Health Committee Report on Primary Care

Whither General Practice Nursing?

It’s no secret that there is a move to deliver much more care in a community setting. Indeed, a manifesto commitment to a fully functioning 7-day per week NHS has been outlined. Of course, this has implications for all health professionals, but particularly for GP’s and General Practice Nurses (GPNs); how is this to be implemented and resourced, especially in light of the workforce shortfall?

Accordingly, the House of Commons Health Committee has enquired into, and subsequently delivered a report which analyses the challenges facing primary care and examines the long-term solutions which can improve access to services and patient care.

Introducing the report, Committee Chair Dr Sarah Wollaston MP, said:

"If we are going to provide the best possible care for people living with increasingly complex long term conditions, then primary care has to be able to change. We need to allow for longer appointments and for people to be cared for by a wider range of professionals.

It is also vital that people have access to timely appointments yet that remains a serious issue for many. The priority for the government should be the workforce and to make sure that we train, develop and retain the multidisciplinary teams as well as the facilities and technology they will need to provide the best care for patients."

Recommendation for General Practice Nursing (summarised)

We support the …vision of teams of professionals using their skills to meet the needs of patients much earlier in their journey through the NHS. This would allow GPs to concentrate on those aspects of care that only they can provide.

The challenges for primary care nursing are similar to those faced by GPs; Primary care competes for young/newly qualified staff as a career choice. Unless this is addressed, the development of multi-disciplinary teams will founder amid a shortage of nurses vital to the provision of patient centred care.

The Nuffield Trust’s evidence noted that:

Like general practice, primary care nursing also struggles to attract trainees and faces the impact of large numbers of retiring nurses over the next decade. For this reason, the Primary Care Workforce Commission has rightly highlighted the need for measures equivalent to the Ten Point Plan agreed for GPs to improve recruitment and retention in primary care nursing. ***

The Royal College of Nursing’s written evidence argued that the age profile of practice nurses and national drivers behind nurse recruitment had adversely affected primary care. The RCN said:

Many sections of the non-acute sector workforce have experienced significant under investment over the last four years: it is an unfortunate consequence of the system’s response to the Francis Report that necessary investment in acute, elderly and general medicine sectors has been at the expense of community based.

Existing workforce demographic: available …the age profile of the total nursing workforce show a progressively ageing primary care nursing workforce…there is expected to be an increase in the numbers of senior nurses retiring within the next five years, which will lead to worrying shortages in some areas.

Commenting on the nursing workforce challenge facing primary care, Professor Ian Cumming told us that in the long term supply and demand should balance out:

We have a huge shortfall at the minute—somewhere in the region of 15,000 to 20,000 fewer nurses than we actually need—but that is because the NHS, as a result of Mid Staffordshire and the focus on quality, has increased the establishment for nurses by about 25,000, and we train 20,000 nurses a year, give or take. [ … ] By 2019 or 2020, we should be back in equilibrium in terms of supply and demand.

Candace Imison of the Nuffield Trust, however, questioned the wisdom of working towards a specific target designed to alleviate nurse shortages:

We have underpinned our nursing workforce—traditionally—from international sources, and as things change internationally people who have come here may well go back again. That argues for an active policy to oversupply nurses, not to try to land the jumbo jet on a pin, which is traditionally what we have tried to do in workforce planning and inevitably come unstuck”.

Professor Chris Ham of the King’s Fund remarked that if

there is equilibrium in demand and supply, it will be the first time in the history of the NHS.

Attracting nurses to primary care

The RCN believes that reform to pay mechanisms could be significant in retaining nurses in primary care. They observed that:

Recruitment and retention for primary care nurses must also be seen in the context of individual local health economies. It is important to note that unlike acute or other community nurses, there is no agreed pay scale for nurses working in general practice. This has led to a gap in terms and conditions between nurses working in general practice and those working in the wider NHS.

Primary care staff do not have the same access to the annual incremental rise under Agenda for Change (AfC) …independent practitioners’ pay remains at the discretion of the employing GPs. The RCN advocates the adoption of AfC terms and conditions for all nurses employed within primary care.

Janet Davies, Chief Executive of the RCN, explained that what is most important is providing consistency for nurses across employers in primary care:

The problem is consistency. There are some surgeries that are fantastic employers—there is lots of opportunity for continuing education and nurses are encouraged to develop their skills—and then there are others where the terms and conditions are poor, they do not get paid very well and they do not have those opportunities.

Conclusion

… nurses in primary care face uncertain and varied career development and locally agreed terms & conditions all determined by their employer. We recommend that Health Education England, NHS England and the Royal College of Nursing develop a plan for primary care nursing akin to the 10 point plan agreed for general practice***. This should include proposals to attract trainees, reform undergraduate training and ongoing professional development, establish recommended pay and conditions, and outline examples of different types of careers that can be accomplished in primary care***.

*** In the next issue of PCNR we will feature Health Education England’s October 2015 report and recommendations ‘District Nursing and General Practice Nursing Service Education and career Framework’; this document presents a comprehensive career ladder for community nursing.