Abstract
The pressure on services is driving change and is a global phenomenon. Internationally, advanced nurse practitioner roles are being developed to satisfy the increasingly complex needs of people who are living longer with multiple conditions.
Advanced nurse practitioners are defined by the International Council of Nurses as registered nurses who have ‘acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice’ (NP/APN Network, 2018).
In the context of this feasibility study the pressure on GPs and their unscheduled afternoon domiciliary visits is examined and evaluated. The premise of the study is that these visits need to go ahead but could effectively be conducted by advanced nurse practitioners rather than GPs. This change in the way services are organised and provided capitalises on policy intentions to work flexibly and give care closer to home.
The setting for this evaluation was Scotland whose chief nursing officer in her long-term strategy Nursing 2030 Vision states ‘we need nurses who are prepared to work flexibly across all settings and agencies’ to improve outcomes. This recognises the need to respond to population needs in the future through transforming roles: an intention which is put into action in this new service.
Similarly, NHS England’s Long Term Plan (2019) suggests that primary-care services should be better networked to create more seamless pathways of care and that it will dissolve the historic divide between primary and community services. For this reason, new primary care networks are to be created which, as paragraph 1.9 says, ‘will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and AHPs such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector’. This implies greater working together across the system rather than the substitution of one profession for another.
It is acknowledged that advanced practitioners need not only be nurses, but the project did not utilise the other professions which could have made the outcomes more effective. It focused on GPs and existing ANPs rather than taking a look at the whole system. It concludes that AHPs, district nurses and paramedics could have performed a similar function, but this thinking was not included in the inception. Indeed, one phrase suggests that district nurses could be ‘trained up’ to provide similar services which seems to disregard their current skills and knowledge in dealing with complex care in the community.
Typically, district nurses also drive themselves: in this model the ANPs had drivers. This raises the issue of costs which are not reported on because it was not a ‘primary aim’ of the research and is for future consideration. Others looking at this model to replicate will be anxious to understand the costs as part of the service redesign.
Much is said in designing contemporary services that the patient should be at the centre of care. In this case, although patients were given satisfaction questionnaires, their views are not reported comprehensively. Whereas, ‘GPs were very satisfied with the service (average score 90%), reporting reductions in stress and capacity improvements’. This therefore gives the impression that the change in service was a solution for the GPs rather than for patients.
In reporting the outcomes of the interventions of the ANPs it is interesting to note that 12% of the ANP consultations resulted in hospital admission. Unfortunately, the rate of hospital admissions before the study is not reported so it is unclear how many hospital admissions were avoided.
This is undoubtedly a useful study and positively reported. It does appear that delivering unscheduled care provision using ANPs is feasible and acceptable to GPs, but it leaves some fundamental questions about patient outcome and cost unanswered.