Winter pressures began early, with nurses in primary care facing a host of challenges, including rising workload and unknowns around the severity of flu and Covid-19. Katherine Price reports
Stationed as ever on the frontline of patient care, nurses in general practice are busy supporting their patients as the colder months loom. But it is a daunting task.
With a ‘depleted and exhausted’ workforce still tackling the backlog of the past two years, nurses worry about missing the usual opportunities to review patients presented by winter preparations. And while they feel confident in delivering the flu vaccination campaign, concerns remain that vaccine fatigue may affect uptake.
What’s more, the UK is likely to face the peak of the cost-of-living crisis this winter – threatening not just people’s wallets, but their health. As QNI chief executive Dr Crystal Oldman warns, nurses can expect to see people unable to heat their homes, worsening long-term conditions and putting nurses under yet more pressure.
NHS England wrote to GP practices and PCNs last month, saying it had ‘taken action to boost capacity ahead of winter’ to ‘support the NHS during this period of sustained and significant pressure’.
Setting out a series of measures to support GPs over the winter, NHS England said it would retire or defer until next year four investment and impact fund (IIF) indicators worth £37m and allocate this funding to PCNs via a monthly payment. But ahead of such a difficult winter, will this additional support be enough?
Confidence despite confusion
The Department of Health and Social Care (DHSC) is expecting a resurgence in flu this winter, with potential co-circulation with Covid and other respiratory viruses.
Planning in advance for the winter has been complex, worsened by ministers’ delays in decision making on vaccinations. In May, The Joint Committee on Vaccination and Immunisation (JCVI) issued interim guidance recommending autumn Covid boosters for over-65s, care home residents and staff, frontline health and social workers and adults aged 16 to 64 years in at-risk groups. But NHS England had told commissioners to plan for a ‘maximum scenario’ of autumn boosters for all over-50s and in July, the JCVI duly extended eligibility to this group.
Similarly, the decision in March to scrap free flu jabs for 50- to 64-year-olds this year was also reversed in July. Everyone in this age group is being offered a free jab, with eligibility also expanded to some secondary school children, focusing on Years 7, 8 and 9 (ages 11-14).
Inevitably, this brought extra problems for nurses delivering the vaccines, and uncertainty for the public.
‘I understand the reasons, but it’s quite difficult on the ground to plan… and I think it’s also quite confusing for the public,’ says Helen Donovan, RCN professional lead for public health.
Marilyn Eveleigh, nurse advisor to Nursing in Practice and a Covid vaccinator at a hub in south-east England, agrees the shifting eligibility has been ‘muddling for the public’, as the spring booster was focused on the over-75s.
‘When policies are announced, it would be so helpful if those who were going to deliver on those policies would either be a part of that policy being developed or be forewarned before it’s in the media,’ says Dr Oldman.
Barnsley Healthcare Federation’s head of nursing and allied health professionals Andrea Parkin adds: ‘I would like to have known sooner that the cohorts would change for flu to make sure we were ordering enough vaccines, but I did pre-empt it and luckily ordered over and above, which I think many nurses will have done.’
Despite hopes of delivering Covid and flu vaccines together, she says it is likely they will be given separately: Covid through vaccination hubs and flu via GP practices and pharmacies.
‘It will depend on receiving flu and Covid deliveries at similar times. If one is delayed it can compromise the co-administration ambition,’ Ms Parkin says. ‘We would benefit from a clear strategy for future years to deliver both flu and Covid together.’
Relying on goodwill
Adele Parsons has worked in general practice for more than 16 years and maintains an honorary general practice contract while working as a senior lecturer at the University of Lincoln. She points out that the success of a flu campaign often depends on the goodwill of practice nurses who, she says, ‘do what they need to do to make it work with what they’ve got’. However, she warns this goodwill is ‘starting to ebb a little bit’.
‘The PCNs have been fantastic because they’ve been able to pool resources, and in some areas they are really well integrated,’ she continues. ‘I have no doubt that the goodwill again will be a major factor. The only problem might be the vaccine hesitancy for patients.’
However, she adds that general practice nurses are used to discussing vaccine hesitancy with patients and ready to have those conversations.
‘Staff are having to juggle priorities… we have to build all that into all the other asks of us,’ Ms Parkin says.
She says strong communication campaigns are needed to highlight the need for boosters, although that itself can be challenging locally if multiple vaccination campaigns have to be run together.
Ms Eveleigh says that in her experience, the elderly and vulnerable are ‘as keen as ever’ and the hub is anticipating a good uptake. However, she says it has been a challenge ensuring the [original] Moderna vaccine, of which vials hold up to 20 doses, matches the numbers of patients being vaccinated each day, as punctured vials have to be discarded after 12 hours. But vials of the firm’s newly authorised bivalent Original/Omicron vaccine will contain 5-10 doses, which could ease this pressure.
In Scotland, changes to regulations have seen responsibility for vaccinations and immunisations shift away from general practice to health boards.
Rhona Aikman, a practice nurse based in west Scotland and Nursing in Practice editorial adviser, is concerned about the impact this will have on uptake in areas where patients have to travel further – and more than once if the flu and Covid vaccinations cannot be administered together.
‘For years [vaccinations have] worked very, very well in general practice,’ she says. ‘What the change will do to the uptake, who knows?’
But despite concerns and initial confusion, nurses who spoke to Nursing in Practice say they are confident they will be able to rise to the challenge and are not aware of any anticipated supply issues this year.
Dr Goldman shares this faith, but underlines her point about the value of consulting nurses on decisions. ‘I’ve no doubt they will rise to that challenge because they always do, but what would be helpful is input into the planning.’
Ms Parsons adds: ‘General practice has got this – they’re on top of it. Nurses know what works for their practice’s population, and they adapt and deliver an outstanding service every year.’
The autumn Covid booster campaign began in care homes in England on 5 September, with a formal launch of the full campaign a week later.
Other programmes will also be adding to the seasonal pressure. For example, in Greater London, practices were expected to simultaneously ensure a polio booster vaccine was offered to all children aged 1-9 by 26 September, following detection of the virus in the capital’s sewage.
These additional challenges mean that while nurses would have previously used the opportunity provided by the high volume of contacts ahead of winter to have catch-up conversations with patients, this is likely to be pushed down the list of priorities.
‘You get to see a lot of patients in a short space of time… normally we would use that to opportunistically catch our pneumonia vaccines for at-risk patients,’ explains Ms Parsons. ‘Even if we don’t do them there and then, we’ll say, “do you know you need this as well?”
‘We’re now trying to deliver a service with all the different arms of general practice and still chase the backlog. And we have to do it, because it’s tied up with our contract payment… it’s made work very hard. So rather than a straightforward child immunisation, you might have one that’s had an interrupted schedule – everything takes a little bit longer.’
As well as the further support for winter set out by NHS England last month, the DHSC also confirmed general practice services will be supported through the recruitment of extra social prescribing link workers and care coordinators. Previous health secretary Steve Barclay had also ordered civil servants to significantly increase overseas recruitment of health and social care staff in time for the winter season.
A DHSC spokesperson said the Government’s planning for the winter period included ‘further measures to rapidly boost capacity and resilience, such as 7,000 more beds, including innovative virtual wards, and boosting the recruitment of new staff in primary care’.
They added that the Government had made ‘£520m available to improve access and expand general practice capacity during the pandemic’ saying GP appointments had ‘returned to pre-pandemic levels’, with 1.3 million on average per working day in June 2022.
However, nurses are cynical about whether ‘throwing money at the problem’ will provide meaningful support for primary care this winter. They want a proper strategy for recruitment and retention.
‘There is always a need for more [winter] funding but there needs to be long-term investment as well, in terms of attracting more people into general practice,’ says the RCN’s Helen Donovan.
‘It is pay, but it’s also recognising the skills and expertise and experience general practice nurses have. They have really advanced skills – a lot are prescribers. And it’s often down to language – you often hear about the doctors and GPs rather than general practice. The nurses need to be recognised for what they’re doing.’
Barnsley Healthcare Federation’s Ms Parkin says the severity of the recruitment problems could worsen winter pressures, citing the federation’s inability to fill a medical director vacancy for more than two years.
Ms Parsons says it’s important to boost existing services that are known to be effective: ‘We can’t just keep creating services – we need to do something about the services that are there and reinforce what we’ve got. General practice works but we do need a review.’
A report¹ released by the Health Foundation’s REAL (research and economic analysis for the long term) centre earlier this year found that healthcare services in England could still face a shortfall of up to 38,000 nurses even if the Government makes good on its promise to recruit an extra 50,000. The number of FTE nurses in general practice is projected to decline by around 0.6% each year over the next nine years.
‘When I started in general practice, occasionally we had clinics with empty appointments. They were a bit of a break and a catch-up. It hasn’t happened for years,’ adds Ms Parsons. ‘The concern is that we have a depleted, exhausted workforce heading into the winter season. We know staff are tired; they’re going to get sick and they’re going to be more sick if they’re tired.’
As winter approaches, nurses also continue to face the misconception that practices are not open for in-person appointments, with some even being abused by patients.
‘I often think we should publish the figures – how many people did we speak to on the phone, how many did we see each week?’ says practice nurse Ms Aikman.
Ms Parsons says dissatisfaction with other healthcare services often arrives at the door of general practice and is leading to a high turnover of reception staff and care navigators. ‘You’re constantly training new staff,’ she says.
‘People see the pressure in A&E – they can visualise it. They can’t visualise it in general practice, they just think somebody is refusing to see them.’
‘We will always strive to meet demand in primary care and nursing staff will continue to work as hard as they can,’ concludes Ms Parkin.
‘However, we need the tools, we need the staff, and we need the staff who are in work to be fit and well.’
‘I’m confident we can deliver what we need to, but it’s often at a detriment to ourselves’
Lucy Brotherton, lead practice nurse based in the south west
This year we’ve tried to work more collaboratively within our PCN – running more central clinics, pooling resources, particularly when it comes to Covid vaccinations. We are predominantly focusing on flu and working closely with the PCNs so our patients will get their Covid vaccines at other practices within the PCN.
Discussions have happened earlier this year because of the amount of planning needed. There’s more to discuss in the logistics, it’s trying to predict every scenario.
Obviously the Covid restrictions are different this year, but we’ve been sticking to the strict infection-control policies, looking at how we move patients through the building, how our reception staff manage the flow. We’ve had to give slightly longer appointment times so that we can follow the IPC guidelines, so that means fewer appointments. We’re also asking people to wait in their cars or outside the building, limiting the number of people standing in the waiting rooms.
It’s going to be very busy – there’s not been a decline, if anything people are more aware of the benefits of vaccinations, and those that may have turned down the flu vaccine before are more keen, particularly the younger groups.
There’s also the challenge of where you’re going to store all these vaccines, as well as your routine vaccinations for child immunisation programmes. It is about trying to maintain a minimum but required stock level of your routine vaccinations, ensuring you’ve got ample space for flu and Covid supplies. When they were doing Covid vaccinations from the vaccine centres, that eased some of the pressure, but now that has come back onto primary care to manage
The flu vaccines tend to arrive in dribs and drabs, whereas you tend to have one big delivery of Covid vaccines, so it’s trying to plan that with your staff and appointments. It will be a huge challenge for staff that are already quite worn out.
I don’t think anyone expected two years in to still be coping with the backlog of work. And we just cannot recruit staff with the necessary experience. We’re trying to find people who can deliver the services we need right now, and it just seems an impossible task, there are shortages across the board.
I’m very confident we’ll deliver what we need to deliver – but it’s often at a detriment to ourselves and our teams.
Cost of living may hit vaccine uptake
Requiring patients to make multiple journeys for their vaccinations could hit uptake – not just due to vaccine fatigue but also rising costs, such as fuel.
‘Nurses are going to be seeing people who are not able to heat their own homes and their long-term conditions are going to get worse. There’s the physical impact that they’re going to be seeing in the patients, and the impact on the nurses knowing that they can’t do anything about it,’ says the QNI’s Dr Crystal Oldman.
Food banks in the Trussell Trust’s network provided more than 2.1 million parcels to people facing financial hardship across the country between 1 April 2021 and 31 March 2022 – a 14% increase on the same period in 2019/20 and the first time the trust has surpassed two million parcels other than at the height of the pandemic.
- Shembavnekar N et al. NHS workforce projections 2022. London, Health Foundation, 2022. Link