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General practice nursing: a specialism in need of a higher profile and more recruits

Concerns have been raised by general practice nurses about a lack of understanding of their expertise, training and independence. How are these issues being addressed?

Concerns have been raised by general practice nurses about a lack of understanding of their expertise, training and independence. How are these issues being addressed?

  • Practice nurses cite other health professionals’ lack of understanding of their role 
  • They are feeling neglected in the public debates about the crisis in primary care 
  • Their caseload is becoming more complex, while pay and conditions are uncertain  

Picture: SPL

The results of a survey of general practice nurses (GPNs) published by the Queen’s Nursing Institute (QNI) in 2016 showed a workforce under pressure.

More than one third of the 3,400 respondents were due to retire by 2020 and vacancies were proving hard to fill. Just 43% of GPNs said their nursing team had the right number of staff to meet patient need.

One third

of 3,400 survey respondents were due to retire by 2020

Source: Queen’s Nursing Institute (2016)

The QNI called for coordinated action to address issues identified by the survey. But three years on, has anything changed?

Continuing disquiet among general practice nurses

Anecdotal evidence suggests continuing disquiet among some GPNs about the state of their specialism. Posting on the RCN Facebook page, one said she had to fight to secure adequate appointment times ‘when clearly GPs don’t do our jobs and don’t appreciate the time we need to work safely’.

She added: ‘Considering GPs’ recent public complaints of needing 16 minutes per consultation, I do feel it’s one rule for them and one for us.’

‘The media, MPs and other health professionals are not aware of what practice nurses are able to do. There’s a lack of understanding of our role, the training we have done or how we can work independently’

General practice nurse who wishes to remain anonymous 

Another GPN, contacted by Primary Health Care after posting her concerns and who asked to remain anonymous, said most practice nurses were highly trained and many were specialists in conditions such as diabetes.

‘But the media, MPs and other health professionals are not aware of what practice nurses are able to do. There’s a lack of understanding of our role, the training we have done or how we can work independently.’

43%

of general practice nurses said their nursing team had the right number of staff to meet patient need

Source: Queen’s Nursing Institute (2016)

She added: ‘I’m passionate about practice nursing, but get frustrated because we don’t have a higher profile.’

Media ignored nursing recruitment problems

RCN’s professional lead for general practice nursing Marie Therese Massey says recent press coverage of the demands on general practice drew attention to the ongoing shortage of doctors, but ignored similar recruitment problems among GPNs.


Marie Therese Massey

‘And there was no mention at all in the media of the fact that if there’s a burden on GPs, there will be a burden on the wider practice team,’ she says.

‘GPNs feel left out of the narrative because all the focus is on GPs.’

It is two years since NHS England launched its ten point action plan for general practice nursing.

‘General practice nurses feel left out of the narrative because all the focus is on GPs’

Marie Therese Massey, RCN professional lead for general practice nursing

Backed by £15 million of investment, the plan pledged new recruits, and more support for existing GPNs and those keen to return after a career break.

Challenges of making general practice fit for the future

At the time of the plan’s publication, England’s chief nursing officer Jane Cummings said GPNs were ‘central to our plan to improve care for patients and ensure the NHS is fit for the future’.

But making general practice fit for the future will mean tackling some huge challenges, not least the growing numbers of older people.

Statistics compiled by Age UK show that in a population of around 66 million in the UK, 12 million people are over 65, and of those, 5.4 million are 75-plus. By 2030 one in five people will be aged 65 or more. And the chances of becoming disabled or living with multiple chronic conditions increase with age.

But that is only part of the problem, says Ms Massey. ‘You’ve also got shorter stays in hospital and the shift from hospital care into the community, not necessarily with the money and resources to follow.

‘We’ve got this situation where the GP is our employer, our colleague and sometimes our friend. And it is weird to try to negotiate a pay rise with a mate’

Jan Glaze, practice nurse


Jan Glaze

‘All those things have been going on for the last few years and have impacted on general practice, coupled with the nursing workforce crisis from which general practice is not immune.’

Jan Glaze, a practice nurse in Crowthorne, Berkshire, who is studying for a PhD, has undertaken research into general practice nursing.

Complexity of general practice nurse caseload

She says patient demand versus capacity is an obvious pinch point, but the complexity of the GPN caseload is also an issue.

‘You no longer get a person in for something simple. It’s always: “While I’m here, can I talk about my asthma, as well as my diabetes?” People’s time is more precious and they’re wanting more things done in any appointment.’

She also argues that a growing tendency to specialise in long-term conditions is not only deskilling GPs, but is undermining nurses’ generalist skills too.

‘We’ve moved from generalist to major specialists. Now there’s a demand that we start to think about moving back again.’

Ms Massey believes GPNs are becoming demoralised as a result of all these workplace pressures, which are sometimes compounded by poorer terms and conditions than NHS colleagues and difficulty accessing clinical supervision, for example, and regular appraisal.

So what is to be done?

Bring general practice staff under NHS employment

Ms Glaze says the first step is simple: bring all general practice staff, doctors included, under the employment of the NHS. She argues that the small-business model, with self-employed GPs, is anomalous and does GPNs no favours either.

‘We’ve got this situation where the GP is our employer, our colleague and sometimes our friend. And it is weird to try to negotiate a pay rise with a mate,’ she says.

‘This is a most peculiar relationship that exists nowhere else in the NHS.’

Could the system ever be remodelled in the way Ms Glaze suggests? ‘It absolutely has to be,’ she says. 

Bringing more new or returning recruits into practice nursing would provide a counterbalance to all those GPNs identified by the QNI survey as being close to retirement.

NHS England’s ten point action plan was clear about the need to increase pre-registration nursing placements in general practice and widen career pathways. According to QNI chief Crystal Oldman, the action plan is beginning to have an impact.

Limited financial incentives for nursing student placements

But she points out that the financial incentive for general practices to offer nursing student placements is limited. While training tariffs for medical students are around £650 a week, practices offering placements for nursing students receive about £80 a week.

8%

increase in nurse numbers in GP practices in England since 2015 to 16,483 full-time equivalent

Source: NHS England


Crystal Oldman

‘It’s an absolutely massive difference,’ says Dr Oldman.

‘Although the tariffs are similar for hospital and community placements, there’s more infrastructure in those settings to support learners.

‘But it’s a disproportionate burden for small businesses and doesn’t make it worthwhile.’

Responding to the concerns expressed by GPNs and nurse leaders, NHS England said nurse numbers in GP practices have increased by 8% since 2015 to 16,483 full-time equivalent.

NHS England added that initiatives to reduce GPN workload are also being rolled out, including group sessions for the collective management of long-term conditions.

The introduction of undergraduate placements in 2015 means more nursing students are now considering careers in general practice, a spokesperson said.

‘Healthcare assistants are now doing things that only practices nurses would have done in the past’

Luella Robb, nurse practitioner and nurse manager of the Lombard Medical Centre in Newark, Nottinghamshire, knows very well how the burden on GPs is affecting the whole practice team.

She manages a team of 11 nurses and healthcare assistants (HCAs), and says the team is always fully booked, with extra patients added to an emergency list daily.

‘The workload has increased year-on-year,’ says Ms Robb. ‘As more work comes out of secondary care to GPs, more work gets passed down to the nurse practitioners who in turn pass more work to the practice nurses.

‘HCAs are now doing things that only practice nurses would have done in the past.’

Widening access to practice nursing

She feels there should be more emphasis nationally on maximising the potential of practice nurses and HCAs.

‘Some practices still only use them to take blood tests and blood pressures.’

Ms Robb’s workplace is also widening access to practice nursing.

‘We’ve been approved by the universities of Lincoln and Nottingham to take nursing students,’ she says. ‘We also have two HCAs undergoing the nursing associate course and will go on to do nursing courses,’ she says.

‘We have just employed a newly qualified nurse as a practice nurse, with funding from Health Education England to pay for the general practice nursing university course at De Montfort University in Leicester.’

 

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Daniel Allen is a health writer

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