Chapter 6: Nurses

Nursing roles in primary care are vast, from community midwives and district nurses to health visitors and general practice nurses. Each nursing sector has its own set of challenges but all require a supportive work environment. Their crucial role has been recognised in the latest iteration of the GP contract as advanced clinical practitioner nurses have now been added to the additional roles rembursement scheme (ARRS). However, actually finding nurses to recruit will prove challenging.

Training and career progression are seen as a key way to both encourage new starters and retain current staff.

Anne Trotter, The Nursing and Midwifery Council (NMC) assistant director of professional practice, says, ‘It’s more vital than ever for employers and agencies to create inclusive cultures that support professionals to thrive, and encourage them to stay in their profession.

‘For example, employers can deliver tailored ‘preceptorship’ programmes to welcome and integrate new nurses, midwives, and nursing associates into their teams, and help them grow in confidence. Good employers will also help keep professionals on our register by providing continuing professional development opportunities that support them to revalidate with us every three years.’

General practice nurses (GPNs)

One quarter of general practice nursing posts in England could be vacant by 2030 – a shortage of 6,400 full-time equivalent nurses – researchers at Health Foundation’s REAL (Research and Economic Analysis for the Long Term) centre suggests.

‘There just aren’t enough nurses in the system to be able to provide the care they want to provide, and that their patients need,’ says Heather Randle, Royal College of Nursing (RCN) professional lead for primary care.

To tackle the shortage of general practice nurses (GPNs), Ms Randle says it’s vital to address their pay, terms, and conditions.  ‘Many general practice nurses don’t get maternity or sick pay – so why would a newly qualified nurse go into general practice when the chances are they won’t get these benefits?’

A problem with general practice is ‘the consistency of the offer’ for GPNs, she says. ‘You could look at fifty different practices and they could all be offering different pay, terms and conditions for their staff.’

She says integrated care boards (ICBs) should look at ‘the need for GPNs to be comparative with their NHS colleagues regarding what is on offer’.

The lack of a prescribed career development pathway is also a problem for general practice nursing, says Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute (QNI).

‘There isn’t that clear pathway that compels you as a newly qualified nurse to take up a prescribed programme in order to have the knowledge, skills, attributes, and confidence to deliver on that GPN role. There’s not that professional or organisational requirement’. To provide that career pathway, she would like to see ICBs working with local universities to develop a prescribed programme for GPNs.  

Supporting GPNs’ continued career development should also be an important consideration for ICBs, says the RCN’s Ms Randle. ‘Practices nurses are looking for good career progression, to opportunities such as leadership, teaching and advanced practice.

‘There needs to be planning for training and development based on individual needs. ICBs can offer these and other opportunities that will not necessarily be available to GPNs working in a small general practice,’ says Ms Randle.

ICBs also need to take nursing leadership more seriously, she says. ‘When you look at an integrated care board, there is often a medical director, but not a nursing director – even though nurses are the second biggest workforce in general practice,’ says Ms Randle.  

ICBs should have a plan for what training and support there will be for GPNs coming into the system, says Ms Randle. ‘This role can feel isolating – you might not see another person for most of your shift except for your patients. There needs to be clinical supervision and support so that you feel a valued member of the team.’

Practices that offer good pay, terms, and conditions, ‘don’t have a problem with recruitment’, says Ms Randle. She advises ICBs look at practices where recruitment and retention is working and to ‘use them as examples of how to do things better’.

ICBs also need to consider how to make the role of the practice nurse more attractive to recruit more people. ‘ICBs have a big opportunity to do things better – to support nurses coming into the role so that they can be given the training and support they need,’ says Ms Randle.

Without that training support GPNs will continue to leave the profession. As Ms Randle says: ‘Nurses are now talking with their feet. They are not going to put up with poor pay and conditions.’

To aid in collaborative working a new network for chief nursing officers in leadership roles in integrated care boards (ICBs) was launched in February by the Queen’s Nursing Institute (QNI) and the NHS Confederation.

Training and pay

To train as a GPN You must be a qualified and registered adult, child, mental health or learning disability nurse to work in general practice. You’ll also either need to undertake further training and education or be willing to after being appointed.

GPNs’ pay terms and conditions will vary from practice to practice and are typically set out by their GP employer.

District nurses

The state of district nursing, and nursing generally, is ‘the consequence of ten years of not recognising nurse led services in the community – of underfunding and not developing the workforce,’ says Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute (QNI).

‘If you have massive and sustained underfunding over a period of years, it means you’ve got fewer experienced district nurses in the workforce to hold things together.

‘The working environment becomes more pressurised because there are fewer people having to meet the same – if not greater – expectations of the service. This makes it less attractive to work in such places, because they are highly pressurised, and you can’t do the job you’re trained to do,’ she says.

Dr Oldman explains that two years ago, the QNI looked at the demand for district nurse training places – asking employers how many were needed regardless of the barriers to releasing staff to go on a district nurse training programme. Their response was ‘double the number being trained right now’, she says.

‘If you have a shortage of district nurses for one year, you struggle through. But to have that shortage for ten years, means you’re left with a massive gap in skills and knowledge, and you need to work really hard to catch up, and to support more nurses to go through the district nursing programme,’ says Dr Oldman.

District nurses play a critical role, helping not only their patients, but the whole of the healthcare system, she says. ‘Their skills and training supports people to come home earlier from hospital, and prevents them from having to go into hospital. Without sufficient numbers of district nurses, hospitals become full of patients who can’t go home.’

Dr Oldman says, ‘many district nursing colleagues in practice right now are telling us they have never seen it so bad in terms of need, and the service not matching supply’. She would like ICBs to do an audit of district nursing services, to help them identify where there has been investment, and the difference that makes to patient flow, including the release of patients from hospital.

In terms of pay rates, she says Agenda for Change has ‘not caught up with the work district nurses do now’. ‘50% of the district nurses we hear of are on band 6, and 50% are on band 7  – but you need to be at least on band 7 to do this work.

‘These are very senior roles where you are managing such a lot of risk within your communities. ICBs should look to make sure district nurses are properly rewarded.’

Pay and training

District nurse training programmes are known as specialist practitioner programmes and are at degree level. You can also find courses at post graduate certificate and Master’s level. They are normally no less than one academic year (32 weeks) full-time or part-time equivalent. District nurses are on the Agenda for Change pay rates – typically bands 6 and 7.

School nurses

Recruitment, retention, and attrition are significant issues for the school nursing profession post Covid, says Sharon White, CEO, the School and Public Health Nurses Association (SAPHNA). 

‘School nurses have lost 35-40% of its workforce. It’s a travesty,’ she says. ‘We have an ageing workforce, which means some school nurses have, or are about to retire. Some retired early, and some felt the “grass was greener” via redeployment.’

Post pandemic, she says the public health and prevention role was ‘completely eroded’. ‘There was a much more reactive approach from school nurses who were focused on complex cases – including those involving mental health issues – and fulfilling mainly bureaucratic roles regarding safeguarding and child protection, rather than the prevention and early help these nurses are trained and skilled to provide. School nurses are constantly firefighting,’ she says.

To address the shortage of school nurses, ‘we need to reinvest in the profession,’ says Ms White. ‘We have lost around 35% of investment since 2015. And the development of mental health support teams in schools should have been directed to expand school nurses, who are known, trusted, and valued by children, schools and families. The current model is blurred, confusing, and not meeting those lower level needs of children and young people,’ she says.

An ‘urgent workforce plan’ with workforce modelling is required, says Ms White. And to tackle the shortage of school nurses, SAPHNA is calling for the use of nursing associates, apprenticeships and a ‘grow your own’ model, supported by Health Education England (HEE), with a clear career pathway and adequate funding of school and public health nurse places for those wanting to progress to qualified school nurses. 

Investing in the school nurse workforce will also have a ‘hugely positive impact on helping to ease demand on general practice, primary care, A&E, and specialist and acute services’, says Ms White.

Pay and training

It takes one year full time, or two years of part-time training to achieve Specialist Community Public Health Nursing – School Nursing (SCPHN – SN) and to become a qualified school nurse, but you must first be a registered nurse. A range of universities provide the school and public health nursing post graduate degree.

Most school nurses have received the same pay awards as all nurses who are on Agenda for Change. However, some are employed by local authorities so aligned to their pay awards.

Health visitors

Health visitors have been described as the ‘backbone of the early years…a safety net for all families’.  But Alison Morton, executive director of the Institute of Health Visiting (iHV) says its annual survey of the profession, published this January, ‘paints a deteriorating picture of a health visiting workforce under immense pressure following years of disinvestment in England’.

‘As a result, families face a postcode lottery of support that is based on where they live, leaving many families without the vital support that they need during the crucial earliest years of a child’s life. As is sadly often the case, this affects the most vulnerable people who may struggle to access services and depend on them the most,’ she says.

State of Health Visiting, UK survey report, A vital safety net under pressure reveals a health visiting service struggling to meet the scale of rising need. The level of health visiting support that a family received in 2022 varied between areas and across the UK nations.  Babies, children, and families faced a ‘postcode lottery’, and many did not get the support they needed. Due to workforce shortages in England, many babies and young children missed out on vital health reviews and were not seen by a qualified health visitor.

Many health visitors experienced work-related stress and burnout, with reduced job satisfaction. There is an estimated shortfall of 5,000 health visitors in England – a loss of around 40% of the workforce since 2015. ‘This requires urgent action to prevent more health visitors leaving the profession,’ says Ms Morton.

Factors contributing to the decline in health visitors in England include insufficient funding in the Public Health Grant to deliver the Health Visiting model for England. The iHV says ‘the biggest costs are staff costs, and this leads to prioritisation or scaling back of the delivery model which must be managed within the budget’. 

There has also been a reduction in student health visitor training places since 2015. In iHV’s survey, 73% of health visitors across the UK reported that there were insufficient health visitor training places to fill vacancies where they worked.

High rates of staff attrition and iHv’s survey findings highlight that the current workforce crisis in health visiting is likely to get worse if not addressed. Some 17% of health visitors in the UK are aged between 55-59, and approaching retirement age, compared to only 2% of health visitors in their twenties. And almost half (48%) of health visitors in England stated that they plan to leave health visiting in the next five years. A lack of job satisfaction poor career progression opportunities, work-related stress and retirement are some of the reasons they are leaving the profession.  

Ms Morton says it is ‘a serious concern’ that there is currently no national health visitor’s workforce plan to address this in England. ‘The government’s commitment to prioritise the recovery of health visiting will require several approaches to improve workforce capacity and support the recruitment, retention, and career progression for health visitors,’ she says.

Recruitment of health visitors is being left to local areas, says Ms Morton. Some areas have developed a number of strategies to attract people into the profession, including staff nurse development posts and an increase in health visitor specialist posts and leadership development to retain experienced staff.

To start to address this, the Institute of Health Visiting has produced infographics on ‘Who are health visitors and what do they do?’ for all UK nations. And iHV also launched a series of short films in December 2022, to promote health visiting and attract people into the profession.

Training and pay

It currently takes one year full time or two years part time to train to be a health visitor (all applicants need to be either a qualified registered nurse or registered midwife to access Specialist Community Public Health Nurse training (health visiting).

Most health visitors are on Agenda for Change pay scale 6 (or equivalent local authority pay scale) and are expressing similar concerns to real term pay cuts following many years of below inflation pay awards as nurse.

Community midwives

While recruitment is not a particular problem for midwifery, retention is ‘a major issue’, says Sean O’Sullivan, head of health and social policy at the Royal College of Midwives (RCM).

‘We know that most midwifery training programmes are oversubscribed. But the problem is we can’t hold on to them.

‘What we are increasingly finding is midwives are leaving the profession at all stages of their career cycle, from those who may be eligible for early retirement or are retiring because of ill health or stress, to newly qualified midwives leaving after a year or two because of workplace pressures, their expectations not being met, or frustrations that staffing shortages mean they’re not able to provide the quality of service they hoped to give.’

Another reason for retention problems is that midwives are asking for flexible working but sometimes their requests are not being met. ‘They are feeling they’ve got no alternative but to leave, because the service can’t accommodate their work-life balance needs,’ says Mr O’Sullivan.

To keep midwives in service, the RCM has a range of recommendations. ‘It’s important that we enable more flexible working for staff who want to reduce their hours,’ says Mr O’Sullivan.

More funding and support for training and development is also needed. ‘What we’ve seen in recent years is that with staffing shortages it’s very difficult for lots of our members to do CPD unless they pay for it themselves and do it in their own time. Even mandatory training is more restricted. So more needs to be done in this area,’ he says.

There should also be greater support for students and newly qualified staff through mentoring and preceptorship schemes. ‘If newly qualified staff aren’t feeing supported they are more likely to leave early on in their career,’ he says.

Pay has also ‘definitely moved up the agenda in terms of key issues for midwives’. ‘Most of midwives are on band 6 and 7 – we’re talking about the equivalent of an average cut in pay of £7,000 in the last ten years,’ says Mr O’Sullivan.

He believes ICBs have a role to play in terms of employment conditions for NHS staff, including midwives, such as facilitating more flexible working agreements for employers within their geographical patch and ‘ensuring a genuine partnership approach with trade unions and professional bodies in order to try and bring in policies that will be beneficial in terms of staff retention. We wouldn’t want to see top down changes imposed’.

Training and pay

Community midwives are not educated separately – all midwives are educated to provide midwifery care, no matter the setting or location. Many midwives rotate around different settings as part of their contract. To become a midwife you’ll need to train and study for an undergraduate degree or postgraduate degree or diploma, or secure a place on a midwifery degree apprenticeship.

Most midwives are on band 6 and 7 of Agenda for Change – the equivalent of an average cut in pay of £7,000 in the last ten years, according to the RCM

Community mental health nurses

The total mental health nursing workforce has declined by 10% since May 2010 – a reduction of more than 4,000 mental health nurses, according to NHS Providers. However, the membership body for trusts says it’s important to note that the reduction has been in inpatient settings, and ‘encouragingly the numbers of community mental health nurses has increased in recent years’. 

A range of initiatives are being put in place to help attract nurses into the specialty and retain experienced ones. The NHS is currently piloting a new role called ‘Professional Nurse Educators’ – senior mental health nurses who support both new and experienced mental health nurses in the community setting to feel confident and competent in clinical practice.  

The NHS is also working in partnership with the QNI to develop specialist practice qualifications in community mental health nursing. NHS England says these standards for advanced practice in community mental health nursing have been co-produced by patients and those with lived experience, and are designed to reflect the complexity and skill required to support the needs of the community.

There are also wider campaigns to encourage people in mental health nursing careers, and to date, NHS England says it has seen more people than ever wanting to join the profession, with a 30% growth in undergraduate mental health nursing places.

Dr Emma Wadey, deputy director of mental health nursing, NHS England, who started her career 25 years ago as a newly qualified community mental health nurse, says: ‘With an increase in demand for mental health services across the country, the recruitment and retention of mental health nurses continues to be an NHS priority.

‘Mental health nurses are key to supporting a person’s recovery and helping them live independent and fulfilling lives, and with the majority of mental health care provided within community settings and the best outcomes achieved the closer people are to home, it is vital we continue to invest in and value our community mental health nursing workforce.

‘We are keen to continue to encourage opportunities for newly qualified nurses to pursue a career in community mental health nursing, as well as retaining experienced mental health nurses.’

Training and pay

To become a mental health nurse the main route is through a degree course at university.

Fully qualified mental health nurses start on Band 5 of the NHS Agenda for Change pay rates.

To learn more about nurses working in primary care visit Healthcare Leader’s sister title Nursing in Practice.

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