Written evidence submitted by the Royal College of Nursing (RCN) General Practice Forum (FGP135)

 

The Royal College of Nursing (RCN) General Practice Forum exists to support nurses working in general practice; our brief is to raise the profile of general practice nurses (GPN) and their importance to primary care; to influence health care policy that directly impacts on nurses in general practice and to support future innovations and projects.  The forum steering committee together have a combined wealth of over 150 years of nursing experience, much of it focused in general practice. Meet the Team | General Practice Nursing Forum | Royal College of Nursing (rcn.org.uk). We, collectively, would welcome the opportunity to present our expertise and experience to the health select committee.

 

The Forum support registered nurses, student nurses and trainee nursing associates interested in a career in general practice nursing through to advanced nurse practitioners (ANP) or advanced care practitioners (ACP) working in general practice who possess a wide range of skills and experience. We work with the RCN professional lead for primary care to influence the sector.

 

 

What are the main barriers to accessing general practice and how can these be tackled?
 

The main barriers are multiple factors aligning to create a crisis and they cannot be easily rectified without a concerted effort by Government with investment, recognition of the work performed by all the workforce in general practice and sustained improvement in investment. Budget for general practice is less than 10% of the NHS funding, yet primary care annually manages 80% of the patient consultations.

 

The forum have noted a number of factors that have impacted access to general practice:

1. Workforce: Insufficient staff and resources to manage current workload. Recruitment has been a government priority for several years with little increase in GP or GPN numbers (Kings Fund, 2018, Ipsos MORI, 2017, QNI, 2021). England has fewer GPs per 100,000 population than other UK and EU countries (King’s Fund, 2019).  Despite the Long Term Plan’s (NHSE, 2019) commitment to increase nurse numbers there is still staff significant shortage and recent data has shown a decrease in overall nursing numbers. The pandemic has caused more nurses to retire early and forced new practice staff to leave due to stress, abuse and poor working conditions. For example, many GPN’s have required time off work due to Covid with no sick pay remuneration.
 

2. Technology: Barriers include, difficulty in accessing GP services, both in person and via remote access.  Core systems inability to speak digitally to each other.

 

The push to digital consultations prior to the pandemic and during the pandemic has caused mixed messaging and pressures on general practice are compounded by the fact that the work is becoming more complex and more intense. This is mainly because of the ageing population, increasing numbers of people with complex conditions, initiatives to move care from hospitals to the community, and rising public expectations.

 

To address these barriers there needs to be additional services and funding, plus attracting staff to work in this environment needs a considerable rethink of all roles. Easy advice and guidance services between all clinicians in primary and secondary care do not exist in all localities.


 

3. Expectations: Patient, political and other professional’s expectations have impacted on the debate around access.

The 2021 General Practice survey indicated a patient satisfaction rate of 83% with services, up from 82% in 2020 and 96% say they have confidence and trust in the healthcare professional they saw, again an increase of 1% on 2020.

Perhaps the constant narrative of health on social media and in the print media has created a perception that many problems are urgent and need to be seen now, creating potential health anxiety and further demand. Public health campaigns, NHS England even Government often use the catch all phrase of ‘see your GP if it persists or is a problem’, this message is reiterated on public health messaging for coughs, colds, dementia, diabetes ad infinitum with less apparent consideration to the impact on appointments, if the GP is the correct professional to see, rather than a nurse, the non clinical workforce or the administrative burden placed on general practice.

 

The newer ARRS roles and non-medical prescribing requirements are being supervised in clinical practice by general practitioners and registered nurses, increasing the workforce is admirable and much needed, but consideration to time taken to train people is not always accounted. Training takes times and requires longer appointments and time for reflective and clinical discussion of decision making processes.

 

 

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

The Plan addresses the complexity of care in general practice and acknowledges patient satisfaction has risen, it fails to acknowledge that unwanted variation is not a new factor, and has been present prior to the introduction of QOF through to the pandemic, in part due to the varied independent contractor nature of general practices as small businesses and the general practice contract variations that practices hold.

 

Remote access works if the systems are aligned rather than creating additional work. For example Footfall, a messaging service for patients is widely used and appreciated but the system does not input data or patient requests directly into the patient’s clinical records, it requires added time and duplication of work to transfer the patient request. 

 

 

What role does having a named GP and being able to see that GP play in providing patients with the continuity of care?

 

Continuity of care, be it a GP, nurse or another discipline provides patients with surety that their care is understood. Continuity provides understanding of when to recognise a problem is new and when to refer or when to adopt a ‘watchful waiting approach’. Reducing continuity may contribute to increased demand for appointments as patient search for a healthcare provider relationship that suits, continuity also provides relationship capital – if errors occur it may be easier to broach a restorative conversation than with a one stop shop clinician.

Should this be a named GP or a named clinician? – many nurses, pharmacist, paramedics etc. are trained to Masters level and beyond, having advanced clinical, educational and leadership skills – the current model of care dictates that pressure is placed on just one profession and poorly recognises or signposts to other disciplines other than medicine manage complete episodes of care.

 

What are the impacts when patients are unable to access general practice using their preferred method?

 

Disgruntlement and a feeling of insecurity.  Many patients appreciate the access to remote consultations, it fits better into their working life, rather than a blanket approach that all patients need to be seen face to face, there are certain categories of patients who are more likely to need to be seen face to face, for example, frail elderly, infants, learning disabilities, we need to enable face to face for those who require it but continue to offer flexible choice to patients, who may not wish to take time off college/work to visit a practice for a short consultation.   What has also been seen anecdotally is the statement ‘it’s my right’ to be seen, rather than allowance given to clinical judgement patients have perhaps adopted an approach more seen in customer service and speak up when whether rightly or wrongly, they feel their rights are infringed.

 

 

What are the main challenges facing general practice in the next 5 years?

 

  1. Workforce, widely varied pay, terms and conditions, pension issues have caused many to reconsider a career in general practice. Why would a nurse, chose to work in a role that does not have competitive pay, few if any pay rises and has poor practice for maternity or sickness pay when they can work in an environment that protects these rights.

    The Government and NHS England have not acted to enforce standard general practice nursing contracts, terms and conditions across England and nursing was not included specifically in the NHS Log Term Plan ARRS arrangements?  This has created an imbalance where nursing is implicit within the GP contract but has no obvious rights and is reliant on the individual practice to provide pay uplift, terms and conditions and excluded from ARRS Agenda for Change arrangements.

    Should the health select committee explore whether an element of bias, hierarchy or misogyny exist in these continued problems, is the fact that the majority of the nursing working in general practice, female, impacting these decisions, is there an element of unconscious discrimination in place?


This is not a new issue, indeed the forum spoke with the previous Minister for Primary Care on these points in December 2020, but the issues continue to impact recruitment and retention.  The BMA negotiated a contract for salaried GPs – as matter of urgency there needs to be parity for all nurses, and allied health professionals working in general practice.

 

In the first instance nursing in general practice should be included in the recent NHSEI recommendations on pay– it could have been a requirement of the contract that staff pay was also declared. The mechanism for reporting average pay for GPs is already in place.

  1. Regional variation shapes the challenges, for example nurses in London don’t receive London weighting, if their pay is already less than colleagues in the NHS it makes nursing in general practice in London unaffordable – there is a high turnover in recruitment and retention for this reason.
  2. The basic payment for practices hosting a student nurse in a general practice placement during their training is not seen as an incentive to hosting student nurses. The payment is viewed as so low in comparison to GP and medical student tariffs, it is not seen as an enabling factor. The payment does not translate to an increase in education time for nurses.
     
  3. Retaining experience is critical, the focus of the £15 million GPN 10 point plan was primarily on recruitment with little offered to retaining or even recognising experience.  No outcome measures of the GPN10PP have been published, nor is there an indication that recruitment and retention have improved. The Kingsfund highlighted to ensure wellbeing and motivation at work, and to minimise workplace stress, research evidence suggests that people have three core needs: autonomy – the need to have control over their work lives, and to be able to act consistently with their values  belonging – the need to be connected to, cared for, and caring of others around them at work, and to feel valued, respected and supported contribution– the need to experience effectiveness in what they do and deliver valued outcomes.

    But nursing need to have a say in how the practice is run – moral runs low when people feel they are not listened too – general practice and the partnership model has incredible variation from supportive partners to those who do not value staff contributions.
     
  4. Support for housing, subsidised rent, removal costs and relocation expenses for a fixed period to all staff to entice to work in rural areas, alongside a golden hello this may help staff to relocate.  Non clinical front end staff receive little recognition, systems should be in place to ensure that these vital resources are empowered to spot errors and systems risks and manage these appropriately
     
  5. General practice is the bedrock of the prevention agenda, nurses are public health specialists but under recognised. Each consultation is around screening and prevention (cervical cytology, immunisations programmes, women’s and men’s health, minimising risks of alcohol, smoking, obesity etc.)
     
  6. Nurses need smooth processes – why do we have so few nurse partners – where are the blockages?  Despite incentives to partnership open to other professionals, many general practice partner jobs continue to be advertised to GPs only, those nurses recruited to partnerships are known to the surgery rather than outside candidates. Perhaps a requirement could be to have a diverse partnership in surgeries reflecting the strengths of other professions and sharing the load.  Partnership is onerous, legal advice is through MDO’s a smooth similar contract and partnership cooperative agreement might widen the scheme to others.

    Why do we not have nurse led practices or pharmacist led practices, the model currently with the GMS contract makes a non-medical clinician less able to negotiate taking on the primary contract – whilst we recognise that some GPs will wish to retain the current system others would prefer a looser system.
  7. Fit notes issued by general practice for patients seen in A&E – why are these not issued in secondary care and why are nurses and allied health professionals unable to issue fit notes due to legislation or even certify death (i.e. for a care home visit for an expected death? Equally why are patient not referred from secondary care speciality in house, they should not come back to general practice for a further referral to secondary care.
     
  8. Appointment data shows that around half the appointments in general practice are managed by nursing or other health professionals.  The emphasis is often just on GPs and general practice is often shortened to GP. Should we move to using the more inclusive term primary care, which better reflects the move to integrated care systems?  NHS England consult mainly with the BMA or RCGP with little emphasis contractually on consulting with other professional bodies representing clinicians in general practice? Is the medical model over stated by those in commissioning and contracting and the current model may obstruct new ideas that may patient safety and patient centred care.
     
  9. There is no obvious incentive within the contract for nursing to define the patient safety aspects of their role, work is often described by others on the basis of work imagined, failing to recognise the complexity of the learnt experience. Rather there has been an uplift in healthcare assistants and a dumbing down of work to the non registered workforce, due to rising costs/profit erosion and perception of work as seen rather than the complex discussion of patient management. This can lead to episodes of care missed, that a more experienced nurse would have acted on early.
     
  10. GPs often take on portfolio roles to provide experience in the different areas such as commissioning, and value a break from 12 hour days in general practice. People burn out because the work load is not sustainable, 10 minute appointments for 10 hours+ a day, day in day out with the extra time for administration, refers, blood results, emergencies is not sustainable for people, system and human factor errors then occur.
     
  11. Primary Care Networks have not yet reached full maturity. They are not separate entities as such rather groups of practices managing individual work and now collective work. For example an allied health professional is shared across surgeries, a day a week in each surgery – this doesn’t create continuity with staff or patients, or in the long term job satisfaction, and there is perhaps duplication of care risks here too – how do we identify patient safety risks as clinicians are shared across systems, does this create further risk?
     
  12. General practice remains a hierarchical model with GPs seen as the leaders, this perception is propagated across systems and arms-length bodies and feeds into the media narrative to the extent that patients will object sometimes to being seen by a nurse or allied health professional and patient’s lack understanding of the skills and expertise these clinicians offer to patient safety, care and continuity, all detracting factors.  Clinical leads within PCNs have almost universally been medics, in part because other professionals are employees of a partnership and may not be released for other roles, opportunities or in the worst case scenario education to remain up to date. The reality for general practice is that without other professionals managing half the work load (see NHS digital appointments data) general practice in its current guise will not survive. 
     
  13. Within the Integrated Care Systems there needs to be clear delegated responsibility for primary care nursing, nursing needs to be at the board level and it needs to be nurses drawn from both primary and secondary care, too often a director of nursing is chosen from a previous secondary care role, with little experience or understanding of the needs. Nursing also needs an explicit presence within the Primary Care Networks.
     
  14. Nursing needs to be represented throughout the systems in roles of head of primary care nursing to meet the workforce needs. Their role should feed into the training hubs and primary care networks, as well as quality, safety and policy.  A costed budget specially for nursing workforce development, education and aspiration, rather than a piecemeal sum of funding that is often pooled and not to the benefit of many nurses.
  15. Finally, a suggestion is that a Royal College of Primary Care be established, which incorporates all aspects and professions working in primary care; Nursing, GPs and allied health professionals, each profession given equal weight to general practice discussions.  This could be created from an existing entity or by creating a new entity. Having all relevant disciplines together creates cohesion for the integrated care systems and the workforce.

 

We look forward to meeting with you to discuss these points and any other pertinent points that space dictated we could not include.

 

Royal College of Nursing Forum Steering Committee Members


Ellen Nicholson, QN, Joyce Pickering, QN, Sarah Hall, Kathryn Smyth, QN, Elia Monteiro, Penny Sibthorp, QN

 

December 2021