How to set up a Nurse Led Minor Illness Management Service
'How to...' Guide
Contents
Background
Why set up a nurse led minor illness service?
Getting started
Minor illnesses are generally described as common, often self-limiting, conditions e.g. coughs & colds, hay fever, head lice. They normally require little or no medical intervention and are usually managed through self care and / or the use of products that are available to buy without a prescription.
However many patients choose to consult their GP about their minor illnesses to seek reassurance, particularly where children are involved, or to obtain treatment free of charge where patients do not pay for prescriptions.
Nurse led minor illness management services are a way to channel demand for minor illness consultations to an appropriately trained nurse instead of the General Practitioner. Generally nurse led minor illness services are delivered in a clinic setting at specified times and for specified conditions. The decision to consult a nurse rather than a GP rests with the patient who is assisted to make a choice by information provided by the practice team. A GP appointment is always available to the patient if it is needed.
Nurse led minor illness services are now an established feature in many general practices, their adoption is a consequence of the escalating demand from patients for minor illness consultations and the competing demands on the time of GPs which has encouraged many practices to introduce the nurse led approach to provide more capacity and to attenuate future demand through patient education.
This guide provides an insight into the characteristic elements of a nurse led minor illness service, it is intended to help practices considering setting up a new nurse led service and to provide a timely opportunity to review existing services for practices that have already put a nurse led service in place. This guide has been developed by drawing on the experience of practices that have contemplated the challenge of meeting demand from patients and decided to introduce a nurse led minor illness service. Many of these practices feature as case studies in the WiPP Database of Good Practice which can be found on the WiPP website – http://www.wipp.nhs.uk/db.php
Minor illnesses account for between 100 and 150 million GP consultations per year, for conditions that are potentially self-treatable1. In addition, research from the Proprietary Association of Great Britain (PAGB) shows that up to 40% of GP time is taken up dealing with patients suffering from minor illness2.
Nurse led minor illness services are a common feature of many general practices. While there are no national statistics for the number of practices offering nurse led services, a browse through the websites of many GP practices shows that the concept of a dedicated minor illness service is well established in primary care.
The overall aim of these services is to deliver cost-effective access to advice and treatment, improve accessibility to primary care across the local community and establish a lesser degree of reliance on GP consultations for self-limiting conditions.
Why set up a nurse led minor illness service?
Understanding what drives workload in general practice is the first step in identifying potential solutions to the challenge of matching capacity to demand. For many practices a key driver of workload is the demand for appointments from patients with minor or self limiting conditions. It is this demand that has prompted many practices to put in place nurse led minor illness services.
The impact of escalating workload is often felt by GPs, however the effect on the rest of the practice team cannot be underestimated. Receptionists are stressed because they cannot meet patient demand for appointments, nurses are frustrated because they feel that they have the potential to help but can't and practice managers have the challenging task of working hard to keep the practice functioning effectively.
The impetus to develop a nurse led minor illness management approach often stems from an "event" or developing situation in the running of the practice, for example:
- the departure of a GP from the practice team
- the demands placed on duty doctors
- the level of "extra" appointments added to routine clinics
By adopting a nurse led approach to minor illness management practices are able to make better use of the GP's time and to provide a challenging and rewarding role for practice nurses and the wider practice team.
Example
The case studies that we draw upon for this guide have achieved their own successes from the introduction of a nurse led approach. These include:
- 60 appointments saved each week for a practice with a 6000 population
- "extra" appointments at the end of routine clinics becoming a thing of the past
- longer GP appointment times, extended from 10 – 15 minutes in one case
- maintaining existing services while dealing with a GP vacancy
Action points
√ Evaluate your current practice workload for minor illnesses, who currently deals with these patients?
√ Review the choices that patients have when they approach the practice for an appointment, are alternatives to a GP available?
√ What current or future challenges does the practice face in managing its workload?
To develop an alternative approach to managing minor illnesses for your practice you will need to begin with a period of planning and consultation. Developing an alternative approach to managing minor illnesses needs to take account of the unique circumstances of the practice.
In all of our case study examples the practices took a consultative approach to developing their service often using a practice away day or similar to focus on how to better manage their workload. Getting the buy-in of the entire practice team is essential as each member of the team has a part to play in making the service a success. Reception staff are particularly crucial to the success of the service as they will need to adopt a new role signposting patients to the nurse led services (see below).
For small practices this is an ideal time to discuss the idea with neighbouring practices to explore the idea of sharing staff and resources to develop the service. Your PCT may also be able to help to bring together a group of practices with an interest in developing alternative approaches to minor illness management.
Lime Tree surgery decided to undertake a survey of patients before setting up their nurse led minor illness service.
A survey was undertaken with 248 patients over a 4-week period. Patients were offered the option of a GP telephone appointment or a face to face nurse triage appointment. The results of this survey showed that:
11% would prefer a GP telephone appointment
68% would prefer a face to face nurse appointment
21% who would prefer to retain a GP appointment
The results gave the practice confidence that the nurse led service had the support of most patients. of survey by Lime Tree.
More information: Dr Liaquat Ali, Principal GP, Lime Tree Surgery. Email: lali@doctors.org.uk. Tel 020 8519 9914
Discussing plans to develop a nurse led service with the practice team is an opportunity to sound out interest among the existing members of the nursing team in becoming involved in the provision of the service. Almost all of the practices that we consulted identified and developed existing members of their nursing team. Nurses who took on the role of minor illness management among the case study sites had an interest in developing their skills to include minor illness management. This enthusiasm is important as the training requires some dedication and dedicated time both on and off the job.
The approach taken to training varies across the practices that we consulted, however all training had a significant practical element which included a period of time working alongside the GP. This is an important part of shaping how the minor illness service will work in practice. By working alongside the GP the nurse can understand how the GP deals would deal with the conditions covered in the service, when they would choose to refer or treat. Nurses and GPs that we spoke to felt that this was important in establishing a practice approach that was consistent whether nurse or GP led.
Fairbrook Medical Practice had prioritised the development of a nurse led minor illness service. An opportunity to access training in minor illness management presented at the same time that the practice was considering how to best manage demand for appointments. The practice accessed training supported by their local workforce development confederation, the training used a mixture of self directed learning and tandem sessions where the nurse and GP worked together. This practical approach supported the nurse to develop the protocols that would ultimately be used in the service.
More information: Sue Radford, Senior Practice Nurse/Nurse Practitioner, Fairbrook Medical Centre. Email: sue.radford@gp-E82012.nhs.uk. Tel: 0208 953 7666
The Minor Illness Management section of the WiPP website includes a matrix (link) of training providers for nurses interested in undertaking minor illness consultations.
What should the service cover?
Deciding which conditions are "minor" and so will be covered by the minor illness service is a matter for the GPs and nurses to agree. Each practice has a list of conditions that the GPs and nurses have agreed will be included in the service. In practice the list will determine how many patients will access the service and how they understand the scope of the service. The service may also be focused on specific groups of patients, for example children. The training undertaken by nurses planning to provide a minor illness service will also determine the scope of the service at the time of launch, the training provides an opportunity to develop the treatment protocols and to reflect on the inclusion and exclusion criteria that should apply to the conditions covered by the service. As minor illness services become established nurses and GPs will find that the scope extends to include new conditions as confidence and competence grows.
Deciding what to include in the minor illness service also needs to be integrated with other local minor illness services, for example pharmacy minor ailment schemes and Walk in Centre services. Careful consideration also needs to be taken of how the illnesses covered in the service are described to patients, avoiding medical terminology and jargon so that they can make informed choices about which practitioners to see.
Ultimately the scope of the service needs to be communicated to patients so that they understand when it is appropriate to make an appointment to see the nurse. Developing the service with this in mind can help to minimise confusion for patients and encourage uptake.
Goyt Valley Medical Practice established a dedicated first contact health visitor service to triage and treat common childhood ailments. The service deals with around 170 requests for appointments each week from parents of young children. The service tackles the immediate need of parents for a diagnosis, treatment and reassurance, it also supports the ongoing contact between health visitor, parent and child to encourage self care and to monitor development.
More information: Mike Richardson, Nursing Team Leader / Health Visitor, Goyt Valley Medical Practice. Email: mike.richardson3@nhs.net. Tel: 01663 732911
Adding a new service like a minor illness management service into a practice will precipitate the need for space and some equipment. Our case study sites all had to deal with the challenge of identifying space to run the service in practices that had limited space.
If space permits then establishing a permanent home for the nurse led clinic can also help to establish the minor illness service in the minds of patients. A permanent location helps patients to identify with the service and to remember the service the next time they need help with a minor illness, this is important in reinforcing the message to patients and to ensure that the nurse always has the equipment and materials that they needed to hand.
Amersham Health Centre established a nurse led minor illness service in 2003. There are three factors that have contributed to the success of the service:
Effective branding
The practice developed a brand for the service by giving it a name, "Express Clinic" and associated this with appropriate imagery – an express train. This branding is used throughout the practice and in all communications relating to the service. Signs lead patients from the entrance to the practice via reception and ultimately to a room dedicated for use by the express clinic. The intention is to help patients to make an appropriate choice when seeking an appointment. It was also considered important to communicate with patients in terms that they would use rather than those that healthcare professionals use hence avoiding terms like "Minor Illness".
A dedicated room
A dedicated room was set aside for the clinic, this is important in reinforcing a consistent message to patients and to ensure that the clinician has the equipment and materials that they needed to hand.
Consistency
The clinic is always available whenever GPs are on duty. The practice has three part time nurses who run the express clinic, this ensures that in most cases the clinic runs with one of the three dedicated specialist nurses on duty. If staff illness or holiday means that neither nurse is available then a GP will run the express clinic. The important message for patients is that the express clinic is always an alternative to a GP appointment.
More details: Dr Alan Dellow, Senior Partner, Amersham Health Centre. Tel: 084 44 77 87 33. Email: alan.dellow@btopenworld.com
Getting started: Action points
√ Take time out to discuss how the practice currently manages minor illnesses
√ Consult with reception, nursing and GP colleagues. Ask patients what they want.
√ If you are a small practice, consider getting together with other small practices to share the work
√ Aim to develop your existing workforce, identify staff with an interest in minor illness management who can be trained to take on a new role
√ Identify local sources of training and funding, e.g. HEIs, PCT and WDC
√ Take into account the impact on the practice of periods of off the job training – the practice will need to be flexible
√ Set aside time for supervised sessions where nurse and GPs can undertaken minor illness consultation together. Allow longer appointment times to give time for discussion.
√ Develop a short list of conditions to be covered – review your current minor illness workload, which conditions are the greatest source of consultations?
√ Identify where the clinic will be provided, if possible set aside a room for the minor illness service
√ Be consistent: The service should be available whenever a GP is available – i.e always an alternative for patients.
Careful planning pays off in the long term by supporting the development of a service that is well run, used by patients and where the staff involved are aware of their role.
Reception staff are critical to the success of the service, the practices that we spoke to had all recognised that the success or failure of the service rests with how it is presented to patients. Patients need to be aware of the service and to be confident about making an informed choice about which practitioner to see. All of our case study sites reported that the development of the receptionist role to support the implementation of the service was a key factor in their success. The receptionist was considered to be acting as a signposting guide for practices helping patients to understand the choices that they had so that the patient could see the most appropriate professional.
This can be a significant cultural change for receptionists who may not be accustomed to asking patients about the nature of their complaint or entering into a discussion about the choices available to them. Training and coaching can build confidence and skills in handling patients.
Example
Amersham Health Centre planned in a series of training sessions for its reception team before implementing the service. This training covered the operation of the service, how to approach patients and how to deal with problems that might arise.
More details: Dr Alan Dellow, Senior Partner, Amersham Health Centre. Tel: 084 44 77 87 33. Email: alan.dellow@btopenworld.com
Helping patients make the right choice
Patients need to have clear and consistent communication about the service. They will probably be introduced to the service by the receptionist when they ask to make an appointment. At this point the reception team need to have clear and useful materials to help them to discuss the service with the patient.
The materials used included:
- A list of condition covered by the service (in terms patients will understand). Use pictograms to make terminology easier to understand
- Posters in the GP practice waiting areas and clinic rooms
- Leaflets for patients attending routine appointments
GP support for minor illness nurses
Generally our case study sites found that patients, nurses and GPs have adapted well to the service. Nurses reported that they often had and relied upon the day to day support of a GP, particularly in the early stages of the service to provide advice and a second opinion. As the nurses' confidence grows then they need to use this support less often but they value knowing that it is still available. A regular debrief to discuss cases of interest is a useful way of providing back up to the nurses and an opportunity for learning from practice. It is important that the nurses feel that they can access a GP for advice whenever they see a patient that falls outside the scope of the service. In some practices there is an arrangement whereby one GP acts as "back up" to the nurse providing the minor illness service. This "back up" GP has capacity built into their schedule so that they can join the nurse in a consultation if required. One practice has found that around 7% of all consultations require the nurse to refer to the GP.
Auditing the implementation and impact of the minor illness service is a good basis for developing the service further. Most services that we reviewed had expanded gradually to include new conditions not covered at the outset. This development was a result of the growing confidence and competence of the nurse providing the service and the confidence of the GPs that the nurse was ready to take on new conditions.
Auditing the impact of the service on the work of the practice can be a useful way to determine the success of the service. The following measures were used by practices to assess the impact and quality of the service that our case studies have measured:
- How many patients are using the service
- What proportion of all appointments offered by the practice are for the minor illness service
- What is the availability of the service? What days and times was the service available in the last week / month?
- How many patients opt for a GP appointment instead?
- How many patients are referred to the GP and why?
- How many prescription requests are generated by the service?
- Number of patient who re-consult with a GP for the same episode?
- Patient satisfaction with the service
Regular structured audit is a good way to ensure that you have a good picture of how the service is working.
Action points: implementation
√ Ensure that your reception staff are primed to support the service, invest some time in training and coaching
√ Provide clear communication to patients about the service, support receptionists with good quality information
√ Set aside GP time to provide ongoing support and coaching to nurses providing minor illness services.
Some examples
The WiPP Good Practice database includes examples of practices that have implemented a nurse led approach to minor illness management. The achievements of these practices have inspired others to develop their own nurse led services, to find out more about their how they did it follow the links below.
| Lime Tree Surgery, Leytonstone 140 appointments each month are managed by a nurse led minor illness service, which represents 50% of all minor illness appointments at this busy surgery. |
Amersham Health Centre, Amersham This nurse led minor illness clinic has resulted in a reduction in demand for "on call" GP appointments and "extra" GP appointments for a busy GP practice giving GPs more time to spend on more complex patients. |
| Goyt Valley Medical Practice, Whaley Bridge 170 GP appointments each month have been released by a first contact health visitor led minor illness service for children. The evaluation of the service shows that 93% of all patients presenting at the clinic had their condition resolved by the health visitor. |
Fairbrook Medical Centre, Borehamwood 150 GP appointments each month have been released by introducing a nurse led minor illness service. Of the patients seen through this service only 4-6% go on to make a GP appointment for the same condition suggesting that the service is effective in managing minor illnesses. |
References
- Whittington. Community pharmacy management of minor conditions – 'Care at the Chemist' scheme. PJ 2001 266 425-432. Available at www.pharmj.com.
- GPs recommend OTC medicines for 40% of minor ailment consultations. PharmaLife news Jul 2002. Available at www.pharmalife.co.uk.