GPN Manifesto Roundtable: Mental health, immunisations and going digital

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

In our fourth and final roundtable of this series, Nursing in Practice met with a group of nurses behind our 10-point manifesto to discuss mental health care, childhood immunisations and the use of digital platforms in primary care.

Why was this an important debate to have?

Our manifesto outlines the vital need to value patients’ mental health needs ‘equally to their physical health’ and for GPNs to ‘play an important role’ in overturning the decline in childhood immunisations uptake. It also urges GP practices to ‘continue to evolve’ by adopting digital platforms to ‘improve patient care and outcomes’.

In this discussion, we explore concerns around a lack of registered mental health nurses – especially in primary care – and the need to make mental health ‘everybody’s business’.

The GPNs involved suggest some among the profession can be ‘frightened’ of addressing mental health needs in patients, and that there this is a need for ‘more awareness and confidence building’ among colleagues.

On immunisations, the group highlight the importance of ‘building relationships’ with families and finding ‘innovative ways’ to run clinics to help tackle hesitancies and boost uptake among children. There should be a focus on being ‘much more patient and mum driven’, as opposed to practice driven, they say.

Technology wise, GPNs say they have ‘still got a long way to go’, but the use of digital platforms and apps is increasing, particularly since the Covid-19 pandemic. They stress the importance of ensuring technologies are ‘patient tested’ and that with apps, for example, that patients understand what to do with the information these digital platforms provide them with.

Georgina Callard, a mental health nurse and professional nurse advocate, has been based in general practice in Northamptonshire since 2018. She is employed directly by a GP practice, as opposed to through the additional roles reimbursement scheme (ARRS), which she suggests is quite unusual.

‘We’re busy. I’m booked up four weeks in advance. It’s a really needed role. We have GPNs that focus on diabetes and other long-term conditions – I don’t see why we can’t have more [for] mental health,’ says Ms Callard.

‘Robbing Peter to pay Paul’

However, she recognises the wider lack of registered mental health nurses across the country.

She says she has had several conversations around getting more mental health nurses into practices, but was warned this could risk ‘robbing Peter to pay Paul’ by taking those nurses from other settings.

‘But it would be fabulous to have a mental health practitioner in every surgery,’ adds Ms Callard.

In her role, Ms Callard sees adults experiencing a full range of mental health issues, such as anxiety, depression, psychosis and mania, and suicidal ideation. GPNs refer patients to Ms Callard and signpost their concerns to her. She also refers patients to GPNs at the practice to look at physical needs, such as asthma reviews.

Her role helps to ensure patients receive an early diagnosis, and feedback from the local mental health team is that referrals to secondary care have reduced since she joined the practice.

Ms Callard suggests there is room for ‘more awareness and confidence building’ among GPNs to help them to support patients’ mental health needs.

‘There is a lot of unknown, and mental health is such an individual based issue,’ she explains.

‘When it comes to mental health, one treatment won’t work for the next person, necessarily. And I think that’s the most daunting aspect of it.’

In recent months, Ms Callard has been working at a national level to develop a Level 6 module on mental health for nurses working in primary care. She says this has ‘come out of recognising that the GPNs and other clinicians just need a bit more information to build on that and then have that confidence to work with the patients the best they can’.

But she also notes the time pressures GPNs are under. ‘Another reason for GPNs to be a little bit hesitant with starting that conversation [about mental health] is because they’re pushed on time as well,’ she says.

‘I think it’s an understandable pressure to not start that conversation, because actually, then what do you do with it, and where is it going to go, and how long is that person going to talk for? And when they’ve got a five-minute appointment, and they’re already behind. I think there’s so much pressure [on] GPNs, but I have so much respect for what they do. It is such a huge job.’

In comparison, Ms Callard says she is given 30-minute appointments with her patients, ‘because mental health is all about talking and observation’.

Some GPNs ‘frightened’ to address mental health

Jenny Aston, a primary care advanced nurse practitioner who recently retired , suggests some GPNs are ‘frightened’ of addressing mental health needs.

She recalls a six-session training series around mental health for GPNs provided in her area a few years ago. ‘The feedback we got was that it was useful. And I think that a lot of nurses are frightened of it,’ says Ms Aston. ‘They’re quite happy to give a clozapine injection because that is… very specific, and they will be kind and understanding with individuals with serious mental illnesses, but they’re very frightened of going any further.’

Ms Aston flags the need to support the mental health needs of patients more generally, and not just being ‘crisis driven’.

‘I think the issue is around how could we facilitate more nurses?’ she says. ‘We’d love to have a CPN [community psychiatric nurse] within our practice.

‘We actually employed a physician associate who had some mental health experience. And very, very quickly, her clinics were very, very full with purely mental health issues.

‘I think practices would bite your hand off. And in a way, lots of them could use it under the ARRS roles.

‘The issue really seems to be there just is not enough trained CPNs who either would want to, or they’re so desperate within the community services that it would be a bit like stealing people.’

Ms Aston adds: ‘How do we get that message across that mental health is everybody’s business, and it’s a huge element of lots of chronic illness.’

Pointing to Ms Callard, she says: ‘We need more of you, but not just that. We need nurses with proper appointments, able to give holistic care and able to provide continuity.’

warned of the ongoing decline in the uptake of child immunisations – with vaccine hesitancy, particularly post-pandemic, and inequality of access among suggested reasons for this trend.

This point had been championed by GPN and lead nurse in immunisations in Leicester, Hina Shah. Although Ms Shah was unable to attend this discussion, she has previously highlighted the need for information about vaccinations to be given in accessible languages.

For example, a text message to some of her largely South Asian 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 earlier this year.

Since the Covid-19 pandemic, Ms Shah says she has 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.

Childhood vaccine uptake in England fell again across all 14 measures tracked by the NHS in the past year, according to an annual report published last month. No vaccines met the 95% target for coverage, the data for 2023/24 shows.

This further decline in uptake comes despite ongoing pleas from public health experts for parents to have their children immunised amid outbreaks of whooping cough and measles.

Relationship building ‘key’

In this roundtable discussion, ANP Ms Aston says the ‘key here is about building relationships with families, with mothers’.

It was also crucial that there was a nurse within every GP practice who is responsible for immunisations, including for managing audits, ‘keeping an eye on where the gaps are’ and finding ‘innovative ways’ of running clinics that fit in with families.

‘Rather than being practice driven, [it must be] much more patient and mum driven,’ says Ms Aston.

She suggests a lot of hesitancies around immunisations is down to a ‘lack of trust’, ‘within particular groups that are hard to reach’, including those who speak a different language or who have a different culture.

‘Somebody needs to be dedicated within the practice to take ownership of it – ideally, a nurse,’ adds Ms Aston.

‘It’s about relationships and trust, much more than it is about numbers and about ticking boxes.’

‘Massive amount of mistrust’

Director of general practice nursing for the Southeast London Workforce Development Hub Rebecca Corneck says there is a ‘massive amount of mistrust’ in South East London and that the Covid jab ‘did a lot of damage’.

She says her organisation was focusing on training healthcare professionals and non-clinicians to be able to have conversations with people about vaccines, including how to use affirmations.

‘I’ve been running some training in South East and in Bromley, just to support people with having those difficult conversations, signposting them to the vaccine knowledge,’ she notes.

‘It’s about identifying what’s the blocker. It’s undoing that or trying to give them the facts around what their fear is.’

This approach also includes ringing patients if their patient doesn’t turn up for their vaccine and to ‘try and get to the bottom’ of why that is.

A lack of health visitors

An issue raised during this part of the roundtable was around the lack of contact GPNs have with health visitors now.

Earlier this year, a report by the Institute of Health Visiting highlighted that capacity problems among the workforce could be helped by closer GP alignment.

Roundtable attendees discussed the need to get health visitors ‘back in the building’ in GP practices to help support with vaccination uptake.

‘It’s so frustrating. We have no contact with health visitors. They’re not around are they? So, they’re not seeing them as much as they used to,’ says Ms Corneck.

Turning to the digital agenda, attendees discuss our final manifesto point – centred on the need for GP practices to ‘continue to evolve to serve patients better’ by ‘adopting approved digital platforms and applications to improve patient care and outcomes’.

The GPNs suggest digital technologies and apps are being used a lot more – especially since the Covid pandemic – but they stress there is still ‘a long way to go’.

‘I think we are using a lot more because we have to, because the public expects us to. Covid pushed us into doing a lot more things,’ says Ms Aston. For example, the use of Accurx for two-way conversations with patients, which she says ‘was very helpful’.

In terms of technologies used to assist patient care, Ms Aston says there had been ‘a revolution’ within diabetes care, through the use of sensors put into patients’ arms.

‘It has changed things out of all recognition,’ she adds.

Patients like to be able to be ‘in control’ of their health and care, and some apps can help to support this and to keep patients ‘better informed’.

Helping patients to understand results

Though she recognises there are some challenges and confusion around patients interpreting the information some health apps provide them, and says this can result in patients ringing up to ask what they mean.

And she adds that getting patients to send over their results, for example their blood sugar levels, could be sometimes problematic if GPNs didn’t have the time to go through and read them.

‘I think we need help in knowing how to best use it, rather than it becoming an extra thing that actually creates more work,’ says Ms Aston.

She adds: ‘I think the other thing with apps is we need them to be more patient tested, to be useful.’

She pointed to the use of digital weight management apps, where patients can record food and calories, which can be sometimes helpful.

‘But people still need to know what to do with the information,’ says Ms Aston. ‘Do they know how to use it? Do they know what the relevance of it is?

‘I think within five years, there is going to be a massive increase in the amount of apps and things. But whether they’re all going to actually help, I don’t know.’

Ms Corneck says she recognises the benefits of some apps for patients, but feels ‘we’ve still got a long way to go’ and that progress around this agenda was sometimes ‘slow’.

She agrees it is important to think about ways to ensure patients understand what information the apps are bringing so they can engage with it.

Rebecca Shearer, lead nurse at West Road Medical Centre and an ANP, cites problems the use of the NHS App in primary care. She says the system ‘does not work perfectly’ in the sector and that is has caused some issues recently.

For example, she says people who use the app were unable to respond to her practices flu vaccination invites, ‘depending on how they set it up’.

Ms Shearer also raised concerns around potential barriers with the use of digital platforms.

‘Digital health works well in an English-speaking population but many of my patients do not have English as their first language,’ she says.

In response, Ms Corneck adds: ‘Rebecca’s right. English isn’t people’s first language, and that’s an issue as well – making sure it’s suitable in all languages. It’s got a long way to go, but at least we’re thinking about.’