Dr David Kernick describes how GPs and nurses in his practice combined their skills to develop a nurse-led dermatology service and a minor illness clinic


The lack of evidence to support the benefits of continuity of care from a GP and the desire to obtain maximum benefit from limited healthcare resources have seen the nursing profession increasingly in the spotlight. It has also become clear that patients appreciate a health professional who addresses their needs, irrespective of the professional's status.

The background to the evolving role of nurses is outlined in Box 1 (below).

Box 1: the changing role of nurses in primary care
  • Since the introduction of the new contract for GPs in 1990 there has been a rapid expansion of nursing in general practice. This has been marked by a growing trend for many activities that were previously undertaken by doctors, such as health promotion, disease prevention and management of common conditions, to be delegated to practice nurses.
  • Over the past 10 years, the number of nurses employed in general practice has trebled. It has been estimated that there are now 9400 whole-time equivalents working in primary care. However, the number of nurse practitioners – nurses who receive advanced training and are able to work with undifferentiated and undiagnosed problems remains quite low.
  • Against a background of evidence which suggests that 30–70% of tasks performed by doctors could be carried out satisfactorily by nurses, a wider role for nurses in primary care is not new.
  • In North America, nurses have had a leading role in the provision of primary medical care for many years. It has been estimated that there are more than 25000 nurse practitioners in the US who work independently, and the numbers are still growing despite vigorous opposition from the American Medical Association.

The emphasis, however, in the UK remains on the development of team working (see Figure 1, below), where each practitioner offers his/her unique skills towards a common goal.

Figure 1: Types of team working

Vertical

The GP decides what is to be done and delegates care accordingly – this is the traditional model within the NHS
Competitive GPs and nurses compete for roles, as they do in many parts of the USA
Horizontal GPs and nurses work together as equally valued members contributing their unique skills

Innovations involving team working

The retirement of a partner in our practice gave us an opportunity to review the services we offered our patients. We introduced three innovations:

  • Patients were given direct access to a physiotherapy opinion.
  • They were able to see a nurse specially trained in dermatology, an area where we experienced a high demand.
  • They were offered direct access to a minor illness nurse. This involved developing practice protocols for the management of common minor illnesses (see Figure 2, below).
Figure 2: Practice protocol for the management of sinusitis
Sinusitis practice protocol

This article describes the two nursing developments. These three innovations formed the basis of our Beacon practice submission.

Nurse-led skin clinic

A recent innovation is for nurses to specialise in specific clinical areas such as asthma or diabetes. Although the role of the dermatology specialist nurse is not new in hospital care, few nurses offer this service in general practice.

Skin disease can have a major impact on patients' lives and research has shown that this disability is often underestimated and many needs remain unmet.

GPs often lack many of the skills needed for practical dermatology care and support. Many patients are embarrassed about their appearance and the psychological impact of skin conditions may go unrecognised.

The dermatology department of our local hospital wished to appoint a primary care dermatology liaison nurse to train practice nurses in the practical aspects of dermatology care.

We set up a clinic to test this concept and collect evidence to support its introduction. Our aim was to test the benefit of our clinic on patients with eczema and psoriasis and estimate the resource implications of setting up such a clinic.

Evaluating the clinic

We invited all patients on our practice list with a diagnosis of psoriasis or eczema to attend the clinic. From this, 109 patients agreed to enter our study.1

Since the project was initially set up as a research study, we randomised patients into those who saw the nurse early on (the intervention group) and those who waited 3 months to see her (the control group). Control patients received routine GP care.

On completion of the study the clinic continued to run, with patients being referred either by GPs or our other practice nurses or by self-referral.

After our initial study, we found that the best way to run this service was for patients to make a specific 'dermatology appointment' with our specially trained nurse, who worked in the treatment room rather than in a specific clinic. This utilised her time more effectively than constraining her to specific clinic times.

It soon became clear that our nurse was able to offer valuable support and advice to patients. She had a range of emollients and additives that she was able to recommend, and the major benefits came from providing psychological support and from having the time to make sure that patients were using the correct medication in the proper manner.

During our research study we found that patients benefited significantly when we determined the impact of their skin problem with a specific questionnaire designed to measure such factors as itch, scaling, redness, dryness etc.

We also collected many positive comments about the clinic, some of which are shown in Figure 3 (below).

Figure 3: Some comments from patients about the dermatology clinic

"I can now go swimming, as before I was embarrassed to take my clothes off."

"I thought my dermatology problems too trivial to bother my GP with, but it was ideal to discuss these issues with the practice nurse."

"I think after all these years I have at last got the medication right."

"I have been very embarrassed staying away from home leaving scaly skin everywhere, but now it is OK."

Our nurse was able to demonstrate a significant reduction in GP consultation time for dermatology problems. During the study period, 14 patients saw their GP in the control group for a skin problem compared with only two in the group who were receiving care from the dermatology nurse.

Nurse-led minor illness clinic

Our nurses were trained in house, using formal teaching sessions and sitting in with GPs.

We developed practice protocols for the management of common minor illnesses (see Figure 2, above, for a sample practice protocol).

A small prescribing formulary was also developed. Nurses were able to issue prescriptions, which the doctors signed without necessarily seeing the patient.

Patients were able to make an appointment to see the minor illness nurse up to 48 hours before any clinic and were encouraged to do so by the receptionists. The most common presentations were respiratory tract infections followed by dermatology problems. A large proportion (45%) of patients were aged under 16 years.

Since the introduction of the clinic, our design has been followed by a number of practices in the area. Nurses from other practices have sat in on our clinics and are now using our treatment protocols.

Patient feedback

An audit of the service provided was undertaken by a postal survey of the 181 patients who attended the minor illness clinic.2

The audit included reason for the appointment, whether the patients were satisfied with the consultation, whether patients required a prescription following their consultation, and whether the nurse requested an opinion from the GP.

In addition, we sought to capture qualitative data by asking patients to comment on their experience of the minor illness clinic.

From a retrospective analysis, we obtained the number of patients who were seen by a GP within 5 days of their appointment.

There was a 53% response rate to the postal questionnaire. The results revealed that:

  • 97% of respondents were satisfied to be seen by a nurse
  • 57% required a prescription
  • In 23% of cases, the nurse requested an opinion from the GP
  • 17% saw a GP within 5 days of their appointment, compared with 5% of patients returning after a GP consultation for minor illness.

This audit was carried out at the start of the clinic when our nurses were inexperienced at dealing with minor illness. With time, the number of cases for which the nurse required a GP's opinion, and the return consultation rate, have dropped considerably.

The majority of our qualitative data was positive and indicated that the minor illness clinic was making a useful contribution to the medical services provided to our patients.

References

  1. Kernick D, Reinhold D, Sawkins J, Powell R, Warin A. A cost-consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis. Br J Gen Pract 2000; 50: 555-8.
  2. Kernick D, Watson M, Baker H et al. An audit of a practice nurse specialist clinic. Clinical Effectiveness in Nursing 1999; 3:132-5.

Guidelines in Practice, February 2002, Volume 5(2)
© 2002 MGP Ltd
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