An in-depth view of the state of practice nursing as our survey results paint a gloomy picture.
Two-thirds of nurses working in general practice in the UK are considering quitting their jobs in the next year. This is the stark finding that emerged from our survey of 393 nursing staff working in general practice earlier this year.
It revealed that 18% of those considering quitting are looking at early retirement, 11% a different nursing role outside general practice, 8% a complete change of profession and 5% a different role within general practice. Six per cent favour retiring as planned, with 14% unsure how they would leave. Many respondents told us staffing shortages have already hit their practices hard, with recruiting proving just as challenging as retaining existing staff.
The RCN called the findings ‘desperately sad’, saying they show a system in ‘crisis’ amid the pressures of the Covid-19 pandemic, worsening staff shortages and poor working conditions. While the past two years have shone a light on the value of nurses in general practice, that period has also demanded unprecedented levels of dedication, hard work and adaptation. And it’s not over: nurses’ work continues to fight the virus, catch up on the backlog of care and deliver everyday services for patients.
Against this backdrop of extraordinary and relentless work, alongside the surge in nurses considering leaving their roles, we search for a light at the end of the tunnel – looking at the state of practice nursing, how it has changed and what must be done to convince more nurses to join the profession and, crucially, to stay.
Getting student nurses on board
‘I’m really worried because I want to go into general practice but everyone is telling me how bored I’m going to be.’ This message from a student nurse was recently sent to Sumeya Gulam, a practice nurse in West Sussex who joined after qualifying in 2018. The sentiment is far from uncommon, Ms Gulam tells Nursing in Practice. ‘Receiving it was so sad, because becoming a practice nurse is one of the most autonomous roles you’re going to get,’ she says.
The 10-point action plan for general practice nursing, published by NHS England in 2018, sought to increase student nurse placements, an ambition Health Education England (HEE) tells Nursing in Practice it is continuing to work towards. Ms Gulam thinks increasing the number of placements in general practice is crucial to changing student nurse perceptions and ultimately to boosting recruitment into the sector. At university she wanted to complete a final or elective placement in general practice, but this proved ‘impossible’ to organise, she says. But she welcomes what she sees as an uptick in student nurse placement, although this has not been ‘entirely across the board’. She also praises the GPN Student Nurse Network, which is active on social media and in higher education institutions, raising the profile of practice nursing as a driver of change.
HEE: ‘We’re supporting GPN development’
Responding to the issues raised in this article, Liz Fenton, deputy chief nurse at HEE, says it is working with NHS England and NHS Improvement to ‘support the development’ of the ‘critical’ practice nurse workforce who provide ‘hugely valuable services within local communities to people of all ages’.
She highlights that GPNs have access to:
• A ‘wide array’ of modules on the free eLearning for health platform and a £1,000 personal continuing professional development budget over three years, per nurse, to support the development of their skills and knowledge.
• Advanced clinical practice and education programmes, such as non-medical prescribing.
Ms Fenton continues: ‘We are working throughout our regions to increase the number of practice placements within primary care, as we know these services offer valuable learning opportunities and a positive experience encourages students to consider this as a career choice.
‘We have recently invested in nurse educator roles in the regions, and student placements are supported by an education tariff which HEE is working to ensure is equitable across all settings.’
Julie Carrick, director of nursing for GPS Healthcare, a primary care network (PCN) formed by the merger of six practices across Solihull, in the West Midlands, says the perception of practice nursing among students has ‘improved slightly’ as a result of such initiatives. However, she raises concerns that during the Covid-19 pandemic, placement capacity in general practice was reduced and practices were not even able to communicate with students as they normally might. ‘I think we’ve got to keep fighting and keep pushing for more progress, but it’s obviously being stalled,’ she says.
The fee paid to a practice for hosting a student nurse is still much lower than that for a medical student: around £3,856 a year compared with a minimum of £28,000, paid pro rata per week. Speaking to the House of Commons Health and Social Care Committee on 1 March, Dr Emma Hayward, a GP and clinical educator in Leicester, raised the issue: ‘[The tariff] covers nothing in terms of student nurse supervision. That’s a whole new budget that needs to be established because otherwise we’re never introducing [nursing students] to the concept of primary care.’
Several nurses who spoke to Nursing in Practice also pointed to the elephant in the room when it comes to recruiting newly qualified nurses and nurses from other sectors to practice nursing: contracts are made with the employing GP, meaning pay, terms and conditions can be highly variable between, and even within, practices. In contrast, all non-medical NHS staff are on nationally standardised Agenda for Change (AfC) contracts. They believe this variation – affecting issues such as maternity and sick pay – may put off prospective practice nurses.
Investing in new nurses
A nurse in general practice can manage long-term conditions including diabetes, asthma and chronic obstructive pulmonary disease (COPD), immunisations and public health work. Yet despite this complexity, there remains no mandatory GPN training for nurses who are new to general practice.
HEE took a major step towards improving training for new practice nurses in 2012, when it commissioned De Montfort University in Leicester to deliver and test a ‘Fundamentals in General Practice Nursing’ programme. This is a university-level short course for qualified nurses, now funded across universities nationwide and covering bread-and-butter practice nursing skills such as long-term conditions management, immunisation and cytology.
Ms Carrick says the programme has vastly improved the education on offer to GPNs since she joined in 2007. ‘Before, everybody’s training was so different and it was a case of watch someone else do it and then carry on and do it yourself’, or surgeries sending their nurses on a ‘study day here, a study day there’ without much structure, she says.
Allison Brindley, an assistant professor at the University of Nottingham, where she helps deliver the graduate entry nursing programme, was involved in the fundamentals course from the beginning. In 2011, while working as a practice nurse in Loughborough, she and other experienced practice nurses joined the HEE steering group to develop the programme. ‘I was excited to support the programme at De Montfort because the whole ethos was about experienced practice nurses training the next generation and making sure new-to-practice nurses got the educational opportunities we didn’t get,’ she says. Her enthusiasm did not fade: after completing her postgraduate certificate in higher education, she ran the course at De Montfort from 2016 until November 2021.
Ms Brindley applauds HEE for providing the funding, without which she thinks the fundamentals programme ‘never would have taken off’. Previously, practices were ‘poaching’ experienced GPNs from each other, she says. They ‘rotated staff from an already depleted pool of experienced GPNs and did not replenish the pool’ because they were hesitant to pay for fundamentals training themselves.
Dr Marie Hill, senior lecturer in practice nursing at City, University of London, summarises how far educational opportunities have come overall: ‘When I started as a practice nurse 30 years ago, the majority of GPNs would have begun their roles without any educational input. Whereas now, at least across London and the home counties where I am, there is a tangible drive to ensure education programmes are available to newly employed GPNs because the role is better recognised.’
However, the fundamentals course is not uniformly accessible; there are limited places and nurses may still struggle to negotiate time to attend the course and study.
In addition, the pressure of staff shortages means not all new practice nurses receive the appropriate training, says Sarah Hall, steering committee member at the RCN GPN Forum. Practices are so ‘desperate [that] there’s been a push to get people employed and trained quickly,’ she says. ‘I think from a safety quality perspective, it’s not good. From a retention perspective, it’s poor because nurses come in and feel unsupported.’
Career progression and training
The pace of practice nursing is increasing, alongside greater time constraints and complexity, continues Ms Hall. As a result, the role is becoming more specialised. ‘Twenty years ago, you could see everybody for everything – whereas now, and rightly so, it’s so complex that it’s impossible for one nurse to do absolutely everything and keep updated.’
Specialising in a clinical area such as health promotion, diabetes or asthma care – as well as undertaking training to enhance existing skills – is a development option for practice nurses. However, Joanne Charlton, a practice nurse in Worcestershire, says GPNs sometimes have to complete clinical training in their own time because practices will not release them. ‘This increased experience is also not backed up in a pay scale,’ she adds. ‘You have to ask for pay rises.’
Meanwhile, leadership opportunities may include becoming a nurse partner or lead practice nurse within a practice or CCG, and there are now also leadership opportunities in training hubs. These are ‘slowly but surely increasing,’ continues Ms Charlton, although she notes there is no nurse on the board of her local PCN. Ms Gulam echoes the sentiment: ‘Within PCNs, I had to push the idea that there should be a nurse involved. We’re so often just hidden behind doctors. I feel we’re nowhere near having the voice we deserve yet,’ she says.
Ms Hall highlights the increased recognition of practice nurses’ leadership potential since the pandemic – during which, for example, they ‘shone’ managing vaccination clinics. ‘Practices have started to realise what they’ve got and those that don’t listen will lose their nurses,’ she says. However, she shares concerns over ‘practice nurses not having enough of a voice in PCNs’.
Advanced clinical practice (ACP) is also a well-trodden route for practice nurses to develop leadership and clinical skills – as well as increase their pay. However, Ms Brindley fears many may be ‘shoehorned’ into it. The ACP or advanced nurse practitioner (ANP) role is closer to the ‘medical model of care involving seeing patients, diagnosing, treating and prescribing’, she argues. Sarah Weaver, course leader for the postgraduate certificate in general practice at the University of Worcester, echoes this view: ‘In a way, ACP training takes you away from the practice nurse role, so there need to be other forms of career progression.’
Meanwhile, multidisciplinary teams in general practice – including paramedics, nursing associates and pharmacists – are expanding, encouraged by recent funding for PCNs through the Additional Roles Reimbursement Scheme (ARRS). This change is seen as both an opportunity and a source of frustration by practice nurses.
‘Where’s the money funding nursing roles?’ asks Ms Weaver. And Ms Brindley also points out that ARRS rates are based on a weighted average of the AfC pay scale, from which GPNs remain excluded: ‘GPNs are then asked to support and contribute to the training and development of these individuals, who are paid more and have better terms and conditions of employment. How is that right?’ However, Naomi Berry, a practice nurse in Bradford who qualified in 2019, says sharing the workload between professions has freed up practice nurse time and could lead to leadership opportunities within the team. ‘A bigger team is better,’ she says. Ms Carrick agrees: ‘I’m hoping this will have a huge impact on allowing nurses to spend more time with patients.’
On top of the issues around career progression, training and leadership explored above, nurses are facing a harsh reality as exposed by the Nursing in Practice survey: more work is being carried out by fewer nurses, many of whom who feel undervalued and unhappy about pay.
Perhaps it is unsurprising, then, that so many respondents revealed they are looking at retirement or quitting. For example, a practice nurse based in south-west England said they were thinking of retiring early because they felt ‘exhausted’ and it was ‘an uphill struggle to keep going’. Another nurse practitioner, based in the East Midlands, said they wanted to move to a nursing role outside of general practice because they could not see ‘any improvements on the horizon’ and did not feel their pay was reflective of their work or responsibilities. And a practice nurse in the West Midlands complained that practice nurses are ‘not included’ when AfC nurses are awarded a pay rise: ‘We are always excluded and so feel undervalued.’
Ms Carrick’s own experiences echo these findings: ‘A lot of excellent practice nurses have left for their mental health,’ she says. And on top of the faster pace and complexity of the role, she also worries it has lost some of its appeal because of changes to working hours: ‘It was essentially nine to five, Monday to Friday. That was one of the attractions, but we’re now open more often.’ She was speaking before NHS England announced on 1 March that practices in England’s PCNs would be required to open from 9am to 5pm on Saturdays from October.
Historically, when nurses leave, they take their experience with them. But Ms Hall, who also works as a lead nurse at NHS Devon CCG, praises a local legacy mentor scheme in its pilot year, which matches a practice nurse coming to the end of their career with a newly qualified nurse. In Devon, 62% of nurses are over the age of 50 and were previously leaving without passing on their experience and knowledge. But now, the course is having a two-pronged effect: ‘It’s supporting newly qualified nurses, but also aiding in the retention of nurses coming to the end of their career. Many of them are loving being a mentor and hopefully will stay on a bit longer,’ she says.
In this way, the retention issue brings us back to the start of a nursing career. Ms Charlton, who is also a mentor for new GPNs and student nurses, is in agreement about the benefits of forging a link between potential joiners, new recruits and more experienced nurses before it’s too late.
She says: ‘It’s a remarkable, rewarding job. Once we get student nurses in general practice, they say, “I love it, I didn’t realise how much you do”. Getting experienced nurses who might want to leave to link up with these younger nurses reinvigorates their passion for their job – because they realise how much they do know, and how good it is to pass on knowledge to the next generation.’
The digital revolution
Practice nursing has also been embracing more digital tools and skills, particularly since the Covid-19 pandemic begun. The push towards digital has opened up new roles and skills for nurses in primary care.
Helen Crowther, who co-founded the digital nurse network, says the Covid-19 pandemic has transformed the face of digital work in primary care. In 2019, as nurse leaders working in the former NHSX, Ms Crowther and Ann Greggs created the network for nurses in primary care and general practice. ‘But the pandemic was a lightbulb moment. It changed from us trying to contact people about digital to people reaching out to us every day about the amazing things they were doing,’ she says.
Ms Crowther was appointed as National Digital Primary Care Nurse Lead in December 2021. After the Covid-19 pandemic saw a rapid rise in the use of digital – from remote consultations to remote patient monitoring – she says now is time to take stock, see what worked well, what didn’t and ensure nurses have the necessary digital skills, experience and confidence. Helen also urges any nurses interested in digital to get in touch with her, adding: ‘I’d encourage all primary care nurses who are interested to find digital opportunities locally and get involved.’
Cheryl O’Sullivan is one of the two chief nursing information officers in primary care, a leadership role overseeing digital and informatics innovation, and agrees that nurses are key to changes in digital.
She tells Nursing in Practice: ‘Encouraging the nurse’s voice and seeing things from the nurse’s perspective, with their knowledge of clinical workflows ensures that we leverage technology to enhance the patient experience in General Practice. GPNs are privileged in their unique relationship with their patients, and we need to support and enable them to adopt digital technology that enhances this.
‘In order to drive up awareness and accessibility to new technology, it is essential that we also build trust where the GPN voice can be heard and recognised. Building relationships, digital literacy, and empowering the nurses within our 18 PCNs in Dorset, is paramount to this to ensure they share the strategic vision and feel part of the digital journey too.’