Workforce development for
practice nurses and HCAs
Lambeth’s Innovative Nurse Lead Group
October 2015
Key messages
Primary care is at the heart of healthcare but there are not enough well-trained
nurses and healthcare assistants to cope. The first ever practice nursing workforce
team in England was set up to tackle this in Lambeth.
Over the past two years, Louise Ashwood, Jude Costello, Anne Macrae and Paula
Marsden have helped to increase the number of healthcare assistants, increased the
training and supervision available to healthcare assistants and practice nurses,
improved retention and increased satisfaction.
Successes include:

Before the nursing workforce team was in place there was no register of nurse
mentors. Now there are 38 trained mentors on the register – at least four
times more than any other area in south London.

Before only one practice took student nurse placements, now four do.

Eight nurses new to general practice are on placements, and five of these
have already been offered jobs at their training practices.

Ten clinical supervision groups run at different times during the week, with 80
nurses taking part (80%).

Six nurse educational forums are run each year focusing on local and national
best practice, with about 40 nurses attending each.

Training on ‘hot topics’ such as mental health and immunisations is offered on
a rolling basis, with high attendance and excellent evaluations.

The number of healthcare assistants has increased by 25%. All HCAs have
attended an upskilling course and seven out of ten attend regular supervision.

100% of healthcare assistants and 90% of practice nurses say that they now
have much better access to clinical supervision and feel well supported.
Local nurses and HCAs sing the praises of the Nurse Lead Group. This innovative
approach is something that Lambeth can be proud of. It shows what can be done by
dedicated nurses, focused on improving the support and skills of the local workforce.
2
Contents
Background
The Nurse Lead Group
4
4
Activities
6
Successes
7
Student nurses in primary care placements
Nurses new to general practice
Supporting nurses in practice
Nurse mentors
Clinical supervision
Practice nurse forums
Ongoing training
Funding for CPD
Nurse practitioners
Revalidation for nurses
Healthcare assistants
Feedback
Suggestions for development
Summary
Outcomes
Key success factors
8
8
8
9
9
9
10
10
11
11
11
12
16
17
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3
Background
Nurses and healthcare assistants in primary care work hard to make sure that
people and families have the best care possible. This can be a rewarding as well as
a challenging role, and requires robust education and support.
Most clinical commissioning groups (CCGs) in England have a primary care nurse
lead to focus on education, supervision and support. This person may work anything
from a few hours a week to full time, depending on the priorities of individual CCGs.
In London, the Lambeth area has taken an innovative approach. A Nurse Lead
Group is made up of four nurses who undertake clinical roles in addition to working
four to six hours per week on educational and support activities. This model has
many merits and may be something that other CCGs could learn from.
The Nurse Lead Group
History
Lambeth has 47 general practices, about 100 practice nurses and 35 healthcare
assistants. For many years, Lambeth had an individual nurse lead, much like CCGs
around the country. The nurse lead was employed by the CCG to make sure that
standards and supervision were in place, and worked with others to provide a forum
for nurses to meet, network and upskill. The post was made redundant and there
was a perception that standards began to suffer.
Practice nursing can be an isolating role and without regular education and support,
it may be difficult to feel confident that the safest and highest quality care is being
provided. Lambeth CCG undertook a review of practice nurse services and identified
a gap. Two years ago, nurse Brenda Donnelly approached four experienced practice
nurses to come together as a Nurse Lead Group to fill the gap.
4
New model
The Nurse Lead Group is made up of four dedicated individuals who work part-time
as practice nurses (three to four days per week): Louise Ashwood, Jude Costello,
Anne Macrae and Paula Marsden. In addition to their clinical role, the CCG
reimburses these nurses for four to six hours each per week to organise education
and support for practice nurses and healthcare assistants. The main roles include
providing a source of information, a support network and commissioning local
training.
The Nurse Lead Group meets about every six weeks to plan and review progress. In
between meetings, each nurse takes responsibility for a specific geographic area
(there are three localities within Lambeth) and for a substantive area such as
mentoring, nurse education, encouraging nursing students to work in general
practice and training healthcare assistants. They also attend CCG, development,
education and governance meetings in to remain informed and involved in decision
making.
The Nurse Lead Group is supported by and reports to a director at the CCG.
The unique components of this model are that it draws on a team of nurses rather
than one individual and that the nurses are working in clinical practice as their
primary role. This has the benefit of spreading the load and means there is a wider
range of interests and peer support. Working every day in primary care means that
these nurses have intimate knowledge of the challenges facing practice nurses.
“As a Nurse Lead team the four of us work really well together, complimenting
each others’ strengths and giving support to one another. We are all in clinical
practice and really appreciate what practice nurses in Lambeth are
experiencing so we can give authentic and accurate advice to our nursing
colleagues.” (Member of Nurse Lead Group)
Another benefit is that if one member of the team leaves, the entire skillset and
background knowledge is not lost because other members would remain.
5
Activities
Key activities that the Nurse Lead Group has focused on over the past two years
include:







encouraging student nurses to attend placements in primary care, with the
aim of recruiting more practice nurses
developing a database of practice nurses and healthcare assistants
contacting practice nurses and healthcare assistants regularly about
employment issues, continuing professional development and mandatory
training
setting up study days and educational opportunities for practice nurses,
including immunisation training, a non-medical prescribing day and a practice
nurse forum every other month
expanding the mentoring and supervision network so every nurse has contact
with a mentor and is invited to attend clinical supervision group meetings
setting up a clinical supervision programme for healthcare assistants
setting up a six-day basic competences course for healthcare assistants, in
partnership with a university. This is now a certified programme incorporating
the care certificate
Each of the nurses in the Nurse Lead Group takes responsibility for a specific
substantive area: healthcare assistants, mentoring, practice nurse training and nurse
placements.
“The nurses who make up the leadership team at the CCG have many years
of experience in primary care. We all share a common goal, which is to
ensure that the general practice nursing workforce is fit to provide high quality
care to our patient population and that we are all safe practitioners.” (Member
of Nurse Lead Group)
6
Successes
Having a Nurse Lead Group has resulted in specific improvements in education and
workforce development. In particular, there have been:







increases in the number of healthcare assistants in post (25% increase)
improvements in the standardisation of training for healthcare assistants
increases in the number of new nurses placed in practices
increases in the number of practices taking nurse placements
increases in the number of practice nurses and healthcare assistants taking
part in clinical supervision
increases in the number of trained nurse mentors on a register
increases in the number and range of training courses available locally
Table 1 lists changes before and after the Nurse Lead model was implemented.
Table 1: Changes before and after implementation of the Nurse Lead Group Model
Feature
Number of healthcare assistants
Number of healthcare assistants
upskilled to standardised level
Number of healthcare assistants
undertaking clinical supervision
Number of practice nurses
New nurses placed in practices
Number of practices that take
student nurse placements
Number of nurses undertaking
clinical supervision
Total number of trained nurse
mentors on register
Number of nurse mentors who
received annual update training
2013
Before Nurse Leads
28
0
2015
After Nurse Leads
35
35 (100%)
0
25 (71%)
100
0
1
100
8 (5 offered full time
contracts)
4
30 in four groups
80 (80%) in ten groups
0
38
0
25 (66%)
7
Student nurses in primary care placements
Before the Nurse Lead Group was in post, only one out of 47 practices took preregistration student nurses on placement. Now, four practices are taking placements
with others getting ready to begin.
The team has devised a workbook for pre-registration student nurses to use whilst
on placement as it was found that the primary care setting is very different to other
experiences that the students encounter during their training.
The team is negotiating payment for practices that take student nurses on placement
so that funding is commensurate with what GPs receive for taking medical students /
GP trainees. Currently practices are not reimbursed by universities for taking nursing
students and this is a barrier for practices, particularly as protected time is required
for planning and assessments.
Nurses new to general practice
The Nurse Lead Group has worked with the Community Education Provider Network
(CEPN) and London South Bank University (LSBU) to support a course for nurses
new to general practice. In the first year, eight nurses from the course were placed in
Lambeth. Of these, five have already been offered a contract within their training
practice (the course ends in January 2016).
The Nurse Lead Group is also involved in commissioning courses for nurses new to
general practice for the next academic year.
All nurses new to general practice in Lambeth have been visited by a Nurse Lead to
offer information and support.
Supporting nurses in practice
Almost all nurses in Lambeth have been visited, in their practice, by a Nurse Lead.
The Leads offer support, assess education needs and signpost to training. The
Leads involve Practice Managers and Partners as appropriate to support the
ongoing development of the workforce.
8
Nurse mentors
Before the Nurse Lead Group was in post there was no register of recognised nurse
mentors. After just two years there are 38 trained and recognised mentors on the
register in Lambeth. This is four times the number in any other South London
borough. Each year, a mentorship update session is provided.
Clinical supervision
When the Nurse Lead Group came into post there were four small supervision
groups running with about 30 nurses in total (30% of the total). Trained supervisors
were not paid for their time.
The Nurse Lead Group prioritised ensuring that every practice nurse and healthcare
assistant was offered the opportunity to attend a clinical supervision group during
their normal working hours. Facilitators were given update training, new groups were
established, standards and guidance for supervision were circulated to all nurses
and managers and the groups were run by trained paid supervisors.
Ten clinical supervision groups are now run at differing times in the week and 80
nurses attend regularly (80%). Nurses new to general practice are given a space in a
group together for the first six months of their employment.
Practice nurse forums
Practice nurse forums were run prior to the Nurse Lead Group, but under the new
model the forums have flourished, becoming a mechanism for peer support and
learning. The sessions run six times per year. They are used to update nurses about
local initiatives, new ways of working and education from local services. There is a
waiting list of speakers wishing to present. On average 40 nurses attend each
session.
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Ongoing training
The Nurse Lead Group has ensured that regular ongoing training is available about
priority topics.
The health of residents with mental health issues is one of Lambeth’s health
priorities. Very few practice nurses have any substantial mental health training or
experience and so nurses felt ill prepared to support these residents with their
physical and mental health needs. The Nurse Lead Group set up a specific course
about this, in partnership with mental health experts. The course, which runs over
two half days, is offered twice yearly. To date, nearly 70 practice nurses have
attended (70%). The course has been offered in an adapted form for healthcare
assistants
Another priority was immunisation training. Nurses were finding it difficult to access
good quality courses on an annual basis to meet their CPD requirements. The Nurse
Lead Group worked with others to run updates twice yearly. Presentations are given
by local public health and community paediatric consultants. Almost all local nurses
have taken part in this course.
Annual updates for the launch of the flu campaign are also run for both nurses and
healthcare assistants.
Non-medical prescribers had previously been left to find and fund their own annual
updates. Local university updates were not wholly relevant to general practice. The
Nurse Lead Group commissioned courses with a primary care focus. These are now
open to local non-medical prescriber pharmacists who are working within primary
care.
Three nurses have been funded to complete a non-medical prescribing course.
Prescribing supervision is offered quarterly to all non-medical prescribers in
Lambeth.
The Nurse Lead Group has also organised for 19 experienced nurses to become
cytology supervisors. These supervisors support and assess nurses completing their
foundation cytology training. Cytology updates are provided for nurses to meet CPD
needs.
Potential nurse leaders of the future have been identified and are being supported
and coached to take on development and administration roles to support succession
planning.
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Funding for CPD
The Nurse Lead Group is responsible for approving funding requests for ongoing
CPD. This is to ensure equity in the administration of the training budget across
individual nurses and practices. Course content is checked for quality.
Nurse Practitioners
There are six advanced nurse practitioners in Lambeth and one in training. Bespoke
one day update courses have been commissioned specifically for this group and are
held four times a year.
Revalidation for nurses
Lambeth CCG has funded software for revalidation for all primary care nurses.
Working together with the software supplier, the CEPN and Nurse Lead Group have
organised training sessions to help nurses use the system. Practice nurses who
have expertise in computer skills are being trained to act as a resource for other
nurses.
Healthcare assistants
Healthcare assistants (HCAs) are increasingly being employed in primary care as
the general practice workload increases and primary care starts to adopt a ‘skill mix’
approach to staffing. Healthcare assistants are an essential part of the workforce but
are not currently required to be registered.
Since the Nurse Lead Group began, the number of healthcare assistants has
increased by 25%. An audit was undertaken to assess numbers and training needs
and a register of healthcare assistants has been developed. All but eight healthcare
assistants have been visited at their practice and all have been offered clinical
supervision.
All healthcare assistants have taken part in a basic training course which now
incorporates the Care Certificate. Ongoing training is offered about priority topics
such as flu, spirometry, venepuncture, ear syringing, foot checks, mental health,
wound care and diabetes.
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Feedback
In September 2015, all healthcare assistants and practice nurses in Lambeth were
invited to take part in an online survey about educational and development activities.
Feedback was received from 43 practice nurses (43%) and 21 healthcare assistants
(60%). Response rates to online surveys of this nature are generally around 10-20%,
so this is a high response rate.
Nurses who gave feedback were a mix of those who had been in post less than one
year (12%), right through to those who had been in post more than ten years (55%).
Similarly, the healthcare assistants who provided feedback were mix of those who
had been in post less than one year (24%) through to those who had been in post
more than ten years (19%).
Nurses and healthcare assistants were positive about the level of supervision and
training available to them in Lambeth. They thought that the clinical supervision set
up by the Nurse Lead Group was valuable (see Figure 1).
“Clinical supervision is excellent. I think it's essential for practice nurses as it
is such an isolated role in a surgery.” (Practice nurse)
“I feel without supervision and support from other HCAs it would sometimes
make my job much harder.” (Healthcare assistant)
“I feel very supported and any questions are always answered and it is good
to be part of a supervision group to find out how other practices run.”
(Healthcare assistant)
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Nurses and healthcare assistants felt that clinical supervision influenced how they
worked and improved the quality and safety of the care provided.
“Clinical supervision has been very useful and informative to me and has
made a significant impact in my everyday practice. I see it as a place I can
rely on for both clinical and emotional support.” (Practice nurse)
“I feel more confident since I am part of clinical supervision group. This is very
useful.” (Practice nurse)
“Supervision gives me a protected space to ask any questions /issues that
are raised in day to day in my role as a HCA. Practice team may busy or do
not have the answers. Any extra training/updates that is required by patient
care are raised and taken into consideration and provided- funding permitted.
I was isolated for many years, thanks to clinical supervision I feel supported,
more informed, competent and enjoying my job.” (Healthcare assistant)
“It is a very important part of the role of HCAs as we are not regulated it is
important to know we can ask things we are not sure of and enforce
boundaries for safe practice.” (Healthcare assistant)
Nurses and healthcare assistants also praised the variety of training and support
available.
“Training opportunities are excellent and cover a good range of relevant
topics. Anticipation also of what we need is good eg the training on our
validation etc.” (Practice nurse)
“There are regular practice nurse forums with great speakers and time for
networking. All the Nurse Leads are approachable, supportive and fun!”
(Practice nurse)
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Healthcare assistants in particular felt that there had been a significant shift in how
they were valued and supported.
“I have seen massive changes in the support for HCAs in Lambeth. In fact I
would say Lambeth are taking the lead for other boroughs to follow.”
(Healthcare assistant)
“We have never had or been represented outside of our work place before.
Now the information on training is always forwarded to us. To know we have
support outside of the workplace is a great comfort.” (Healthcare assistant)
Nurses said that the Nurse Lead Group had specific skills and were providing
support in a unique and innovative manner.
“Any clinical nursing related info is good to query with them... This wouldn't be
possible from a non nursing or different nursing group/person.” (Practice
nurse)
There was wide appreciation for the work that the Nurse Lead Group does.
“Very informative on all training and study days and they work tirelessly to
answer all our e-mails and concerns. Great to have this team.” (Practice
nurse)
“Very positive and supportive resource to have. We are lucky to have them.”
(Practice nurse)
People noted that they felt more supported over the past two years and had more
access to training. In other words, they could see a discernible difference since the
Nurse Lead Group have been in post (see Figure 2).
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Figure 1: Feedback about clinical supervision from nurses and healthcare assistants
Healthcare assistants
Practice nurses
90
88
I am part of a clinical supervision group
76
I attend clinical supervision meetings
most of the time
80
90
Clinical supervision improves my
practice
85
90
Clinical supervision is good for sharing
ideas and information
98
90
Clinical supervision is supportive
95
86
87
My practice makes it easy for me to
attend supervision
0
20
40
60
%
80
100
Note: Feedback was provided by 43 practice nurses and 21 healthcare assistants.
Figure 2: Perceived changes in the support and training available over time
Healthcare assistants
Practice nurses
94
Compared with two years ago I have
better access to training
82
100
Compared with two years ago I have
better access to supervision
91
100
There is more support for nurses/HCAs
in Lambeth compared to two years ago
72
95
I feel better informed about local
issues compared to two years ago
84
94
I feel better informed about national
issues compared to two years ago
68
0
20
40
60
%
80
100
Note: Feedback was provided by 43 practice nurses and 21 healthcare assistants.
15
Suggestions for development
Practice nurses and healthcare assistants were asked for ways that the work of the
Nurse Lead Group could be improved. Few provided suggestions for change, with
some saying that the team was ideal as is.
The small number of suggestions for development focused on:








continuing to have a wide range of training topics available (2 practice nurses)
investigating further flexible funding sources, including funding for online
courses and help to find placements (2 practice nurses)
having training sessions on a variety of different days, as some people cannot
attend specific days (1 practice nurse)
having larger venues as sometimes courses are cramped (1 practice nurse)
campaigning for more than one nurse from practices to attend sessions (1
practice nurse)
developing a competency package or workbook (1 practice nurse)
looking at pay rates and job descriptions to help rectify discrepancies (1
practice nurse)
providing administrative support for the Nurse Leads (1 practice nurse)
“Some GPs are not supportive of their nurses furthering their education and it
will be helpful if the nurse leadership team can help plan and organise better
support for nurses in Lambeth that are interested in developing or improving
their scope of practice eg advocating for extra funding if a nurse needs
placement.” (Practice nurse)
“The main issue is being released from surgery - often the learning on events
is through the questions from other attendees so it is not realistic to say only
one member of a nursing team attend and feed back.” (Practice nurse)
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Summary
Outcomes
Having a team of practice nurses leading workforce development has resulted in
tangible outcomes in Lambeth. Local practice nurses and healthcare assistants sing
the praises of the team.
Key successes include:

Before the nursing workforce team was in place there was no register of nurse
mentors. Now there is a register with 38 trained mentors – at least four times
more than any other area in south London.

Before only one practice took student nurse placements, now four do.

Eight new nurses to general practice are on placements, and five of these
have already been offered jobs at their training practices.

Ten clinical supervision groups run at different times in the week with 80
nurses taking part (80% of practice nurses).

Six nurse educational forums are run each year focusing on local and national
best practice, with about 40 nurses attending each.

Training on ‘hot topics’ such as mental health and immunisations is offered on
a rolling basis, with high attendance and excellent evaluations.

Nineteen experienced nurses have been trained to become cytology
supervisors.

The number of healthcare assistants has increased by 25%.

All HCAs have attended an upskilling course and seven out of ten attend
regular supervision.

100% of healthcare assistants and 90% of practice nurses say that they now
have much better access to clinical supervision and feel well supported.
17
Key success factors
The successes in Lambeth have a lot to do with the dedication and commitment of
the four nurses making up the Nurse Lead Group. However, this is an approach that
could work in other areas too. Other areas wishing to test this approach could
consider the following tips:

Ensure that those planning and supporting workforce development are part of
the clinical workforce themselves to promote empathy and credibility.

Having a team helps to share the workload and means that nurses can divide
their time between clinical practice and workforce development activities.

Consider selecting nurses that have been in the area for a considerable
length of time. This helps with credibility and means nurses are well versed in
local structures and practices.

Make sure that the Nurse Lead team has a clear and direct link to the CCG for
strategic input and support. This includes clear lines of accountability and
access to information and funding support.

Divide the work clearly between the Nurse Lead team members, so each
person has a defined role and set of responsibilities.

Visit every practice initially to speak to practice nurses and healthcare
assistants so they know there is a support network available and to assess
their needs.

Ensure regular communication with nurses and healthcare assistants by email
and using educational forums and meetings. Regularity is key.

Focus on ensuring good mentoring and support within practices, so that there
is a solid foundation for recruiting new people.

Focus on healthcare assistants. Providing training and supervision can help
these team members feel supported and valued, can build their career paths
and can improve the quality and safety of care offered.
“This has never been tried before. It works well because the team leading
workforce development are working day to day as practice nurses and
drawing on the skills of a whole team. This is an effective and sustainable
approach that other areas could try.” (Member of Nurse Lead Group)
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Nurse lead Team
Louise Ashwood
Senior Practice Nurse and Lambeth CCG Nurse Lead
Paxton Green Health Centre. London.
Judi Costello
Nurse Practitioner and Lambeth CCG Nurse Lead
Herne Hill Road Medical Practice. London.
Anne Macrae
Senior Practice Nurse and Lambeth CCG Nurse Lead
Herne Hill Group Practice. London.
Paula Marsden
Nurse Practitioner and Lambeth CCG Nurse Lead.
Binfield Road Surgery. London.
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