E24: Workforce Transformation in Primary Care

PLEASE NOTE: THIS TRANSCRIPT WAS PARTLY AI GENERATED AND WILL CONTAIN ERRORS!

Introductions & overview

[00:00:00] 

[00:00:06] Munir Adam: Hello, it's Munir Adam here and welcome back to Primary Care UK. We bring you an episode on workforce transformation. It's hot, it's topical, it's happening. In case you didn't realize it's been happening over the last few years, and it's likely to continue. Primary care is transforming like never before. 

[00:00:26] But what exactly is happening? Why, and how do different clinicians see all this? Is this relevant to you? Well, surely you can work better as a team if you understand each other's roles, right? And even better, and this is something that's less commonly discussed, if you can understand what it's like for them, their aspirations, challenges, and fears, and those of you who have listened to Episode Zero or the introduction to Primary Care UK may remember that multi-professional is what this podcast is all about.

[00:00:56] So what do you get if you put an experience GP, Practice Nurse, Paramedic, Clinical Pharmacist, and a Physician Associate in a room together? Well, we may never find out since everything's gone virtual, but we did manage to get this group together remotely as they discussed some of the changes that have been taking place, the rationale for those changes, and to try and share an appreciation of how some of these roles fit together.

[00:01:21] So this episode isn't about how you might deal with the tricky scenario when you're feeling all alone trying to manage somebody's hba one C or diagnose that unusual rash, or try and persuade the patient to take their regular medication. But rather this is the kind of episode that you should listen to when you're in the mood of trying to get better at connecting with those around you.

[00:01:42] And you know what? If you can get good at that, then the next time you're faced with a tricky scenario, maybe you won't feel so alone. 

[00:01:50] In collaboration with Integrated Care Support Services, let us continue season two of the podcast that is for all the clinical staff in primary care. 

[00:01:58] 

[00:02:12] Rachel Roberts: Hello and welcome to the podcast today on Primary Care Workforce. I'm delighted to be here with colleagues from a range of areas in England and a range of professional groups, who have a wealth of experience from within and interfacing with the primary care workforce. We are each going to introduce ourselves, a little bit about the aims of our roles, and also a memorable patient, just so you can get to know us a little more.

[00:02:37] So I'm Rachel Roberts. I'm a GP and Primary Care Dean in London for the Workforce Training and Education Directorate of NHS England. This was formerly known as Health Education England. The main aims for me of my role are to really support primary care workforce through education and development throughout professional careers, um, and most importantly, to ensure those meet the needs of our patients and populations.

[00:03:02] So when I tried to recollect one of my most memorable patients, a lady comes to my mind who presented in the middle stage of pregnancy, um, but who was homeless and had no resources, including no mobile phone, and this was her first time she'd sought help or support in relation to her pregnancy. And the real challenge for me was thinking, how can I really help, knowing that I may have no other way of contacting or being in touch with her if I didn't sort out some connections and arrangements while she was there in the room with me. And I was dramatically supported by my colleagues, both within the practice and across the sectors, into antenatal care so that I had a way of her presenting and accessing care before she left the building. But understanding the challenges of this in the middle of a busy surgery and with a person for whom accessing care was really difficult. 

[00:03:53] Irina Varlan: Hello everyone. My name is Irina Varlan. I am a pharmacist and my current job is a medicines optimization and interface pharmacist for Nottinghamshire ICB. One of the main roles that I do, I. Is to basically engage all stakeholders in solving problems or updating guidelines. So, so to, to make sure that everyone is on board.

[00:04:16] And then to also make sure that the changes that we adopt or the guidelines that we update are known by everyone. So I try to share and make sure that everybody who needs to use that guideline is aware of it.

[00:04:30] And one of my most memorable patients has to be, a lady that I was seeing on a monthly basis when I was working down in London in Charing Cross Hospital. She was diagnosed with cancer probably 30 years ago, and she was still going strong. She had a very active, very positive life. She was always optimistic and she was an absolute inspiration to me and told the other patients that were coming there. So yes, I definitely remember her, and her attitude towards life. 

[00:05:03] Chaima Hale: Hello, my name's Chaima and I'm a Physician Associate. I'm also the NHSE Physician Associate Ambassador for North Central London. So I would say one of the key things around my role is developing professional development opportunities for Physician Associates, qualified Physician Associates and in fact, one of my bigger projects, Rachel I dunno if you remember this, but you coined the term orientation into practice, which is the name of my big project that I'm working on at the moment. If you remember conversation we've had in the past that's developing training frameworks for Physician Associates in primary care. With regards to a memorable patient experiences, I think most recently I had a, a very, very concerned patient who's very worried about her health and her husband had recently been unfortunately diagnosed with cancer.

[00:05:53] And at the end of the consultation, she sort of revealed her, you know, all her concerns and anxieties around this. And she turned around to me and she said, you know, I really, I really wish I get to see someone as diligent and as thorough as yourself. And it was, for me, it was just so rewarding to hear that, that Physician Associates have experienced some negative press currently, so to just hear something like that after she really kind of probed me about my role, that was really memorable to me. 

[00:06:21] Andrew Preece: Hi I'm Andrew. I'm a advanced Paramedic Practitioner and clinical supervisor for London Ambulance Service. So when I'm rotating in primary care, my sort of day-to-day role is supporting that same day list. So mostly focusing on sort of minor injury, minor illness, patients that are allocated by the GP. 

[00:06:42] In my supervisor role, I'm supporting my colleagues in my team providing clinical supervision. 

[00:06:49] And I think for me, I was trying to think about my most memorable patient. I saw a young patient who is 19, who came to see me about his anxiety. And I think the reason why I think about this person was because I was the first person they'd seen. They'd come from university. They've sort of wanted to get some help and support. And I felt very privileged that I was able to start that person on that direction and that journey and where they were perhaps quite anxious about joining and seeing us at the surgery, actually the consultation at the end was, was quite positive and happy to get some help. 

[00:07:29] Paul Jeffrey: Hi, I'm Paul Jeffrey. I'm strategically Practice Nurse in Cornwall and Isles of Scilly, and I also work for the Cornwall Training Hub. So my main role is around professional and educational development across nursing from HCA through to consultant level.

[00:07:46] We also work around quality improvement projects, so developing new ways of working and trying to encourage people to think about how they're dealing with their patients and how, how those pathways might be changed to be more efficient and more adaptable for patients. 

[00:08:03] My memorable patient is actually someone that I met in a supermarket with my wife when we were shopping. And he was chatting 'cause he hadn't seen me for quite a long time. And he said, oh. I always used to see Paul because he always listened to what I said. And that really stuck with me that how important it is that we listen to what patients are saying. That's my memorable patient. 

[00:08:27] Rachel Roberts: Oh, thank you all so much.

[00:08:28] So straight away we've heard a range of skills that people are bringing to their roles and the way that connects with patients. So a really big thank you. So I, I think it's important we're welcoming each other as team members into the discussion today. And I think that's a real parallel to what we're experiencing in primary care at the moment., our teams are broader, they're more varied in terms of the members of the teams, their skills and their roles, and how do we understand each other and work together, and particularly how do our patients understand that and how do we meet their needs?

A bit of background

[00:09:03] Rachel Roberts: So, I'm really interested in us speaking about that today and hearing from each of you as to your perspectives on that. So first of all, a little bit of background. So I think we all have our perspectives on, you know, our time in primary care or our time working in the health and care professions. But I think for most of us, the last five years may have felt the most turbulent that we can remember.

[00:09:27] Some of the things that have happened are tremendously positive. Others are, of course tremendously challenging. So we know there have been changes in the health of our populations going of course through the Covid Pandemic but also the significantly increased aging population and the number of illnesses that patients live with, and how can we help them to live well during their lives and throughout.

[00:09:51] So meanwhile, we know there've been a significant shortage of GPs and nurses in primary care. There's been a very increased range of consulting during Covid and an increased number of consultations happening now compared to pre Covid, but with the dramatically different ways that we access care now. 

[00:10:11] There have been some differences in perception of how patients feel they can access primary care. And we have the real opportunity of now an extra 29,000 people coming into the profession for a range of additional roles. And we have increasing numbers of trainees in terms of GPs. 

[00:10:30] So what are our opportunities? I think those are the things that I'd be interested in talking about. We know that some of them are underpinned by various policies such as the Fuller Stock -Take and how we can work together in integrated neighborhood teams and across sectors. We also have now the long-term workforce plan, which is really ambitious, so approximately double the number of people over 15 years coming into medical schools.

[00:10:56] New roots into the whole range of professions. So apprenticeships, including medical and the whole nursing career pathway developing as well as those of First Contact Practitioners and additional roles and the big challenges of where do we have space for our teams and estates. So I'm going to hand over in a moment to all my team members to see what they feel they have to offer.

[00:11:20] And in terms of what are my hopes I'd like we would all think about retaining. All of our team members think of it all the time. And also that challenge of can we all become environments where people can learn from across all professional groups and come into our workforce? And how can we best communicate with our patients to make sure that we meet each other's needs?

Challenges and hopes...

[00:11:41] Rachel Roberts: So I'm just really keen now to hear on all of your personal experiences of what your roles bring, what are your challenges, and what are your hopes? So, Irina, can I come back to you first? 

A Clinical Pharmacist's view

[00:11:51] Irina Varlan: Yes, of course. So, when I first heard about the topic about workforce, the first things that come to mind to me as a pharmacist is the fact that in a couple of years, I hope I don't get the year wrong, but in 2026, we should have new graduates from pharmacy who are already qualified as independent prescribers.

[00:12:11] Then also the opportunities from health education England for pharmacists who are already in the workforce to qualify as independent prescribers. And there was a cohort last year and the funding was approved as well for this year. However, there's challenges to that in the sense where will they fit in the system? How do we train them? How do we make sure that they get the right support when they start? They will of course need to specialize on a certain thing. They would need mentors and people to guide them throughout. Also regarding the independent prescribing course that's offered through funding, it's quite challenging to actually get someone to mentor you and to support you through the course ' cause everybody is so booked with training: PCN pharmacists and junior doctors and nurses and other staff that serve primary care; that is quite challenging to actually find the support. 

[00:13:06] So although we acknowledge that there is the good intention, I think there's needs for a bit more support and better planning for this. And a few thoughts that I was thinking for my area was, it might be a good idea, it might be already there and I haven't just seen it, is to basically try and figure out what areas you're lacking and what specialties you'd need more support in, and maybe prep a pack or a course, so that when these pharmacists graduate and they come out of university, they already know, oh, Nottinghamshire for example, is looking for independent prescriber or specialist in these certain areas. And maybe we could go there if we're interested in that. 

[00:13:47] So I don't know if that's some sort of an idea that could be applied to the whole of the country and I dunno what other areas are doing about this and how are they welcoming them. But yes, these are just a couple of thoughts from my side. 

[00:13:58] Rachel Roberts: Thank you so much. So fantastic opportunities there, as you say, in those skills that pharmacists can offer the future, independent prescribers being even more, but then something about needing to think about the career pathways and opportunities and matching those up. So really interesting challenges and thoughts. 

[00:14:16] So I'll hand over next to Chaima. Please do say a little bit about yourself, your role in terms of challenges and opportunities, and also if any of you want to come back on the points Irina's made, please feel free to do that.

A Physician Associate's view

[00:14:28] Chaima Hale: Thank you. Rachel. I think I'm gonna build on what Rachel said about the challenges because some of the challenges that she's identified is definitely something that I've identified for Physician Associates.

[00:14:37] Rachel, you mentioned earlier the workforce plan, which is highly ambitious to say that we're going to train all these new medical teams. However, who's gonna support them, when they qualify. Who going to train them; and this is a real concern, especially when the current qualified senior teams that exist currently are already snowed under with the workload that they have. So one of my passions as a the Physician Associate Ambassador, is actually developing leadership within Physician Associates.

[00:15:05] As the Physician Associate workforce is growing, they're gonna need leaders in order support them to train them, to train the new cohorts, to train the apprentices, to train the students, to train the newly qualified Physician Associates. 

[00:15:16] And one thing I didn't mention in my introduction was that I'm a program director for the north Central London Faculty of Education and faculty were set up to support multi-professional training of supervisors of multi professional teams.

[00:15:31] So we've developed a series of multi-professional workshops, which supports understanding multi-professional teams scope of practice. I think Andrew's been involved in the Barnet multi-professional team, showcasing, the support that he provides for the paramedic teams. But just to, to develop some understanding of what the teams can offer primary care, what do they do, what is their practice, because this is a question I get all the time. What can you do? What are your development needs? What are your learning needs? What can you not do? What can you train to do? And there are so many questions that educational and clinical supervisors are asking. And actually, for myself, I dunno what that is. And actually, if I dunno what that is, I feel like my workforce also similarly, don't dunno what that is.

[00:16:14] And so, To trying to fill those gaps and developing those needs and, and supporting that is really essentially the crux of what I do. And that challenge, you know, comes back to funding. It's, it's always the problem. And I think a lot of funding is ring fence for particular workforce. And I'm constantly trying to find is there any underspend that I could potentially utilize, and actually, what has been a positive, is in trying to utilise opportunities for Physician Associates, recognizing that there is opportunity for clinical pharmacists, for paramedics, for advanced nurse practitioners to also join the training that I'm developing because we see that the learning needs overlap significantly. And so rather than making it more of a specific workforce training program, we really have made it a one workforce training program.

[00:17:03] And I think I can see that primary care is going in that direction . 

[00:17:06] Rachel Roberts: Thank you so much, and again, very inspirational. And the words that are coming out for me, and the first two narratives are around support. So support for people and that support needing to build from within their own professional groups and across multi-professional groups.

[00:17:22] And certainly not being particularly dependent on any one profession to support all of the others, which has been, I guess, one of the concerns sometimes that GPs have expressed: feeling that importance of sharing the supports that can be offered. So support was mentioned, education absolutely was mentioned, faculty was mentioned, and then obviously the challenge of funding.

[00:17:46] So in terms of faculty, that's the power of conversations between people and trying to search the answers and look for resources to support themselves. And I understand around the country, you know, people at different stages in the journey. And so do you agree that the power of conversation has been really helpful or helped transform the group?

[00:18:03] I. I wonder if anyone has any thoughts? Chaima, have you got any thoughts on that? And then we'll move on to Andrew after you. 

[00:18:11] Chaima Hale: I think so. I think having multi-professional representation at the table definitely transforms and helps innovate because if you only have one group of professionals at the table, table at board meetings at senior sort of operational and strategic meetings that the, view's always gonna be skewed. And I think it's definitely important that, that there is that representation in order to, you know, you, you provide a different perspective. So having those conversations are important. 

[00:18:38] And Rachel you mentioned retention. It's really important that we are supporting our senior clinicians where they can provide that training for those who are coming into the profession and passing on that in a way so that supports retention by providing these skills and opportunities for training. 

[00:18:57] Rachel Roberts: Thank you so much. 

A Paramedic's view 

[00:18:58] Rachel Roberts: So Andrew can we hear a little bit from you, your thoughts, your feelings of challenges and what your roles offer? 

[00:19:05] Andrew Preece: Yeah, of course. I think the first thing to say is that, and, and this will be across all professions, but certainly where we recruit paramedics from say, an ambulance service background. It's not uncommon for people to come from the ambulance service to go and work into primary care. You don't tend to see paramedics come straight from university into that role because there's an expectation that you've got a couple of years of experience; and certainly if you are applying for, say, the first contact practitioner or an advanced practice role you are, you are gonna have worked in that profession for a number of years.

[00:19:42] And there's something certainly about that transition from moving from say, an ambulance service to a primary care. So there's some different skills, there's a different knowledge base. And for me, working within the ambulance service and, and going into the rotational working environment, certainly it's been the, the GPs, the practice nurses, the nurse leads and other professionals that I've come in contact with who have helped me build my confidence and feel better working in those environments because I know some of the skills, I know some of the knowledge, but you put someone in a different environment and you suddenly feel like you are the new person all over again. 

[00:20:24] And certainly supervision is a really important aspect of that, and as I've said it, it's come from other professions as well as the support from my employer, but I also think there's something about how we explain to patients that they're being seen by a different practitioner and what can that practitioner offer and provide, because we all see that by having different professionals who are doing, you know, different clinics, or in my case, it's largely supporting the same day clinic patients, should know that they're being seen by a paramedic and what that means. Because otherwise we sometimes get patients who come into the surgery and they go, I thought I was being seen by a doctor and instantly feel a bit aggrieved by that. They feel like they've been shortchanged.

[00:21:16] Now I feel that most of the time you can bring a consultation round and you can, you know, because we are fortunate, we have slightly longer clinic time, so we can try and help make sure that a patient has a good experience. But there's certainly something about telling patients, that's what we are there for and what we're doing.

[00:21:34] And certainly more as the workforce grows and different professionals are, are working in there I think sometimes if you are told you are going to see a physio, it's a bit more obvious why you are going to see a physio. Whereas perhaps for, for paramedic and other professions, it isn't always so. 

[00:21:51] As I sort of said before, the supervision aspect of that, so also being supervised by other professions really does help and provide a, a very different experience than perhaps just being supervised by your own profession. 

[00:22:06] Rachel Roberts: Well, thank you so much. So I think, again, you've referenced a few things. The the real critical importance of supervision. The fact that you need to be welcomed into a new environment, even if you are really experienced in another sector, that you can feel new, and then really beginning to dig into that whole element about meeting patient's needs and communicating with patients so they know what to expect. And I guess you almost describe having to counteract a feeling of concern by a patient as to who they're expecting to see. Whereas, again, in an ideal situation they would already be expecting that.

[00:22:40] And obviously welcoming what you have to offer whilst recognizing that, it can be difficult for patients to choose who they want to access. So something about that connection and needing to explore it and meet each other's needs to get the consultation on the best footing. So really interesting. Thank you. 

A Practice Nurse's view

[00:22:58] Rachel Roberts: Paul, could you come in with some of your thoughts? 

[00:23:00] Paul Jeffrey: Yeah, I'm coming really from probably the training hub angle really thinking about the development through the nursing pathway and we've been doing quite a lot of work around developing the pathway , and we've had one lovely story where someone was actually a receptionist and then trained as an H C A and then has gone on to do their nurse training and have just done the fundamentals of general practice nursing.

[00:23:26] So I've got gone through that whole route within primary care. Very difficult to do that because of the cost of the apprenticeship for the nurse training. So that's one of the areas that's really a difficult area through that career pathway. 

[00:23:43] But we've also got some other great opportunities with the Nursing Associates being developed. So that's a great opportunity for having a different role in nursing and different skill sets. There's also some challenges around that, around what people understand by the role a bit. So like we were talking about with, people don't really understand the role always and how that fits. So there's been some discussions with the Nursing Associates themselves and the managers about how perhaps those roles fit. So that, that could be quite a challenge sometimes. 

[00:24:18] Moving further up the line, we've, we've got very experienced nurses that don't want to go on to do advanced practice. They like doing the long-term conditions and how do we look after those nurses?

[00:24:31] We've got some exciting things coming through with enhanced clinical practice practitioner apprenticeship and the specialist qualification. How do we link those in and make those fit into a career pathway? And it that need only be for nurses in the enhanced clinical pathway. We don't want everyone to be advanced practitioners work into the four pillars at advanced practice level. That we do need some people with that. And then we need to look at what advanced practice looks like in general practice. 

[00:25:03] At the moment. We use advanced practice quite often just to prop up the medical model of first contact, but. We should be looking wider than that. We should be looking at how we use nurses at advanced practice level to lead on pathways in long-term conditions, for example.

[00:25:21] Into QOF, we've had quality improvement put in. We need to see nurses leading in quality improvement. There's hundreds of good ideas out there where, where people can think about how to improve patient pathways and how to improve the piece of work that they're doing around patient care. And if we look at the workforce plan, we can see that actually, although it's quite ambitious, if we carry on doing things the same way, we're still not gonna have enough staff. So what we need to do is look at what we're actually doing and what people need to be doing.

[00:25:55] I also think there's probably an opportunity to look at how primary care is delivered as we go into multi-professional working. Is the partnership model, and this is probably a bit contentious, is that the right model for now? Or do we need to be looking at different models? We know that a lot of GP trainees that are qualifying don't actually wanna be partners, so is that sustainable?

[00:26:18] Challenges really as I said about understanding people's roles, and I think we need to do some more work around that, especially as Andrew said around for patients and for managers and staff of how those roles can fit and how we can best use them. There's a really nice lecture given by Professor Allison Leary with the Q and i, William Rathburn, the 10th lecture recently, and I'd encourage anyone to ever listen to that, that wants to think about workforce differently because she really says about nurses being the air traffic controllers of patient care pathways, which is really nice, and that we don't value safety and quality always. We're, we're more looking at the activity and how much work is done rather than the vigilance that nurses and other members of the team can bring to that care pathway. 

[00:27:14] Rachel Roberts: Thank you so much Paul. So I want to pick up on a couple of points next if that's okay. So Paul, I'm going to come back if you like with, you've brought us onto the whole question of patient pathways and patient care and quality. And so we've heard some really amazing things just now about all of your different roles, what you are offering, and also something about your memorable patients.

Working effectively with the patient

[00:27:37] Rachel Roberts: What we do know during the times of Covid Pandemic and now into 2023, is there has been a drop in general practice patient satisfaction with their services in primary care. And, and Paul, what are your thoughts about that? And you talk about patient pathways. What do you think patients feel currently about primary care and where could you see that going for the future to maybe shift that perspective or improve the situation for patients?

[00:28:06] Paul Jeffrey: Yeah, patient pathways and access obviously is a big thing that's being looked at across general practice. I think we're getting quite bogged down sometimes with technology. I see the reports coming in from practices saying how many clinic emails they've had in to deal with, and I think the pressure on primary care is extensive at the moment, and I'm not quite sure how we deal with it. 

[00:28:32] I'm not sure that I've got an answer to that, but I do think in some practices it seems to be working well, but there is a limit to what practices can actually deal with in a day, and maybe we need to start to think about how we help patients self-manage. In Cornwall, we, we've set up some hubs around to support people, because we know that a lot of interactions in general practice, we've got social prescribers, care navigators, health coaches, to try and work on some of the things that don't need to see a clinical professional that are really important to patients in how they're actually gonna manage their condition.

[00:29:13] From my perspective, probably the demands are too much on primary care and we need to actually refocus on what is acceptable for primary care to be dealing with because I don't think we can just be the answer to everyone's question really. 

[00:29:30] Chaima Hale: So I just wanted to add especially around access to primary care. And it's definitely something that's heavily cited by patients that they can't seem to access GPs.

[00:29:39] GPs have during covid move to a sort of telephone triage system, but post covid GPs are seeing more and more face-to-face. One thing that I experience, and I work in a relatively large practice. We have 15 consultation rooms, but we have more than 15 clinicians in one day. So how does that work if you only have 15 consultation rooms?

[00:29:58] Some clinicians do have to be remote or you know, telephone only basis. And when patients call and they say, I should have been given a face-to-face. Why is this a telephone? And when I explain to them the rationale by, this is a telephone call. We don't have the space to offer you a face-to-face. They're usually very reasonable about that and actually really tried to think of solutions for you.

[00:30:19] So I think, raising awareness about the problem with estates that primary care has would really help debunk some of the views that patients have around patient access, especially with the the whole triage system that we currently have. 

[00:30:31] Irina Varlan: Yeah, I agree. If you explain to patients why something is happening they generally understand and I think, not education, but communication. Trying to explain to them where can they get a service faster or who is it best to address to prevent all that number of calls from one side to another to try and understand your problem.

[00:30:53] And in the same lines hopefully the community pharmacy, it's already sort of like a start point. 'cause a lot of people tend to go there first. And they tend to go there and ask, what do I do about this? Can you help me? Or do I need to go to the hospital or should I actually go and see my GP?

[00:31:08] Rachel Roberts: No, thank you so much for your thoughts on that. 'cause here's a critical point in, in terms of how we interact with patients and, and how we look at their needs being met and where that is.

[00:31:18] So thank you. So we've heard a lot about your different roles.

How the roles fit in with that of the GP

[00:31:22] Rachel Roberts: What I'd be really interested in hearing from each of you, in just a couple of moments, how do you feel your role connects with that of the GP? How, how does that fit in? So, coming to you arena first, what are your thoughts on that? 

Pharmacist

[00:31:35] Irina Varlan: So as a pharmacist in my current role, we work along with GPs quite a lot. They get involved in guidelines. We help out with different queries. They sit on the APC meetings, so the area prescribing committee where we make decisions about our local formulary, and I think the whole of the NHS is under a lot of pressure. I don't think the pressure is just on primary care. Secondary care is going exactly through the same thing. And with the current shift in more opportunities, at least for my profession, opening in the, in the GP sector with PCNs opening up, a lot of the pharmacists have migrated from secondary care to primary care. So there's a huge gap to fill there.

[00:32:17] And there's also this need of perhaps maybe advertising the NHS as a great place to work in. 'cause there's been so much media about it being stretched. And, you know, there's also all these gaps that are highlighted even in the media. And I know it's been praised during Covid 'cause everybody's put in so much effort. But I feel that apart from that, not a lot of the other efforts are acknowledged. So I feel like it it, we need to advertise NHS like a great place to be in. You get trained a lot, you get to experience a lot of different professions, a lot of different situations. 

[00:32:52] Some of it summarizes what you said earlier about retaining your current employees and, and giving them the appropriate break and not overwork them and overstretch them 'cause they will eventually move on if, if this doesn't fit their needs anymore.

[00:33:06] Rachel Roberts: Thank you so much. 

Physician Associate

[00:33:07] Rachel Roberts: Chaima can I ask a little bit about what your thoughts are of how your role fits with that of the GP? And so feel free to also express your thoughts about retention 'cause that's an absolutely critical point.

[00:33:18] Chaima Hale: Absolutely. So I'll talk on behalf of Physician Associates in general practice. 

[00:33:23] So PAs are trained to a medical model. So they are trained to take histories, order investigations, do examinations, and make diagnosis under the supervision of a consultant or a GP. So they work under a GP and there must always be an, an allocated named supervisor. Initially when a Physician Associate first qualifies, they're sort of orientating into their role in settling in and developing their learning needs and kind of meeting their performance expectations.

[00:33:53] They'll start off with long-term conditions minor ailments. And then as they build on their experience, they're able to see more complex patients who may have you know, multiple comorbidities. They may then go on to develop aish specialist interest. For example, diabetes, hypertension; care home. So I'm a care home lead in my practice, and I'm also the asthma lead in my practice as well. So I lead on the asthma team. We get together every quarterly review, the QOF figures. Do we need to sort of increase clinic availability to escalate our asthma patients that we haven't seen as we're getting closer to the deadline, but also reviewing, is there anyone that's, you know, had recent exacerbations that needs urgent review? 

[00:34:34] So I would say Physician Associates are quite unique in that they can support both general practice and the nursing team. So the Physician Associates in my practice are trained to do childhood imms; are trained to do smears. Each PA leads on a particular QOF, L T C work. So I do asthma. My, the other Physician Associate does hypertension, have another Physician Associate who works in diabetes so, not only are they supporting the nurses with the long term conditions, over time, and again, with experience, they're, they're providing more complex care for those who do have complex care. So they're developing on those skills and experience 

[00:35:08] Physician Associates can be developed to support the needs of the practice in line with what the Physician Associate interests are as well, and I think that's what's really important, especially for retention. Practices or PCNs when they're thinking about taking on a Physician Associate, they're a very versatile clinician. To, of course, making sure that they're supporting the practice and, and are developing the PAs that it's in light of the practice's needs.

[00:35:32] They may have a very large cohort of diabetes patients, for example. So one of the first practices I worked in, I was in East London and over 60% of their patients had metabolic disease. So I was become very skilled in hypertension, hyperlipidemia, and diabetes management very, very quickly because very much, a lot of my patients were very much this.

[00:35:52] And then moving over to North central London, the patient cohort is so different. It's very much mental health, women's health, and asthma. So, you know, making sure that the Physician Associates experience and, and skills are developed based on the needs of the practice, and also for retention, of course, ensuring that that's also in line in what the PA or any clinician's interests are and supporting that development.

[00:36:13] And I, I think there's lots of evidence actually as well around retention of workforce around making sure that we are not over utilizing our clinicians, and I see this a lot with Physician Associates and that's something that I'm quite passionate about with my role as ambassador, is ensuring that PAs aren't doing too much because it can be unsafe if they're expected to, see un triaged patients, especially when they haven't yet met their learning performance objectives. 

[00:36:41] And then it's important that as, leads or as supervisors, that we're ensuring we're empowering our teams and fostering an environment where it's supportive and nurturing and clinicians feel that there is always that open door to kind of knock on some doors, say, you know, I'm actually not sure about this. Or, you know can you support me with this? Or, I have a question to ask. Because if they're in an environment that doesn't provide that support, then this is where patient safety can be compromised.

[00:37:08] So, I'm really, really passionate about ensuring that there is very clear guidelines in place in terms of governance to, to have those support structures in place. 

[00:37:17] Rachel Roberts: Thank you. So you've described the enormous potential of your role, how you connect both with GPs, nurses, the type of patient care you can offer, but those really important bits around governance, safe structures, guidelines, and a supported environment for the teams to how we can best make the use of the range of people we have in our teams and to retain them . Absolutely. So, thank you. 

Paramedic

[00:37:39] Rachel Roberts: Andrew, do you have a couple of thoughts about how your role connects with that to the GP? And then if you want to share any thoughts on retention, that would be great. 

[00:37:48] Andrew Preece: Yeah, of course. So I think I guess very similar to the other professions, certainly in some GP practices paramedics might be used to help with some of that initial triage of the sort of list that's coming through.

[00:38:02] Some might help support GPs by doing some of the home visits and seeing some of the patients who aren't able to come to the surgery, but also perhaps do some assessments around frailty and, and also considering some long-term conditions. Paramedics may also help support our GP and nursing colleagues around some of the long-term clinics and the things that, that are there.

[00:38:27] I think for, from my experience, there are sometimes still a shortage of GP nurses, so with that, it means that actually , there is potentially a place where if like, you know, PAs and, and a paramedic has some interest and we want to develop them as well that they can equally also help support some of those clinics.

[00:38:49] Again, where it fits within the practice and our communities. And I think certainly long term, you know, it, it would be great to also see that those that are in advanced practitioner roles, being given the time and space to be able to help support some of those other pillars.

[00:39:08] So we've already talked about quality improvement, research, leadership, and, and also supporting education of their colleagues. So I think all of that together working with GPs and, and colleagues within those environments can help with that retention. And also, Like we say, not everyone necessarily wants to become a consultant practitioner, but what can we do to try and help support those that do or what else can we do to transition people from, say, a first contact practitioner to advance practice?

[00:39:42] Rachel Roberts: Thanks so much, Andrew. Really helpful. Thank you. 

Nurse role

[00:39:45] Rachel Roberts: And so Paul, your thoughts on how your roles connect with that of the GP and then a little bit about retention, if you don't mind. 

[00:39:53] Paul Jeffrey: Yeah. Obviously nursing and the nursing pathway have been linked with. Primary care for many years and have developed through that.

[00:40:02] So it's interesting to hear from Andrew and Chaima about their roles and how they're linked in. Very similar parts of the nursing roles would fit with both of both those. And then obviously we've got the, the lower end coming into nursing and around the healthcare Associates and moving through the training, nurse Associates, nursing Associates all slightly different roles and I think just from this discussion you can see how complex the workforce is in primary care and how important that is to actually look at what the patients requirements are what the population health needs are for each area, and work out how best to use the workforce in that area. 

[00:40:48] I think one of my thoughts with the ARRS roles was it was a bit artificial. I. I, I know we need to get people on the ground, and that's probably why it was brought in, but it's made it a bit artificial and, and those new roles are all really useful and you can just see the multi-professional way that all these different roles come pull together to make a team. Going forward, I think working together is the answer, but we need to not be professionally isolated within those roles. We need to work as a multidisciplinary team and take the strengths from each bit of the roles going forward. 

[00:41:22] Retention, there's a nice little document that NHS employers pulled together a few years ago about what nurses want. And what they said was, nurses want opportunities for development and to be included. And one of the biggest things I hear is where members of the team aren't always included in decisions going forward, where they're actually just told this is what's gonna happen. There's not an explanation. There's not a discussion around what that means for them professionally.

[00:41:52] And I think one of the major things for retaining staff is to make them feel involved and part of the decision making process of care going forward. I think that's important. And the other thing is around understanding the roles we've, we've talked about. The difference in roles. And you can just see from this conversation the complexity of that.

[00:42:14] And just trying to pull out those points about where each person fits, how they're working in a safe way across their, their role, and how all those things link together. I do think there's a, a tendency to push people to work to the top of their license, and I do think we need to keep an eye on that and make sure that we've got enough experts in the system to be training new people coming through.

[00:42:39] I think that's a really big challenge about how we manage the number of trainees that are coming through and making sure that we've got the quality of staff to deliver that training to. 

[00:42:50] Chaima Hale: I just wanted to add to what Paul mentioned about ensuring that you are not over utilizing your team, but also making them feel included and empowering them to support the wider initiatives, to improve patient quality in, in care. And in the different various practices that I've worked in, the one that always stands out to me the most is the one that exercised that sort of distributed leadership model where it, it, it empowered their teams to sort of take on the role of leads within a particular area, and the senior management team didn't get involved. They just entrusted that their team had the abilities to perform. And actually they are a high performing practice because of that. 

[00:43:28] And they also gave them the protected time in order to deliver. And I think providing that protected time, rather than saying, you know, this is kind of your own expectation, do this on top of the other workload that you had. That doesn't work because I've seen that in other practices. Delegate, delegated, delegated on top of your day, your day job, and, and that's unsustainable. So that definite sort of distribution of leadership and empowering teams you know, enables teams to feel that they're supported and also they're appreciated in thereof and valued for what they do.

Final comments

[00:43:59] Rachel Roberts: Thank you so much. So it's been a really stimulating conversation and I think what we've heard are a range of roles you all have and what you contribute both clinically and also all of you I think are involved in educational or educational pathways and the setting up of groups who support each other across the range of professions.

[00:44:19] And I guess this is the time of the most rapid team development we've ever had in primary care. And you've all highlighted the real need to look at how people are supported and their career pathways right from the beginning and that critical importance of retention. And it comes back to a number of words you've all said things about opportunity, things about inclusion, things about listening, being listened to and empowerment, and then the absolutely critical engagement with patients. Because for this to work for patients, our teams need to really be connecting and listening with and alongside them.

[00:44:57] So I think those would be my concluding thoughts, and the need to really support each other as workforce. And again, it's been mentioned, the need to have educational support structures; to have funding for that; to know that we can develop ourselves and our teams and meet the needs of patients and to always hear what it requires to retain our teams and our staff.

[00:45:18] So really big thanks to everyone today for your contribution. It's really much appreciated. 

[00:45:23] 

[00:45:26] Munir Adam: That was incredible. So much richness, so much in common yet so important to understand each other's differences too. Of course, this was just a snapshot of the view of individuals from any particular profession. It's not supposed to necessarily be representative of the entire profession, and you may well have a different view.

[00:45:45] If you have time and lots of staff, you may well be able to get everybody together in a room and explore this topic, but if not, we hope that you found this episode gave you some insight into some of the issues to consider. 

[00:45:56] Or you may be from a different profession to any of the five that were represented in the discussion. Does your role align closely with any of them or is it a unique experience? Do let us know through the feedback form, link, and do share ratings on Apple Podcasts or wherever you listen to your podcasts. As always, I ask you to consider what you can do differently having heard the discussion in order to become an even better person.

[00:46:20] But that's it for now. Join us again next time and some of our upcoming episodes will be on Advanced Care Planning, dealing with the homeless patient, and the importance of accurate medical records. Thanks for staying with us and until next time, keep well and keep safe.

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