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GPs buried under trusts' workload dump

If GPs gave practice nurses better training and support, they could transform primary care

Shared staff and opportunities to progress professionally could help nurses step up to the challenge facing primary care at the moment, writes Caroline Alexander

With a growing and ageing population, more long-term conditions and stark health inequalities, London’s primary care is under unprecedented pressure.

In November 2013 we launched our General Practice – A Call to Action, which invited CCGs, GPs, patients and other bodies to begin discussions about how to improve GP services in London.  These conversations must cover the challenges facing the workforce, and practice nurses are at the heart of this.

With 90% of all patient contacts occurring within general practice, practice nursing is a great opportunity for nurses to work at the heart of the community, with exposure to a wide and varied case load and the opportunity to make a difference to the outcomes of patients.

However, many are put off by a perceived lack of training and support in the profession. By increasing opportunities for nurses to train with GPs, as well as better support for practice nurses in training and on the job, we could encourage more nurses to build rewarding careers in primary care.

In London, the number of people over the age of 65 is set to increase by 19% by 2020 and long-term conditions are also on the rise, and the situation is similar across the country. To meet this challenge, the workforce will need to be developed to include systems of mentorship, supervision and support for practice nurses.  There are a number of ways in which this can be achieved – for example, practices working closely in groups will tackle the issue of isolation among nurses, allowing them to share best practice and support each other, as well as enabling them to develop specialist interests across a wider community.

Workforce crisis looms

With more nurses leaving the UK each year than arriving from abroad, there are staff shortages across the profession and this is acutely felt in primary care. Furthermore, a potential retirement bubble is looming, with many older nurses concentrated in primary and community care. We desperately need to attract more student and newly qualified nurses to pursue a career in general practice, and training is key to this.

Student nurses currently have little exposure to general practice, and although there is an increasing emphasis on community exposure, training is still overwhelmingly focused on hospital settings. If we are to make practice nursing an attractive career choice for these nurses, we need to enable them to experience the benefits and challenges of the role from early in their training.

There is also an urgent need to develop more bespoke training programmes in primary care, as well as increasing opportunities for nurses to train alongside GPs. There is currently a lack of standardised training programmes in practice nursing for nurses who have already qualified, such as experienced nurses looking to move from acute settings into primary care.

There are a few examples of these kinds of training schemes rolling out – for example the Primary Care Placement pilot (placements in primary care settings for both pre and post registration nurses) and the Open Doors programme (supports the transition of nurses into primary care and leads to a BSc (Hons) in Primary Care (Practice Nursing)) – but more needs to be done. For initiatives such as these to work, we’d like to see more GP practices working with universities and training providers to support the development of practice nursing.

Alongside a lack of training available for aspiring practice nurses, we also need to work with GPs to help improve support and professional development for nurses in their practices.  We held a focus group with practice nurses from across the capital which highlighted low morale and scope for further professional development support for this workforce, as well as concerns about isolated working, a lack of career progression, and gaps in basic clinical governance. Something needs to be done to make practice nursing an attractive and long-term career option for talented nurses who want to work at the heart of the community.

All sections of the health service need to think creatively about how to make the most of the current workforce, and how this should look in the future. Focusing on the wider workforce would relieve the pressure currently felt by the GP workforce, not only in London but across England, but to make this ambition a reality GP support is crucial.

Caroline Alexander is the Chief Nurse in NHS England’s London region.

Readers' comments (19)

  • Excellent Work ! ( a practice nurse who wants to help!)

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  • In order to make practice nursing an attractive career, the pay scales need to be brought in line with those of the hospital trusts and Agenda for Change as well as the provision of training. The terms and conditions, particularly annual leave and sick pay are often inconsistent and less favourable than those of the trusts, and are dependant on the attitude of the employing GPs. Why not bring practice nurses under the NHS contracts like the community district nursing teams, with defined job roles/job descriptions which match the AFC national profiles and pay bands. This would also lead to a larger body for support and organised training and equality of care provision for the patients.

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  • Excellent vision for the future. Just as long as "making the most of the workforce" doesn't mean getting nurses to do as much as possible for as little pay as possible. Pay, terms, and conditions vary widely and standardisation is also needed to help to transform the service. Most doctors are good employers but ,for your ideas to have maximum impact and be available to all patients, a standard contract for practice nurses would avoid disparity in the future and attract more applicants.

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  • totally agree! re the above

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  • Commendable article. However Practice Nurses are paid far more than their equivalent banded Nursing colleagues in Acute Trusts and depending in which practice they belong to they progress far quicker.
    All of our P Nurses came across to Primary care as they wanted a 9-5 job and increased pay.
    On an average, we paid our practice Nurses 3-4k more tha. What they were earning on equivalent banding and pay scales in secondary care. Locally across practices in Cheshire, this is the norm. Therefore, if you want a 9-5 job and want appx 20% more pay, then come across to our patch. We don't really understand AfC as it is really outdated and stifling in terms of progression. It does not allow the innovative, bright young nurse colleagues to progress through hard work and dedication as they have to jump through ridiculous hoops, or "wait their turn" or have an interest in management. Thereby it simply fosters am attitude of ," don't do any more than you have to, as no one will acknowledge you or give you a pay on the back".

    If you are unhappy with your own GP practice contracts, speak openly and honestly to your GP colleagues or P manager and ensure that along with increased pay you add on PDP time as part of the enhanced pay and that you will attend educational and practice development meetings as part of the extra pay rather than claim claim back TOIL or have hours owed. If that does not work, apply to other practices around you. If you are bright and hard working, General practice is the best place to be ( within the right practice).
    Chief Nurses should get together with the CNO Jane Cummings and attempt to pull together a national model for indicative pay for General practice as well as deal with terminology such as Practice Nurse, Senior practice nurse, minor illness nurse, minor illness practitioner/ prescriber, nurse clinician, nurse consultant , nurse clinical manager etc . Once this is done specifically for primary care, then there will be a successful recommended structure that will evolve and most GPs will attempt to follow the same( at least the good ones!).

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  • you make some really good points regarding terminology, and yes we need national guidance and a leadership strategy for practice nursing... however disagree regarding the pay.. I am paid far less than my secondary care counterparts... and in addition to that, some terms and conditions in some practices can be less favourable ( annual leave) as example. Many nurses (LIKE GP's) working in GP practice settings, go way above and beyond the 9-5 contracted hrs!! I am lucky I work with a supportive team who value my contribution. Some nurses feel 'burnout' overwhelmed and undervalued.

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  • Scream!

    In my 15 year experience working for 8 GP practices, but the last 2 has spanned 13 years, it has been my greatest frustration that my GP employers have not known what I am capable of doing or indeed, what my training has been, apart from the mandatory as it has been brought in.

    My appraisals have only been done to tick the QOF box and never been followed up. I also find much of my work load does not even require a trained nurse and anyone could train to do ECGs, smoking cessation, or phlebotomy.

    In my observation it has been GP employers and practice managers that need encouragement and training to know, in many circumstances, who they are employing, and that nurses often do not become practice nurses to become mindless pair of hands.

    On the hand, I do love my job. My higher management friend states I should have been a practice manager, but it should not be a them and us battle. I had to leave my last job due to subtle bullying from the manager and she started to exclude me and put herself between myself and the GPs in my attempts to communicate. The GPs condoned this behaviour. However, in pay and holidays I have never had a problem (except the GP who was still getting away with giving his secretary of 14 years 2 wks annual leave!).

    I do think a different mentality of person generally chooses nursing over becoming a doctor and it is not always academic. I think this is why we have high intelligence in many nurses, but nurses tend to not speak out or are oppressed more easily.

    It is the oppression that is often the problem, not the enthusiasm and the oppression needs to be removed as it appears to be still ingrained in the hierarchy of general practice.

    It isn't the nurses that do not want to train but the employers who will not release the nurses. I did most of my extra training in my own time and at my own expense.

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  • All the nurses in our practice get paid more than their community equivalents. Furthermore they only spend 63% of their time allocated for clinical care - this is before empty appointment slots and DNAs and still they think they are hard done by! It seems for every hard luck story from nurses out there, others are letting your profession down.

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  • To anonymous above! nursing is a vocation. If the nurses at your practice only spend 63% of their time with patient care, something is far wrong..... this is not a 'hard luck' story. This is reality... like many other public servants, times are difficult. nurses have had a hike in NMC fees RCN fees and pay cuts in real terms. Nurses are seeing more patients in general practice,( Not less!) and caring for more vulnerable complex patients. The nurses at your practice maybe letting our profession down!

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  • Louise absolutely agree with your response to Anonymous 4.45am. Their practice needs to take a serious look at how they are utilising their nurses time. Perhaps the nurses in that practice feel demoralised and undervalued. Often a reason for staff to feel "hard done by". Sounds like some restructuring of appointment times, more training and most of all some team building might be beneficial.

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