It is no surprise that the general practice nurse (GPN) role has evolved over time, with nurses at the centre of the provision of care. Practice nurses have seen a huge growth in skills, scope and responsibilities in past decades.
But today, some nurses are starting to raise concerns that the recent pace of change in primary care might be bringing risks for the established GPN role.
What is causing this unease?
Difficulties in recruitment, an ever-increasing workload, cost cutting, and the Covid-19 pandemic – where processes were stream-lined and new ideas thrived – have all been impacting on the GPN role.
Another major driver for change in general practice has been the additional roles reimbursement scheme (ARRS) in England that has introduced new roles and skills, including pharmacists with specialist medicines knowledge, and nursing associates who can do some set tasks that a nurse might have done before.
But talk to nurses working in primary care, and common themes, patterns and messages emerge, including fears that the established role of the GPN is being ‘chipped away at’.
Here’s what some of them say about what they are seeing where they work, and how things have changed or could change for them.
‘Some nurses are feeling disempowered, and that their role is under threat,’ says Naomi Smith, a clinical general practice nurse manager based in Bradford, who has worked as a GPN.
‘We are being pushed to one side because there is a suggestion that other roles such as physician associates, clinical pharmacists, and nursing associates are replacing us,’ says Donna Loose, nurse manager and women’s health specialist nurse at Birchwood Medical Practice, North Walsham.
Our conversations with nurses begin to uncover some more areas of concern.
ARRS roles in general practice
In some cases, pharmacists in general practice are ‘taking workload’ from GPNs to do respiratory reviews, says Sarah O’Donnell, strategic lead for primary care and integration, Leeds Community Healthcare Trust, and a locum GPN in Bradford.
‘This works well when there is good communication, and an understanding of exactly what that role is undertaking.’
Pharmacists delivering respiratory reviews can be helpful for areas where practices cannot recruit nurses, and have had to look at alternatives, she says.
But if ‘workload is passed to somebody else with no discussion; no understanding, these cases can lead to professionals feeling upset and devalued’, says Ms O’Donnell.
Sarah Hall is a Royal College of Nursing General Practice Nurse Forum committee member, and a general practice nurse lead at an ICB, who has worked for more than two decades in general practice. She says recent feedback from nurses about pharmacists doing asthma reviews is that they are working to a medical model, and do not have the GPN’s ‘holistic approach’.
Nurses report that the asthma clinics being reassigned from nurses to practice pharmacists can be a ‘tick box exercise’, and result in creating the need for additional practice nurse appointments, she says.
Jenny Aston, an advanced nurse practitioner; an advanced clinical practitioner ambassador at Cambridge and Peterborough Training Hub, and a Queen’s Nurse, says while pharmacists may be up to date with asthma medication and local guidelines, they may ‘lack understanding of the whole picture of asthma’ – unlike the GPN with an asthma diploma.
She says it would be ‘better if nurses did the more complex reviews’, and there is a need for ‘more joint working with nurses and pharmacy, with nurses being valued for their training and expertise’.
Impact of new roles
The nursing associate (NA) role – eligible for ARRS funding since 2020 – has also prompted concerns. Mrs Smith says NAs’ lack of training and mentors is affecting the GPN’s role. ‘Nursing associates are constantly being pushed to do more and are adding to the work of GPNs because the appropriate support is not in place.
‘GPNs don’t have capacity to train and support nursing associates, unless senior management provide sessions out of practice. And without the training they can’t give us the support we need, and our workload continues to rise,’ says Ms Smith.
Ms Smith says a lack of mentorship and training for NAs is affecting the GPN role, they are constantly being pushed to do more and are inadvertently adding to the workload of the GPNs because the time is not being allocated to mentor them effectively.
‘The nursing associate is a good role and there’s a place for it, but it’s been introduced with a lack of guidance around the scope of practice and that’s causing challenges, putting nursing associates, as well as potentially patients, at risk,’ says Ms Hall.
‘They are being asked to take on roles outside of their scope of practice. We need to be mindful of this, and support them as much as we can to ensure they are not put in these difficult positions.’
To support NAs and trainee NAs, in West Yorkshire, Ms O’Donnell has created a forum for them to share learning. ‘Nurses should not see nursing associates as a threat – they need our guidance,’ she says.
While the introduction of ARRS roles were brought in to support general practice, an unforeseen consequence has been that they have had a negative impact on the morale of GPNs and have led to them feeling undervalued,’ says Ms Hall.
The salaries of ARRS roles are typically linked to Agenda for Change pay bands and in recent years ARRS staff have been eligible for pay rises in line with Agenda for Change. GPNs are excluded from these roles.
‘People are taking on the roles that GPNs were traditionally doing but without their experience and qualifications. And GPNs are expected to support and train them,’ says Ms Hall. ‘The crux of the problem is the difference in pay scales and terms and conditions,’ she says.
‘Openness and honesty’ are paramount to having good working relationships for nurses working with those doing additional roles, says Ms O’Donnell. And employers need to have discussions with nurses, so they are aware of the reasons why people with additional roles are working in the practice.
Some blurring of role responsibilities
Related Article: What we do and don’t know about practice nurses being added to ARRS
Boundaries between primary care roles are becoming blurred, and practitioners are now working one step up above what they used to do, nurses have told Nursing in Practice.
‘We’ve all moved up a level. GPNs are becoming more specialised with nurse prescribing, leading clinics for long term healthcare, and undertaking procedures GPs used to do. Nursing associates are following in our footsteps with health education and promotion,’ says Ms Loose.
However, the GPN’s more specialised role is not always recognised by those running practices. ‘It’s frustrating that practice managers often see our role as skills based – someone to deliver cervical cytology and do dressings – and don’t understand the complexity of the work we do,’ she says.
In Scotland, GPNs are being encouraged to ‘enhance our clinical skills’, says Rebecca Grant, a GPN based in Gourock Health Centre in Gourock in Inverclyde and Largs Medical Group in Largs in North Ayrshire, who works for two different health boards.
In its Paper 6 Developing the general practice nursing role in integrated community nursing teams, the Scottish Government defines the refocused general practice role.1
GPNs are being supported to do training in prescribing medications, referrals, minor surgical procedures, and to take on more of a leadership role within the team, says Mrs Grant.
Core areas of the role include focusing on public health and supporting management of long-term conditions, and those with complex conditions.
Teams taking on GPN tasks
Immunisations, wound care and contraceptive injections are typical tasks on the GPN appointment list. In Scotland this is changing. Community Treatment and Care (CTAC) teams are delivering a range of interventions including wound care management, ear syringing, and bloods, and community vaccination centres are delivering immunisations, including babies’ and children’s vaccinations.
Ms Grant suggests the rationale behind the changes could possibly be to improve access to care, and expand GPNs’ scope of practice to do more management of conditions. For example, a patient has their bloods and blood pressure done by the CTAC team for a diabetic review, and their chronic disease management, including lifestyle advice, is carried out by GPNs.
For some GPNs, the changes to their role have ‘been really hard’, she says. ‘They feel forgotten about, and not as important.’ Reaction to the changes can depend on how supported the GPN is within their practice, she says.
‘Some don’t feel they have been involved in these decisions and informed of the reasons. It can be upsetting.’
How nurses feel about the changing role of GPNs may also depend on the kind of work they prefer to do.
‘Some feel having roles taken away is a threat – others that it allows them to do more complex skilled work,’ says Ms Smith.
Social isolation can be a factor
Since Covid-19, nurses report a sense of isolation within the GPN community. During the pandemic, lunchtime get-togethers and informal catchups stopped due to social distancing and for some, have not resumed.
‘GPNs are becoming more isolated because they don’t get that time to spend with colleagues,’ says Helen Lewis, an advanced nurse practitioner and Queen’s Nurse based in South Wales. ‘That rejuvenation from getting together is missing.’
‘Workload has increased, practices are so busy and as many appointments as possible are being squeezed in, and that time previously set aside to come together with colleagues has gone out of the diary,’ says Ms Hall.
That lack of contact with colleagues can have consequences, both for nurses and their patients. ‘None of us should work in isolation – it’s a risk for our practice to go unchecked and to not have that peer support,’ says Ms Hall. ‘It’s those incidental conversations over coffee that are invaluable for the care that we deliver. But that value is hard to measure so not seen as a priority.’
Those opportunities to meet with peers are ‘invaluable’, and without them can risk patient safety and impact on job satisfaction and retention, she says.
Actively supporting nurses and encouraging them to take breaks can help to tackle isolation. ‘It is vitally important to talk to peers and colleagues, even if it’s a quick coffee or a corridor chat,’ says Nicola Wallis a nurse manager and advanced clinical practitioner at Riverside Surgery in Port Talbot, South Wales.
Increased use of digital tools
The advancement of digital tools for communication and sharing information that came out of the pandemic, helped to combat GPN isolation during that time, and continues to benefit the role, with remote meetings cutting out travel time and boosting attendance.
Pre-Covid, Ms Hall set up a virtual leads network in Devon as the size of the region meant it wasn’t feasible for nurses to always meet up in person. ‘Virtual platforms save a lot of time traveling in rural areas,’ says Ms Hall.
During Covid, the peer-to-peer support through this network was ‘fantastic’, she says. Since the pandemic, this virtual network of nurses continues to meet on a fortnightly basis. Recently the network met in person. ‘You cannot replace the value of meeting face-to-face to catch up,’ she reflects.
During the pandemic, technology in healthcare developed and was implemented quickly. Post-pandemic, with online consultations ‘it shouldn’t be all one way’, says Ms Hall. ‘We have the technology, the skills and the ability to deliver our consultations in different ways and should be able to offer what’s best for the patient.’
Post pandemic, practices vary in their ratio of remote to face-to-face consultations, which may be a response to patients’ needs. In South Wales, at Ms Wallis’ practice, which has a large elderly population; 90% of consultations are face-to-face. ‘You can’t put a price on seeing someone face-to-face as a nurse practitioner - 80% of diagnosis comes from seeing the patient,’ she says.
Nurses, as well as patients, may struggle with new technology and need support, Ms Hall says. ‘It’s very different managing a consultation remotely compared to face-to-face. Nurses need to have the confidence and competence to deliver consultations in different ways. There are training programmes out there on delivering remote consultations – but perhaps nurses have been overlooked.’
Is sufficient training available?
The GPN role – a specialist generalist – ‘is an amazing career opportunity for newly qualified nurses’, but requires additional training and support, says Rachel Viggars, strategic nurse lead for Staffordshire Training Hub, and programme director for Staffordshire GPN Foundation School.2
In recent years, GPN fundamentals courses, – a standardised programme of training and education for nurses new to general practice nursing3 – and the Primary Care and General Practice Nursing Career and Core Capabilities Framework, for example4, have been setting the bar of where general practice nursing should be.
However, this training is not compulsory, and standards of GPN training vary from practice to practice, says Ms Viggars.
Last September, a new GPN Foundation School was launched in Staffordshire – a project aiming to standardise training and move away from a ‘pick and mix’ of education that many GPNs currently face.5
‘We’re providing a more standardised approach to general practice nursing recruitment and education,’ she says.
Those on the programme – newly registered nurses and those new to general practice – attend while being centrally employed via a Federation on behalf of PCNs/practices on a full-time fixed term contract for 12 months – some within a primary care network model and some within a GP practice.
Ms Viggars would also like to see the establishment of a GPN deanery, to be rolled out regionally and nationally.
There has been a ‘big shift to online training’, she says. This is about convenience of access to training – GPNs are more likely to be released from practice to attend online rather than face-to-face training, she adds.
Online training ‘has a place but it’s also important to have training face-to-face. Sometimes one size doesn’t fit all’, says Ms Hall.
Rising workload and pressures on practice nurses mean there is less time for training, and nurses are not able to update as often as they would like, says Ms Lewis.
Funding changes that impact GPNs
In recent years, Ms Hall says ‘the biggest impact’ on general practice nursing has been about the implementation of NHS England’s general practice nursing ten-point plan.6
‘The funded plan had key programmes of work to support recruitment and retention in general practice, which really benefited from this,’ says Ms Hall. GPN fellowships, for example, have supported new nurses working in general practice, she says.
However, since the end of March, funding for GPN fellowships7 and associated programmes now no longer comes centrally from NHS England (NHSE) and is instead at the discretion of integrated care boards (ICBs) as to whether these schemes continue.8
‘These funding changes will impact on general practice nursing and is our biggest challenge going forward,’ says Ms Hall.
What might be in the future?
‘There is always going to be a role for nurses in general practice, but in the future, there will be fewer registered general practice nurses working,’ suggests Ms Hall.
She proposes that there will be HCAs, NAs and a smaller number of GPNs, and advanced clinical practitioners.
‘GPNs will be more qualified, working at a much more specialised level – essentially as enhanced level nurses – and managing long-term conditions.’
Looking ahead, PCNs are to have a new role of an enhanced practice nurse, providing clinical nursing leadership.
Related Article: GPN pay: A reflection on the last 12 months
Earlier this year, NHS England announced that enhanced practice nurses will be included in the list of roles that PCNs can claim salary reimbursement for under the ARRS – capped at one per PCN or two for those with 100,000 patients.
An enhanced practice nurse has been defined loosely by NHS England as a nurse with ‘a level seven or above postgraduate certification or diploma in one or more specialist areas of care’.9
The enhanced nurse role is also referred to as part of career progression in the GPN career framework.10
Ms Lewis says GPNs will become upskilled, and potentially go into specialisms, such as coronary heart disease or epilepsy, and oversee routine tasks carried out by NAs. However, with more of a supervisory role, nurses ‘may move further away from clinical work and lose that expertise’, she says.
The move towards specialisms is also a concern because ‘this is not what GPNs are – we are generalists’, says Ms O’Donnell.
Some practice nurses may decide to combine working part time with another role, or do locum work, ‘to have that variety’, says Ms Smith, who works for a training hub one day a week.
In the future, Ms Loose hopes GPNs will be recognised for understanding patient care pathways, used as a voice in management to recruit into general practice, and have a say in how patient services should look.
So, is the GPN role under threat?
For the present, there are fears the GPN role is being eroded. ‘There is concern that the role of the general practice nurse with years of experience and a variety of training – the true generalist – is being chipped away at,’ says Ms Aston.
Taking away work like cervical screening, immunisations or asthma reviews for example, could be ‘taking away the essence of what people love about working in general practice’, she says.
‘Potentially, GPNs are under threat because of the amount of GPNs about to retire – and who is going to take their place?’ says Ms Lewis.
There is also ‘a lack of awareness about what GPNs actually do’ and ‘we do not seem to be valued for what we deliver’, says Ms Loose.
‘The GPN role is being diminished,’ says Stephanie Zakrzewski, a GPN in the Ribble Valley, Queen’s Nurse, and formerly a nursing and quality manager for Lancashire and South Cumbria ICB. The many reasons include financial ones, staffing levels, limited career opportunities, and terms and conditions, she says.
‘Perhaps we need to accept this is the demise of the GPN role, and it won’t last much longer unless something serious is done about it.’
What can be done?
Steps can be taken now to address these emerging problems, the nurses we spoke to suggest.
Newly qualified nurses should be encouraged to go into general practice, and there should be forward planning for career progression with this specialty, says Ms Lewis.
‘A lot of effort needs to go into upskilling nurses to be really experienced in managing long-term conditions well, so they can demonstrate their value in primary care, a PCN or a practice. The problem is a large percentage of those that are experienced are retiring, so we need to get new people upskilled fast,’ says Ms Aston.
Ms Aston, who was involved in the development of the GPN career framework, hopes it will be ‘used more widely and help nurses when trying to negotiate further training or pay’.11
A greater understanding of the GPN role and its value is needed. Ms Loose calls on those who hold budgets for recruitment into primary care, and anyone making ‘high end’ decisions on service provision, to shadow a GPN for a day, ‘to live and breathe our day, see how many lives we touch, and the skill mix we deliver’.
GPs and practice managers, PCNs and ICBs need to ‘recognise the importance of the role’, says Ms Zakrzewski. ‘We need nurses to advocate for the role, and for them to be provided with opportunities to enhance skills and knowledge through continuing education and professional development,’ she says.
Practices should offer appropriate salaries to attract new nurses, and nurses need to ‘fight for terms and conditions’, says Ms Zakrzewski.
Nurses also need to ‘make sure they stay connected and be part of wider networks in general practice’, says Ms Hall. ‘You’re not on your own. We’re stronger together,’ she suggests.
She encourages nurses to join online professional groups ‘and if there isn’t a network, make one’. ‘Networks are so powerful. And nurses are great at networking.’
Encouragement to embrace change
General practice nursing is ‘still a rewarding career,’ says Ms Wallis. ‘Primary care nurses need to be looked after and cherished. We’re the first port of call for patients.’
‘One of the things I’ve really loved about working in primary care is we nurse patients from cradle to grave. This is what we trained to do. We care, we’re compassionate, and that’s why we came into practice nursing,’ says Mrs Zakrzewski.
‘As a primary care nurse, you have the opportunity to make a significant difference to patients’ lives,’ says Mrs Grant. ‘You’ve got such a range of tasks, which keeps the job engaging. And things are changing all the time, so you need to keep up to date.’
Since its inception, a constant in general practice nursing seems to be change.
Ms O’Donnell adds that while it is hard for people not to become upset and worried by changes, ‘you have to show your passion and keep fighting’.
She concludes with a call to stand together that may resonate with any GPNs who are indeed feeling uneasy about their future position in general practice: ‘The only way you’re going to do this, is if you do it together. Embrace change. And hold on to each other.’
Tell us about any changes you are seeing in your PCN or ICB that are impacting on the GPN role. We would like to hear from you.
Related Article: The GP Awards shortlist: Ann-Marie Blaney, nurse lead, The De Parys Group
References
2. https://staffordshiretraininghub.com/gpn-foundation-school/
4. www.skillsforhealth.org.uk/wp-content/uploads/2022/05/Primary-Care-and-GPN-Framework-May22.pdf
7. https://www.england.nhs.uk/gp/the-best-place-to-work/gp-fellowship-programme/
8. https://www.nursinginpractice.com/latest-news/nhse-to-close-national-gpn-retention-schemes/
10. www.skillsforhealth.org.uk/wp-content/uploads/2022/05/Primary-Care-and-GPN-Framework-May22.pdf
11. www.skillsforhealth.org.uk/wp-content/uploads/2022/05/Primary-Care-and-GPN-Framework-May22.pdf
