Many of the proposed solutions for the general practice workforce are centred around GPs, clinical pharmacists, paramedics, and physician associates, but do not recognise the contribution that general practice nurses (GPNs) offer. We need both more GPs and a wider variety of clinicians to help share the ever-increasing workload. Health organisations often fail to consider GPNs when planning workforce in primary care.
The Queen’s Nursing Institute survey identified that 30% of GPNs plan to retire over the next 2 years, demonstrating that there is a very similar workforce issue to that of GPs.1 NHS England’s 10-point action plan for GP nursing2 suggests that another 8000 GPNs are needed to cover this shortfall by 2020. Ipsos Mori showed that very few nurses are entering general practice before the age of 40 years to start replacing those experienced nurses who are leaving.3 Unless more nurses are attracted into general practice or choose to retire later, we are approaching a cliff edge.
Training for GPNs varies widely across the UK, often lacking standardisation, funding, or infrastructure.
There are four key actions required to secure the future of the GPN workforce: raising the profile of general practice nursing; tackling recruitment; tackling retention; and increasing training capacity.
RAISING THE PROFILE
Few school children or nursing students are aware of general practice nursing as a career option, unless they have experienced a placement in general practice.
Media images of nurses usually show hospital settings rather than GP surgeries, where it is much easier to demonstrate nursing activities than in a general practice setting. Perceptions of general practice nursing revolve around dressings and injections rather than health education, managing long-term conditions, prescribing, or working as an advanced nurse practitioner (ANP). The potential to develop a really fulfilling career in general practice is therefore rarely recognised. University programmes usually focus on hospital nursing rather than recognising and promoting the value of a career in general practice nursing. The advanced training practices programme in Yorkshire is changing student perceptions of general practice by giving them substantive placements, which thereby increase the chance that an individual will choose general practice as a first-destination career.
Health Education England (HEE) has developed a short film to promote general practice nursing to try to challenge some of the misconceptions about what GPNs do.4 NHS Scotland,5 Public Health Northern Ireland,6 and HEE have developed GPN career frameworks,7 but they are not standardised like GPs frameworks and are not widely used for the development of GPNs.
How can GPs help to raise the profile?
Utilise the HEE GPN career pathway to develop the nursing team.
Provide student placements to widen experience of general practice.
Offer sixth-form work placements to those considering nursing careers.
RECRUITMENT
The Ispos Mori research provides a clear analysis of why it is so difficult to recruit nurses to general practice. Historically, nurses were attracted to general practice by the better hours or the part-time nature of the role. Today, increasing numbers of nurses need full-time employment for financial reasons, so they may need several jobs in different practices or work for out-of-hours providers.
There are many barriers to becoming a GPN, not least knowing where to look for jobs. The NHS jobs website, where most nurses look first, advertises GPN posts all needing experience, which hospital nurses are unlikely to have.
Experienced hospital nurses may have some relevant specialist skills, but still lack the generalist skills needed to equip them for a GPN role. Those skills provided on general practice nurse fundamentals courses, which equip nurses new to general practice with the necessary skills, are not universally available across the UK. Ipsos Mori found that a phased transition to general practice worked well, especially for attracting more experienced nurses.
Pay is a further barrier, as senior nurses are likely to have to take a pay cut while they develop relevant GPN skills. Losing Agenda for Change annual leave and sickness entitlements is also cited as a deterrent.
An untapped source of nurses are the many thousands of nurses who have lapsed their nursing registration and might be attracted back in to the workforce by completing a nationally funded Return to Nursing course.8 General practice is an ideal placement for these students, and there would be the prospect of employing them once they were back on the NMC register.
Now that there are nursing apprenticeships it will be much easier to support healthcare assistants (HCAs) to become registered nurses while remaining in practice.
Traditionally, practice managers have been able to recruit GPNs from other practices by offering financial incentives, but given the falling numbers recruitment needs to be more imaginative.
What can help recruitment?
Consider employing nurses from other settings and train them up.
Consider having local pay and conditions guidance to help recruit and retain staff.
Consider employing a nurse wanting to return to nursing.
Support HCAs to access nursing apprenticeships.
RETENTION
There is huge potential to grow and develop all members of the nursing team so that they reach their full potential if the right education and support is in place. Nurses are known to vote with their feet when they are denied training, not able to use certain skills, or offered better pay elsewhere.
Education is often the driver of change, so where nurses show an interest in developing teaching skills such as mentorship or educator training it should be encouraged as it opens the door to taking students, return to practice, or new GPNs.
Encouraging nurses to gain relevant specialist or advanced skills and using them at work can often motivate them to stay at a practice. This is especially true for those training as ANPs, where it is not uncommon for them to move, once qualified, unless their new role is embraced. Wales, Northern Ireland, and Scotland have all developed advanced practice frameworks to encourage ANP roles.
Spotting and encouraging leadership potential can become a useful asset for both the practice and local networks such as federations, clinical commissioning groups, or training hubs.
Annual appraisals can help to explore individuals’ career plans and seek ways to support and develop them.
What helps retain nurses?
Supporting role development, either specialist or advanced.
Enabling GPNs to become educators.
Supporting nurses to become leaders.
INCREASING TRAINING CAPACITY
Because general practice nursing does not have UK-wide standardised training like GPs have, the infrastructure and funding are variable. Where it has been prioritised, as in Scotland, the Midlands, and Yorkshire, the workforce is becoming more sustainable. With strong leadership, infrastructure, and appropriate incentives, those practices are starting to see more nurses wanting to move into general practice. It does require enough nurse mentors and educators to facilitate training such as ‘Fundamentals in GP Nursing’, ‘GPN Ready’,9 or ‘GPN Return to Practice’ courses.
Busy practices find it hard to justify taking students when the placement tariff is so low. The non-medical tariff is at least five times less than the medical students’ fee and considerably less than the secondary care fee for medical students.10
Organisations across the UK are recognising the importance of increasing GPN training capacity, but all are struggling with the lack of long-term funding and in some cases the willingness of practices to prioritise training.
What helps increase training capacity?
CONCLUSION
GP recruitment is unlikely to provide enough GPs to meet the ever-increasing demand, so we need to up-skill nurses and others to share the workload.
If we are to have a sustainable primary care nursing workforce in the future, infrastructure and funding need to be identified at local and national levels. In addition, GPs do have an important role in supporting the training and development of GPNs.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
The author has declared no competing interests.
- © British Journal of General Practice 2018
