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A red electrocardiogram
A red electrocardiogram
A red electrocardiogram

An Interview With Our Lead Primary Care Expert - Discussion around primary care roles

Due to recent questions that have arisen during medico-legal enquiries and instructions, our Scott Harding-Lister (Head of Practice) asked Louise Marriott (Primary Care Expert) about the different clinical roles and responsibilities within primary care settings.

We have lots of queries raised on cases about the different roles of nurses – what is the difference between a Practice Nurse and an Advanced Nurse Practitioner ‘ANP’? What is the role of an ANP? What is an Advanced Clinical Practitioner?

A Practice Nurse ‘PN’ is a Registered Nurse working in primary care (General Practice) undertaking a wide range of activity from the basic to the complex. Their role includes dressings, chronic disease management, immunisations, cervical screening programme, health education. PNs have frequently completed modules at Bachelors or Masters levels in subjects such as Management of Diabetes etc. PNs are often non-medical prescribers and prescribe medications relevant to a specific role.

As yet, an ANP is an unprotected title however voluntary credentialing is available via the RCN. ANPs can deal with acute illness and manage the ‘on the day service’ for medical problems. They often work alongside GPs but also make autonomous management decisions, referring and prescribing for patients without direct oversight.

There is no practical difference between an ANP and an ACP in Primary Care. An ACP may have an initial professional registration in any of the Allied Health Professions (AHPs) an ACP with a physiotherapy or paramedic background are often found in General Practice. It would be reasonable for an ACP to provide an opinion on the practice of another ACP in the same role regardless of each clinician’s primary registration.

A nurse becomes an ANP by completing a course now delivered at Masters Level which is often part of an MSc Advanced Clinical Practitioner Pathway and should be working at Masters level in 4 pillars of advanced practice (clinical, research, education and leadership). It is possible for those ANPs/ACPs with original qualifications at Bachelors level to be formally accredited. There are various accreditation routes with some leading to ACP membership of medical Royal Colleges as is the case with the Royal College of Emergency Medicine. In Primary Care there is a competency framework developed in conjunction with RCGP although no formal associate membership is available to ANPs or ACPs in Primary Care.

I assume that an ANP starts off as a registered nurse?

Yes, ANPs are initially registered nurses and ACPs may also belong to the AHPs regulated by the HCPC.

Do ANPs work independently?

ANPs (ACPs) work independently within scope of practice and experience. They are independent practitioners.

Do ANPs have to refer to GPs or medical staff?

ANPs do not have to refer to medical staff and are responsible for clinical decisions. However, it needs to be recognised that in hospitals all ACPs and junior doctors are under the responsible consultant. ACPs in hospital, when qualified and experienced, work at the level of approximately an ST3 doctor and in primary care usually functionat least at the levelof a registrar. All employed staff medics or ACPs are bound by employment contracts which can limit autonomy.

How long have you been providing expert witness cases for nursing in general practice and community?

I have worked as an expert since Apex Health Associates was created and am now part of the furniture! I have been providing advice/reports since 2014 and my case numbers increase year on year. I deal with Claimant, Defendant and joint instructions. In addition, I also train and support expert colleagues who are just starting out.

What type of cases do you do and see most often?

I deal most often with cases relating to first contact care and autonomous practice. These are cases where the clinician involved is an ANP but who is working in a role more often carried out by doctors. These cases involve diagnosing, prescribing and referring cases where patients present with a new condition or for review.I deal with cases in routine (in hours) and urgent (out of hours ‘OOH’) and increasingly remote and telephone consultations as I have current experience in all of these areas.

Do ANPs have to have their own independent insurance?

If dealing with NHS work then all clinicians are indemnified under the NHS scheme. There is no need for separate insurance unless working in other spheres e.g. aesthetics.

Are the ANPs employed by the Practice?

ANPs are employed by acute Trusts, primary care providers, partnerships or may be partners in the provider business. ANPs can also offer their services as an independent practitioner workingad hoc sessions for the healthcare provider.

What advice do you have for a party looking to instruct an ANP expert witness?

My advice would be to look for someone with current experience and understanding of the role and its current issues. The role is expanding and evolving, and it is helpful if the expert is conversant with current challenges. For example, we are just beginning to see the emergence of cases relating to the use of remote consultation during the Covid-19 pandemic and the expert would need to show experience of working within a role where decisions around risk management are integral. Ideally the expert should have the ability to work with other experts as they are often not the only clinician instructed. The expert should be confident in conference with legal and medical professionals and willing to appear in Court.

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