Written evidence submitted by the Royal College of Nursing (FGP0208)

 

  1. Introduction to you and your organisation

 

With a membership of around 465,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of primary care and community settings.

General Practice Nurses (GPNs) now make up the second largest group of RCN members and are particularly keen to contribute and influence both the delivery of health and care and policy aligned to this. 13,000 GPN members are employed by 7,500 independent NHS contractors, and their employment terms and conditions are recognised as being significantly inferior to colleagues employed directly by the NHS.

The RCN received responses including a number from members working within Clinical Commissioning Groups (CCGs).

 

  1. Reason for submitting evidence

 

The RCN has heard strongly from our membership that there is strong consensus that the role of the general practice nurse is generally devalued and invisible. This is underpinned by the perception of extensive reporting of the pressures on hospitals and more recently on general practice during the pandemic. Yet there has been very little coverage of General Practice Nurses (GPNs) themselves despite the critical role they have played throughout the pandemic seeing patients, leading vaccination programmes, and working in their own time (often unpaid); in addition to now working long hours to catch up on the remobilisation work.

This perception of being undervalued is compounded by the fact that GPNs are not paid on NHS terms and conditions and often have only statutory sick pay (including for COVID), statutory maternity pay, and no release or funding to access training, education, and development. This is a serious source of concern for RCN members who quite rightly feel that they are entitled to the same terms and conditions as their NHS colleagues. In addition, the Additional Roles Reimbursement Scheme (ARRS), which excludes GPNs, means that some practice members of staff are being employed on Agenda for Change (AfC) contracts, which creates inequality. The GP contract needs to include a standard pay scale for all nurses working in general practice.

As part of the member engagement one member shared the message, she received last year about her pay rise demonstrating the inequity that exists in nurses pay in general practice.

“This years backdated pay rise will be in your salaries at the end of the month. The partners have agreed a 3% pay increase for GPs and 1.5% for nursing and admin staff from the 1st of April 2021.”

Poor morale has also exacerbated following recent reports that senior policy makers were of the opinion that the inclusion of AfC terms and conditions within the standard contract would be unaffordable, therefore unlikely, adding to the frustration and feeling of being undervalued.

Other inequity is identified in policy such as the NHS Long Term Plan which supports professions and roles such as paramedics, pharmacists, and physiotherapists to develop and expand to become Advanced Care Practitioners.

Nurses working in general practice are usually autonomous practitioners with generalist specialist knowledge. It is well understood that they are key to the reduction of referrals/admissions into secondary care and play a fundamental role in health promotion and prevention. The role of the nurse in general practice is essential to the provision of safe and effective care.

The RCN has also heard from our membership that demand far exceeds supply and that patients’ needs are frequently not met with staffing levels at the level they are. General practice was already under significant pressure prior to the pandemic and the unprecedented increase in demand along with the largest vaccination programme in modern times and the resulting work left undone has created unsustainable pressure.

 

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

 

As noted above there are several challenges in general practice and lack of funding added to a pandemic has now created a position where it is considered that general practice is in crisis.

Workforce and recruitment- it is recognised that there are insufficient staff and resources to manage current workload. However, the RCN would like to concentrate on the nursing challenges within this submission. Recruitment has been a government priority for several years with little increase in GPN numbers (Kings Fund 2018, QNI 2016). Despite the Long-Term Plan’s (NHSE 2019) commitment to increase nurse numbers there are still very significant challenges. There is a great deal of concern that in five years’ time the most senior experienced GPNs will have retired, and we are also witnessing many choosing to retire early due to the pressure of the pandemic. The RCN has additionally heard from members that many new general practice staff have chosen to leave due to stress, abuse, and poor working conditions. For example, GPNs have required time off work due to catching Covid themselves but received no sick pay remuneration because they only get statutory sick pay, and the NHS Covid scheme did not include general practice.

Patient expectations- It is recognised that this has been a difficult time for patients and their families. At the start of the pandemic patients were supportive of the changes to services, made to keep staff and patients safe. The messaging regarding a return to normal has raised expectations as to what this now translates to and an associated increase in demand with patients often struggling to get an appointment. This has also increased because many patients have delayed seeking medical advice for fear of catching covid. It should also be noted that GPNs have undertaken additional roles such as leading large scale covid vaccination which has taken them away from their usual duties and added to the day to day return to ‘business as usual’ pressures.

It should also be recognised that although it is understood that it is important to reassure the public, and the public health campaigns are supported by the RCN, that sometimes the catch all phrase of ‘see your GP if it persists or is a problem can create a significant administrative burden and it would be helpful to also highlight other choices and channels in accessing other health care professionals like the GPN, ANP, pharmacist, non-clinical workforce or a voluntary organisation, which can also be appropriate routes.

Career Pathways- There is no clear staff development pathway so ultimately nurses accrue extra skills in one or two areas and then either leave to go and specialise in one area such as respiratory for example or go on to undertake an ANP course and so no longer perform in a Practice Nurse role. With no AFC pay and conditions there is no parity across the country with nurses being paid whatever the surgery going rate is. Generally, opportunity for discussion about pay and career progression is limited to an annual appraisal, and these do not always happen on the frequency they should. Despite support and training nurses remain poor at approaching the subject of pay, terms and conditions with their employer.

Reassuringly and without doubt a reflection of the hard work that has been undertaken by all practitioners, the 2021 General Practice survey has indicated a patient satisfaction rate of 83% with services. This was up from 82% in 2020 and 96% of patients responding say they have confidence and trust in the healthcare professional they saw, again an increase of 1% on 2020.

  1. How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

 

There continues to be regional variation in the provision of care and the role of the GPN. Nursing in general practice has therefore developed in a fragmented and disjointed way, often leading to inconsistency in practice and competence. Additionally, as the role has evolved many have not moved at the same pace to recognise the autonomous and expert role it has now become. The role of the GPN evolved from originally one of support to the GP, into the specialist autonomous role it is today, and which has led to unwarranted variation in the role that can only be changed with agreed job roles underpinned by equitable pay structures.

The expertise of the GPN can often be overlooked and have less recognition than other professions and the depth and breadth of expertise, experience, adaptability, compassion, and care must become more visible.

There is a shared frustration of patients in accessing appointments but there is often just no capacity. There has also been a huge demand for appointments with complex presentations and nurses have continued to see patients face to face, and it should be recognised that this can also be undertaken successfully via technology.

There has been a great deal of work successfully undertaken in embracing technology so that services can be accessed remotely, often reducing the need for further face-to-face consultation.

Nurses are familiar and competent in practising remotely. However, our members are also aware that one size does not fit all, and some patients will struggle with virtual consultations and use of technology, and it is important that they are supported to access services. The needs of vulnerable patient groups must also be met as they may decide not to seek medical advice because it is simply too difficult to get an appointment.

It should be noted that resource allocation for the general practice nursing workforce is fragmented across the country; this includes roles such as the Nursing Associate.  A variation in training and development provision has been identified and can be dependent upon which Primary Care Network (PCN) a practice is situated. RCN members have indicated that often this variation is impacted by the infrastructure of a PCN and importantly the recognition and positioning of nurse leadership.  Members have also reported significant variation in the funding Health Education England (HEE) provides across England which has led to inconsistency in workforce development and training provision.

A helpful document for reference is the RCN workforce standards which highlights the absolute need for executive level nurse leadership and sets out what is required for staffing for safe and effective care and how nurses are a safety critical profession.

RCN members also report unwarranted variation in integration of extended access provision which includes out of hours and urgent care services, 111, Urgent Treatment Centres and local clinical hubs.

It is recognised that as some areas in the UK have higher deprivation, and there are substantial health inequalities, the allocation of resource is varied with some areas requiring substantially more resource to deliver the same service as those with lower health inequalities.

The RCN is aware that a number of areas have invested in sustainable workforce plans by positively investing in advanced nurse practitioners and multi-agency teams.

 

  1. What part should general practice play in the prevention agenda?

 

The RCN believes that General Practice is in a key position to offer prevention services, in fact they are already pivotal in leading many components of the public health agenda.  However, it is recognised that there is a requirement for increased resources in areas where there is higher need to understand and address deprivation indicators.

General Practice is key in providing early interventions and support to families, particularly as there is an opportunity to potentially have oversight of a family over a couple of generations and helping to identify issues more easily.

It is considered that prevention for general practice should be triangulated with other universal services that also need further investment such as health visiting teams, school nurses, early years workers and childcare providers. Following the tragic death of Arthur Labinjo-Hughes and the Government’s intention of a national review of Safeguarding, the RCN specifically wants to highlight the consequences of cuts to health visiting and school nursing alongside the need to fully recognise and value general practice nursing, as these roles are often best placed to identify some of the most vulnerable and at-risk cohorts including those managing self-neglect.

Further investment is also needed in early help services for adults who become vulnerable.

 

  1. What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

RCN members believe that morale in general practice nursing can be improved in a number of ways. This includes the assurance of consistency of practice via a national career framework, and support for the development of GPN leadership roles at local, regional, and national levels.

It is also proposed that formal progression/development opportunities should take the form of a structured regular and formal career review alongside a clinically supported appraisal process, mandated as part of the GP contract along with formal clinical and safeguarding supervision. This is to ensure that the GPN role is recognised and valued for the highly skilled role it is.

Additionally, there is a requirement to:

-          Utilise skill mix and source alternative solutions to aid completion of administrative tasks such as Fit notes/ DVLA reports.

-          Merge back-office functions across a geographic area or PCN to reduce administrative burden.

-          General Practice to be more integrated in other universal services so patients do not have to have long waits to see specialist services.

 

  1. How can the current model of general practice be improved to make it more sustainable in the long term?

In particular:

 

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The RCN has heard clearly from its membership that the current model of general practice is unsustainable. Reports are that general practice is in crisis with morale at an all-time low and stress levels at an all-time high.

RCN members recommend:

-          A commitment to pay fair wages, terms and conditions to nurses employed in general practice. It is noted that there is a standard contract for salaried GPs, and RCN members are calling for a standard national contract for GPNs at least of equivalence to NHS AfC . This would reduce variation in pay and conditions and prevent current inequities as set out within this submission. Good practice has been noted which has resulted in recruitment of large numbers of nurses to fill gaps as a result.

 

-          Primary Care and General Practice Nursing Career and Core Capabilities Frameworks which are inclusive and include other nursing roles (e.g., Nursing support workers in General Practice) using evidence and research to develop an inclusive nursing workforce thus supporting appropriate utilisation and safer care.

 

-          The new transformation models must have a nurse on their board or executive team (RCN Nursing Workforce Standards 2021), with each system ensuring visible Practice Nurse leadership as equal partners.

 

-          Annual appraisal with a clinical colleague rather than the practice manager.

 

-          Requirement for both clinical and safeguarding supervision.

 

-          Professional recognition of nurse’s role, knowledge, skills and expertise in general practice should bring improved partnership and team work in managing care and the planning and provision of responsive and effective services.

 

-          GPN training and providing placements for student nurses should also be a mandatory condition of the GP contract. All nurses new to general practice should undertake full induction via the GP fellowship programme. Funding for nurse placement fees needs to be revised and brought into line with medical student fees. Along with this general practice should expect to teach and mentor student nurses and other trainees as appropriate.

 

-          General practice should also be enabled to support health care assistants to undertake TNA apprenticeships and full RN apprenticeships

 

  1. Do the current contracting and payment systems in general practice encourage proactive, personalised, co-ordinated, and integrated care?

 

RCN members have fed back that the current system can make it difficult to have a patient centred approach when general practice is principally business led and seen to be run by practice managers. There is a need for joined-up provision of coordinated and truly integrated care to ensure the optimal delivery of health and care for patients and individuals being cared for.

 

  1. Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated, and integrated care and reduced the administrative burden on GPs?

RCN members have indicated that in their experience PCNs have significantly increased administrative responsibilities in relation to general practice, thus offering the risk of reducing clinical time to see patients.

It is considered that there are some benefits for GPNs to belong to a PCN, especially if there is a nurse clinical director, however this is reported as an exception not the rule currently.

  1. To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

 

RCN members have highlighted that many practices already have in-house pharmacists to assist with monitoring of prescribing, however members also suggest there are other areas where partnerships could improve patient care:

-          Enabling self-care and direct access to other services (community / voluntary / charity provision)

-          In-House Mental Health Services and physiotherapists as first point of contact

-          Workforce resource allocation which includes “the wider workforce” which will include nursing support worker roles to further support nursing care

-          Home treatment teams in all areas

-          Utilising other roles such as care navigators to support nursing care

 

[END]

December 2021