Thousands of HCAs working in GP practices want to progress their careers to become practice nurses, but may leave the NHS entirely if their path is not made easier. Dan Parton reports
In September, official NHS figures confirmed what many healthcare professionals on the frontline already suspected – that there are currently record levels of vacant nursing posts.
Across England, there is a shortage of at least 40,000 registered nurses, with fears that this figure could further grow in the coming years. General practice in particular is struggling, with the number of practice nurses in post remaining static, at best, since December 2016. As of March 2018, there were 22,976 nurses in primary care (15,889 full-time equivalent), according to figures from NHS Digital, an increase of just over 200 from the year before.
With a 2016 Queen’s Nursing Institute report finding that around a third of practice nurses were due to retire by 2020, some will, by now, have retired, but many more will be coming up to the age when they can – if they wish to.
It places huge questions marks over the Government’s intention to use practice nurses to make up the shortfall in GP numbers.
Speaking at a Health Select Committee meeting in July, health and social care secretary Matt Hancock said: ‘I know that there are many GP surgeries that are moving to having more of a structure whereby the GPs only see cases that a GP can see, and there are more nurse practitioners and other staff for the rest. So that direction of travel is important. That doesn’t mitigate the fact that we need more people in primary care, but we also need a culture change in the way our GP practices work.’
However, this change may take some time to develop. Recruitment of nurses in England is down; new student nursing numbers were down by 570 to 20,250 in 2018. This represents a fall of 2.73% from 2017’s figure of 20,820, according to the Universities and Colleges Admissions Service (UCAS).
With general practice struggling to recruit, and nursing in general facing record numbers of vacancies across the board, an alternative may exist in the form of those non-medical workers already operating in the NHS.
As of March 2018, there were 9,851 (6,677 FTE) healthcare assistants (HCA) working in GP practices, according to figures from NHS Digital, and many are desperate to become practice nurses.
One of these is Christie Belton, who has been working as a HCA in Leicestershire for 11 years. She performs a number of tasks at her surgery, including phlebotomy, checking blood pressure, heart tracing, applying/changing dressings, ear syringing and injections.
She would love to take the next step and become a practice nurse, but the practicalities and lack of suitable study options make it impossible for her to move up the career ladder.
‘I am desperate to progress but there is so much that is stopping me from being able to do that,’ she says.
One of the biggest stumbling blocks is money. The bursary to train as a nurse was removed last year, and finding other ways to finance her study would be difficult. Ms Belton only works 16 hours a week due to childcare commitments, and giving up that part-time income by training full-time to become a nurse is not an option, particularly as childcare costs would increase as a result.
‘My daughter goes to nursery and my two boys are in breakfast and after-school care – but there is no care before 7.30am or after 6pm. My husband works full-time and we have no other forms of childcare,’ she says.
‘I have explored the Open University and that costs just short of £30,000, but you have to go to placements in hospitals. And, at the moment, with three small children, it is not possible for me to work full-time hours with childcare availability to do that kind of thing. Trying to put myself through 12-hour shifts and paying for extra childcare, if it was available, just isn’t an option at all,’ she says. ‘And I don’t see it being an option in the future.’
And she is not alone in feeling frustrated at the lack of progression. She has a colleague who has similar desires to progress, but faces the same issues and blockers.
‘What we [HCAs] are able to do just isn’t enough for what we need in general practice,’ she says. ‘They need to be filling more practice nurse places now; my practice currently has six nurses above the age of 50 and in the next 10-15 years, when all those lovely ladies have retired, we’re not going to have anybody else to carry the practice through. It worries me what is going to happen in the future if they don’t invest in the fantastic HCAs that are around at present.’
Ms Belton thinks that many HCAs ‘will look elsewhere for different roles’ if investment in their career pathway isn’t forthcoming.
She has looked at other potential career options within the NHS and other caring roles herself, such as social work, as an alternative if she can’t progress in the next few years. But she doesn’t want to do something else.
She says: ‘I don’t want to lose the skills and knowledge base that I have built up over the past 11 years. At 31, I want to increase my knowledge and to continue learning over the next 10-11 years and beyond, but unfortunately I don’t see that happening if they don’t create anything further for healthcare assistants to achieve.’
Earn while you learn
Helga Pile, Unison’s deputy head of health, agrees that a lack of career development options – combined with relatively low pay levels – does mean some HCAs will look elsewhere to develop their career.
‘HCAs are generally really dedicated to working with patients and for them to feel they have no prospects is really sad,’ she says.
She echoes Ms Belton’s assertion that many HCAs want to train to become nurses or other healthcare professionals but find it hard to do due to having childcare issues, for example.
‘Most people can’t afford to give up work and go into full-time study, especially in England now with the student loans and no bursaries,’ she adds. ‘It is really off-putting for people who have responsibilities.’
The nursing apprenticeship was, in theory, meant to solve some of these problems, particularly by giving students a way of earning while learning. But the uptake has been disappointing and the model is not perfect, with many employers put off by the lack of flexibility in the apprenticeship levy, which cannot be used to fund backfill costs.
‘There was a lot of interest [in it] but the big disappointment is that so few options are available on degree nursing apprenticeships,’ Ms Pile says. ‘From what we’ve [Unison] heard the main reason employers are saying for this – and I think this will be particularly acute in general practice – is that although paying for the fees is one thing, and a general practice probably gets most of that paid because they’re not paying into the levy, it is the backfill and salary costs that employers are saying they can’t afford. So the apprenticeship route hasn’t really materialised for people and that leaves them with nowhere to go.
‘We have been pushing for some funding to be made available within the health service to support employers to pay for backfill costs so that people can do apprenticeships to become nurses, and we think the only real way we’re going to see an expansion in them is if there is some extra investment in it.’
Ms Pile believes that degrees such as this should have extra support behind them because of the financial demands that placements put on people, such as childcare and travel costs.
Liz Fenton, deputy chief nurse at Health Education England, points out that there is a career pathway for those with a care certificate to become registered nurses, but it does involve obtaining a nursing degree through either the standard degree, nursing degree apprenticeship or via the nursing associate route.
She says: ‘HCAs are valuable members of the nursing workforce. Shape of Caring, published in 2015, had among its recommendations the need to support and develop these members. HEE has, in response to this recommendation, developed a career pathway from care certificate to registered nurse.
‘All of these routes would enable an HCA that wished to become a practice nurse to begin on that career pathway,’ Ms Fenton says, adding that the nursing associate route has proven especially popular with HCAs.
‘Many of these [nursing associate] trainees have been recruited from the HCA workforce and bring valuable skills, knowledge and experience with them,’ she says.
There is no doubt the nursing associate programmes have been popular. When they were first introduced, there were 2,000 places available, but 8,000 applications for them, according to Ms Fenton.
‘We are working to ensure that the growth of training places meets the demand for the role from employers,’ she says.
Ms Belton has considered the nursing associate path, but it is an option hindered by the lack of funding.
‘I looked at the latest nursing associate role, which is fantastic, but again it is having to go into hospitals and do placements. And when you have the lack of the bursary and you are funding yourself you have to increase your childcare costs, which aren’t covered.’
Lack of support
Ms Pile acknowledges that the nursing associate role is another potential route, but again that is something only a small number of general practices are supporting people to do currently.
‘That is something we would like to see expanded as that is something that people can do while being employed, so it makes it more accessible to healthcare assistants,’ she notes.
‘By diversifying the types of placements [such as into general practices or other healthcare settings] people could do would really help HCAs with those challenges.
‘I think that is something people would welcome because it comes at a time where we are looking to join up services more, if we were training people in a way that gave them more exposure to different types of settings, that would be positive.’