Analysis: The nurse recruitment crisis continues

The shortage of nurses across the UK is no secret, and in terms of the NHS and acute settings, is widely recognised by those at the top. But it’s not often that the situation in general practice is given the attention it deserves.

Nurse morale is worryingly low in general practice. Many are unsatisfied in their role, are feeling under constant pressure and are working several hours a week unpaid to meet increasing workloads and patient demands.

GPNs are also falling behind their NHS colleagues regarding pay, terms and conditions. A lack of ringfenced funding means GPNs are not getting annual pay rises promised by the government and has forced many among the profession to seek better employment conditions elsewhere.

Practices are sounding the alarm that nurse recruitment is a struggle – again citing pay and conditions among the top barriers.

And as previously reported, the introduction of the Additional Roles Reimbursement Scheme (ARRS) is in many ways compounding the registered nurse workforce crisis – with GPNs feeling pushed out of their roles in place of cheaper alternatives. Requirements of the scheme have also caused serious problems for advanced nurse practitioners (ANPs) who are struggling to secure posts.

This article, informed by our publisher Cogora’s general practice workforce report, will explore the current state of GPN recruitment. Of course, when looking at recruitment, you must also consider retention – and so a further article on this can be expected soon.

Data from NHS Digital reveals that the number of nurses in general practice in England is increasing and currently stands at 17,770. But at the same time, they make up a much smaller percentage of the general practice workforce – 18% in 2024, compared with 26% in 2019. And they are carrying out a decreasing percentage of general practice appointments.

Previous governments’ have, in some ways, recognised the need for more nurses across the country more widely. But the focus on practice nurses specifically has been particularly poor.

For example, in 2023, when the previous Conservative Government met its manifesto pledge of having 50,000 ‘more nurses’, it was revealed that practice nurses made up less than 1% of the total. This meant there were just 361 additional nurses working in general practice over a four-year period, compared to tens of thousands in acute settings.

And for the last six years, GPNs have been excluded from the ARRS – leading to several concerns that the registered nursing workforce is being sidelined and replaced by roles on the scheme, such as nursing associates and care coordinators.

In December, the new Labour Government announced plans to add GPNs to the scheme – but it’s unclear what impact this will have on nurse recruitment in primary care. Some are concerned it could cause more problems than solutions, and that it could even deplete some practices of nurses altogether as they look for an ARRS role elsewhere.

As revealed in Cogora’s report, GP practices across England are already struggling to recruit much-needed nurses. According to a survey of GPs and practice managers cited in the white paper, practices have a registered nurse vacancy rate of 23%. In comparison, they report a 16% shortfall of GPs.

Practice managers and GP partners say they are finding registered nurses ‘particularly difficult to recruit’ – largely because of core funding constraints that mean practices cannot keep up with pay and conditions given in other settings, especially in secondary care.

This was an issue also identified by our General Practice Nursing Manifesto last year – which urged the government to ensure practice nurses had the same pay, terms and conditions as their secondary care colleagues.

A practice manager in Blackpool warns they cannot afford to match salaries for nurses.

‘We currently have four practice nurses; they do the bulk of our chronic disease management and are worth their weight in gold,’ they say. ‘Nurses are particularly difficult to recruit, mainly because the local out-of-hours provider pays significantly more than we can ever offer.’

Meanwhile, a GP partner in the West Midlands says they have made their nursing associate role redundant and had ‘not been able to pick up the slack with any other roles’. Despite wanting more nurses, this GP partner says incoming National Insurance rises could mean more of its staff are made redundant and that they were also unable to offer current staff any pay rise.

They add that they are in a worse position now ‘in terms of numbers, equivalents and what we can offer’, than almost 10 years ago.

One nurse team lead in Dorset says even if a nurse wanted to move from secondary care into general practice, there was a ‘limited number’ of those able to afford to. ‘Our practice cannot afford anywhere near the level of pay in secondary care,’ they say. ‘Some of the very large, multiple-site practices seem to be able to afford a higher wage, although I understand from colleagues that working in them carries its own difficulties.’

A Nursing in Practice survey, cited in the Cogora report, revealed half of general practice nursing staff had not received a pay rise for 2024/25. Of those who had, only around one in six (16%) were awarded the 6% recommended by the government in England.

The survey of more than 550 nursing staff working in GP practices also saw a significant 28% of respondents report thinking about leaving the sector within the next year. Concerns over pay and feeling ‘undervalued’ were cited as reasons to blame by many. GPNs told us they continued to feel that their pay had ‘fallen behind’ colleagues working in secondary care.

One practice nurse says: ‘I have been nursing for over 45 years, and I have never felt so undervalued as I do now. I have not received a pay rise for over two years, so I am worse off than I have ever been.’

Of those wanting to quit the sector, the most commonly cited reason was because they felt ‘undervalued’ in their job (68%), followed by concerns that pay is not keeping in line with the cost of living (67%) or reflecting their responsibilities and workload (60%).

Some 97% of GPNs also told us their workload was ‘very’ or ‘somewhat intense’. Busy workloads have also meant that, on average, GPNs are working 3.5 hours above their contracted requirements per week.

One GPN responding to our survey says: ‘Practice nursing has become relentless. We have little or no say in our list size and at times I feel we work unsafely with no support from GP.’ An enhanced level practice nurse describes their workload as ‘constant pressure without let up’, while a nurse team lead says: ‘Conditions in primary care continue to get worse.’

In a recent interview with Nursing in Practice, the Royal College of Nursing’s new primary care nursing lead said fair pay, ringfenced funding and greater leadership opportunities for GPNs were among her top priorities coming into the role. Ms Ball says she recognises the ‘precarious position’ general practice nursing is currently in and is committed to bringing a ‘renewed focus’ on the profession.

In December, the RCN used our survey findings as evidence when asking the independent pay review body for GPs to explore the reasons why many GPNs are not being given a pay rise.

Something potentially exacerbating the nursing workforce crisis in general practice is the issue of an NHS ‘digital badge’ – required for ANPs to secure a job in GP practices when employed through the ARRS. Primary care networks are reportedly struggling to recruit ANPs through the scheme and in some cases have said the digital badge scheme is to blame.

ANPs came to Nursing in Practice in the summer to sound the alarm over the scheme which they describe as ‘discriminatory’ and ‘deeply flawed’.

The digital badge scheme was launched by NHS England in 2022 as a way of evidencing the ‘accredited education and training’ of ANPs. It is currently voluntary for all ANPs, apart from those seeking employment under the ARRS in general practice. It can be obtained via two routes: from doing an accredited Master’s programme or via an ePortfolio which includes a 5,000-word essay.

But several concerns have been raised that as it is largely courses post-2017 that are accredited – because they are matched to a ANP framework launched that year – ANPs who have done their education before then have to undergo the extensive ePortfolio option if they want to obtain the badge. And Nursing in Practice understands there have been ‘huge delays’ and several barriers in ANPs accessing the digital badge, especially via the ePortfolio route.

Some ANPs have been pushed to take sick leave over the situation, while others are forced to look for jobs elsewhere. In September 2024, research from the Queen’s Nursing Institute (QNI) warned GP practices are at risk of losing ‘many’ experienced nurses because of the scheme, while calling for an urgent review. The report found that experienced nurses in general practice were ‘significantly’ disadvantaged, and that this workforce was at particular risk.

In December 2024, the outgoing QNI chief executive Dr Crystal Oldman said she was confident that conversations were being held at a ‘national level’ and that she was ‘anticipating a change’ to the scheme that would make it potentially fairer for ANPs employed through the ARRS.

Despite this challenge, the ANP workforce in general practice has risen from 343 full-time equivalent staff in December 2023 to 501 in December 2024, according to data from NHS Digital for England. However, this data for December 2024 is understood to include the new enhanced level practice nurse role – an experienced GPN with postgraduate qualifications – which was added to the ARRS in April 2024.

Perhaps unsurprisingly, it seems pay and conditions are among the biggest issues causing recruitment challenges. Of course this is made worse by increasing workload pressures and demands put onto a workforce that is already feeling undervalued.

Practices want to recruit more nurses but don’t have the funding to back it up. And while nurses want to come into general practice, some can’t afford to and those with advanced qualifications are struggling to prove their experience because of a tick box scheme.

Proposals to include practice nurses in the ARRS will not necessarily mean the addition of new nurses into the sector – it could just spark a mass moving exercise between practices or PCNs.

It is clear that as with many issues facing the sector, funding is the key to the situation.

As the struggle to recruit continues, the need to retain will be ever more pressing – look out for our next analysis on this in the coming weeks.

The full Cogora General Practice Workforce White Paper can be downloaded here