News Focus  

By breaking the link between GP numbers and practice income, the new GMS contract paved the way for a more diverse general practice workforce.

It created opportunities for nurses that had not existed before - more senior nursing roles and even partnerships. But since the new contract took effect in 2004, the revolution has been frustratingly slow.

Many GPs, desperate to retain their status as gatekeepers of the NHS, have been happy to impose endless QOF duties on nursing staff but reluctant to hand over responsibility for consultations and other advanced work. In many practices the numerical balance between nurses and GPs has remained broadly unchanged.

Changing general practice
Alternative provider medical services contracts, which allow non-GPs to run practices, may stimulate change in general practice models, because private and voluntary sector organisations seem to be more open to skill mix (IN , 18 February).

But nurses have now won significant new allies in the battle to take on a greater role in primary care: the architects of the new GMS contract, former chair of the BMA GP committee Dr John Chisholm and former deputy chair Dr Simon Fradd. They now manage practices through their company Concordia Healthcare.

Dr Fradd told Independent Nurse that in future practices could operate with three times the number of advanced nurses and 75 to 80 per cent fewer GPs. This reversal of the traditional doctor:nurse ratio, Dr Fradd believes, will allow practices to offer 50 per cent more appointments for the same cost.

His plans are also likely to appeal to ministers and senior NHS managers. Dr Fradd says this cultural shift will mean GPs can take on more practice-based commissioning (PBC), and manage work transferred into primary care from hospitals.

Dr Fradd has worked at a practice in Nottingham for the past two decades, and Concordia runs two further practices in London.

In most UK GP practices, there is a GP for every 1,500 or 1,600 patients, and a nurse for every 3,000 or 4,000 patients, Dr Fradd says.

'In a future model, my view is that you could manage a list of 7,000 patients with one whole-time-equivalent GP, with a first contact nurse for every 1,200 patients and some support from healthcare assistants and other practice nurses,' he says.

Replicated across the NHS, this model could have a dramatic impact on the capacity of primary care to take on new work, he says. 'PBC is a real opportunity to transfer work from secondary care. GPs have said they are too busy to take it on, and PCTs have not had the imagination to make it work, but this solves those problems.'

In a less GP-heavy primary care model, GPs could offer more specialist services by developing their skills in specialist areas. But they would also act as a form of primary care consultant - available to manage the toughest consultations and to advise nurses where appropriate.

Dr Fradd says his Nottingham practice has been leaning increasingly towards extended nurse roles for some time. It now employs four nurses with advanced training in specific clinical areas, and nurses deal with half of the practice's consultations.

'I have always felt nurses could do a lot more - that was the philosophy we took to the two practices in London.'

Concordia's two practices are in East Dulwich and Camberwell. 'The model when we arrived was very much doctor-led,' Dr Fradd says. 'One of the practices had a nurse practitioner, the other had no nurse.'

The firm has now hired four more 'first-contact nurses' - three are nurse practitioners and one is undergoing nurse practitioner training - in addition to the nurse practitioner already in post, to work across the two practices.

Nurses at the East Dulwich practice, which has around 7,800 patients, have been handed control of all same-day GP appointments and triage all callers.

Successful nurse triage
Dr Fradd says an audit of more than 1,000 calls shows that the nurses are able to resolve half of the issues on the phone. Of the rest, some attend for face-to-face appointments with the nurse or another member of the practice team. Just 13 per cent end up having a face-to-face GP consultation, Dr Fradd says.

Greater nurse involvement has freed large numbers of appointments. GPs at the East Dulwich practice have one appointment per hour set aside to offer advice to nurse practitioners. 'You must not leave other health professionals without the support they need,' Dr Fradd says.

He also dispels doubts over the productivity of nurses: 'The belief is that because nurses work slower they are not cheaper. But doctors see 16 patients per half day, and nurses see 14. The difference is minimal.'

Nurses in the East Dulwich practice match or outstrip the GP consultation rate because they manage 12 phone consultations an hour, and resolve around six of these immediately, Dr Fradd adds.

Concordia now plans to roll out the nurse-led model to the Camberwell practice, and is reviewing its overall workforce in a move that could see GP numbers cut if they cannot agree more specialist roles that fit with the firm's business model, although Dr Fradd refused to discuss the likely outcomes of the review.

It may take a generation, but if the Concordia model becomes the norm the revolution promised by new GMS would be complete, with nurses firmly in the driving seat of general practice.

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