GP services for older people: a guide for care home managers

GPs' role in relation to the resident, the home and the wider NHS - Role of nursing staff in facilitating joint working

Care homes and primary care providers should recognise and support the role that nurses in care homes and GP practices can play in facilitating communication between homes and GPs. This includes practice nurses undertaking initial assessment visits and nurses in homes raising professional concerns. Nurse practitioners and other senior nursing staff can share up-to-date knowledge and skills with nursing and care staff in homes, and with residents and relatives.

Changing roles of nursing staff

A change has been taking place over a number of years in the relationship between the roles and remits of medical practitioners and nurses. Some professional tasks which were once the preserve of doctors are now shared with designated categories of nursing staff. Several different types of nurse may now be part of the practice team based with the GP, and in registered nursing homes, nurses will undertake nursing tasks and oversee some aspects of the work of care staff. Care home managers need some understanding of the different nursing roles, and skills in dealing with the more complex links with general practice which are now required.

Registered nurses may occupy a variety of roles, including:

• Registered nurses in care homes for older people. They bring to their work two fundamental elements of expertise: [33] caring, empathy, understanding patients as individuals, communication, building therapeutic relationships and working with families; and the use of clinical nursing knowledge, skills, experiences and clinical judgement to support health, identify ill health and ill being, and manage medical aspects of care including medicines and therapies.
• General practice nurses, trained to be part of the practice team undertaking a range of general nursing tasks.
• Advanced nurse practitioners, often with an advanced nursing qualification, who can make an assessment of people's health care needs, carry out physical examinations, screen people for disease risk factors and early signs of illness, make differential diagnoses, develop an ongoing nursing care plan, order necessary investigations, provide treatment and help people to manage and live with illness.
• Nurse independent prescribers, who are experienced nurses specially trained and allowed to prescribe any licensed and unlicensed drugs within their clinical competence. In 2006, they were given full access to the British National Formulary (BNF), putting them on a par with doctors in relation to prescribing capabilities.
• Community matrons, who provide expert case management for people with long-term conditions with deteriorating health that may result in declining quality of life or potential hospital admission.

Nurses employed in nursing homes may be the natural staff group to liaise with nurses based in the practice, and with GPs when they consider a matter requires the attention of a medical practitioner. For care home managers without nurses on their staff, the challenge is to establish appropriate working relationships with the various nursing staff based at the practice, some of whom may now be carrying out tasks that would formerly have been undertaken by the GP.

Nurse-led liaison and support services

There are examples in the literature of nurses and nurse-led teams, in particular nurse clinicians, advanced nurse practitioners, Macmillan nurses and community matrons:

• working to mediate the relationship between care homes and GPs, pharmacists and specialist services – for example, operating a 'nurse triage system' to regulate GPs' workload, [28] or taking on a liaison role [34]
• acting as an informal advocate for the care home in their communications with GPs [16]
• taking on some of the work of GPs (e.g. reviews and assessments which may be signed by GPs) [20, 26, 35]
• taking a lead role in individual care homes or local service development, working in partnership with GPs to different degrees – for example: working with other health practitioners to lead intermediate care units [36] or care home support teams; [35] leading on chronic disease management and proactive weekly visits in GP local enhanced service schemes; [13, 34] and implementing end of life frameworks.

Nurse-qualified home managers participating in the SCIE focus groups said that their status as registered nurses meant that GPs listened to them if they said there was clinical need. Their clinical knowledge also helped to make them better advocates.

Participants in the SCIE Practice Survey said that it was often district nurses who provided the main link between homes and GP practices. This could work well, but barriers included varying capacity, availability and quality of district nurses; frequent reorganisations; and district nurses giving higher priority to people in the community.

Research and practice literature stresses the need to ensure the right level of skills if nurses substitute for GPs in medical care. There was no robust evaluation found in the literature that gave evidence on outcomes when nurses partially replace GPs. However, one evaluated model of a care home support service run by a nurse and a pharmacist, with the nurse liaising with GPs, reported resident, family and GP satisfaction, reductions in GP callouts, positive outcomes and cost savings (in a before-after evaluation.) [35]