General practice nurses (GPNs) will continue to leave their jobs if role substitution, poor pay and other fundamental issues are not addressed, a study has concluded.
The new report, published in journal GMC Primary Care this week, surveyed dozens of nursing staff in general practice across England and Wales to investigate what keeps them in their jobs – and what could force them out.
“Nurses in general practice experience factors which leave them vulnerable and underserved”
Study
Lead author Dr Helen Anderson, Queen’s Nurse and University of York qualitative research fellow, said GPNs were being pushed to a “breaking point” by pressures including job insecurity and feeling unable to challenge unfair treatment.
This, Dr Anderson said, has left many of them feeling like they have “no choice” but to leave general practice altogether, driving up already high GPN vacancy rates.
As well as Dr Anderson, the study authors included Louise Brady, who is the national primary care nursing lead at NHS England, and University of York health services researcher Dr Joy Adamson.
The team interviewed 41 nursing staff from general practice in England and Wales, including some who had recently quit their roles.
These nursing staff members, who ranged from healthcare assistants (HCAs) to advanced nurse practitioners to national nurse leaders, told the study about the issues affecting retention.
Some pointed to what the study described as the “commodification” of nursing in general practice, and a feeling that the profession was not valued in the sector.
One GPN said she had felt pressure from GP partners to “get more people in, to tick more boxes”, with appointment times cut without consultation among staff.
“So, [for] a lot of the consultations, the clinical focus can sometimes be overridden,” she told the study.
Others spoke about a creeping “de-professionalisation agenda”, in part due to the practice of lesser qualified staff such as nursing associates and HCAs taking on duties previously reserved for registered nurses.
The study noted that nursing associates, which are deployed in England and due to come to Wales in the next few years, were considered as “valued members” of the nursing team, but that they – alongside HCAs – were being “exploited” as cheaper alternatives for nurses.
This, in turn, had “implications” for retention, the study found.
Another GPN told the study: “This is about bolstering a nursing workforce through a side door, instead of investing money in nurses.
“Nursing associates are being used unsafely, working in practice without a registered nurse being employed, which goes completely against the governance behind the [nursing associate] role. I think it’s being exploited.”
The nurse said there was a “danger” that the value of the registered nurse had been “missed” in general practice.
Others told the survey about dissatisfaction with pay.
General practice nursing staff are contracted to their workplace, not the NHS. As a result, while contracts may mirror the health service’s Agenda for Change scheme, some general practice staff are paid less than their NHS counterparts.
Staff told the survey they had to “battle and fight” for better working terms and conditions, including negotiating for pay rates and rises.
Some aired frustration about a lack of a voice at a decision-making or strategic level.
Further, interviewees raised concern about the impact of the additional roles reimbursement scheme (ARRS), which allows general practice providers to get government funding for the salaries of certain posts.
There was a feeling, the report noted, that practice owners opted to hire people into ARRS-funded roles instead of registered nurses to save money.
“Some felt this was leading to a loss of professional identity and making it harder to keep nurses in general practice”
Helen Anderson
Staff felt that this was hampering the retention of nurses.
A former GPN and current primary care network lead told the report: “[ARRS has] definitely had an impact, particularly on the larger practices in our [primary care network].
“A huge motivating factor is the benefit financially that has brought to practices, then they just change everything else around that.
“Where they’ve lost their more experienced practice nurses, they’ve chosen not to replace them and then when practice nurses have come in, they’ve felt as though they’ve been unsupported. They don’t feel valued as health professionals.”
Since the interviews for this study were carried out, between October 2023 and June 2024, it was announced that the ARRS will be expanded to include GPNs.
Staff also told researchers about the positives of working in general practice that kept them in their jobs.
These included flexible hours, working with their local population and the complex and diverse nature of their caseload.
The study authors concluded that these positive, “protective” elements of work should be maximised by employers.
They said: “Nurses in general practice experience factors which leave them vulnerable and underserved.
“Policymakers, employers and professional organisations ought to work to support retention and enable nurses in general practice, not only survive, but thrive.”
Dr Anderson added: “Participants in the study appreciated the wide range of work, including caring for people of all ages with many different health needs…
“It was clear, however, that these valuable aspects were being lost due to increasing workload pressures and a focus on meeting targets rather than providing quality care.
“Some felt this was leading to a loss of professional identity and making it harder to keep nurses in general practice.”
She said it was important that the voice of GPNs was “drawn on” to inform future policy and practice.
