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A pilot approach to change ways of working in primary care

Building on success with a nurse-led hypertension clinic at Bewdley Medical

What prompted the initiative?
How was the work taken forward?
Creating local guidelines
Moving from paper records
Equipping nurses for their new role.
What difference did it make?
Building on success
Tips for success
For more information contact

What prompted the initiative?


In the early 1990s Bewdley Medical Centre realised GPs were under too much pressure. They wanted to maintain or improve standards but this was becoming impossible. Demands from patients were increasing without enough doctor time to meet them. Fundholding (and then total purchasing) offered opportunities for innovation with management of chronic conditions a suitable candidate for change. Traditionally these patients were always seen by the GP, but it seemed probable that nurses could manage these consultations. Research evidence was providing a strong lead towards the essential components of effective care for patients with hypertension.

How was the work taken forward?


Developing nurse-led clinics needed a new approach to teamwork in primary care and a radical move away from the clinical independence of GPs. It would take time to develop an approach where all members of the team worked to common standards. The intention was to empower nurses as members of the team rather than define a set of tasks to be delegated. The practice needed to work together.

With no model for nurse-led clinics Dr Robert Marriott asked practice nurses to work with him to set up a hypertension clinic: get going and see how the idea evolved. The process worked well with growing confidence in the new approach in the first year. Patients were referred to the nurse for assessment and treatment. Audit confirmed the quality of care being provided. The pilot study showed what was possible, but a more deliberate plan was required if the concept was to be adopted by the whole practice. Work was needed on the development of guidelines, information systems, on training and on team development.

Creating local guidelines


Informal enquiries uncovered variation between partners. These variations would have to be addressed if a new system of nurse-led clinics was to be effective. The challenge was to assemble evidence on which the partners could rely at a time when the general understanding about evidence-based practice was in its infancy. A guideline for the care and treatment of patients with hypertension was developed and adopted by the practice. The practice learnt how to adapt national guidelines to meet local needs and manage them within available resources. The key to success was flexibility and focus on patient: what was reasonable for the individual patient, rather than continually striving for the guideline standard.

Moving from paper records


When the first nurse-led clinic was set up traditional paper based records were used, though a structured record system would be required to monitor patient management. There was no ready-made solution, but a chance encounter at an IT conference in 1993 enabled the practice's computer manager to learn about a promising new system. This would allow the practice to develop its own template rather than require it to work with systems developed elsewhere. This was a major leap forward. A template for the hypertension clinics was developed which not only provided a practical management system but also allowed past practice to be reviewed at the press of a button.

Equipping nurses for their new role.


Some practice nurses were anxious about taking on extra responsibility when the new clinics were first mooted. Training courses were not available because at that time few people had experience of managing nurse-led clinics. Training in the practice was organised taking their local guideline as a starting point. The aim was to create a spirit of team working to allow nurses to gain confidence in their new role.

What difference did it make?


The model for the hypertension clinic has been a resounding success, providing high quality care. There is little outcome data on hypertension in primary care, but the care at Bewdley compares with achievements elsewhere (Table 1). The success was reflected in Dr Marriott being named Doctor of the Year in 1999, when the practice was also given Beacon status. This success has encouraged nurses to develop their skills, experience and role in the team. Practice and district nurses are involved, and probably know more about the management of hypertension than their GP colleagues!


Table 1: Hypertensive and IHD patients: BP levels

Bewdley Practice Comparison
60% of hypertensive patients have BP below 160/90 (BMJ 1996; 313 :93-96) Study of 876 hypertensive patients in primary care and found that 46% were well controlled with BP 160/90 or below.
35% of patients with IHD meet the new standard of BP below 140/85 (J Hypertens 1998; 16 : 747-753) Study reported that only 6% of UK hypertensives were reaching the target levels set by the British Hypertensive Society.


Building on success


Effective team working has allowed the model for nurse-led clinics to be adopted for several other chronic conditions including diabetes, heart failure, and asthma. These all help to improve quality of care. Key features are creating local guidelines, preparing a template for records and training. Guidelines are reviewed several times a year to ensure relevance. The use of templates means that all information is Read-coded and entered in the records in a standard way. Auditing is made easy and regular meetings reinforce the process of team working.

The changes have allowed GPs to increase consultation time from seven minutes to about 10 minutes per patient. Relationships with consultants have improved: they now have confidence in the quality of referrals from Bewdley because patients are referred appropriately.

The investment in team building has borne fruit. It has had a significant impact on working relationships in the team and helped strengthen the spirit of teamwork. The practice seeks to recognise and work with conflicting interests and views and not sweep them under the carpet. External facilitation has played a big part here. The aim is to build on the different abilities rather than expect everyone to be the same. Referrals across disciplines are now a normal way of working, from doctor to nurse, from nurse to doctor, from therapist to doctor.

The overwhelming reaction from patients has been positive. After much effort to explain the new approach, they are used to seeing the nurse as a first point of contact rather than expecting to see a doctor as a matter or course. A later development was the creation of a patient advisory group to help ensure that on-going developments are sensitive to the views of patients. Other developments being planned include the encouragement of patients to monitor their own blood pressure with home monitoring kits.

Tips for success


√ Don't be afraid to try something new.
√ Don't wait for help because it might never come! Find your own solutions.
√ Effective team relationships don't just happen. They take time, but there is no end of the road when you can say done that .
√ Effective teams require leadership, a sense of direction, good organisation and efficient communications.
√ Information is a major component of effective care; investment of time and energy to get the right system will be well spent.
√ Create records systems that support audit and review and don't rely on someone looking for paper records.
√ Don't be fazed by IT: there are practical ways to develop IT solutions locally. Find the right person to help you.

For more information contact


Dr Robert Marriott, Bewdley Medical Centre, Bewdley, Worcester DY 12 2 EG

Telephone 01299 402157 Email bmc@bewdleymedical centre.force9.net

Further information is available from the Centre's website (www.bewdleymedicalcentre.force9.co.uk), including the Centre's Annual Report and clinical guidelines.

ImpAct bottom line

Avoid the impression that the aim is to delegate tasks. Seek to empower those involved.

 


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