Practice nursing: the pitfalls and the potential
A survey by the Queen’s Nursing Institute has confirmed that practice nursing is facing major pressures, with one third of practice nurses due to retire by 2020, patchy access to training and widespread discrepancies in pay. But there is also cause for optimism, as new initiatives aim to ensure practice nurses are better supported and rewarded.
A report published in January by the Queen’s Nursing Institute (QNI) provides a detailed picture of the role of general practice nurses, based on a survey that attracted almost 3,500 responses – thought to be about 15% of their workforce in the UK. Headline findings are that one third of practice nurses are due to retire by 2020, while only 35% think their salary reflects their role within the practice.
Queen’s nurse Heather Henry, who is co-chair of the NHS Alliance – an independent leadership organisation representing primary care – says this authoritative report should be listened to: it confirms the challenges outlined in previous reports, including a 2014 survey by the Royal College of General Practitioners (RCGP).
‘The position for practice nursing is the perfect storm,’ says Ms Henry. ‘There are several significant difficulties.’ High among them is the chronic underfunding of primary care. Currently, general practice receives about 8% of the total NHS budget, with surgeries receiving around £140 per patient each year. At a special local medical committees conference in January, organised by the British Medical Association, GPs backed a motion calling for this to rise to at least £200, with the aim of returning to a budget of 11% of overall funds.
The conference also discussed the possibility of mass resignations if a package of emergency help is not agreed for general practices in the next six months. ‘We’re coming to a crunch time with GPs, where mass resignations are being seriously considered,’ says Ms Henry. ‘It’s been 25 years in the making, but we’ve reached the burning platform now.’
As negotiations begin on the new contract for 2017, based on the government’s commitment to seven-day NHS services, nurses and GPs need to work together, says Ms Henry. ‘Nurses don’t usually get involved in these discussions, but they need to now. We need the nursing voice.’
As part of its wish list for NHS England’s emergency package, the RCGP is calling for return to practice schemes for practice nurses. Chair Maureen Baker says these will ‘boost the nursing workforce, alleviating pressures across the GP team, and allowing us to deliver the care our patients need and deserve.
‘It’s important that practice nurses receive the best possible education, training and support to do their jobs well, and to help keep our patients safe.’
But at the moment, training and development is inadequately funded ‘and getting progressively worse,’ says Ms Henry. She points to huge variations in how the practice nursing workforce is supported across the country, whether attracting newcomers or helping existing employees to develop their skills.
Regionally, Health Education England’s (HEE) teams often work with their local universities to offer courses, but many are targeted at nurses working in secondary rather than primary care, notes Ms Henry. ‘If it’s a respiratory course, then it’s about ventilators, rather than the child who comes to surgery with asthma,’ she says. And senior nurses in clinical commissioning groups (CCGs) are becoming increasingly frustrated that their views are not being heard. Ms Henry says: ‘Some CCGs have become so worried that they are beginning to take over this educational role themselves.’
Meanwhile, HEE is facing its own financial challenges. ‘It says it has had its budget cut in the last comprehensive spending review, so workforce planning has been scaled back,’ Ms Henry explains. ‘But at the same time it says that practice and community nursing places were not fully taken up.’
She believes this has much to do with continuing poor perceptions of practice and community nursing. ‘I don’t think the role and value is fully understood by the nursing profession. It’s subsumed in secondary care, which takes priority. To work in primary care, there’s a view that you have to have earned your brownie points in secondary care first.’
Ms Henry is wary of talking down the profession by focusing solely on the difficulties, fearing it will discourage nurses from joining. ‘It’s such a fantastic role – that’s why nurses stay until they retire,’ she says. ‘You have the opportunity to look after patients from cradle to grave, building long-term relationships, and develop professionally into an advanced and autonomous role. It’s extremely rewarding.’
‘While trying to negotiate a pay rise last year – the first for six years – I rang round several other surgeries to find that practice nurses, who are all doing the same job, get very different salaries and remuneration.’
‘My experience is that access to training and development varies between practices, and can be at the whim of the employers. CCGs provide training opportunities, funding and access to support, yet often general practices feel this is not enough and will not allow their nursing staff to access training.’
But Dr Baker says that nurses have been feeling the squeeze on general practice alongside GPs. ‘It is concerning that as a result of these pressures, practice nurses do not feel they have the capacity to adequately prepare for revalidation or complete continuing professional development,’ she says.
Salaries are also an issue. The QNI’s report reveals huge variability between nurses, with some paid on band 4 while others are on band 7. Some of those surveyed reported receiving no pay rises for six years. ‘We need to talk about remuneration for a 21st-century workforce,’ says Ms Henry, calling for a cost-benefit analysis of the work primary care nurses do. ‘At the moment, they cannot state their economic value – they will always be sidelined until they do.’
Encouraging practice nurses to gather evidence about the difference they make is high on the agenda for fellow Queen’s nurse Debbie Brown. She says: ‘We want nurses to raise their own profile and articulate their role within the practice. Say what you do – or how else will anyone understand your contribution?’
A former general practice nurse adviser, Ms Brown was appointed last September as a nurse consultant in practice nursing at Lewisham CCG. In what’s believed to be the first role of its kind, she is supporting GP practices across the borough to deliver integrated services, alongside the training, education, revalidation and supervision of practice nurses. Already she is making progress in many of the problem areas identified in the QNI’s report.
The role was created following detailed local audit, which revealed a lack of leadership and support, with a need for workforce planning and common clinical protocols and competences. Peer support was also highlighted. Local practice nurses are now supported much more comprehensively, especially when they are new in post, having access to an adviser in each of four local neighbourhoods.
Initially the CCG was not even sure how many practice nurses there were, as numbers were not recorded centrally. Now figures are updated at least weekly, and the most recent statistics show that Lewisham has 91 practice nurses, five nurse practitioners and 29 healthcare assistants.
At the outset of her job Ms Brown met with practice managers, looking at how they could be helped and encouraged to support their practice nurses. Through the practice managers’ forum, she initiated a discussion about how many surgeries were losing nurses to other practices that were paying more. ‘Some were then having to employ nurses through agencies or take on those who were less skilled, often paying what their original nurse had wanted in the first place,’ she says. ‘It was a good debate that opened up discussions.’
Continuing research has uncovered wide-ranging local discrepancies in nurses’ pay. Some earn just £12 an hour, while others are paid almost three times as much. ‘Some surgeries are willing to pay more for someone who is less skilled because they are desperate,’ says Ms Brown. ‘We also have some fantastic evidence of nurses’ pay matching their skills. What we’d like to see is a standardised approach.’
Training is another key issue. It's made more difficult by the fact that many practice nurses work part-time, while others work in two surgeries.
‘There are some good practices that encourage training, with time off, but unfortunately they’re not all supportive,’ says Ms Brown. She also explains bluntly the potential repercussions of a lack of investment. ‘Without training, a nurse cannot complete their professional development, which means they cannot revalidate – so, the practice may not have a nurse.'
The message is starting to hit home, she believes, with much larger numbers of staff attending training provided by the local practice nurse forum every two months. ‘We’re now getting 40-plus nurses now – up from 25 at most,’ she says.
Ms Brown is looking further into the future as well. She is keen to attract new recruits, working with local universities to provide first, second and third year placements and giving talks about the rewards of becoming a practice nurse. Lewisham CCG has also developed a bespoke mentorship scheme with King's College London, creating 15 mentors – more than they have ever had before. These efforts are already paying dividends; two new practice nurses started last year after doing placements.
‘We’re committed to recruiting more nurses to move into primary care,’ says Ms Brown. ‘It’s such an exciting place to work, with so many opportunities. The most fantastic aspect of practice nursing is the relationship we build with the local population. That’s the bonus for us as well as for the patient.’
Despite all the difficulties, the QNI maintains in its report that practice nursing has enormous potential. ‘Above all, theirs is a story of opportunity,’ says the report. ‘The opportunity to work as highly skilled, autonomous practitioners and to serve a local community – but also the unrealised opportunity for a higher profile and a more comprehensive, supported role in meeting the needs of the registered population'.