

GENERAL PRACTICE OVERVIEW BMA April 2017: Over 11 million people over 65 years old By 2021 over 1 million living with dementia 18 million people are currently living with a chronic disease By 2035 an extra 550,000 cases of diabetes and 400,00 cases of Heart Failure By 2050 Obesity 60% men, 50% women, 25% of children Average Member of Public sees 6 times per year 340 million consultations per year 41,985 GPs in England

NURSING ASSOCIATES IN GENERAL PRACTICE

NURSES IN THE UK There were 287,100 full-time equivalent nurses and health visitors working in hospitals and community health services in NHS England in October 2017. 15,500 full-time equivalent nurses working in GP practices across England in March 2017 In Camden: 70 Practice Nurses 28 Health Care Assistants

WHAT IS A NURSING ASSOCIATE The nursing associate role is designed to bridge the gap between healthcare assistants and registered nurses in England. Nursing associates will deliver care, freeing up registered nurses to spend more time using their skills and knowledge to focus on complex clinical duties

NURSE ASSOCIATES In Dec 2015 new nursing support role introduced Jan 2017 1 st wave of training in 11 sites 1,000 trainees April 2017 2 nd wave of training in 24 sites 1,000 trainees 5,000 more will begin in 2018 7,500 every year from 2019 Estimated 4,600 extra nurses by 2020 Training delivered in an apprenticeship model

TRAINING Regulated level 5 qualification such as a Foundation Degree or Level 5 Diploma of Higher Education delivered by an institution approved by the NMC to provide pre-registration nursing education Apprentices must also achieve, if they do not already hold these qualifications, level 2 English and maths prior to taking their end-point assessment 104 weeks course 80% of which is work based. Learning takes place in home, close to home and hospital setting - 60% will be in the primary placement and 20% each in the other settings

ENTRY REQUIREMENTS Experience of working in health care setting Health care assistants Health care support workers Key workers Outreach workers Administrative staff Equivalent of 5 GCSE s at grades A C, including Maths and English or equivalent e.g. NVQ Level 2 in Health and Social care Employed status with a Trust / Organisation who is able to second and support the student https://www.youtube.com/watch?v=kddyi067-x8&t=60s

LOCAL PICTURE Jan 17 59 trainees started program at Middlesex University The employers participating in the Nursing Associate pilot programme are: Whittington Health NHS Trust Royal Free London NHS Foundation Trust Barnet, Enfield and Haringey Mental Health NHS Foundation Trust Camden and Islington Mental Health NHS Foundation Trust Central London Community Healthcare Trust Haverstock Healthcare (Camden GP Federation) Haringey Clinical Commissioning Group in partnership with local GPs Marie Curie

REGULATION January 2017, the Nursing and Midwifery Council (NMC) formally agreed to a request from the Department of Health to be the regulator for the role. Expected by July 2018 maintain a register of those eligible to practise as nursing associates in England set the standards nursing associates must meet to join and remain on the nursing associate part of our register set requirements of education programmes and approve and monitor programmes against those requirements investigate concerns about nursing associates conduct or practice and take action if required to protect the public.

DUTIES Support individuals with all aspects of care including daily living, providing person-centred care and promoting health and independence through awareness raising and care navigation to other professionals as appropriate Perform and record clinical observations including blood pressure, temperature, respirations, pulse. Undertake clinical tasks including cannulation, venepuncture, ECGs Accurately record nutritional and fluid intake. Ensure the privacy, dignity and safety of individuals is maintained at all times. Demonstrate the ability to recognise changing priorities seeking advice and guidance from the Registered Nurse or other registered care professionals as appropriate. Report back and share information with the registered nurses on the condition, behaviour, activity and responses of individuals. Assist in the implementation of appropriate action to meet the specific physical, emotional and psychological, social, cultural and spiritual needs of individuals and carers.

DUTIES Develop understanding of caring for individuals with particular conditions for example dementia, mental illness, learning disabilities. Develop skills in relation to coaching/teaching individuals/carers/other staff. Assist with the implementation and monitoring of clinical standards and outcomes. Develop a working knowledge of other providers resources and referral systems to ensure individual s needs are met, within parameters of practice. Engage in reflective practice including management of self and reflection on own reactions, asking questions and reflecting on answers given. Demonstrate good understanding of principles of consent and ensure valid consent is obtained prior to undertaking nursing and care procedures. Demonstrate good understanding of the Mental Capacity Act / Deprivation of Liberties and applies principles to everyday practice seeking advice / guidance from the Registered Nurse or registered care professional as required.

SUMMARY https://www.youtube.com/watch?v=vchzzzspmjm

CLINICAL PHARMACISTS IN GENERAL PRACTICE

CURRENT PERSPECTIVE The General Practice Forward View, committed over 100million to support an extra 1,500 clinical pharmacists to work in general practice by 2020/21 40% of surgeries in the country will have access to pharmacist The Clinical Pharmacists in General Practice programme launched in 2015 Phase 1 Pilot July 2015-2016 In October 2016: 491 pharmacists in 658 practices across 89 pilot sites

CURRENT PERSPECTIVE Phase 2 2017 4 application waves 112m has been made available to NHS England for the roll-out of Wave 2. Investment of 36 million over three years The funding will cover recruitment, employment, training and development of clinical pharmacists and the development of employing/participating practices. For London this equates to 252 WTE Clinical Pharmacists

TRAINING In the Pilot all pharmacists who participate are expected to undertake predominantly workplace-based development and education provided by the Centre for Postgraduate Pharmacy Education (CPPE). 18 month program covers: Fundamentals of general practice Prescribing Clinical assessment, examination and monitoring Consultation and communication skills Long-term condition management Common ailments management Medicines optimisation, multimorbidity and polypharmacy Evidence-based medicine and safety Leadership and management

INDEPENDENT PRESCRIBING Regulations allow Pharmacists to prescribe since 2006 Independent prescribers must complete a GPhC accredited program Usually runs over 6 months includes 26 days of teaching and 12 days of supervised practiced with a medical practitioner

DUTIES OF THE CLINICAL PHARMACIST Management of repeat Prescriptions - Practice pharmacists can interpret blood results, BP readings and other clinically relevant information required to assess the efficacy and adverse effects of medicines to reach a decision on reauthorisation. Actioning clinical letters and reconciling medicines from a discharge summary - Practice pharmacists can process discharge letters, which are often complex, and update the patient s medication accordingly. Patient facing in practice, telephone, care home medication reviews - Pharmacists/GPs may identify patients who can be referred to the pharmacist for a review of their medication.

DUTIES OF THE CLINICAL PHARMACIST Acute requests of Medications - Often the administration staff will forward requests for medicines not on repeat prescription to the duty GP to process. Pharmacists can process many of these requests and save the GP a great deal of time, improving the speed of turnaround for patients. Patient facing Long--term condition Clinics patients with single or multiple medical problems where medicine optimisation is required (e.g. COPD, Hypertension, Asthma). Review the on-going need for each medicine, a review of monitoring needs and an opportunity to support patients with their medicines Management of common/minor/self-limiting ailments. Managing caseload of patients with common/minor/self-limiting ailments while working within a scope of practice and limits of competence. Signposting to community pharmacy and referring to GPs or other healthcare professionals where appropriate

PHARMACISTS IN GENERAL PRACTICE What do Pharmacists do in General Practice? https://www.youtube.com/watch?v=-ws2iwwktnk

MEDICAL ASSISTANTS IN GENERAL PRACTICE

WHAT IS A MEDICAL ASSISTANT A new role to that has been introduced, to upskill current administrative staff to undertake additional medical administrative tasks, that will reduce the work load of GPs and other Clinical Staff

DUTIES Managing and Triaging Practice Correspondence Managing referrals to secondary care Producing test request forms Managing Lab results Buddying with GPs for Phone Calls Routine test requests and recall Clinical Audit work *Basic Clinical Tasks

MEDICAL ASSISTANTS TRAINING TIMETABLE Time Topic Presenter 09.00 Introduction Katie Rack & Sandy England 09.30 How to Read Code Accurately Katie Rack 10.30 Break 10.45 Dealing with routine letters Katie Rack 11.45 Producing Forms and Referral Letters Katie Rack 12.15 e-referrals Katie Rack 13.00 Lunch 13.30 DNA Management Katie Rack 14.00 Giving Results Sandy England 15.00 Break 15.15 Urine Testing Sandy England 16.15 Measuring Blood Pressure Sandy England 17.15 Q&A Katie Rack & Sandy England

CASE EXAMPLES Medical Assistants processing letters, Brighton and Hove GP Access Fund Members of the practice clerical team are trained to read, code and action incoming clinical correspondence according to a standard protocol. The protocol was developed by local GPs and refined through live testing in practice, using feedback about its safety and efficiency. Impact In the first 6 practices to trial this, this has saved an average of 45 minutes of each GPs time each day, with no significant events having occurred in the first 15,000 letters to be processed. GPs report being satisfied with the safety of the approach, the improved quality of coding and the release of their time. Clerical staff report that they are confident to run the new process and describe renewed job satisfaction. Some of the most experienced staff describe it as the best thing that has happened to their job.

CASE EXAMPLES Clinical 'buddies AT Medics practices London Each GP sits alongside a buddy. This is a specially trained member of the clerical team, who acts as an assistant to the GP. They prepare for the full clinical consultation by obtaining details of the patients need. They undertake opportunistic screening and signposting, for example reminding patients about upcoming immunisations and due investigations, or informing them about services in the community relevant to their situation. After the consultation with the GP, they perform administrative tasks such as arranging investigations and follow-up, or ensuring the patient is fully aware of the next steps for their plan. Face-to-face consultations with GPs are reserved for those problems which need a physical examination, more in-depth input for personal continuity of care. The use of multidisciplinary pairs of staff in the frontline teams increases uptake of preventive care.

PHYSICIAN ASSOCIATES IN GENERAL PRACTICE

WHAT IS A PHYSICIAN ASSOCIATE https://www.youtube.com/watch?v=nq-o3msh5ia Physician Associates are a new (ish) health care practitioner, who are trained in the medical model and work as part of the medical team to manage patients. Physician Associates are dependant medical practitioners, who work under the supervision of a consultant or GP

TRAINING Student can apply to training if they have an undergraduate degree in life sciences or an allied health profession. Each university has a different entry requirement re: grade requirement, previous clinical experience etc The training is a full time intensive 2-3 year course in medical science and clinical reasoning. The course is 50% theory 50% practical. It includes a minimum of 1,400 hours of clinical experience. Covering Adult and Paediatric Medicine. Resulting in a PgDip or MSc in Physician Associates Studies In order to qualify students must pass their university course examination and then they can be put forward for the national certification examination. This consists of both a written examination and 14 station OSCE

ONGOING TRAINING There is currently no statutory regulation for Physician Associates in the UK There is however a Physician Associate Managed Voluntary Register (PAMVR) housed at the Faculty of Physician Associates at the Royal College of Physician Associates In order to remain on the PAMVR, PAs must maintain: 50hours of CPD each year An annual appraisal Sit a re-certification examination every 6 years

WHERE CAN YOU TRAIN? University of Aberdeen Anglia Ruskin University Bangor University University of Birmingham University of Bolton University of Bradford Brighton and Sussex Medical School Brunel University Canterbury Christ Church University University of Central Lancashire University of East Anglia University of Hertfordshire Hull York Medical School University of Leeds University of Liverpool University of Manchester Newcastle University Plymouth University Peninsula School of Medicine Queen Mary University of London University of Reading Sheffield Hallam University University of Sheffield St George's, University of London University of Surrey Swansea University Ulster University University of the West of England (UWE Bristol) University of Wolverhampton University of Worcester De Montfort University Leicester

WHAT IS A PA TRAINED TO DO? Take a medical history Conduct physical examination Formulate differential diagnosis and management plans Perform diagnostic and therapeutic procedures Request and interpret diagnostic studies Provide health promotion and education

PA LIMITATIONS Due to lack of statutory regulation PAs are unable to prescribe medications They are also unable to request ionising radiation i.e. x-rays and CT scans Cannot complete Sick Notes Dependant practitioners even with regulation, will always work under the supervision of a GP or Consultant

EXPERIENCES OF PHYSICIAN ASSOCIATES WITH JUNIOR DOCTORS https://www.youtube.com/watch?v=we71pobtj1y GP Registrar Perspective https://m.youtube.com/watch?t=5s&v=1gqncoccd30 Swiss Cottage GP Registrar Video

WHAT DO I SPECIFICALLY DO? Morning on the day appointments previous triage by reception/new telephone triage system Do not book under 28 days, Methadone patients, acute psychosis, complex depression, patients on multiple controlled drugs. Afternoon appointment patients self book and also booked by surgery to manage chronic diseases. Extended Hours Saturday morning clinic 14 appointments All appointments 15 mins long and patients booked into double appointments for COPD, Diabetes etc

CHRONIC DISEASE SERVICES OFFERED Asthma COPD + Spirometry screening Hypertension and manage 24 hour BP service Heart Failure Diabetes orals/injectable therapies Anticoagulation Service Smoking Cessation Travel Health

NON-CLINICAL WORK Practice Correspondence Docman Audits Prescribing Quality Scheme Cleaning and calibration of equipment MDT meetings Teaching for PA students

SUPERVISION Beginning 30-50% cases reviewed by Duty Dr or assistance needed with prescribing and management 100% of cases reviewed by GP Supervisor Now Once weekly dedicated time with GP supervisor to review cases Day to day support from Duty Dr <10% of cases reviewed

IMPROVING PATIENT CARE Hypertension case reviews and ambulatory blood pressure monitoring increased hypertension diagnoses by 30% since introduced in 2014 Reviews of patients on inhalers without diagnosis, attendances to A+E and conducting extending asthma reviews ensuring all patients have PAAP resulted in 179 new diagnoses of asthma COPD low diagnosis number of 54 patients the introduction of handheld spirometry screening program for GPs and full post bronchodilator spirometry in the surgery resulted in 117 diagnoses. Improved management of patients with COPD, 5 patients experiencing exacerbations, 1 A+E attendance and 1 admission. Overall reduction in Respiratory Referrals in the last 3 years down by 25% and a year on year reduction in patients managed under secondary care.

CASE STUDY https://www.youtube.com/watch?v=dpvinm-pq9o Dr Speed-Andrews GP Partner List Size 4861 Staff 12 sessions covered by Salaried GP staff 1 Practice Nurse 1 HCA 1 Phlebotomist

CASE STUDY What are the Key workforce shortages here? How could any of these new roles help meet these needs? By what means could this GP develop her workforce?

REFERENCES Bma.org.uk. (2018). BMA - Home. [online] Available at: https://www.bma.org.uk/ [Accessed 24 Mar. 2018]. England.nhs.uk. (2018). [online] Available at: https://www.england.nhs.uk/wpcontent/uploads/2016/03/releas-capcty-case-study-4-137.pdf [Accessed 25 Mar. 2018]. Fparcp.co.uk. (2018). Faculty of Physician Associates - quality health care across the NHS. [online] Available at: http://www.fparcp.co.uk/ [Accessed 4 Mar. 2018]. Full Fact. (2018). The number of nurses and midwives in the UK. [online] Available at: https://fullfact.org/health/number-nurses-midwives-uk/ [Accessed 18 Mar. 2018]. Nmc.org.uk. (2018). Nursing associates. [online] Available at: https://www.nmc.org.uk/standards/nursing-associates/ [Accessed 13 Mar. 2018]. Pharmaceutical Journal. (2018). All you need to know about GP practice pharmacists. [online] Available at: https://www.pharmaceutical-journal.com/careers-and-jobs/career-feature/all-youneed-to-know-about-gp-practice-pharmacists/20201042.article [Accessed 4 Mar. 2018]