Participants had been invited to talk about changes to their own roles in community palliative care. Unexpectedly, they talked a lot about their interactions with GPs, and it is their accounts of these interactions that we draw on here.
The main new roles mentioned were verifying death and prescribing; GPs were mentioned indirectly in connection with these, where community nurses described being expected to take on new tasks — ‘extra things keep being added on’ (Group 3) — which participants said used to be done by GPs:
‘The GPs seem more remote now and we seem very heavily involved […] it’s totally switched round really.’
(Group 4).
Alongside these accounts of new tasks, a more complex picture emerged when nurses talked about ways in which their established roles had extended and deepened. It is this picture that we focus on here. Within it, we highlight accounts of GPs’ new ways of working and their perceived effects on community nurses’ work. Two changes, increased remote working by GPs and diversification within primary healthcare teams, were both seen as problematic, particularly where community nurses sought to collaborate in caring for people with complex problems at the end of life. Underpinning the data we present here about these two issues is the assumption, widely visible in participants’ accounts, that:
‘An important part of nursing at home is that we need the GP back-up.’
(Group 8)
Perceived impact of remote working
Nurses identified GPs’ adoption of alternatives to face-to-face encounters as affecting them in two ways. First, moving to remote encounters with other healthcare professionals made it harder to build and maintain working relationships and to communicate quickly and effectively about a patient. Second, GPs moving away from face-to-face encounters with patients was felt to contribute to task-shifting from GPs to community nurses, helping drive the extension of nurses’ established roles.
Remote communication between colleagues.
There was considerable variation in participants’ accounts of their working relationships with GPs. Some had been able to go back to face-to-face communication (after a pause during the pandemic); the following exchange shows that this was regarded by both speakers as a good thing, although it was not considered universally possible:
Speaker 1:‘We’re quite lucky because we’re quite rural […] So we do have good, I mean I’m in the same physical building as both the practices.’
Speaker 2:‘Wow!’
Speaker 1:‘[…] so yeah we’re quite different […] I can walk around and grab somebody if I really needed to.’ (Group 2)
Further variation was visible where practices asked nurses to communicate remotely with GPs, either by using various messaging systems or else by phoning. Of practices who preferred to be telephoned, some set up professionals-only access, bypassing the patients’ line, but participants reported that others did not do this, leading to frustrating delays and a feeling of professional disrespect. Even where nurses were given a priority number, it linked to a receptionist:
‘We have a direct line that bypasses the patient line but it’s still straight through to a receptionist, so you’re still then relying on the receptionist then agreeing to message the duty doctor […] they’re on their mobiles so the surgery then phones them and you’re then waiting for them to phone you back.’
(Group 8)
As well as often being slow, getting the receptionist to agree to contact the doctor was felt to be an annoying obstacle to efficient communication, adding an unwelcome layer of gatekeeping:
‘It’s so frustrating because you just think if you just put me through to the GP it would take me two minutes to explain it, whereas I’m trying to explain it to you who doesn’t understand […] but they’ve got that pressure from the GP not to put us through to them […] they get […] quite short with us, like well what’s this, I’m trying to speak, can I just speak to a GP, and they’re like, well no if you just tell me what it is and I’ll task them.’
(Group 7)
These practical difficulties were seen as contributing to the weakening of interprofessional relationships:
‘We’ve lost touch with our GPs […] the relationships aren’t as strong as they used to be.’
(Group 6)
‘I don’t know any of the GPs now, I very rarely speak to them, each one has a different way of communicating, emails, tasks, different systems to write on, the relationships are so fractured and the patients just say to you “I don’t know who my GP is”.’
(Group 4)
Remote communication with patients.
As the previous excerpt illustrates, some participants suggested that GPs’ increased use of remote working was a factor leading patients to say they do not know who their GP is. These suggestions often led into nurses’ accounts of having to extend their previous roles to take the lead regarding person-centred palliative care of people with complex problems:
‘You just naturally have to do [difficult conversations about future care preferences] because over the telephone you don’t have that same relationship.’
(Group 3)
Video consultations were not perceived as better in this respect:
‘The GPs in my area still do it all over video so they can’t really have that real person-centred care’.
(Group 1)
Many nurses described pride and satisfaction at taking the lead in providing this care:
‘We build up such good relationships with our patients, it kind of goes hand-in-hand with that relationship that we’ve established, and the trust.’
(Group 3)
But some of the same participants expressed resentment about what they saw as a move from GP-led to nurse-led care:
‘The GPs are sort of thinking, well they can do it so we don’t need to be involved, so it’s putting more pressure on us.’
(Group 1)
In summary, participants saw the move towards remote working as deleterious both to GPs’ collaborative relationships with their community nursing colleagues and to their ability to provide person-centred care for patients and their families. This reduced ability was seen as contributing to the shifting of work from general practices to community nurses.
Workforce diversification and task-shifting within practices
Our community nurse participants commonly expressed concern about workforce diversification within general practice. This concern centred on the shifting of tasks from GPs to other primary care clinicians, and was underpinned by the widely expressed feeling that community nurses want and need support with managing the complex needs of their patients who are receiving palliative care. Although a few participants mentioned getting this support from palliative care specialists, most emphasised the need for ‘GP back-up’. Accounts of seeking back-up varied between participants. Some spoke of routinely being offered a paramedic or nurse practitioner to speak with instead of a doctor when they asked for medical input from the practices they worked with:
‘A lot of the housebound patients are visited by their paramedic practitioners or their advanced clinical practitioners from the surgeries.’
(Group 8)
The participant quoted next compares two practices in their area, highlighting that some practices do still offer what was seen as adequate GP back-up. In so doing, the practice is seen as showing ‘respect’ for the community nurse’s assessment of the situation; implicitly, a lack of respect is indicated by either declining to visit or delegating the task to a paramedic:
‘If myself or any of the staff nurses go one practice with an issue about a patient, like [name of participant] was saying if you’ve gone to a GP to ask a GP to review a patient it’s because you need a GP to review that patient, and they will respect that. The other practice don’t, and they would ask a paramedic to go sometimes, or they won’t visit.’
(Group 2)
Concerns about lack of ‘respect’ were also voiced elsewhere in our data, in the context of professional colleagues’ perceived lack of acknowledgement of the scope and depth of community nurses’ competence.
Participants’ negative comments about paramedics were mainly rooted in a broad discomfort with the way traditional clinical hierarchies were being disrupted by diversification. This discomfort was sometimes visibly infused with a normative discourse that was critical of GPs and implicitly equated traditional with ‘normal’ or proper ways of working:
‘The surgery I work for have got two paramedics who are absolutely fantastic but they are not GPs, and I think the GPs need to stop relying on other services and come in and actually muck in again, get their hands dirty and get back to some form of normality.’
(Group 1)
The move away from this ‘normality’ was at odds with expectations based on the hierarchy that has traditionally placed doctors above nurses, with paramedics below community nurses or at most on the same ‘level’:
‘If I’ve requested for a GP to go and see a patient I’ve seen, I would expect somebody senior to review that patient, not someone at my level.’
(Group 2)
‘They seem to be sending like paramedic practitioners instead and their kind of skill scope is quite similar to ours […] you request one thing [that is a GP assessment] and you kind of get another.’
(Group 4)
In contrast with these negatively flavoured comments, other participants spoke positively about the new clinical roles within primary care. Rather than focusing on levels within a linear hierarchy, these nurses spoke of paramedics’ skills as complementing their own, particularly in relation to assessing and managing a patient’s acute deterioration and avoiding hospital admission:
‘Admission avoidance is something that paramedics are quite good at, they’ll liaise with GP practices, with care agencies et cetera to try and keep patients at home if that’s the best place for them.’
(Group 5)
Even where this positivity was visible, however, many participants indicated unease and unhappiness when talking about their extended role in assessing and managing complex problems. These community nurses spoke of being given more responsibility than they felt comfortable with. They noted that their pay had not increased to reflect this increased responsibility; that they felt anxious that they sometimes risked their professional registration by acting autonomously without GP input; and — referencing traditional norms again — that they were taking ‘clinical decisions that we perhaps shouldn’t be doing’ (Group 1, Roman indicates emphasis), work that they felt was part of ‘the duties of a GP’:
‘There’s no recognition in our pay that we’re taking on basically the duties of a GP […] we are just so autonomous and with that comes a massive responsibility […] We are putting our registration at risk quite often […] for patient care.’
(Group 6)
Particular concern was expressed about the work of assessing a complex situation in order to make clinical decisions; participants spoke about ‘diagnosis’, uncertainty, and the worrying possibility of being ‘wrong’:
‘Most nurses aren’t diagnosticians, it’s not part of our […] remit unless you’ve done additional training, so [it’s hard] for us to sort of go “oh this is what we think might be happening but we don’t know for sure” […] when you haven’t got the confirmation from a medical professional, a GP or a doctor who is meant to diagnose things […] There’s an overreliance on the community nurses especially to diagnose the problem and then the GPs will just react to whatever we’re telling them without actually seeing the patient face to face. And we might be wrong, you know, we might be wrong.’
(Group 8)
Calling this ‘overreliance’ indicates the perception widely visible in these data that GPs’ task-shifting, both to other clinicians within the practice and to their community nursing colleagues, has led to some unwelcome changes in nurses’ roles, albeit also some changes that were welcomed by participants. Overall, community nurses’ accounts were often coloured by anxiety about complex decision making with what was perceived to be inadequate senior support, and by resentment at what they described as lack of recognition of their extended roles and absence of consultation about the changes.
