General practice nurses have worked harder than ever since the start of the Covid-19 pandemic. They have risen to every unexpected challenge and kept services running while carrying out mass vaccination, often with a depleted workforce due to staff illness and pre-existing vacancies. Not only that, but they’ve had to deal with rising levels of abuse from the public.
Practices are usually quieter over the summer months but thanks to Covid and the backlog of services it has created there was no such respite this year. Levels of stress and burnout among staff are worryingly high.
Now the busiest time of the year for primary care and the NHS is upon us. Practice nurses will be integral to delivering the biggest-ever flu vaccination campaign this year, alongside Covid booster doses and jabs for children aged 12 to 15. This is on top of other vital vaccinations and continuing to tackle the huge care backlog.
Despite this heavy workload, Covid-related funding for practices seems to have dried up.
NHS England delivered a £150m ‘Covid capacity fund’ for practices up to March 2021 and a further £120m for April to September. The Department of Health and Social Care gave £270m between November 2020 and September this year. Neither NHS England nor the DHSC would directly confirm to Nursing in Practice whether general practices would receive any funding to support them over the extremely difficult months ahead. And it remains unclear how much, if any, of the extra £5.4bn awarded to the NHS in September will come into primary care.
In August, the BMA launched a petition calling on the Government to commit more funding to practices because of ‘unmanageable’ workloads. It is still awaiting a response from ministers. And in July, Devon LMC warned that GP surgeries in the county would be on the ‘brink of collapse’ without urgent action – a picture mirrored across the country.
As nurses consider the scale of the challenge ahead, they are asking: how will we cope?
Impossible to plan ahead
One major issue for nurses has been difficulty in planning for the coming months because of uncertainty over the possible Covid booster programme.
Nurses are often left out of the loop when it comes to information and decisions. Nursing in Practice reported their frustration last November when their views were not sought over the introduction of the direct enhanced service – a nationally negotiated opt-in contract for a specific service – for delivering the Covid-19 vaccine.
This year, in common with all staff, nurses are behind with preparations for the flu season, which runs from September until the end of March next year. This is because of the Government’s repeated failure to provide clarity on the Covid booster programme, which health and social care secretary Sajid Javid had said would start in September and could be given alongside the flu jab. Announcing the autumn/winter plan on 14 September, Mr Javid finally confirmed booster jabs would be offered – giving just a week’s notice for the programme to start, even though some 30 million people will be eligible.
They include over-50s, health and social care workers, older adult care home residents, those aged 16 to 49 with underlying health conditions, adult carers and adults who share a household with vulnerable people.
The Medicines and Healthcare products Regulatory Agency has now determined that co-administration of flu and Covid jabs is safe and can go ahead. Although, deputy chief medical officer Professor Jonathan Van-Tam admitted on 13 September that combining the programmes may not be ‘straightforward’ or even practical.
With the flu season already under way, teams have been left scratching their heads as to how the two jabs could now be scheduled together, and to what extent Covid mitigation measures will still be required. Speaking before Mr Javid’s long-awaited confirmation that boosters would be offered, nurses shared their concerns.
Emma de Chenu, an ANP and lead nurse at the practice at the University at Sheffield, told Nursing in Practice her team faced uncertainty over preparation for this academic year. They usually begin in the early summer but ‘didn’t really know what was happening’, she says. ‘We haven’t been able to plan.’
Delivery and storage issues
Ms de Chenu highlights the lack of guidance on how the flu and Covid booster programmes could be run together, given the complications over vaccine delivery and storage. Covid vaccines typically arrive in large orders, while flu jabs arrive in ‘dribs and drabs’, she explains. This means if practices are told to administer them together, flu appointments may have to be delayed until Covid jabs are delivered. The JCVI has recommended the Pfizer vaccine should be used for booster shots regardless of which brand was received for earlier doses. It can only be stored for 31 days at normal fridge temperatures, so the flu jab – which can last for months – would have to be administered on the same tight schedule.
‘You’ll need a lot of nurses to deliver both simultaneously, working beyond normal time,’ Ms de Chenu says. ‘And understandably people are tired and goodwill can be tight.’
Elia Monteiro, a practice nurse who works across multiple practices in London agrees that planning for the flu campaign at her workplace has been delayed by a lack of information around the Covid booster programme. She also worries there will not be enough nursing and other staff available to get the required vaccinations done, especially without the access to volunteers to coordinate and administer vaccinations they had at the height of the pandemic. ‘I have no idea how we’re going to manage to go about it,’ Ms Monteiro concedes.
Another ANP, who is also clinical director at a primary care network in the south of England, tells Nursing in Practice they wish their PCN had opted out of Covid booster vaccinations. ‘There’s been a black hole of information around the boosters. We didn’t know what vaccine we’d be using, how it would be delivered or to what cohorts. Without clarity, there’s a lot of unnecessary work having to be done. But primary care can’t do everything.’
To complicate matters further, Seqirus, the largest vaccine provider in the UK, revealed in early September that vaccine deliveries would be delayed by up to two weeks because of the nationwide shortage of HGV drivers. This has led to yet more workload for practices through having to cancel or reschedule appointments.
One practice nurse, based in the south-west of England, explains: ‘We’re now having to start our flu jabs at the beginning of October, instead of mid-September. It has meant a lot of disappointed patients and extra admin too, when we’re already so busy.’
But even without the effect of uncertainty about the Covid booster programme, nurses were already snowed under with work and playing catch-up.
This is not surprising. Nurses have been vital to delivering well over 90 million vaccinations so far against Covid-19 and to making a start on the biggest flu vaccination campaign in NHS history. For the first time, the latter will include all secondary school children aged under 17 – making a record 35 million eligible people.
It is also not surprising that demand for mental health support is soaring. Ms Monteiro explains: ‘The number of mental health patients being discharged has increased. Those patients need more input from us. And we’re also making more mental health referrals for patients needing this support for the first time because of the impact of lockdown. This then comes with the additional workload of following those patients up.’
Ms de Chenu’s university practice usually delivers measles, mumps and rubella vaccines as well as meningitis ACWY vaccines to overseas students during the first week of term in September. But this year, her team has faced decisions on delaying some or all of those clinics to accommodate international students having to isolate on entering the country. ‘There are all these new things to work around,’ she says.
Rhona Aikman, a practice nurse based in west Scotland and Nursing in Practice editorial adviser, says: ‘We are running over six months late calling people for shingles [vaccination]. They are coming now but it’s taking time to catch up.’ She adds: ‘Referrals to colposcopy for abnormal smears are waiting much longer than usual – even fairly urgent ones – and calls to patients for smears are themselves running about six months late.’
The PCN clinical director in the south of England has similar concerns: ‘In my own practices, we’ve still got diabetic patients who haven’t been seen for over 12 months. I know diabetes has got significantly worse as people have been sat at home and not moving much. On top of that, there’s all the prediabetic work – we haven’t reached many of those people. I wonder how many more of them have crossed the threshold and become diabetic without our support.’
Ms Monteiro is concerned the pressures also mean nurses cannot dedicate the time they need to patients, and this could compromise patient safety. She used to have 20 to 30 minutes for an annual care planning diabetes appointment covering blood tests, blood pressure, weight and more, but this must now be squeezed into 15 minutes because of workload pressures. ‘The amount of work is not safe – It’s pressurising nurses,’ she says.
But patients, who have often not seen a clinician in person since the pandemic began, have lots of questions and may come to appointments with multiple issues, Ms Monteiro adds.
‘People with diabetes might end up with permanent damage if blood sugar levels are high for a long time and it’s not being managed effectively,’ she says.
Lower immunity to normal viruses
Practices are also likely to be dealing with higher levels of coughs, colds and flu this year. Lower temperatures and humidity in autumn and winter are linked to increased transmission of flu and other respiratory viruses such as respiratory syncytial virus, which causes coughs and colds and is the most common cause of bronchiolitis in children aged under age two. Because lockdowns cut transmission rates of these viruses last year, clinicians believe immunity against them will be lower and they will be more common than usual in the coming months.
Flu cases in the community were about 95% lower than normal last season, according to the Royal College of General Practitioners. And in a letter to practices in July, NHS England warned: ‘It is expected that winter 2021 to 2022 will be the first winter in the UK when seasonal influenza (and other respiratory viruses) will co-circulate alongside Covid-19.’
Of course, nurses may catch these viruses themselves. Practices are already short staffed but they may see greater numbers of nurses going sick or leaving the profession, which will increase pressure on those left.
‘Burnout is a real issue’
Ms Monteiro says this pressure is having a ‘domino effect’ on nursing. ‘There is a chronic shortage of practice nurses. It’s hard to get a fully qualified nurse who can do diseases on top of screening and treatment room duties, and everything else a practice nurse does. It’s a result of a lack of long-term investment. But Covid has definitely worsened staff shortages through burnout, sickness and people leaving the profession.’
The practice nurse based in the south-west of England admits to Nursing in Practice: ‘For the first time in 25 years, I am thinking about leaving practice nursing. Two of my senior colleagues are also in that position. I think burnout is a real issue. I think we’ve been really unrecognised during Covid.’ Bradford-based practice nurse Naomi Berry agrees: ‘Morale is not good. A lot of GP nurses are leaving. A lot are saying it’s not worth it, things are getting harder and they’re not appreciated. We can’t do more than what we’re doing.’
Ms de Chenu says: ‘I’ve never been as busy in summer as this year. Normally, we’d have set dates and clinics for the start of term, and know how many international students are coming. We’ve been working flat out for 18 months. We only just stopped vaccinating and now we have to start again.’
Heather Randle, professional lead for education and primary care at the RCN, says: ‘We shouldn’t underestimate the resourcefulness of nurses in general practice, but they are tired and overworked. They’re coming a point now where they can’t do the things they’re being asked to do. Something must give. On the ground, I’m starting to hear of people retiring earlier. If lots of these nurses are going to stay, they need to start feeling valued as part of the team that has been vital to fighting Covid and they need a chance to rest.’
The BMA petition for more government funding, which is part of its Support Your Surgery campaign, calls for extra resources to ‘urgently increase the number of GPs, practice nurses and other practice staff and improve the premises in which they work’. Will the Government heed this call?
In a statement released to Nursing in Practice, the DHSC said: ‘We’re hugely grateful to GPs and their teams for their hard work and dedication, bringing appointment numbers back to pre-pandemic levels with over 330 million appointments delivered in the last year.’ It highlighted the £270m extra given to general practice but could not say whether there would be any further additional support.
But as BMA GP committee chair Dr Richard Vautrey told Nursing in Practice: ‘We went into the pandemic with far too few GPs, nurses and wider practice staff, meaning practices were already struggling to meet the needs of patients safety.
‘As we head into what looks to be one of the most difficult winters most of us will ever have experienced there needs to be an understanding of the huge pressure on practices.’
Dr Vautrey wants patients to join healthcare staff in calling on ministers to allocate funding to help practices cope.
Before the Government’s autumn/winter plan was unveiled, Boris Johnson warned: ‘The pandemic is far from over.’ The Prime Minster will be heavily reliant on the NHS and needs to protect it but he may find if he allows funds to run low in practices, morale and staff numbers may also fall.
No let-up in pressure on community nurses ‘drained’ by end-of-life care in pandemic
Community nurses have experienced rising levels of stress during the pandemic, and one of the principle reasons for this has been the increased need for end-of-life and palliative care to be provided in the community.
QNI chief executive Dr Crystal Oldman explains the rise in end-of-life care at home was in large part due to people’s reluctance to go to hospital because of limitations on visitors and the risk of catching Covid-19.
Community services had to adapt rapidly to meet increased need in terms of volume and complexity. However, as Dr Oldman points out, this shift happened against a ‘backdrop of underinvestment in nursing in the last decade’, resulting in decreasing numbers of staff being asked to deliver increasing levels of care at a time of huge uncertainty.
‘Underinvestment is coming home to roost, says Dr Oldman. ‘We didn’t do the workforce planning we needed, and more investment is also needed.’ And with winter coming, the situation is likely to get worse. As well as an anticipated rise in Covid cases and a major flu epidemic, terminally ill patients are more susceptible to cold weather, while non-infectious conditions such as asthma can also be exacerbated.
‘The country and the world owe a great debt to all nurses’
By David Munday, lead professional officer at Unite the Union
In March 2020, a few days after the country entered its first national lockdown, I emailed mental health nurse members of Unite the union to thank them for all the efforts they had already made in battling against the emerging global pandemic.
You may remember 2020 had been designated the Year of the Nurse and Midwife long before the term Covid-19 had even been uttered. What a bitter irony that, instead of sharing with the public a celebration of the value of nurses, this value would be seen and felt through our collective labours at a time of unprecedented national and global distress. And what labours they have been! No matter what your level or sector, the country and world owe a great debt to all nurses.
But will that debt be satisfactorily honoured? The biggest factor is pay. While there’s a differing picture across the UK, I’m sure you’ll all agree that the 3% pay rise about to be implemented in England and Wales does not come close to recognising nurses’ efforts. As a recent Nursing in Practice survey showed there is much dissatisfaction with the varying pay, and terms & conditions for nurses in general practice. Politicians may have imagined a weekly clap would fit the bill but it certainly won’t pay the bills.
Another area where the system has been found lacking is in support for healthcare professionals. Multiple reports, published both during and before the pandemic, testify to this. Some action has been taken. We’ve seen the development of support hubs across England, based on those created after NHS staff responded to terrorist incidents in the UK. NHS England and NHS Improvement have also done work, in which I’ve been involved, to address the National Confidential Inquiry into Suicide and Safety in Mental Health report highlighting the worrying levels of female suicide in the nursing professions. More of this work should become apparent this year, and I hope it will make an impact.
As we head towards what could be a very difficult winter, I reflect on the steps I’ve taken to support my own mental health and that of the team of people I’ve worked with and led at an NHS vaccination centre. At the start and end of every shift, I remind those amazing people that simply by turning up that day we will have saved people’s lives. I hope that over the next few months I’ll be able to meet and thank more of you in person as I chair three planned face-to-face Nursing In Practice and PULSE Live events.
Dave Munday will chair Nursing in Practice live events in London, Liverpool and Birmingham this autumn. To book, click here.