As more demands are made on GP time, practices are increasingly looking to delegate tasks to other members of the primary care team.
But with a range of potential roles available to a practice, GPs may not always be clear about the qualifications each would require, or the range of roles regulators regard as appropriate for each.
The following article provides a quick guide to three relatively new roles in general practice – the healthcare assistant, the advanced nurse practitioner and the pharmacist – to help practices achieve the skill mix they need, as cost-effectively as possible.
Role Healthcare assistants
A 1988 position paper by the UK Central Council of Nursing, Midwives and Health Visitors defined the role of the healthcare assistant (HCA) as confined to undertaking clerical work and maintenance of the workplace. However, since then the role has developed. HCAs are now trained to undertake specified tasks that have been taught, assessed and delegated to them by registered health professionals.
There is little guidance available for the expanding role of the HCA. However, this may change as health secretary Andrew Lansley has announced plans for a voluntary register, code of conduct and basic training standards for HCAs.
The Nursing and Midwifery Council (NMC) states: ‘The delegation of nursing or midwifery care must be appropriate, safe and in the best interests of the person in the care of a nurse or midwife. The decision to delegate would be judged against what could be reasonably expected from someone with their knowledge, skills and abilities when placed in those particular circumstances.'#
The Royal College of Nursing (RCN) states that HCAs should be trained up to Vocational Qualification (NVQ) level 3 in order that they can work independently.1
The Working in Partnership Programme (WIPP) defines an HCA as ‘someone who works under the guidance of a qualified healthcare professional'.# All work undertaken is done according to strict protocols. Unlike a nurse, an HCA is never expected to make a clinical judgment.
Examples of key tasks
There is no definitive list of tasks that an HCA can undertake, but common clinical examples include:
• blood pressure monitoring
• new patient checks.
More complex tasks that an experienced HCA might perform include:
• venepuncture – including taking blood for warfarin monitoring
• immunisations – for seasonal flu, not child health or travel vaccines
• ear syringing.
Occasionally, an HCA may also be asked to do non-clinical work such as records summarising. Whatever task is delegated to an HCA, the healthcare professional or registered clinician must ensure the HCA has the necessary knowledge, skills and competence to undertake their tasks, and that accountability is clear.
HCAs do not assess patients. Any task involving assessment, followed by a procedure – such as undertaking cervical smears – is not an appropriate one for an HCA. However, undertaking vaccinations for influenza is an allowed task under a patient-specific directive.2
Julie Wilson is clinical risk programme manager at the Medical Protection Society. Dr Richard Stacey is a medicolegal adviser at the MPS and a former GP.
This piece is based on the MPS article ‘Unsung heroes or hidden risk?', which can be found at tinyurl.com/c2dwcc7
Role Advanced nurse practitioners
The first wave of nurse practitioners graduated from the Royal College of Nursing in 1992. The college published its definition of the ANP role 10 years later.3
ANPs are expected to work almost at the same level as GPs, but as nurses they are still accountable to their GP employers. And while GPs have a high level of expertise across the full range of primary care, ANPs more often specialise – often in long-term conditions. The International Council of Nurses in 2001 described the ANP as ‘a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice'.
The role of the ANP is essentially unregulated – even though in 2007 the NMC highlighted this as a problem. However, in 2010 the Department of Health published a position statement on advanced level nursing, intended to be used as a benchmark distinguishing advanced nurses from their colleagues working at registration level.4 The document didn't define tasks but did specify that advanced nurses, including ANPs, should practise autonomously, act as practice leaders and work at the forefront of their area of practice.
The RCN also has a document listing core ANP competencies.3
Nurses are always accountable for their own actions and practice – even when employers are also vicariously liable. If a patient consults an ANP in lieu of a GP
then it is expected the ANP will accept their accountability and they can be measured against that expectation if sued for negligence.
Key principles in determining the risks of using ANPs are the extent of their self-governance (autonomy), the ability to take responsibility for their own actions (accountability), and their knowledge of the boundaries of their own practice.
An ANP typically holds a master degree, a full independent prescribing qualification from the NMC and a diploma in autonomous nursing practice.
ANPs have the skills to:
• take a comprehensive patient history
• carry out physical examinations
• refer patients for investigations where appropriate
• make a diagnosis
• decide on and carry out treatment, including prescribing and making referrals
• plan and provide care to meet a patient's health and social care needs, involving other members of the healthcare team as appropriate
• ensure continuity of care including follow-up visits
• assess and evaluate the effectiveness of the treatment with patients
• provide leadership.5
Examples of key tasks
• running specific clinics
• performing triage
• running walk-in clinics.
Some ANPs specialise in certain conditions, especially long-term health problems such as diabetes, COPD and arthritis, making them ideal leaders for special clinics. They will also commonly be used to run triage and walk-in clinics.
The RCN has claimed that ANPs can improve QOF scores by targeting ‘hard-to-reach' areas, such as finding and screening patients at risk of developing deep vein thrombosis before they go to hospital.
Ghislaine Young is a senior ANP in Shipley, west Yorkshire, and former editor of the RCN Nurse Practitioners' Association newsletter
The majority of pharmacists work in the community or are employed by high-street pharmacy businesses – but increasingly, GP practices are employing them as part of the primary care team.
In 2010 the Royal Pharmaceutical Society shed its regulatory function to become the new professional leadership body for pharmacists in England, Scotland and Wales.
Since 1 July 2011, pharmacy technicians have had to register with the GPhC – the regulatory body for the profession – in order to practise.
The pharmacist's role is becoming more focused on ‘optimising medicines use', or getting greater patient benefit from prescribed medicines – for example by improving adherence.
Pharmacists are now also involved in the provision of public health services such as stopping smoking, substance misuse, sexual health, seasonal flu vaccination and weight management services.
To qualify as a pharmacist, candidates need a four-year master degree in pharmacy from one of the accredited universities, one year's practical training in a community or hospital pharmacy, and to pass the GPhC registration exam.
Pharmacists have the skills to:
• provide expert pharmaceutical advice for patients and clinicians
• manage interactions and synchronisation of medicines
• pick up prescribing errors
• report adverse reactions
• ensure safe and effective management of controlled drugs (such as diamorphine) in line with best practice for substance misuse
• plan and deliver care in emergencies, for instance supporting the supply of anti-viral medicines and vaccinations in pandemic and seasonal flu, and co-ordination of medicines supply.
Community pharmacists are involved in:
• dispensing of medicines
• public health advice.
Examples of key tasks
• Medicines Use Reviews (MURs) – these are available for patients who have been regularly taking more than one prescription medicine, patients who have been taking medicines for a long-term illness, and for patients who have recently been discharged from hospital. Recent changes to MURs have ensured they are targeted at patients who will gain the most benefit.
• New Medicine Service (NMS) – this is similar to the MUR, and focuses on patients with long-term conditions who have been prescribed a new medicine. The service is available in five clinical areas: asthma, COPD, type 2 diabetes, antiplatelet/ anticoagulation and hypertension.
• Testing for high and low blood pressure and diabetes.
• Smoking cessation.
• Weight management.
• Advising doctors and commissioners on drug costs.
• Ensuring provision of pharmaceutical public health services at population level, such as partnerships with drug and alcohol misuse teams.
• Antibiotic stewardship (advising on appropriate use to reduce resistance).
• Advice on medicines legislation including procurement, storage, prescribing, supply, transport and administration, as well as advice on clinical and cost-effectiveness of medicines.
• Advising commissioners on NICE guidance for public health medicine.
• Advising on safe medicines use, for instance in care homes, schools, early years settings and playschemes.
Heidi Wright is the English practice and policy lead for the Royal Pharmaceutical Society
Go to pulse-learning.co.uk to read a longer version of this article
1 Hopkins S and Young L. Employing healthcare assistants in general practice. RCN, 2003
2 BMA. Patient group direction and patient-specific directions in general practice. 2010
3 RCN. Advanced nurse practitioners. 2010. tinyurl.com/24xsm3
4 Department of Health. Advanced level nursing: a position statement. 2010.
5 AANPE. Advanced nursing practice factsheet. 2012. tinyURL.com/cuj3v4n