It’s a professional obligation, and a crucial part of ensuring that care is delivered safely, backed by the latest evidence.
But commitment to primary care nurses’ continuing professional development (CPD) is being eroded in the current climate of NHS cuts.
The community and district nursing CPD budget has dropped by 60% over the past two years, according to the Royal College of Nursing (RCN). After the concerns raised from a recent health select committee meeting, the Government has recommended these CPD cuts be reversed.
While the Government and the nursing profession have voiced concerns about the CPD cuts, the amount of money allocated to individual nurses or nursing teams to help them develop their careers remains varied and vague.
This contrasts with the clear Nursing and Midwifery Council (NMC) requirements on revalidation: 35 hours of CPD relevant to the scope of the nurse’s practice since their registration was last renewed – or when they joined the register – and at least 20 of those hours must include participatory learning.
CPD funding for community and district nurses
CPD funding for community and district nurses is restricted to the Trust they work for. Janet Davies, chief executive and general secretary of the RCN, believes that funding for CPD for nurses is ‘critical,’ and should be ring-fenced as there is ‘little left in the pot to provide the further education nurses need to advance their careers and develop their skills’.
She warns that if CPD budgets are not ring-fenced ‘we will have fewer advanced nurses in the NHS and fewer nurses out in the community, where so much of patient care now takes place.
If we are to stop nurses leaving the profession the Government must invest in the existing and future nursing workforce’.
Ms Davies welcomes ‘the health select committee’s timely recommendation to reverse the CPD budgets cuts’.
Danny Mortimer, chief executive of NHS Employers, says there is ‘an urgent need to reverse the disinvestment we have seen in CPD funding’.
He says: ‘Employers in all settings have been reporting reduced availability of funds to support access to postgraduate courses for nurses and midwives. This impacts on motivation and retention of staff and makes it more difficult for employers to deliver the essential training and development needed to maintain safe practice’.
Commenting on funding for CPD training for its community and district nurses, the Royal Wolverhampton NHS Trust says: ‘There is there is no specified amount per head for any member of staff, including nurses, as we work on a prioritised approach to ensure that the money is used efficiently’.
A spokesperson for Lancashire Care NHS Foundation Trust says that CPD funding allocated by HEE ‘has been reduced nationally’.
‘We receive a flexible cash allowance for CPD and this has been utilised for external training courses. Requests are received from clinical teams and each application is considered by a panel in terms of clinical priority and best value for money.’ They add that while the reduction in CPD funding is challenging, ‘we are exploring how alternative funding sources could be utilised in the future’.
Primary care nurses are obliged to achieve these standards, but trying to meet them appears to be as varied as where they work. Health Education England (HEE) told Nursing in Practice that CPD funding for all NHS staff, including nurses, is ‘the responsibility of their NHS employer’. But what does this mean for individual nurses in primary care?
For community and district nurses it means relying on their NHS trust employer to support their CPD. However, these employers have been reporting less availability of funds from HEE for professional development – a situation the RCN has described as ‘critical’ (see box, left).
Less well known is what’s happening ‘behind the scenes’ of CPD for practice nurses. Employed by GPs, nurses depend on them for their CPD funding and development. But unlike NHS trusts, GPs are not allocated funds from HEE but instead from a global sum given by NHS England.
Being responsible for providing practice nurses with the support for CPD – whether that’s paying for a magazine subscription or course, or relieving a nurse to attend training – presents many challenges for GPs.
On a need-to-do basis
Dr Peter Holden, GP principal of a Derbyshire practice, allocates a notional budget of £500 a year for CPD to each of the practice’s three nurses ‘to be spent on courses we deem necessary and appropriate’, he says. He points out that the global sum for GPs is ‘to provide for everything in the practice – staff, premises, the lot’.
So the £1,500 CPD allocation for the practice’s nurses is ‘money the partners have decided not to take home for themselves – it’s technically GP money’, he says. And he points out that the money allocated for a practice nurse to attend a training course can then jump to £3,000 a year as partners also need to find locum nurses with equivalent skills to cover for the practice nurse’s absence.
At Dr Holden’s practice, nurses raise their desire for specific training to the practice manager. A business case is then assembled and brought to the partners to make a decision. But while he says the practice prides itself on ensuring people have training, it has to be on a ‘need-to-do’ not ‘nice-to-do’ basis.
‘If it’s a course the nurse might need to do for their registration – the word is “need” and in accordance with the business needs of the practice. But it’s not my job to train a practice nurse to prescribe, or take a diabetes diploma, so they can go for a higher-grade salary elsewhere,’ he says.
Funding cuts also present a challenge for GPs supporting nurses with their CPD. Dr Keith Hopcroft, a GP in Essex, says his practice allocates £1,420 a year for education and development of its six nurses and two healthcare assistants. He suggests that reduced funding for CPD could lead to fewer free or subsidised courses, making nurses more reliant on practices to fund courses or having to pay for training themselves.
‘Cuts might also show in other areas, for example in posts not being filled in whatever the nursing educational hierarchy comprises, which is what has happened [because of funding cuts] in the field of GP education and training,’ he says.
Some GPs may not even be aware what the CPD budget is for practice nurses. GP partner Dr David Turner says: ‘Speaking for myself, and I suspect a lot of GPs, funding for CPD for practice nurses would be something that practice managers deal with and not necessarily something GPs would be very involved in.
Professor Lisa Bayliss-Pratt talks to Nursing in Practice about her thoughts on CPDfor practice nurses
How important is access to CPD for a practice nurse?
We have lots of debates about CPD and what it actually means and who is responsible for it. Is it the individual, is it the employer, is it Health Education England (HEE)? In reality, there are different views out there about who is responsible. First and foremost it isn’t just about access to a pot of money for training, you also need clarity of what the training needs are of those working within a practice. Then how does that benefit the patients and the people you are looking after. And then who contributes what in terms of financial input. So there is a need to have a much better and more rounded conversation about ongoing learning and investment, and everybody’s role within it. CPD means different things to different people, but what we are absolutely sure of is that when employers invest in their workforce, you know that workforce is engaged and, on the whole, stays and feels great job satisfaction, which you would imagine leads to better patient outcomes.
It’s very important not to have a binary conversation about workforce, about CPD and whose business is it. It’s actually how do you understand what you need, and then how do you find the answers to the funding of it. Because sometimes it’s about the individual, the employer and the third party.
So it’s important for the nurse themselves to be aware of what training they need, and to communicate that?
Absolutely. What they need, why they need it, and how best it is achieved, because sometimes you want access to shadow somebody. There are a few people that I coach and mentor; sometimes it’s an experience and other times it’s ‘you absolutely have to do this course’, to deliver this new skill in a different way.
The HEE workforce budget has gone down over the past two years by more than half. Do you think that will impact the level of CPD available to practice nurses?
Without a doubt our budget has shrunk, because of the comprehensive spending review. And the decisions we are left with, such as do you invest in the future workforce? Or we haven’t got enough for the future, so do you put more money to your existing workforce? It’s that continual balance. But what we don’t understand enough and, through our local workforce action board, what we are working hard to understand is what are the priorities for people, and how can we help them the most and what sort of funding arrangement is needed. They are the important conversations, because not everybody accessed that budget. And I would say that general practice nursing probably had the least access to the budget.
So it’s important that all practice nurses receive learning and development. But what must be clear is what learning and development do they need, how they retrieve it, and what does that require. And what it requires in terms of commitment from the various parties.
‘I phoned the practice manager at my previous surgery and she was not aware of any money for CPD for practice nurses. I guess this lack of awareness by practice managers/clinicians may be noteworthy itself,’ he adds.
Practices not always perfect
The experience of nurses highlights the disparity between practices of the awareness about CPD funding and budgeting as well as the support they give. Ellen Nicholson, an advanced nurse practitioner and interim course director for the practice nursing programme at London South Bank University, says her take on CPD from feedback from a social media community of general practice is that it is ‘very varied up and down the country’.
Working in primary and community nursing for the past 18 years, Ms Nicholson has found that some areas are forward thinking, such as the City and Hackney GP Confederation, where the nurse lead was director of workforce and allocated money to CPD.
‘It helps if someone at the top of the organisation actually understands what nurse CPD is about. It’s an easy area to forget about, and to cut out,’ she says, adding that even within local regional areas there is disparity with CPD for nurses she finds. ‘Some nurses in practices I’m told don’t receive study days’.
Ellen Shuker is an advanced nurse practitioner in Nottingham and has worked in general practice for 15 years at several practices. She has found that even though GPs are the decision-makers for CPD funding, its provision is more dependent on the practice manager who is ‘like a gatekeeper’.
Ms Shuker told Nursing in Practice: ‘Some places I’ve worked at are very proactive, very supportive and happy to encourage a master’s degree pathway – which I’ve done – and also give support for shadowing and clinical supervision – that’s how we gain our experience, it’s not just about theory.’
But she has also had negative experiences at practices where there has been little CPD. One practice she worked at was so lacking in professional development that she left.
She adds: ‘I was not allowed to do anything outside of that practice. They would put on in-house training but if I asked to do an external course the practice manager said no. If I didn’t stay up-to-date I would have become unemployable, so in the end I left.
‘I didn’t complain to the GPs – maybe I should have been stronger. At the time I felt they would back the practice manager. It was all about the money.’
And money is the reason ‘things are going wrong’ with CPD for practice nurses, Ms Nicholson believes. ‘Lack of CPD funding for practice nurses has always been a problem. But it’s not helped in the current political climate of cuts and when the value of nursing in society is under threat,’ she adds.
The value of nurses is not reflected in the GP contract, so ‘there is no hook for nurses to hold onto’, Ms Nicholson says. And although nurses can help GPs with the pressures of an increasing workload because of a rising older population and patients with more complex problems, such as managing minor illnesses, ‘some GPs don’t necessarily want to let go of what they do’.
But work has, and continues to be done, to help highlight the importance of CPD for nurses working in general practice. Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute (QNI), says: ‘One thing that is really positive is the NHS England work on the ten-point plan for practice nursing. This is shining a light on CPD needs of general practice nurses and recognising the challenges of supporting practice nurses accessing CPD’.
She says the QNI has provided evidence from its report on General Practice Nursing in the 21st Century: A Time of Opportunity, which outlines problems and solutions about CPD for practice nurses. The report includes how 43% of respondents to the QNI’s snapshot survey of the practice nurse role in 2015 did not feel their nursing team had the right number of appropriately qualified and trained staff to meet the needs of patients.
Dr Oldman would like to see ‘specific ring-fenced funding for general practice nurses. As well as helping to develop nurses’ careers, this would also help with pressures in general practice, as many of my GP colleagues say that so much in general practice is doing what could be done by an educated nurse, post-qualifying’.
From a GP perspective, a solution to the difficulties with CPD is that general practice ‘needs its resources restored’, says Dr Holden. ‘No one is looking at the total cost of CPD,’ he adds.
For practice nurses, there is no quick fix for the difficulties they experience with CPD. What is lacking is ‘solid evidence in the value of nursing,’ Ms Nicholson stresses, adding that what is needed is a ‘vision for investment’.
She urges: ‘GPs must value their nurses and understand the value in what nurses are doing.’
Nursing in Practice offers free CPD at all of the 12 Nursing in Practice events throughout the UK in 2018. For more information please visit nursinginpractice-events.co.uk/ or contact [email protected].