There is currently a recruitment and retention crisis in general practice (GP) (NHSE 2023). The shortage of GP nursing staff is compounded by an ageing population and an associated, ever-increasing demand for primary care services (Carrier and Newbury 2016). In the United Kingdom (UK), it is estimated that ~58% of people over the age of 60 are living with at least one long-term condition (LTC), with most of these individuals being managed in primary care by general practice nurses (GPNs) (Stafford et al. 2021).
In addition, the age profile of GPNs means that the pool of experienced GPNs available to recruit is rapidly shrinking. Prior to COVID-19 pandemic, a QNI report identified that approximately 33% of GPNs were due to have retired by 2021 (QNI 2016). Exacerbated by the upheaval precipitated by the pandemic, a significant proportion of this critical mass of experienced nursing staff have now completely disappeared from the general practice workforce (Halcomb et al. 2020).
This crisis has long been recognised by government, and the need to develop short, medium, and long-term solutions identified. In addition to the NHS General Practice Forward View (2016) and the NHS Long Term Plan (2019), the recent NHS Long Term Workforce Plan (2023) outlined strategies and funding to significantly boost the number of nurses working in primary care, in order to meet the needs of an ageing population in the 21st century.
While some of this may be achieved through improving GPN retention, if there is no clear recruitment strategy put in place to increase the numbers of GPNs ‘at scale’, then post COVID-19 there is a ‘perfect storm’ brewing in which there will be an acute shortage of staff at the very time when the workload in primary care, particularly in LTCs, is increasing exponentially (Levene et al. 2020).
The context: the need for change
To understand the current situation, it is important to look at the historical context. Attracting nurses into primary care has always been a challenge, and the reasons for this are complex and multifactorial. Historically, GP nursing has not been considered a suitable ‘first post’ destination for new graduates (Lewis and Kelly 2017b). This is in large part due to the rather arcane ‘independent business’ model still used in UK general practice. General practitioners (GPs) are effectively small businesses, sub-contracted to provide general practice services for the NHS (Lewis and Kelly 2018).
Because GPNs are employed by the ‘business’ and not the NHS per se, they are a cost to that business. GPs are therefore reluctant to invest in education and training for neophyte GPNs, much preferring to recruit experienced nurses who can ‘hit the ground running’. In the UK, there has therefore existed a ‘laissez-faire’ attitude to GPN recruitment predicated upon access to a (rapidly diminishing) pool of experienced GPNs who may be simply ‘poached’ from other practices as required. In the long term, this has had the effect of dissuading many younger, new graduates from applying for GPN posts (Lewis and Kelly 2018).
Primary care in the undergraduate (UG) nursing curriculum
In addition, unlike their student doctor colleagues, student nurses have had minimal access to GP placements. In recent years however, there have been attempts to address the impending GPN crisis through improving student nurse access to placements in GP. In the early 2000s, the National Training Hubs Initiative (NTHI) was developed as an innovative and sustainable way to meet the needs of the primary care workforce. Through schemes such as Community Education Provider Networks (CPEN) and the Advanced Training Practices (ATP) support was provided to increase student nurse access to GP through the provision of increased placement support for GP teams (Lewis et al. 2019; Walsh 2017).
The evidence shows that whilst they have made a difference to GP attitudes towards the utility of student nurses, the CPEN/ATP schemes alone would not be able to deliver the numbers of new GPNs that were required to address the predicted shortfall (Lewis et al. 2019; Walsh 2017).
In addition to the dearth of student nurse placements in GP, it has been argued that some part of the ongoing recruitment GPN crisis relates to the continuing emphasis upon secondary care in undergraduate nursing curricula. Despite moves to address this, the UG curriculum remains based upon secondary, hospital-based care (Calma et al. 2022).
The absence of much specific primary care content within the UG curriculum, together with the shortage of general practice placements for student nurses has meant that a significant number of student nurses still do not know what general practice nursing is or what it has to offer (Calma et al. 2022).
There are, however, student nurses who would like to specialise in general practice but still face significant challenges when applying for GPN vacancies. It is clear from the evidence that this is often because they are unable to evidence sufficient understanding of the clinical context within general practice (Crossman and Rogers 2020).
‘Discovering a nursing career in general practice’: developing a module
Until now, increasing access to GP nursing has been largely addressed at a local level, however a concerted national approach to the challenge has long been advocated. Indeed, evaluation of the various NTHI programmes, including the SY ATP scheme (Lewis and Kelly 2017a), identified the importance of a national strategy to address these issues.
Informed by the evidence presented, Health Education England (HEE) (NHS England Workforce Training and Education (NHSE WTE since 2023) put out a tender in 2022 for higher education providers. The tender involved the development of a national ‘introductory’ module to provide NTGPNs (including undergraduate (UG) students) with an insight into GP and which would provide them with an entrée into the Primary Care Nursing Career and Core Capabilities Framework (Skills for Health [SfH] 2021). Of the HEIs that responded to the nationwide tender, SHU was one of seven successful HEIs awarded a contract to deliver the module.
The focus of the module: insight into GP nursing
This national module is aimed at providing support for those nurses looking for their first role in general practice, by helping them to develop skills and gain knowledge of the GPN role. The remit of the module was therefore to provide learners with an insight into working within a Primary Care organisation and would therefore help them to feel more confident when applying for a role in a general practice (NHSE 2022).
As can be seen from figure 1 overleaf, the module targets learners at both the ‘learning’ and ‘pre-employment’ stages of the proposed education process. This strategy enables the module to meet the needs of current UG students in their final year, new graduate nurses immediately post-qualification, and already-experienced nurses from other areas of practice. The NHS WTE tender required the module to be available to learners in a non-credit bearing format, and at both level 6 and level 7. Whilst this approach may be desirable, it requires participating HEIs to be flexible and innovative in their approach to the module. Pedagogical approaches to the development of the module
The level 6 and level 7 versions for learners accessing the pre-employment stage of the process would be delivered as standalone modules, whereas the non-credit bearing version would need to run alongside the existing UG degree programme as an ‘optional’ module choice for third-year pre-registration students. Embedding the module into the UG curriculum is an important aspect of the development process and will be integral to the long-term sustainability of the module as a ‘taster’ for final year students interested in a career in GP nursing (Lewis et al. 2019).
From a pedagogical perspective, there are a number of factors that need to be considered in the development of a module such as this. The fact that learners will be undertaking the module in their own time, and their own pace, means that flexibility is key. The delivery of a flexible, blended programme such as this involves the use, in addition to taught content, of both synchronous (real time) and asynchronous (pre-recorded) online delivery (Jowsey et al. 2020).
By offering both ‘real time’ synchronous teaching and learning together with recorded content and an extensive repository of learning resources, students will be able to access the programme at times that suit them, but with the opportunity for real time synchronous learning (Jowsey et al, 2020).
Students can engage with the online sessions wherever they are, increasing the likelihood of them accessing synchronous teaching and learning ‘as it happens,’ but with the knowledge that, if necessary, the content can and will be recorded and placed on the online teaching and learning ecosystem for the students to access. Post the COVID-19 pandemic, SHU have developed considerable expertise in delivering this type of interactive, blended learning, which is well suited to this type of module (Kim and Kim 2023).
Strategic partnerships with practice
The undoubted strength of the SHU ‘offer’ lies in the strategic partnership with the South Yorkshire Primary Care Workforce and Training Hub (PCWTH). The regional primary care training hubs, including the SY hub, are now well-established organisations, funded through the NHS, providing education and training for the primary care workforce.
In SY, the PCWTH have responsibility for the co-ordination of placements in general practice for SHU student nurses. They also have a team of skilled, experienced practice nurse educators who are aware of the content required for a module such as this.
Taking an HEI such as SHU, with all of the academic resources at its disposal and the primary care specific skills, expertise, and networks possessed by SY PCWTH, means that the student experience is not only of a high quality, but the module can be delivered ‘at scale’. The combination of academic expertise and rigour provided by SHU, the clinical credibility, and work-based expertise of SY PCWTH means that by continuing to work in partnership, the module will always be ‘fit for purpose’ (QNI 2020).
Developing a future workforce ‘pipeline’ in general practice
SHU continue to work closely in partnership with the SY PCWTH to develop and sustain the necessary infrastructure to support primary care nursing. Together with increases in GP placement capacity and a greater focus on primary care in the UG curriculum, the incorporation of the national module into a GPN career pathway will further support the development of a sustainable ‘workforce pipeline’ for GPNs. The pipeline will now begin prior to qualification, by enabling UG student nurses with an interest in GP to gain the necessary insight into the requirements of the GPN role (RCGP 2015; SfH 2021).
Conclusion
If the predicted ‘perfect storm’ for the primary care workforce is to be avoided, there is a clear need to increase the number of GPNs entering GP. Initiatives such as the national module, described here, are therefore crucial in terms of both increasing interest in GP nursing amongst students, and making it a desirable career for new graduates. In addition, providing GPs with the support to employ new graduate nurses with confidence is also key to meeting the GPN workforce challenge.
KEY POINTS
- There is a workforce crisis in general practice nursing
- The population is ageing, but with increasing numbers of people with one or more long term conditions
- Primary care is under significant pressure to manage these individuals
- General practice nursing needs to be made an attractive career prospect for new graduate nurses
REFLECTIVE QUESTIONS
- What are the main causes of the workforce crisis in general practice nursing?
- What may be done to address the crisis?
- What are the key challenges to successfully delivering a module such as ‘Discovering a Nursing Career in General Practice’?
- What are the key priorities for general practice outlined in the 2023 NHS Long Term Workforce Plan?
- How might these priorities be achieved?