Analysis: How will the next cohort of practice nurses get trained?

Practice nurses are suffering from a lack of morale, and many are looking to retire in the near future.

To revitalise the profession, there needs to be a steady influx of practice nurses.

This will be helped by nurse trainees having exposure to general practice. Such exposure will also help with their induction into general practice.

But applications to study nursing have just fallen for a fourth consecutive year and practice nurse training faces a number of problems.

This article, informed by our publisher Cogora’s general practice workforce report, will explore these issues and look to some potential solutions.

The number of nurses trained in GP practices has stayed the same for the past seven years – 181 in March 2017 to 187 in October 2024. Even including the 37 trainee nurses in primary care networks (PCNs), this does not represent much of an increase.

Cogora’s report suggests there is a lack of ‘imperative’ to address training capacity for practice nurses – especially compared to GPs.

Regulations around the time needed for GPs to spend training in general practices and the government’s own targets means there will be ‘scrutiny’ around GP training, the report argues.

But for practice nurse training, ‘this imperative does not exist’.

The NHS Workforce Plan put in measures to increase nurse training places from 30,000 a year in 2022 to 40,000 a year in 2024, with an emphasis on community nursing. But this doesn’t seem to be on general practice, with the emphasis on health visitors, and little mention of practice nurses.

Trainee practice nurses are recruited on an ad hoc, local basis. The only requirement for nurses is they need to spend two weeks in a community setting – but not necessarily in general practice.

The incentives seem to be against placing trainee nurses in general practice. First, from the universities’ point of view, there is no obligation for nurses to spend time in general practice so it is far easier for them to place nurses in secondary care, which has the infrastructure to take on hundreds of students rather than the one or two that a GP practice can take in.

From the practices’ point of view, there is little incentive for them to take on nurse trainees. In terms of funding, the clinical tariff that trainee nurses attract is £5,519 – or around £150 a week, for what would be a two-week placement.

Asha Parmaran ANP in north central London, says: ‘I have been trying to get a GP nurse trainee for two years across two practices and have been getting push back on the renumeration of the nurse and lack of room space with little room for flexibility on working patterns.’

As one practice nurse training co-ordinator puts it: ‘The dilemma and the thing that scares me as a practice nurse, is whether there is a need for us at all? Is that why there is a lack of training and support provision for new practice nurses as there isn’t a role for us in the future?’

Cogora’s report suggests that in the battle for training capacity in general practice, nurses are ‘low down’.

Nursing in Practice’s GPN Manifesto for 2024 called on the NHS, practices, universities and other stakeholders to ‘change the narrative to encourage more nurses to choose general practice’.

Discussions had as part of the manifesto heard from practice nurses who stressed that, in some areas, more must be done to show nursing students that general practice is a viable, exciting and skill-driven career, from the outset of their registration. But perhaps of greater concern was the funding barriers preventing students from being able to learn in a general practice setting in the first place.

A recent report from the Nuffield Trust also warned GP practices are ‘often reluctant’ to take on nursing students because of funding constraints and a limited number of practice supervisors or assessors.

NHS Digital data suggests there are currently more than 650 nursing associate trainees in general practice. Nursing associates need to obtain a foundation degree, typically taken over two years, which are usually in the form of an apprenticeship.

PCNs and practices receive funding to employ these trainees – a training grant worth £4,000 a year (£8,000 for the two-year course), or £7,900 a year if more than 50% of their time is spent with patients with autism or learning disabilities.

When the role was created, it was designed in part to ‘allow nurses to concentrate on more intricate clinical tasks’.

But as one nurse training co-ordinator put it: ‘Many practice nurses feel we are under pressure to train our replacements.’

Last January, a report from the Queen’s Nursing Institute (QNI) found that almost half of GPNs were expected to provide education and supervision for staff employed under the additional roles reimbursement scheme (ARRS) – which includes nursing associates – despite often being paid less and given free development opportunities.

For physician associates, there is again no requirement to spend time training in general practice. However, they are required to do 1,600 hours of clinical training, including 350 hours in general hospital medicine. But practices and PCNs are heavily incentivised on a local basis to take on training for physician associates. For example, in the Greater Manchester Training Hub, organisations are offered £130.96 per week to take on a nurse, compared with £555 a week for a PA, the Cogora report found.

As previously reported, the Staffordshire GPN Foundation School was launched in September 2023, modelled after the GP training scheme, in an attempt to help standardise training and move away from a ‘pick and mix’ of education that nurses new to general practice may face.

While the school is for nurses who are qualified and registered, it hopes to help remove the ‘ad hoc nature’ of recruitment and education of nurses in primary care.

Those behind the programme are currently striving to create a deanery for the practice nursing profession – based on its school. And they hope that one day, the need for standardised practice nurse training will be written into the GP contract.

Cogora’s report explores several issues around capacity – especially in terms of having the space to house staff and trainees.

As a result, practices and PCNs are having to prioritise. There is only so much physical space for each staffing group. Trainees may not always require their own space, but they certainly will if they need to contribute to the practice workload.

NHS England’s educator workforce strategy, from 2023, found there were problems with service pressures eroding the time available for training, and an ageing educator workforce.

As part of the report, Cogora surveyed its brands – including Nursing in Practice, Management in Practice and Pulse and results provided a bit more cheer on this.

For those who do train, it can be ‘one of the most rewarding parts of my work’, as one nurse put it. For the 198 nurse trainers who answered the Nursing in Practice survey, the average time they wanted to remain as a trainer was 5.7 years. For the GP trainers who answered Pulse’s survey, the figure was 5.7 years.

More trainers are needed, however. As Professor Kamila Hawthorne, Royal College of General Practitioners chair, put it at the Health and Social Care Committee hearing in December: ‘More and more people need to be trained in generalism, and the best place to do that is in general practice. And that’s not just medical students and GP trainees. It’s nursing students, it’s physician associates, its clinical pharmacists.

‘The whole raft of the team needs to come out into general practice, and we don’t have the room to train them properly, nor do we have the trainers.’

Then there is the problem of the number of trainers and their time. Nursing trainees need to be supervised by their senior equivalents. But these trainers will be able to oversee allied healthcare professionals accordingly.

The data around the number of professionals providing training within general practice is patchy. The Nursing and Midwifery Council says there are 1,346 nurses on its register with a general practice nursing SPQ qualification, who can provide training, but they do not know how many are actually providing training. And according to the General Medical Council (GMC), there are 7,940 GP trainers in England.

While there is a lack of capacity, practices need to prioritise. There are many non-financial benefits in taking on trainees of all types.

But, with a funding squeeze, practices and PCNs are having to prioritise the financial aspects – whether that be taking on certain staffing groups because of the funding they attract, or eschewing certain groups because of cost-benefit analyses.

This doesn’t necessarily translate to the long-term benefits to the workforce; for example, there are greater financial incentives to train PAs and nursing associates than there are practice nurses, for example.

This is an example of the GP contract being ‘fundamentally broken’, as Cogora’s report puts it, with incentives unaligned with long-term needs. The British Medical Association (BMA) and NHS England are currently discussing an overhaul of the contract, which should be implemented in 2028, and training must factor into this.