GPN Manifesto Roundtable: Health inequalities, long-term conditions and public health

Overview of the roundtable discussion

The manifesto for general practice nursing was launched by Nursing in Practice this year, to highlight key areas in which GPNs want to see improvements.

Nursing in Practice met with a group of nurses behind our 10-point manifesto for general practice nursing as part of an exclusive roundtable discussion series focused on health inequalities, long-term conditions and health promotion. Here we explore the barriers GPNs face when trying to address and manage these parts of their role and the action needed to boost the confidence of GPNs and ultimately improve patient care and outcomes.

Why was this an important debate to have?

The GPN Manifesto calls for action on tackling health inequalities, reinstating time for long-term conditions and prioritising public health promotion and disease prevention.

Through the following discussion, those among the workforce highlight the need for increased opportunities for training and career progression for GPNs, as well as the ‘time and space’ to consider and reflect on the needs of their patients.

Concerns emerged around a move to use less qualified and ‘cheaper’ staff in place of GPNs to manage long-term conditions, while some nurses have been ‘thrown into’ managing conditions such as asthma or diabetes ‘with almost no appropriate training’.

It was widely agreed that GPNs needed to be given ‘the tools in their box’ to support patients who often have ‘a whole suitcase of conditions’, and that more training and career development opportunities are required to instil confidence and safe practice.

Nurses also discussed the importance of considering the needs of patients from different areas and backgrounds, and explored initiatives that could help improve engagement with health services and health promotion, including the use of accessible languages.

The role of GPNs in addressing health inequalities

Jenny Aston, an advanced nurse practitioner (ANP) working in a large primary care network outside Cambridge, argued GPNs often did not have ‘the time or space’ to ‘think, reflect and work out’ how they can meet the individual needs of patients from different backgrounds, wherever they are in the UK.

‘Often, if you are in quite an affluent area, you assume there is no health inequity, but there is if you look for it,’ she said.

In her area of Cambridge and Peterborough, the training hub recently ran a health equity conference, exploring the needs of specific groups such as traveller communities, those who are homeless and people dealing with bereavement and human slavery.

‘For a lot of nurses, it was eye opening – which is shocking in itself that they weren’t aware of them,’ added Ms Aston.

Rebecca Corneck, Queen’s Nurse and a director of general practice nursing for the Southeast London Workforce Development Hub, said she felt the GPN workforce was ‘beginning to open our eyes’ to health inequalities, but stressed ‘we need to do it more’.

She talked from her own experience as a practice nurse in London and said: ‘I worked in surgery in Blackheath, social classes one and two. And then I moved a mile down the road to another practice in Lewisham, with a completely different demographic. And the needs are so, so different. And I was quite shocked.’

Ms Corneck said there was a need to ensure the workforce was aware of different cultural needs, for example offering services in different languages.

In addition, she pointed to a programme for people from African Caribbean backgrounds with diabetes that focused on support with specific types of popular foods.

‘We [often] talk about Western food, but actually it is nothing to do with what they will eat. So, I think it’s making nurses more aware of that.’

Ms Aston and Ms Corneck both also highlighted the need for increased training for GPNs around supporting people with learning disabilities.

For example, Ms Corneck said GPNs were not always confident in carrying out a learning disability review and were sometimes ‘worried about making a mistake or doing it wrong’.

‘They will follow the template, but they really don’t go any deeper than that,’ she said, adding that currently it is sometimes seen as ‘a tick box process’.

She added: ‘We need to get more training out there for the nurses to give them confidence. Because if they have the tools in their box, they’ll do it well.

‘We’re trying to get more training out there to make sure nurses feel equipped to do that review properly, because it can be a template base.’

When looking at the workforce more widely, Dr Helen Anderson, research fellow at the University of York, and previously a GPN and ANP, highlighted the importance of having a workforce that reflects the populations it serves.

And she suggested that having a practice nursing workforce that is ‘more reflective of populations may be something that needs work’.

Is general practice supporting the work of GPNs in long-term conditions?

Dr Anderson said through her research work and from talking to GPNs there had been ‘some concern around skill mix’.

This included healthcare assistants (HCAs) and nursing associates doing what has been described as ‘straightforward reviews’.

However, as Dr Anderson pointed out ‘how do you know it’s a straightforward review until you have done the review?’

Worse still, Dr Anderson said there were examples were patients ‘aren’t even getting a review’. Instead, patients are asked to fill in forms online – for asthma, for example – and being considered as not at risk despite not being seen by a GPN.

‘So, there are concerns around that and how do you address that because we know the importance of being a registered general practice nurse, but the voice and the scope of practice and the level of practice of these nurses doesn’t seem to be acknowledged or recognised,’ she added.

Hina Shah, a GPN and lead nurse in immunisations in Leicester, also questioned the skill mix of the workforce and ‘whether they are using their skills correctly or not’, including during patient coding activities.

‘If a certain thing is not within their limits, then a highly trained person should look after that area. For example, our diabetic nurse looks after complex patients only,’ she added.

Concerns about skill mix and even the substitution of registered nurses with different and sometimes less qualified staff have been raised in recent months, including at this year’s Royal College of Nursing (RCN) Congress.

Within general practice specifically, nurse leaders have been sounding the alarm around nursing associates working in place of registered nurses – especially since the introduction of the Additional Roles Reimbursement Scheme, which funds the salaries of some roles, including nursing associates.

Earlier this year, the Queen’s Nursing Institute (QNI) also called for ‘clear guidance’ on the ‘scope and limits’ of nursing associates amid reports of those in post running independent clinics in general practice.

Ms Aston, who championed our manifesto point focused on reinstating time for GPNs to manage long-term conditions, said: ‘Part of the problem is it gets taken away from [nurses] because [practices] see that somebody cheaper can do it.’

In her area, she said there was a system within long-term conditions management where HCAs ‘do all the data gathering’, including weight and blood pressure checks.

But while these HCAs know to refer onto someone else if needed, they ‘do not do any decision making’, said Ms Aston, who stressed ‘that’s the difference’ with a registered nurse.

She suggested many practice managers would say they ‘can’t waste’ an experienced nurse on doing a blood pressure check, but that this meant the approach was in some ways ‘disjointed’.

‘How do you make it work safely and use the value of a general practice nurse to do that holistic more experienced stuff?’ added Ms Aston.

‘Long term lack of investment in training’

More widely, Ms Aston said the area of long-term conditions had been up against a ‘long term lack of investment in training and career development for nurses’.

‘A lot of nurses have been thrown into doing diabetes or asthma or COPD with almost no appropriate training,’ she suggested.

She added: ‘I think it’s an area where we need to be making sure there is enough training and not just the training, but the ongoing support for nurses, particularly in those key areas of asthma, diabetes, COPD, and cardiovascular disease, because nurses do it well.

‘It’s about training and it’s about career development, not just for the nurse but to have safe practice.’

As director of general practice nursing at a workforce development hub, Ms Corneck said she really enjoyed teaching long-term conditions training and that she was currently writing programmes that could be delivered more widely.

‘The way I teach it now is, you don’t just think you’ve just got a diabetic patient in front of, you’ve got a patient with a whole suitcase of conditions that you need to be able to deal with,’ she said.

‘And that’s the tools we need to give our nurses to deal with. So, it’s looking at everything, [urine microalbumin], blood pressure, cholesterol – and the training I try and deliver now is all about that, so the nurses think holistically and proactively.’

How to support public health and disease prevention

As part of the roundtable event, GPNs discussed the action needed to support the profession and practices within public health and disease prevention.

The topic of immunisations was a central part of this conversation. Ms Shah, who has a leadership role in the immunisation of the 23,000 patient population in her area of Leicester, talked about its large South Asian population and the need for accessible languages.

For example, a text message to some of her patient population about the need for a routine vaccine would not have the same impact as her delivering a consultation on the importance of the vaccine and its role in preventing serious disease, she explained.

Since the Covid-19 pandemic, Ms Shah said she had also noticed that among certain non-English speaking populations when using the word ‘booster’ for a vaccination, patients only think about Covid.

‘I have to invite children for preschool boosters, or a second dose of MMR, but if my admin reception staff use the wording as a booster MMR, they only think about the Covid vaccine, and they become so hesitant not to go for an appointment,’ she added.

Also highlighting the importance of language and terminology, Ms Aston said she learned that in some cultures ‘there isn’t even language to describe some of the female genitalia’.

This was something GPNs must consider when encouraging women to come for cervical cytology, or for issues around childbirth or the menopause. ‘There is no word in certain cultures for menopause. And that was a real eye opener to me. But I think it is something that we need to think about,’ she added.

Ms Aston also suggested that working with communities to promote public health and reduce vaccine or appointment hesitancy was the key.

‘A lot of the time the message about hesitancy needs to come from someone else, not from us. We’ll do it. We need to make it available and make it easy, but actually, the message of vaccination is good needs to come from their own community,’ she said.

‘So, it’s working with someone in that community to be able to get the message across, rather than us because it doesn’t appear to work that we just tell them, and it certainly doesn’t work to sending them messages or ticking them off because they haven’t appeared.’

She added: ‘I think health promotion is much bigger than that. It is about using every opportunity.’

When thinking about health promotion, Dr Anderson referred back to the issue around ‘who is providing the consultation’, adding ‘who is interacting with the patient is important’.

‘I know that I’ve worked in the past with some really enthusiastic HCAs, and I’m not knocking them,’ she said.

‘But when you sit in with people, sometimes the information given isn’t accurate. And we have to be really careful around what we’re delegating in that as well.’

Our thanks to the nurses who contributed to developing the GPN manifesto, and those taking part in the GPN manifesto roundtable events. Further roundtable discussions will follow on more of the manifesto points.

#1 IMPROVE EMPLOYMENT TERMS

The government should ensure general practice nurses have the same pay, terms and conditions as their secondary care colleagues.

#2 TAKE ACTION ON WORKFORCE

The NHS, practices, universities and other stakeholders need to change the narrative, to encourage more nurses to choose general practice.

#3 TACKLE INEQUALITIES

Practices, PCNs, the NHS and government should do more to promote the health of our less well-off families.

#4 REINSTATE TIME FOR LONG-TERM CONDITIONS

Practices and PCNs need to free up time for GPNs to empower patients to manage their long-term conditions, including diabetes, asthma and COPD.

#5 PRIORITISE HEALTH PROMOTION

NHS England, PCNs, and GP practices should ensure GPNs have the time and resources to carry out their crucial role in public health promotion and disease prevention.

#6 SUPPORT WELLBEING

GPN employers, PCNs and nursing bodies need to support nurses with their health and care, so they can care for others.

#7 FOCUS ON PROFESSIONAL DEVELOPMENT

All nurses should be given the time for professional development to progress their careers. NHS England, PCNs and practices should encourage and support the GPN and ANP roles to grow in general practice.

#8 ADDRESS MENTAL HEALTH

It is important for general practice nurses to consider parity of esteem – valuing the patients’ mental health needs equally to their physical health.

#9 TARGET IMMUNISATION UPTAKE

GPNs need to play an important role in overturning the decline in childhood immunisation uptake.

#10 ADAPT TO DIGITAL HEALTH

General practice needs to continue to evolve to serve patients better, adopting approved digital platforms and applications to improve patient care and outcomes.

If you have your own comment on any of the manifesto points, we would love to hear from you. Please email the editor: [email protected]