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Skill-mix drive faces training shortfall as tensions build over pay and accountability – by Pulse reporters

The Government's drive to

relieve workload pressures on GPs by increasing the skill mix in primary care could founder on an acute shortage of highly trained practice nurses, GPs and academics are warning.

GPs have generally welcomed plans to shift 15 per cent or more of their workload to practice nurses, but concerns are growing over precisely how the changes should be implemented.

And tensions are beginning to emerge between the professional bodies representing GPs and nurses over issues of pay and legal responsibilities.

The increase in skill mix is planned to occur by transferring tasks from GPs to other members of staff and employing specially trained nurses to run clinics for chronic diseases such as asthma, diabetes and hypertension.

But a recent RCGP report claimed an extra 4,000 practice nurses would need to be recruited in the next three years if targets for transferring workload were to be met.

Professor Bonnie Sibald, deputy director of the National Primary Care Research and Development Centre, said the issue of training was 'highly problematic' with demand greatest for the most highly qualified nurses. 'There is a

real problem delivering on this target,' she said.

GPs are similarly concerned. GPC member Dr Rob Barnett said: 'Not only are there not enough GPs, there are not enough skilled nurses,' while Dr Andrew Oakenfull, chair of Durham LMC, said the training system was 'a mess' and needed organising.

The RCGP also cautioned that the increase in skill mix was largely unplanned and not based on effectiveness studies.

It said there was some evidence that diversifying tasks within primary care could be an effective way of relieving GP workload and improving patient satisfaction, but little data to suggest it would be any more cost-effective than standard GP care.

RCGP chair Professor David Haslam said nurses were cheaper to train than GPs but took longer to do the same tasks, and so the overall cost was likely to be the same.

And research reported in Pulse (August 2) questioned the effectiveness of nurses at running chronic disease clinics, suggesting they could be less flexible about negotiating targets with patients for blood sugar and blood pressure.

Professor Sibald said such problems could occur when insufficiently trained practice nurses were pressured into taking on extra tasks before they were ready, something which could occur more often as the drive to increase skill mix gathered pace.

But she said nurses were being trained to 'higher and higher standards' and were capable of delivering high-quality care through chronic disease clinics.

Professor Sibald added that some studies suggested 70 per cent of GPs' work could move to practice nurses, although she continued to believe GPs were 'the best people to deal with the complex health problems of an ageing population'.

The issue of which work should be transferred to nurses and which should remain the preserve of GPs as been term-ed 'the crunch question' by the RCGP.

'One thing GPs are trained to do that nurses aren't is to diagnose illness and manage complicated illness,' argued Dr Barnett, also secretary of Liverpool LMC.

But Professor Haslam said: 'In the past I would have said diagnosis was the doctor's task, but now nurse practitioners are doing that on a limited basis.'

He said a Government-

dictated 'top-down' approach to skill mix was unlikely to be successful and GPs should instead assess the skills within their own teams and the best way to deliver services.

Dr Oakenfull agreed, saying: 'I don't think you can draw lines in the sand [between GP and nurse work]' and suggesting the boundaries had to be set 'very much on people's capabilities'.

But there are concerns that with the increasing onus on specialist services, both GPs and practice nurses may end up missing out on one of the most valued aspects of their professions – their generalism.

And as nurses increasingly take on highly-skilled roles within practices, they are beginning to demand a greater share of rewards, with evidence emerging of growing tensions over the issue of pay.

Nurse leaders are demanding rates set in the Government's Agenda for Change career structure guide, but the GPC has not accepted the recommendations.

Sara Richards, vice-chair of the Practice Nurses Association, complained that practice nurses felt the investment in primary care had not filtered through to them. 'The average practice nurse pay is probably £12.50 to £18.50 per hour and when you consider what they do that's pretty poor.'

Mrs Richards added that many practice nurses were 'talking with their feet' and negotiating new jobs where they would be valued better, saying it was currently 'a difficult time' for nurses.

She highlighted legal responsibility in the case of nurse error during a patient review as another area of potential conflict between nurses and GPs.

She demanded clearer protocols from GPs, saying: 'All nurses are responsible for their own work. If you go out on a limb, even for a valid reason, you are totally responsible for your own actions.'

Dr Nicholas Norwell, a medicolegal adviser at the Medical Defence Union, agreed that GPs should 'be very involved in writing and reviewing the protocols', but said it would be the GP, and not the nurse, who would normally be legally responsible for a nurse's error.

But political disagreements between GPs and nurses are unlikely to filter down to the ground, according to Professor Sibald. 'Doctors and nurses work together extremely well in general practice, she said. 'They get the chance to get to know each other and develop mutual respect.'

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