Prior to 1948 most General Practitioners (GPs) worked independently, usually from a room in their own home. There were few, if any, staff and the duty of answering the phone usually fell to the GP’s wife (most GPs were male at that time) or housekeeper.
When the NHS was first formed, back in 1948, GPs were appointed as independent contractors. This meant that GPs work for the NHS but as an independent contractor rather than an employee.
There was a framework already in place, Lloyd George’s National Insurance Act of 1911 gave limited health cover for working men but this did not include their families. Anyone not covered by the scheme had to pay to be seen by the GP and for people who could not afford to pay, they would leave conditions until they became unbearable or often fatal (although I have heard stories from my grandad that locally, the GP would see family members for payments in kind, such as, putting a new tyre on his car or in my grandad’s case, doing some building work).
The scheme at this time was run by local insurance committees who held a panel (or list) of doctors who were prepared to work under the scheme. These doctors worked under “Terms of Service” which were later lifted directly into the NHS GP contract. The NHS also adopted the medical cards which were issued by the local insurance companies and the record system which was made up of a set of cards in a “Lloyd George envelope” which interestingly are still found in the filing system for any paper patient notes.
Overnight General Practice was given the responsibility of providing medical care for the entire population from birth to death. This also involved being the gateway into hospitals and specialist care. Within a month 90% of the population had registered with a GP. The GP was responsible for the care of their patients 24 hours a day, 7 days a week and 365 days a year. Any failure in that provision could result in fines or “withholding of remuneration” from the Medical Service Committee.
It’s hard to imagine the immense pressure on GPs and this was highlighted in the Collings Report of 1950, which showed conditions for GPs were not good and they were isolated from other professionals. At this point there were very few nurses in general practice, besides the occasional GPs wife with nurse training. Understandably some of the care provided was described in this report as being poor.
It wasn’t until 1966 that the first contract between GPs and the NHS were drawn up. This included funding for support staff, including nurses, so the role of General Practice Nurse was born.
In the early days, nurses were usually employed to work in treatment rooms. Often alongside reception and administration work.
They undertook general tasks such as dressing wounds, taking observations such as weighing patients, taking their pulse or temperature, obtaining specimens and testing urine (Cartwright and Scott 1961). These tasks will have been as instructed by the GP and it was unlikely that nurses were at this stage involved in the holistic care of the patients.
It was thought that any extra training was not required as none of the skills required exceeded those of any Registered General Nurse (RGN) and this was mainly the case until the 1980s. The role continued to evolve to include screening and health promotion.
With changes in the GP contracts with the NHS, both in 1990 and 2004 the role of the General Practice Nurse began to develop further. The management of long term conditions such as asthma, chronic obstructive pulmonary disease and diabetes became central to the General Practice Nursing role. This brought with it the requirement for additional training and support.
General Practice Nurses have embraced this rapid expansion of their role and developed new skills, knowledge and networks.
The Royal College of Nursing (RCN) Practice Nurse Forum lobbied for specialist practitioner recognition from the United Kingdom Central Council (UKCC) in 1994, however although accepted this did not result in a recognised qualification.
As the General Practice Nurse role continued to develop, many developed skills in managing patients with undifferentiated diagnoses and patients needing urgent care. This led to the development of Advanced Practice Nurses and Advanced Nurse Practitioners, examining, diagnosing, prescribing medication and referring to secondary care and other services.
In only a couple of decades, the roles for nurses in primary care have grown beyond recognition. There is now a wide variety of nursing roles within primary care, working alongside the rest of the multidisciplinary team.
The introduction of the Health Care Assistant (HCA) role into the multidisciplinary team in General Pratice has contributed a great deal to the care of the population and the development of the multidisciplinary team. The Shape of Caring review (2015) chaired by Lord Willis describes the intention to improve the capabilities of Health and Social Care Assistants and to promote structured career development for these increasingly important members of the staff team. This began with the introduction of the Care Certificate.
From being quite isolated in the 1950s, GPs are now surrounded by a whole multidisciplinary team. Besides other health care professionals (such as paramedics, Emergency Care Practitioners (ECPs), Physiotherapists, Pharmacists, Physician Associates and many more) there are various nursing roles, treatment room nurses, general practice nurses, advanced nurse practitioners, minor illness nurses, triage nurses and nurses with an array of skills that are far too many to mention.
Stronger regulatory and governance mechanisms were introduced with a requirement to register with the Care Quality Commission (CQC) by 2011 and to show evidence of compliance with the Health and Social Care Act 2012.
The Health and Social Care act of 2012 brought the introduction of Clinical Commissioning Groups (CCGs) led by GPs responsible for the commissioning and delivery of health care. Nurses are involved in the commissioning of services and monitoring quality of services, something that could not have been imagined in 1948.
The Five Year Forward View (2014) describes the need to change the ways that care is delivered and suggests new ways of working.
In March 2017 Health Education England (HEE) published it’s General Practice Nursing Workforce Development Plan. This recognises that General Practice Nurses have a vital role in driving innovation to meet the changing needs of people in their communities. This document looks at four key areas, including raising the profile of General Practice Nursing as a first career choice and dispelling the myth that newly qualified nurses cannot work in primary care, improving access to training, supporting career progression and standardising training and career pathways.
The NHS is 70 years old this year and general practice has evolved So much in this time. The role of a nurse in primary care has grown into a selection of roles. Nurses hold a key position within primary care, often reducing the stretch on GPs. Along with all these changes and expansion of skills for nurses, it has to be acknowledged that the GP’s role has also evolved and developed to allow patients with more complex needs to be cared for in primary care. Care is being provided by General Practice that even only a decade ago would have been carried out in hospitals. The population is living longer and for most, the quality of life has improved, although this can be attributed to the care available because of the NHS, this also adds extra pressure on the service.
General Practice Nursing is, in my opinion, the most rewarding, patient focussed role with a variety of exciting career development opportunities.
What does the future hold? I imagine the use of technology will become more common such as virtual consultations. I am in no doubt that nurses will continue to develop new skills to support practices and benefit their patients and that primary care will remain an exciting place to be.
Baird B, Charles A, Honeyman M et al. (2016). Understanding pressures in general practice. King’s Fund, London
Cartwright A, Scott R (1961). The work of a nurse employed in a general practice. Br Med J 1(5228): 807-13
Queen’s Nursing Institute (2017a).Transition to general practice nursing. https://www.qni.org.uk/wp- content/uploads/2017/01/
The King’s Fund (2015). The NHS five year forward http://www. kingsfund.org.uk/projects/nhs-five- year-forward-view?gclid=CL Kx6eqv7sYCFYvHtAodIhcLSA
The Kings Fund (2011) The evolving role and nature of general practice in England.