Supplementary written evidence by the Royal College of Nursing (FGP0399)

Health and Social Care Select Committee future of general practice inquiry: evidence session follow up

Dear Mr Hunt,

Thank you for the recent opportunity for the Royal College of Nursing (RCN) to give oral evidence to the Committee as part of its inquiry on the future of general practice in England. We appreciate the Committee drawing on the expertise of RCN members who work as general practice nurses, as they are fundamental to the design and delivery of effective primary care. As I highlighted in the RCN’s evidence session, our general practice registered nurse members feel undervalued and invisible, despite them providing crucial patient care.

On behalf of the RCN, I am providing some additional information that we trust will be of use to the Committee in informing its final report.

In June 2022, the RCN published Nursing Under Unsustainable Pressure: Staffing for Safe and Effective Care report which reflects the experiences and expertise of over 20,000 nursing staff. Over 500 general practice registered nurses responded. The findings underline a significant concern about staffing within general practice and an urgent need to better support nursing staff.

1. Over half (55%) of respondents working in a general practice said the actual number of nursing staff was not sufficient to meet all the needs and dependency of the patients/service users safely.
2. A third (33%) of respondents working in a general practice said there was a shortfall of one or more registered nurses on their last shift, and 22% said there was a shortfall of one or more health care support workers.
3. Almost a third (32%) of respondents working in a general practice said they felt that patient care was compromised during their last shift.
4. Two in five (41%) of respondents working in a general practice said the skill mix was not appropriate to meet the needs and dependency of the patients/service users safely and effectively.

It is the RCN’s position that nursing leadership must be a cornerstone in all health and care settings, and, indeed, in both health and public policy making. A lack of nursing leadership within any health and care organisation impacts on safety, quality of care and patient mortality, as well as the mental health and general wellbeing of the nursing workforce. The requirement for registered nurse expertise present within decision-making structures is clearly set out in the RCN Nursing Workforce Standards. The requirement for registered nurse expertise present within decision-making structures is clearly set out in the RCN Nursing Workforce Standards.

Registered nurses are safety critical professionals who lead, design and deliver care. Their unique relationships with patients enable them, among other things, to co-ordinate care because they understand the needs of their patients and the services that are available both locally and nationally. In particular, their unique relationships with patients enable them, among other things, to co-ordinate care effectively because among other things, they understand the needs of their patients as well as the services that are available both locally and nationally. With their advanced skills, registered nurses in general practice should be the lead care provider for patients, including those with long term conditions. Registered nurses within primary care are also best placed to meet the performance requirements of General Practice Contract such as the Quality Outcomes Framework and Key Performance Indicators.

Specifically relating to general practice registered nurses, the RCN urges the Committee to adopt the following recommendations within its final inquiry report:

1. Priority must be given to registered nurse leadership in Integrated Community Boards (ICB), Integrated community systems (ICS) and Primary Care Networks (PCN). Registered nurses have a unique perspective on patient care and training and development needs that cannot be met without a registered nurse on every ICB, ICS and PCN board. This is in line with the RCN Nursing Workforce Standards which recommend there is a registered nurse on every board, and not subsumed into a medical structure. Nursing leadership will ensure a clear understanding of the registered general practice nurse's role, expertise and development needs a medical structure.
2. There must be protected administration time for general practice registered nurses – at present professionals are having to manage providing patient care and completing key administrative tasks resulting in care being left undone, staff working additional hours (often unpaid) and patients being put at risk as outlined by the findings of our Nursing Under Unsustainable Pressure: Staffing for Safe and Effective Care report.
3. Assurance of consistency of practice through a national career framework and support for the development of general practice registered nurse leadership roles at local, regional, and national levels. Assurance of consistency of practice through a national career framework and support for the development of general practice registered nurse leadership roles at local, regional, and national levels.
4. Formal progression and development opportunities for any registered nurse working within general practice should take the form of a structured regular and formal career review alongside a clinically supported appraisal process, mandated as part of the General Practice Contract along with formal clinical and safeguarding supervision. Unless this is mandated within the General Practice Contract, progression and development opportunities for registered nurses will continue to be inconsistent.  At present, there is no standard approach to formal supervision and appraisal for registered nurses in general practice, with practice managers overseeing appraisal and supervision despite having no clinical expertise. Embedding a formal appraisal process with an appropriate clinician would ensure that the general practice registered nurse role is recognised and valued for the highly skilled role it is, and for the impact and benefits they bring to general practice. This approach is in line with the RCN Nursing Workforce Standards, which recommends each system to have a visible Practice Nurse leadership as equal partners within general practice.

Thank you once again for the opportunity to contribute to this timely inquiry. Registered nurses in general practice must be understood, supported and enabled, as a key stakeholder in shaping the future of primary care in England. The RCN is clear that compassionate nursing leadership helps to create a psychologically safe workplace culture which ensures that staff feel able to raise concerns, knowing they will be supported as a team or as individuals to pursue high quality standards of care.

Registered nurses in general practice must be understood, supported and enabled, as a key stakeholder in shaping the future of primary care in England, and delivering safe and effective services. 

The RCN looks forward to receiving the Committee’s final report, and should you have any further questions, please do not hesitate to get in touch.

Yours sincerely,

Heather Randle, RCN Professional Lead for Primary Care and Education

June 2022