the decision to appoint a health care assistant hilary andrews helen dyer vanessa whillier woodlands health centre

1. Introduction Good morning/afternoon The three of us (and Kathleen) A bit about the practice – Partners, List size, Rural Kent, Proactive Practice Employed and trained HCAs since Feb 2003 This has made a positive difference to the smooth running of the health centre and delivery of patient care We were appointed by WiPP as a pilot site to share our experience and contribute to HCA toolkit development The purpose of this workshop is to look at the issues around the decision to appoint a Health Care Assistant, In other words……. (Next Slide) Introduction Good morning/afternoon The three of us (and Kathleen) A bit about the practice – Partners, List size, Rural Kent, Proactive Practice Employed and trained HCAs since Feb 2003 This has made a positive difference to the smooth running of the health centre and delivery of patient care We were appointed by WiPP as a pilot site to share our experience and contribute to HCA toolkit development The purpose of this workshop is to look at the issues around the decision to appoint a Health Care Assistant, In other words……. (Next Slide)

2. 2. ……Do I need a Health Care Assistant? How do I know that I need a Health Care Assistant? The next few slides cover common issues that might lead you to asking these two questions….. (Next Slide) 2. ……Do I need a Health Care Assistant? How do I know that I need a Health Care Assistant? The next few slides cover common issues that might lead you to asking these two questions….. (Next Slide)

3. Increased pressures in general practice QOF targets Pressure of work on staff Maintenance of morale Staff retention. 3. So, the increased pressures on General Practice encompass ….Read through list Everyone is feeling the pressure. Why don’t we quantify what's really going on and identifying where the pressure is coming from….. (Next Slide)3. So, the increased pressures on General Practice encompass ….Read through list Everyone is feeling the pressure. Why don’t we quantify what's really going on and identifying where the pressure is coming from….. (Next Slide)

4. Subjective v. objective measurements of workload WiPP Workload Analysis Tool QOF targets Staff turnover Activity data. 4. So to objectively measure workload… WiPP hope that their Workload Analysis tool will be available from early 2007, but until then…… QOF Targets – Are there any targets unmet at your place of work? Staff Turnover - Are your staff leaving the practice faster than seems the norm? – A large number of traditional practices have practice nurses that are close to retirement - we all know that recruiting experienced practice nurses is not easy - along with a lack of career structure in practice nursing in the past - these things can all lead to posts being left unfilled - These issues are all being addressed by another WiPP initiative – the general practice nursing project Activity Data – Undertaking your own study of activity data is an option…..(next slide)4. So to objectively measure workload… WiPP hope that their Workload Analysis tool will be available from early 2007, but until then…… QOF Targets – Are there any targets unmet at your place of work? Staff Turnover - Are your staff leaving the practice faster than seems the norm? – A large number of traditional practices have practice nurses that are close to retirement - we all know that recruiting experienced practice nurses is not easy - along with a lack of career structure in practice nursing in the past - these things can all lead to posts being left unfilled - These issues are all being addressed by another WiPP initiative – the general practice nursing project Activity Data – Undertaking your own study of activity data is an option…..(next slide)

5. Woodlands Health Centre In 2002 Senior Practice Nurse due to retire Possibility of employing HCA? Employed an ‘independent’ advisor to report on: Nursing activity data What was happening elsewhere Current skill-mix and future skill-mix options. 5. In 2002 our senior G grade practice nurse who had been at Woodlands for 17 years gave notice that she was to retire the following spring. This gave us time to look at all options – whether to employ another G Grade to directly replace her, whether to promote one of the existing F grade nurses and employ a replacement for her or whether there was in fact an opportunity to restructure the nursing team completely. We employed an independent advisor to undertake a piece of work on nursing activity, what was happening elsewhere, and current and future skillmix options. Initially there was some conflict within the remaining nursing team when an outsider was appointed to undertake the review but this was overcome by listening to their concerns, having an inclusive approach and ensuring that the decision making process took into account nursing issues and concerns. We will talk about the results of Hilary’s report and the impact of this later in our presentation. 5. In 2002 our senior G grade practice nurse who had been at Woodlands for 17 years gave notice that she was to retire the following spring. This gave us time to look at all options – whether to employ another G Grade to directly replace her, whether to promote one of the existing F grade nurses and employ a replacement for her or whether there was in fact an opportunity to restructure the nursing team completely. We employed an independent advisor to undertake a piece of work on nursing activity, what was happening elsewhere, and current and future skillmix options. Initially there was some conflict within the remaining nursing team when an outsider was appointed to undertake the review but this was overcome by listening to their concerns, having an inclusive approach and ensuring that the decision making process took into account nursing issues and concerns. We will talk about the results of Hilary’s report and the impact of this later in our presentation.

6. Inability to recruit experienced nurses or GPs to the team Unsuccessful advertisements Inappropriate applicants Nurses inexperienced in general practice. 6. Us, and neighbouring practices, have found that when we have advertised for practice nurses we have experienced some of the following….. Unsuccessful advertisements Inappropriate applicants Nurses inexperienced in general practice For example: at woodlands we advertised for a treatment room nurse for several weeks – some of which had no response at all. When we did shortlist we interviewed 7 applicants, only 6 of which were currently registered nurses, only 4 of the six were currently employed, and only one out of all 7 applicants had practice nurse experience. So, we’ve identified that you have increased pressures in general practice and many of these are related to increased workload. Therefore, rather than just employ another nurse, or replace like for like its time to step back and look…..(next slide)6. Us, and neighbouring practices, have found that when we have advertised for practice nurses we have experienced some of the following….. Unsuccessful advertisements Inappropriate applicants Nurses inexperienced in general practice For example: at woodlands we advertised for a treatment room nurse for several weeks – some of which had no response at all. When we did shortlist we interviewed 7 applicants, only 6 of which were currently registered nurses, only 4 of the six were currently employed, and only one out of all 7 applicants had practice nurse experience. So, we’ve identified that you have increased pressures in general practice and many of these are related to increased workload. Therefore, rather than just employ another nurse, or replace like for like its time to step back and look…..(next slide)

7. Skill-mix Is the right person for the task undertaking that task? At Woodlands in 2002 over 3 nursing hours a week were spent on non-nursing housekeeping tasks Thistlemoor Practice, Peterborough The Ridge Medical Practice, Bradford. 7. At Woodlands in 2002 we measured nursing activity and found, amongst other things, that the three highly qualified practice nurses were undertaking on average 3 hours a week on non-nursing tasks for example washing and sterilising equipment, ordering and unpacking stock. Also a significant proportion of their time was spent on basic nursing which could have been carried out by a more junior nurse. This made us look at our skillmix and restructure our nursing team with the introduction of a health care assistant role and a treatment room nurse. Other practices have looked at their skillmix such as Thistlemoor Practice in Peterborough where they now have 2 GPs (with a list size of about 10,000), 3 nurse practitioners, 2 practice nurses and 9 HCAs. They have found this skill mix ratio to be successful – their nurses see patients as the first point of contact and have their own chronic disease caseload. At The Ridge Medical Practice in Bradford their skillmix and the introduction of HCAs has enabled their GPs to become GPwSIs and their practice nurses to become Practitioners with Special Interest. More details about these three practices and further examples of good practice can be found on the WiPP website. With the introduction of Practice Based Commissioning. it is even more important to free up GP and senior nurse time by having a more appropriate skill mix. 7. At Woodlands in 2002 we measured nursing activity and found, amongst other things, that the three highly qualified practice nurses were undertaking on average 3 hours a week on non-nursing tasks for example washing and sterilising equipment, ordering and unpacking stock. Also a significant proportion of their time was spent on basic nursing which could have been carried out by a more junior nurse. This made us look at our skillmix and restructure our nursing team with the introduction of a health care assistant role and a treatment room nurse. Other practices have looked at their skillmix such as Thistlemoor Practice in Peterborough where they now have 2 GPs (with a list size of about 10,000), 3 nurse practitioners, 2 practice nurses and 9 HCAs. They have found this skill mix ratio to be successful – their nurses see patients as the first point of contact and have their own chronic disease caseload. At The Ridge Medical Practice in Bradford their skillmix and the introduction of HCAs has enabled their GPs to become GPwSIs and their practice nurses to become Practitioners with Special Interest. More details about these three practices and further examples of good practice can be found on the WiPP website. With the introduction of Practice Based Commissioning. it is even more important to free up GP and senior nurse time by having a more appropriate skill mix.

8. Skill-mix Magic formula? Skill-mix audit Skills needed by a practice team must meet the needs of the patients in that practice Problems of ‘role’. 9. Unfortunately there is no magic formula for skill mix. The needs of each practice has to be looked at individually. There is an easy to use Skillmix audit tool available in toolkit The needs of patients must be paramount in deciding the skillmix needed to meet those needs. If everyone understands that patient and practice needs are of primary importance then this will stop people feeling threatened about their ‘role’. Ultimately it will lead to a more integrated team and efficient team working. You may be asking yourself now what a HCA can do?...... (next slide) 9. Unfortunately there is no magic formula for skill mix. The needs of each practice has to be looked at individually. There is an easy to use Skillmix audit tool available in toolkit The needs of patients must be paramount in deciding the skillmix needed to meet those needs. If everyone understands that patient and practice needs are of primary importance then this will stop people feeling threatened about their ‘role’. Ultimately it will lead to a more integrated team and efficient team working. You may be asking yourself now what a HCA can do?...... (next slide)

9. The HCA role 9. This is a very busy slide but feel that it helps to demonstrate the many activities that a HCA can undertake. In the HCA Toolkit there are examples of HCA roles divided into three categories – Standard clinical role Non-clinical duties Possible extended roles after further training You’ve now seen what an HCA can do but there are three common concerns surrounding the HCA role…. (next slide)9. This is a very busy slide but feel that it helps to demonstrate the many activities that a HCA can undertake. In the HCA Toolkit there are examples of HCA roles divided into three categories – Standard clinical role Non-clinical duties Possible extended roles after further training You’ve now seen what an HCA can do but there are three common concerns surrounding the HCA role…. (next slide)

10. Common concerns Delegation Accountability Regulation. 10. Delegation – you should only consider delegation once competency demonstrated (Tools for assessing competency and tools for helping with delegation are in the toolkit) Accountability – HCAs have social, ethical, legal and contractual accountability and are responsible for the tasks they undertake. Only the task is delegated to an HCA not the overall responsibility (this remains with whichever professional who delegates the task – whether it’s a doctor or nurse). HCAs must not work beyond their level of competence. Methods for assessing competence that would provide sound documentation are available in the toolkit. Regulation – Currently not professionally regulated. NMC MDU, Unison and RCN These issues will be (or have been) covered in detail during the morning/afternoon.10. Delegation – you should only consider delegation once competency demonstrated (Tools for assessing competency and tools for helping with delegation are in the toolkit) Accountability – HCAs have social, ethical, legal and contractual accountability and are responsible for the tasks they undertake. Only the task is delegated to an HCA not the overall responsibility (this remains with whichever professional who delegates the task – whether it’s a doctor or nurse). HCAs must not work beyond their level of competence. Methods for assessing competence that would provide sound documentation are available in the toolkit. Regulation – Currently not professionally regulated. NMC MDU, Unison and RCN These issues will be (or have been) covered in detail during the morning/afternoon.

11. Woodlands Health Centre Nurses well qualified, innovative and motivated Nurses undertaking some long-term conditions management Nursing hours below the national average Skill-mix not apparent Identified tasks suitable to be undertaken by a HCA Identified the time needed by a HCA to undertake these tasks Identified 6 skill-mix options Recommendations for HCA supervision, induction, training and development. 11. As we mentioned in the introduction to this workshop, we have been employing and training HCAs since early 2003. We thought that it would be helpful for you to see the impact that this has had. Vanessa has outlined why I was initially employed by the practice and these are the results of the first piece of work that I undertook. The three nurses were all well qualified, experienced, innovative and motivated They were already undertaking some areas of chronic disease management – diabetes, coronary heart disease, COPD and asthma The nursing hours were below the national average quoted at the time – this was from a study from Sheffield where on average a practice had 8 nursing hours a week per 1000 patients. The BMA at the time were recommending that each GP had one full time practice nurse (equating to 17 hours/ week!) Skillmix was not evident in the team – all nurses were doing all jobs. Read out the rest 11. As we mentioned in the introduction to this workshop, we have been employing and training HCAs since early 2003. We thought that it would be helpful for you to see the impact that this has had. Vanessa has outlined why I was initially employed by the practice and these are the results of the first piece of work that I undertook. The three nurses were all well qualified, experienced, innovative and motivated They were already undertaking some areas of chronic disease management – diabetes, coronary heart disease, COPD and asthma The nursing hours were below the national average quoted at the time – this was from a study from Sheffield where on average a practice had 8 nursing hours a week per 1000 patients. The BMA at the time were recommending that each GP had one full time practice nurse (equating to 17 hours/ week!) Skillmix was not evident in the team – all nurses were doing all jobs. Read out the rest

12. Woodlands Health Centre Continual evaluation of nursing team and workload 2003 and 2005 compared In three years 64% increase in nursing hours yet only a 44% increase in nursing budget Increased from a team of three qualified nurses to a team of six including two HCAs QOF targets 99.5% of clinical indicator points met. 12. After the success of the first project I’m still here! I’ve been involved with many other projects- GMS contract work, protocol development and other practice initiatives. In late 2005 I repeated the nursing activity data analysis that I had first done in 2003 in order to evaluate employing an HCA. It was reassuring to see that in general the right person for the task was undertaking that task but there is still room for improvement. By restructuring the nursing team rather than replacing like for like we increased the amount of nursing hours available in the most cost effective manner- a saving of over £10,000 for this coming financial year. This purely the cost benefit relating to the nurses. QOF targets – as you can see we have met our clinical QOF targets It is more difficult to quantify the fiscal benefit of the change in skillmix to the GPs. Although none of the partners at Woodlands have become GPwSIs or taken on additional roles, we feel that it has freed them up to give better patient care and has meant that a partner has been able to go part time without employing another doctor. So to sum up …. (next slide)12. After the success of the first project I’m still here! I’ve been involved with many other projects- GMS contract work, protocol development and other practice initiatives. In late 2005 I repeated the nursing activity data analysis that I had first done in 2003 in order to evaluate employing an HCA. It was reassuring to see that in general the right person for the task was undertaking that task but there is still room for improvement. By restructuring the nursing team rather than replacing like for like we increased the amount of nursing hours available in the most cost effective manner- a saving of over £10,000 for this coming financial year. This purely the cost benefit relating to the nurses. QOF targets – as you can see we have met our clinical QOF targets It is more difficult to quantify the fiscal benefit of the change in skillmix to the GPs. Although none of the partners at Woodlands have become GPwSIs or taken on additional roles, we feel that it has freed them up to give better patient care and has meant that a partner has been able to go part time without employing another doctor. So to sum up …. (next slide)

13. HCAs Effective and valued addition to the practice team Increased overall efficiency of team Value for money Wish we’d thought of having one sooner! 13. To sum up – read out So, back to the decision making…… (next slide) 13. To sum up – read out So, back to the decision making…… (next slide)

14. The decision to appoint a health care assistant Do I need an HCA? 1414

15. You’ve decided to appoint a health care assistant YES! 1515