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Insight: Driving Skills

15 May 2014

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Getting the right people with the right mix of skills in your practice is vital to successfully delivering the vision of general practice

It’s a cliché, and an old Bob Dylan song, but times really are a-changing. The hopes, dreams and mindsets of patients from the baby boomer generation, and from generations X and Y, are as different as chalk and cheese. What sort of impact this will have on patient expectations in the years to come can only be dimly envisaged. What we can confidently say is that the knock-on effect on the relationship between patients and the medical profession will be considerable. Attitudes and behaviours will need to keep pace with the internet generation. They cannot stay locked in the past.

Demographics are changing, too; in 1901, life expectancy for men was 45 years, and 49 years for women; in 2012, it was 79 and 83 years respectively. Those figures are expected to rise in coming years, and as a result, the number of people in England aged between 65 and 84 will increase by one third; the numbers over 85 will double. 

As a consequence, while about 15 million people in England are currently living with a long-term condition, in the next decade, this is expected to increase to 18 million. In a nutshell, we are looking at very considerable growth in the populations of the frail elderly and those with dementia.

Couple that with the shift from hospital to home service delivery means that primary care services that will have to go through a lengthy period of change and adjustment in order to meet the challenges and demands of healthcare now and in the future. Part of this, for sure, will be about increasing the scale and scope of existing provision. Simply put – more skills in the surgery will be required.

The Centre for Workforce Intelligence agrees: “Our analysis of the available evidence on the demand for GP services points to a workforce under considerable strain. The existing GP workforce has insufficient capacity to meet current and expected patient needs.” 

And all this change and growth will take place in the context of the Francis report. 

“Patients must be the first priority in all of what the NHS does by ensuring that, within available resources, they receive effective care from caring, compassionate and committed staff, working within a common culture, and protected from avoidable harm and any deprivation of their basic rights.”

Taken together, this new patient-centred future, with a requirement for general practices to work harder and smarter – and with a wider, more modern outlook – means that it is vital to think long and hard about the kind of people that you will need to ensure your practice keeps pace.

The role of practice nurses

On November 2013 an event was hosted jointly by the GP foundation Committee of General Practice Education Directors (COGPED) and Health Education Wessex at the Royal College of General Practioners (RCGP) headquarters in Euston. The aim of the event was to bring together Health Education England (HEE), NHS England, the Department of Health (DH), the RCGP, COGPED and the Queen’s Nursing Institute (QNI) with representatives from the 13 local education and training boards (LETBs) in England, to debate the future of practie in England and to develop a roadmap with recommendations to enable a secure pipeline of expertise for the future.

Several themes emerged, including a tight focus on the needs of current and future patients, a recognition that care would move closer to home, and that nursing in the future would involve improving population health needs.

Most importantly, there was acceptance of the unique role of the general practice nurse in co-ordinating and supporting a health team to deliver care and support in primary care settings. 

This was echoed by Professor Steve Field, the Care Quality Commission (CQC’s) new chief inspector of general practice, who recently highlighted that nurses were “central” to all areas of primary care, especially long-term conditions.

“My worry is that we don’t have enough nurses trained properly to work in general practice and primary care,” he said. “We need the nursing schools in universities to actually start to train nurses for general practice and primary care now.” He said this was vital if the NHS was “serious about moving care out of hospital and into the community”.

For sure, the current health workforce planning literature is much concerned with discussion and suggestions as to the optimal composition of a health workforce. Below, you will find a simple yet profound approach to future-proofing your own practice.

Getting the right people on the bus

There is a mantra that the most successful organisations adhere to – ‘recruit for attitude, train for skills’. There is more than a grain of truth in this. This is because simply collecting the right skillset around you does not guarantee that a practice will work successfully. The old adage, ‘People are your most important asset’ is wrong. The right people are your most important asset. This is the assertion made by Jim Collins in his book, Good to Great, one of the very few management books that are actually worth reading. It’s all about getting the right people on the bus and in the right seats. 

You may find it revealing to take time to think about the competencies your practice needs for current and future success. Then, take a look at the qualities and expertise that you have in your existing team. The chances are, it is a narrow spectrum; in general, people work with, and recruit like-minded people. It is certainly worth taking a step back and attempting to list any capabilities which are missing or underrepresented in your team (including yourself). 

One of the resources you may want to use to help you do this is a competency framework which was incorporated into the NHS Working in Partnerships Programme (WiPP) General Practice Nursing (GPN) Project. It is hosted within the GPN Toolkit on the Royal College of Nursing (RCN) website. The document is presented in a format that aligns the competencies with the Knowledge and Skills Framework of the NHS.

This competency framework addresses the common core competencies and the wider range of skills, knowledge and behaviours a nurse needs in order to be a fully proficient GPN. The framework includes no fewer than 31 competencies, ranging from professional skills such as the ‘management of emergency situations’ to ‘family planning and sexual health’; but also, interestingly, touches briefly on personal qualities such as the ability to communicate with patients and colleagues.

Most individuals will have abilities in about six to eight of these competencies, so the trick is to choose team members so that collectively, they make up the whole set you have identified to enhance and broaden your practice. However, it is important to recognise that these competencies may take time to fully develop and consolidate; don’t discount the possibility of further training – and experience – on the growth of your team’s capability.

Skills alone are not enough

In a perfect world, all your people need to conform to the “3Ps” – professional, personable, proactive. They need to be good at their job, able to relate well to, and understand patients, and always being on the lookout for newer and better ways to deliver excellence in healthcare.

These days, there is a lot of focus on what are known as ‘strengths’. Research is showing how successful people possess both skills and personal qualities like resilience – the ability to remain calm in a crisis, staying focused when working to tight deadlines, and responding positively to challenging targets; or empathy – an ability to sense the feelings of other people by imagining themselves in others’ lives or others’ situations. Many more of these strengths have been identified, and there are several ways to measure them.

When you are recruiting, it is really important not to lose sight of the fact that it is a combination of skills and strengths like this which are going to make a difference to the way your team meets the complex needs of patients.

Building a high-performing culture

Putting together a team of skilled, caring and dedicated people is not difficult – but for sustainability, there is a vital ingredient which must be in place. To quote from Francis again:

“All who work to provide patient care, from porters and cleaners to the secretary of state, will be working effectively in partnership in a common and positive culture.”

One of the most exciting ideas to surface recently in organisational thinking is the shift from hierarchy to holocracy. In the 19th Century, we thought of organisations in the same breath as the military – in the armed forces, there obviously had to be a hierarchical structure. But we are a long way from Victorian times, medicine is not warfare, and much has changed in the world. There is now a move to think of organisations of every size and shape as a network. This is exactly what underpins the notion of patient-centred multi-disciplinary teams and networks.

It’s all about working in partnership with colleagues, and the uncomfortable truth is that this does not always happen. The outcome of a failure to make it happen is all too apparent. Francis has something to say about this, too.

 “Frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisation.”

And Professor Steve Field, chief inspector of general practice at the Care Quality Commission, warned that nurses in small practices could be “disempowered” by GPs, by which he meant they sometimes did not act professionally or speak out about concerns.

This has profound implications for the way leadership in practices is conducted. It is all too easy to forget that it is followers who get a lot of the job done. Meeting their needs as is just as vital as finding the right people…. but that is a whole other story in itself.