As the government pushes to move more care out of hospitals, what is the current shape of the wider frontline workforce in general practice. Here we look at nurses and pharmacists
Nurses
There is little doubt that morale in practice nursing is low. In September a survey by sister title Nursing in Practice revealed half of practice nurses were considering leaving the profession in the next 12 months, and in an interview with NIP, the new professional lead for primary care at the Royal College of Nursing (RCN) Kim Ball said the profession was in a ‘precarious’ position.
There are several factors behind this and, as with GPs, some of the issues predate the ARRS. But it is apparent that the ARRS has compounded this low morale. More than half of respondents to Nursing in Practice’s September survey said their work is more solitary than two years ago, and this is on the whole due to new staff taking over nurses’ work and nursing teams being shrunk. Around a third say their job has changed for the worse since the ARRS was introduced in 2019.
Most feel they are poorly recompensed and – while this is not completely linked to the ARRS – comparisons with the new staff (especially those whose pay is linked to Agenda for Change) are exacerbating their displeasure. Furthermore, there is a growing feeling among practice nurses that they are being replaced, and that is closely linked to the ARRS.
In her Nursing in Practice interview, Ms Ball said the practice nurse role ‘can be very isolating’. She added: ‘I think there’s been a lot of change in general practice in terms of having more of a multidisciplinary team and nurses feel that they’re being excluded from discussions about service provision.’
One nurse, who has been practising for four decades, agrees that the job is more solitary now. ‘There used to be time for nurses to meet up in peer groups. Now, often, there may only be one nurse in a practice along with ARRS staff. The nurse might be doing mostly cytology and baby immunisations. Long-term conditions will be delegated to the physician associate or nursing associate, who will not have the clinical knowledge that I do.
‘Without practice nurses, general practice will lose its heart. When I read that GPs will have to do all these new immunisations or checks, I know the truth – it will be the nurses who do them.’
There is a total of 16,929 full time equivalent (FTE) working in general practice according to the latest NHS data from November 2024, this is a drop of 83 or 0.5% since November 2023. Between 2015 and 2023 numbers had been steadily rising.
Pay
Pay has been a huge issue for practice nurses. NIP’s September survey found that half of practice nurses received no pay rise in 2024. The RCN cited NIP’s findings in its evidence to the independent pay review body for GPs, calling for an investigation into why practice nurses are not getting pay rises. The college also issued a joint statement alongside the BMA in December 2024 urging practices to give nurses the 6% pay rise recommended by the Government.
The RCN said nurse practice pay was lagging behind that of hospital nurses. Its pay review body submission said ‘large numbers of staff now find themselves further away from the pay, terms and conditions of their peers who are directly employed in the NHS’.
One nurse team lead in Dorset says that even if hospital nurses wanted to come to general practice, they would be put off by the pay. ‘Morale in general practice is very low. There are limited numbers of nurses able to afford to come out of hospital even though they would like to, as our practice cannot afford anywhere near the level of pay in secondary care.
‘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.
‘Due to the funding not having been available for practice nurses via ARRS, there is little possibility for our career progression. Even if we are allowed time towards additional training, there is no money to then financially reward the additional qualifications and responsibilities or to pay for extra hours to offer more consultations to patients.’
Concern that practice nurses are being replaced is widespread. A nurse team lead in Herts and West Essex puts it bluntly: ‘GP nurses will soon be replaced with nursing associates, physician associates and advanced nurse practitioners.’ She says practice nurse roles will be ‘reviewing long-term conditions, which can be repetitive and sometimes boring. Our years of experience and knowledge will be lost. There should be a way to encompass this. Not everyone wants to do further training.’
This will all have an effect on patient care, nurses say. A practice nurse in Manchester says: ‘Many peers have expressed concerns about the erosion of the GP nurse role with a move to less holistic care and a desire to ‘get through the numbers’ by using shorter appointments with staff who give brief advice rather than personalised care. They are often inexperienced in primary care and have a broad overview of conditions but lack additional training in chronic disease areas.’
A November 2024 study from London South Bank University supported these findings. It concluded: ‘There was positive impact on workloads from ARRS roles working in original scope, for example pharmacists’ medicine reviews. However, any benefit was offset by the increased workloads created by those new to general practice and/or working outside of traditional scope.
‘This ranged from a lack of resources to provide the support those new to primary care require to practise safely, the expectations of others that [practice nurses] will fill the gap in support and teaching to directly safety netting the work of others. There was a lack of consultation regarding a major workforce change, leading to feelings of devaluation. There are some significant equity issues highlighted particularly around pay and opportunity.’
Pharmacists
For pharmacists who have come into general practice, morale seems higher. Around 70% of practice pharmacists see themselves still being in general practice in five years’ time.
On the whole, practice managers and GP partners responding to our sister title – Management in Practice and Pulse – surveys have found pharmacists useful.
But there is debate around whether their introduction to general practice has had a destabilising effect on community pharmacy. One thing is certain – a significant number of pharmacists who are now in practice originally worked in the community.
The House of Commons Health and Social Care Committee’s report on pharmacy concluded there should be a review of the ARRS to explore flexibility on the funding criteria that could ‘reduce the drain of community pharmacists into primary care networks’.
Of the 137 practice pharmacists surveyed by sister title The Pharmacist, only 9% had never worked in community pharmacy, with 76% transferring to general practice completely and 17% working across both sectors.
The latest data show there are 1,835 FTE pharmacists working in general practice and primary care network data show there are 5,461 pharmacists recorded, although not confirmed, under the ARRS.
The Pharmacist survey found that 58% of the 101 practice pharmacists who had left community pharmacy said they made the move because they preferred the work in general practice, while 42% said they wanted to develop their prescribing skills. From summer 2025, all newly qualified pharmacists will need to be able to prescribe.
Utilising skills was a major factor for those who made the move. Mayoor Kerai, a practice pharmacist in Kent says: ‘I had completed independent prescribing training in community pharmacy and I wanted to use this skill. I had also reached a glass ceiling in community pharmacy and was unable to progress any further. I chose the practice role to allow for this personal development along with better salary and work/life balance.’
Another practice pharmacist in Swindon says: ‘I worked in community pharmacy for many years and I really loved interacting with people. That’s something I knew I would miss when I left community pharmacy. But although I was learning new things from time to time, I didn’t feel I was learning enough. I wanted to have a more clinical role and I wanted to learn more in that area. Although there were new services being offered by community pharmacists, I did not feel we had enough support to deliver them.’
There are also those who say there were issues with workload in community pharmacy. One practice pharmacist in Staffordshire says they left due to ‘pressures in community, underfunded pharmacy contract resulting in fewer staff, with more stress and more services alongside a prescription factory system that didn’t make best use of clinical skills’.
Another based in southeast London says: ‘I work fewer hours and don’t have to stress for being late and finding a queue of angry patients or even angry staff on occasions. I have the flexibility of managing my own break times without feeling like being micromanaged. And of course not having to stand on my feet the whole day was the icing on the cake!’
There is also little dispute that community pharmacy is facing workforce problems. A Community Pharmacy England (CPE) survey representing 6,100 pharmacy premises in 2024 found that 58% of pharmacy owners said they were short of pharmacists, while almost two-thirds (62%) of pharmacy team members reported a reduced ability to offer services or advice to patients because of staffing shortages.
Indeed last year a net loss of 432 bricks and mortar pharmacies over the 2023/24 financial year, was revealed by the Company Chemists’ Association (CCA).
This equates to more than eight pharmacies permanently closing each week, the CCA said.
But there is some dispute over whether this is a direct result of the ARRS. CPE said the scheme had ‘led to the recruitment of over 5,000 pharmacists, primarily from community pharmacy, into GP surgeries and PCNs’, resulting in ‘shortages, temporary closures and rising costs’.
But President of the Primary Care Pharmacy Association Dr Graham Stretch says there should still be enough pharmacists to support both sectors.
He told the select committee in November 2023: ‘The actual numbers are very interesting. ARRS supports 4,689 pharmacists, of which, in July 2019 to September 2023, 3,047 have come from the community sector. That is a significant number and I am not pretending otherwise. In the same period, the General Pharmaceutical Council’s register has grown by 7,308, more than double the number of pharmacists moving from community into PCN.’
However, Dr Stretch did acknowledge that ‘that oversimplifies things, because we have portfolio roles’.
A qualitative study of the effect of ARRS found there were ‘unintended consequences at system-wide levels, including large numbers of staff moving from other services to work in the scheme, which left some services depleted of their workforce’.
Dr Zoe Anchors, a researcher at the University of the West of England and one of the authors of the study, says: ‘The three things that were coming up in terms of concerns around the destabilising of NHS services were: pharmacists being taken from hospitals and community pharmacy; paramedics moving from emergency care services; and the impact on wider mental health service providers of including them in the ARRS. All of these were impacting NHS services. Some people said we are “robbing Peter to pay Paul”.’
This chapter is based on a major new white paper from the publishers of Healthcare Leader, Cogora, on the changing general practice workforce in England, in conjunction with the Rebuild General Practice campaign group. Alongside our sister titles – Pulse, Pulse PCN, Management in Practice, Nursing in Practice and The Pharmacist – we have surveyed around 2,500 general practice professionals, interviewed more than 100 frontline practitioners, analysed hundreds of data for every practice in England and brought together all the editorial expertise within our titles.
Download our General Practice Workforce White Paper here.
