In an exclusive interview, Royal College of Nursing primary care lead Heather Randle discusses with Megan Ford her concerns over the growing threats to the general practice nursing workforce
The Royal College of Nursing’s primary care lead doesn’t hold back in issuing a stark warning for the profession when she sits down with Nursing in Practice to discuss the future of the general practice nurse role.
The next 12 months will be ‘the making’ or ‘the demise’ of general practice nursing, Heather Randle tells us, insisting the profession may not survive without urgent action. She highlights the challenges and risks ahead for a workforce that she says feels ‘invisible’.
While this year has been ‘a lot more business as usual’ for general practice nurses (GPNs) following the Covid-19 pandemic, demands have been ‘a lot higher’ and patients are presenting with ‘later disease’ than before, she says.
In addition, concerns over pay and employment conditions have ramped up this year, while GPNs have felt increasingly undervalued by the wider system.
Among the main challenges currently faced by GPNs is the effect of the additional roles reimbursement scheme (ARRS) – an initiative that Ms Randle says has seen nursing associates and other roles increasingly being used in place of GPNs.
Coupled with ongoing concerns over GPN recruitment and retention, the ARRS runs the risk of eroding practice nursing altogether, she warns.
‘Substitution of GPNs’
Concerningly, GPNs are increasingly being substituted with the ‘cheaper alternative’ of nursing associates, in a move that is ‘devaluing’ the profession and its skills, Ms Randle tells Nursing in Practice. This situation has worsened since the introduction of the additional roles programme in 2019, and the college is now seeing it happen ‘a lot’, she says.
The ARRS programme allows primary care networks to claim reimbursement for the salaries of some roles in practices, including pharmacists and physiotherapists. While the scheme covers nursing associates and advanced nurse practitioners, it does not include GPNs – something Ms Randle insists must change.
While stressing that nursing associates do ‘have a role’ in general practice, Ms Randle adds: ‘We need to be making sure that they aren’t replacing the general practice nurse.’
Ms Randle says the way ARRS is used in primary care is ‘devaluing GPNs as the skilled workforce they are’.
‘Nursing associates have their role, but they don’t look at the whole person, that is not what they are trained to do,’ she says. ‘They are not trained to do that autonomous assessing. They are trained to complete those tasks that are in front of them.’
Ms Randle suggests there is too much focus on ‘task orientation’ in practices, instead of on using the skills of GPNs, who build relationships with their patients and look at healthcare holistically. Having worked in general practice for 30 years, Ms Randle says: ‘Some of the most important conversations I’ve ever had with patients have been chance conversations, because there’s a relationship there.
‘The lady that’s walking out the door and says to me “I’ve had this funny thing on my breast for a couple of weeks, could you have a look”.’
But Ms Randle warns practices are moving away from this and towards ‘you need to do this many blood pressures today’ or ‘let’s go back to task orientation, instead of using that skill’.
‘Too much compromise is needed’
The number of GPNs in post is not increasing in line with rising demand and Ms Randle says an underlying issue is that to become a GPN, nurses have to compromise ‘too much’ on the pay and conditions enjoyed by colleagues in trusts.
Latest figures show there were 16,968 full-time-equivalent nurses working in general practice in England in October 2023 – just 198 (1.2%) more than a year earlier. Meanwhile, the overall headcount in that period has actually decreased by 0.3% to 23,355.
‘We’re not seeing the numbers go up at all,’ says Ms Randle. The ‘biggest issue’ is that not enough thought has gone into why nurses are not coming into general practice. Being a GPN is an ‘amazing career’, she says, and a ‘unique role in nursing because of the experience and knowledge you need to have across the system’, from cradle to grave.
‘The role is something that should attract people to it, but the compromise is too much,’ she says. This includes sacrifices on maternity pay, sick leave, salary and study release, she notes.
‘Pay is my first priority’
Ensuring GPNs are given the 6% pay rise they were promised this year by the government is Ms Randle’s number one priority as 2023 comes to an end. Ongoing concerns around funding of the uplift – which could see some GPNs get less than the full rise – have seen the RCN promise to ‘step up’ its pay campaign for the sector. And in October, the college teamed up with the British Medical Association in a pledge to ensure ‘fully funded, fairer terms’ for GPNs.
GPNs who do not receive the full 6% uplift are being surveyed by the RCN about how their employers have handled the situation. Findings will then be used to ‘put a case’ to the government over the experience of GPNs in relation to pay, says Ms Randle.
The RCN is also working to ‘empower’ GPNs with ‘knowledge’ around how the pay process works within general practice and about what to ask their employers concerning the uplift.
In recent months, GPNs have spoken to Nursing in Practice about how ‘inherently unfair’ and ‘disappointing’ it is that some risk missing out on the full pay rise because of the complex funding formula used to distribute it. Some have warned the situation will ‘do little to address the workforce crisis in primary care’, with others saying it ‘demoralises and devalues’ the profession.
Ms Randle says her ‘ideal’ would be to see ‘ringfenced money in order to protect nurses working in general practice, so that they would get equal pay, terms and conditions to nurses working in hospitals’.
‘Leadership is the key’
Ms Randle says action must be taken to ‘empower’ GPNs to be leaders, in order to build a voice and value for the profession. She believes there should be ‘a requirement’ for every integrated care board to have a nurse director.
‘Very often, it’s a medically led model, with a nurse sitting as part of the team. And actually, what we need is to have that [nurse] leadership, because the leadership will then create the voice, which will then create the value of the nurses,’ she says.
Seeing GPNs in leadership positions would also help tackle ongoing issues of nurses feeling ‘invisible’ and undervalued by key stakeholders and the wider system. ‘Patients who see nurses regularly know what they do. It’s everybody else that doesn’t,’ says Ms Randle. ‘And if you ask a GP, they wouldn’t be able to manage without their nurses, but that doesn’t seem to translate into communication – people don’t see that.’ She concludes: ‘For me, I think the key is leadership.’
‘RCN making breakthroughs’
Asked for the highlights of 2023, the college’s professional lead for primary care says: ‘From an RCN point of view, we’ve got practice nurses on board.’ GPNs ‘feel like we listen to them now’, she adds.
‘We’re providing support to them with the
challenges they are facing. I think we’re starting to make those breakthroughs.’
The college is ‘becoming a voice within the system’, with invitations to workforce planning and contract meetings with the government, explains Ms Randle. ‘I think it’s really important that the RCN is there, both as a union and a professional body, because we can help them steer the future of general practice nursing.’
She says it has been good for GPNs ‘to get back to business as usual’ over the past year, following the pandemic, and to continue demonstrating the ‘valuable’ and ‘rewarding’ career on offer in general practice.
What will 2024 bring?
Ms Randle says she believes 2024 ‘could be the demise of practice nursing, or it could be the making of practice nursing’ – depending on what action is taken to recruit, retain and support the profession.
It’s an ominous warning. ‘We’ve got an ageing population of practice nurses [and] there’s no incentive for nurses to be recruited into the system because they have to compromise on too much,’ she says.
‘We need to see improvement in the recruitment of nurses and improvement to the offer we can give to nurses in general practice, so it becomes a career of choice.
‘Because if we don’t, we will lose practice nursing, lose nurses in general practice and we’ll lose that massive skill set that we’ve already got.’