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.
Previous governments’ solutions over the past decade have been focused away from the traditional roles of nurses and GPs, and have been focused on the wider team – specifically through the ARRS.
The ARRS includes nursing associates, advanced nurse practitioners and more recently enhanced level practice nurses.
Until December 2024, there had been no plans to include the general practice nurse (GPN) role in the scheme. But just before Christmas, health secretary Wes Streeting announced that a proposal to include practice nurses in ARRS had been put to consultation with the British Medical Association (BMA) as part of the incoming GP contract.
ARRS has drastically changed the configuration of the general practice team.
Data from NHS Digital reveals that the number of nurses in general practice is increasing. 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 the appointments.
Then there is the influx of nursing associates. According to latest figures from NHS Digital, the nursing associate workforce in general practice has increased by a quarter from December 2023 to December 2024 (from 410 to 511 full-time equivalent staff). Being an ARRS role and a Band 4 position, and there are concerns that GPNs are being substituted or replaced by this cheaper alternative role.
The RCN has previously warned that the ARRS has sparked ‘a lot of role substitution’ of GPNs since its introduction, while the Queen’s Nursing Institute (QNI) has been calling for clearer guidance on the ‘scope and limits’ of nursing associates amid some reports of those in post working above their clinical responsibilities in general practice.
There is also the increasing role of advanced nurse practitioners to consider – a workforce that 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.
This change in the make up of staff is having an impact on the work of practice nurses.
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.
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.’
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.
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.’
There is a fear that GPNs are being pushed out in place of ARRS staff.
It is currently too soon to tell what effect that adding practice nurses to the scheme will have, and of course this is also still undergoing union consultation. As a core role in general practice, putting them under the label of ‘additional’ sparks some concern. And the potential move begs the question of: will it work to protect the role of nurses in general practice, or will it cause instability among the sector as nurses move to find a practice offering an ARRS position?