Tackling the problem of excessive workload in general practice

With the latest report confirming what clinicians in primary care have suspected for years, general practice is near saturation point. But what can be done to ease the pressures, and are general practice nurses the right people to do it? Or are they just as much victims of rising clinical workload as their GP employers?

Ask any general practice nurse or GP working in primary care right now about their experience of workload and pressures in general practice and it is likely that you will be inundated with a deluge of accounts of clinicians stretched to their limits. And now we have the evidence to support what primary care teams have known for some time.

In April this year, The Lancet published a report detailing the results of the largest retrospective analysis of consultations by GPs and practice nurses in the UK.¹ The study was conducted by The University of Oxford on behalf of the National Institute for Health Research School for Primary Care Research and was funded by the Department of Health Policy Research Programme. This retrospective analysis looked at more than 100 million consultations by GPs and practice nurses at 398 practices in England between April 2007 and March 2014. The data was obtained from the Clinical Practice Research Datalink where all face-to face and telephone consultations, as well as home visits, are recorded. In essence, the data show that workload in general practice has increased by 16% during the 7 year period and that consultations are more frequent and are taking longer. The demands on primary care services are higher than ever with both face-to-face contact and telephone consultations, and practice staff are simply being swamped. Essentially, the study demonstrates that primary care, in its present state, is reaching ‘saturation point’.¹

Significantly, the study shows that direct clinical workload has increased consistently over and above the growth in population. In addition, the researchers highlight the fact that there is also a disproportionate rise of consultations for the elderly, with their more complex health needs, and children under 5 years old. Equally, there is also no sign that this demand on primary care services is slowing – and indeed, is likely to continue to rise. Telephone triage, which has been seen as a way of combating the growing problem of demands on consultation time, hasn’t come out too favourably from the study either. The Lancet report has demonstrated that telephone triage has doubled in the past 7 years, with little impact on the overall workload, appealing to only a small sub-set of the population and reducing opportunities for health promotion. In addition, there is the time taken to conduct a telephone call, write it up, possibly take action on it and then, after all that, half the patients needed to come into the surgery to see a clinician anyway. The report certainly questions the benefits in terms of reducing clinical workload.

In terms of overall workload, the researchers acknowledge that the data are based on consultations with direct patient contact only and don’t take into account administrative workload, follow-up from consultations, auditing, achieving quality performance targets, attending clinical meetings, mentoring staff and undertaking professional development, which are all part of a day’s work in primary care. And the likelihood is that these elements of life in general practice are also on the increase. Factor in low levels of recruitment, a surge in the number of GPNs and GPs retiring within the next 10 years and there is clearly a problem threatening the existence of primary care as we know it.

THE NURSES WILL TAKE CARE OF IT

You could say the outlook appears somewhat bleak. A report by the independent think tank, Reform, ‘Who cares? The future of general practice’, was published in April this year. It suggests that what primary care needs is more nurses to take on GPs’ work in, reducing the strain on the doctors and saving the NHS an estimated £700 million a year.² The suggestion is that it’s nurses who should be the ones to see even more patients to reduce the pressures on the overworked GPs. Clearly GPNs and nurse practitioners are doing sterling work in their surgeries already, seeing patients for minor illness, minor injuries and managing long term conditions among a plethora of other clinical and administrative activity and are fit to bursting themselves. Needless to say, such comments are likely to be perceived as provocative, and practice nurses are responding unfavourably. The RCGP has spoken out publicly in support of nurses working in primary care, pointing out that nurses are under just as much pressure as their GP colleagues –combined with the fact that surgeries are also struggling to recruit practice nurses and nurse practitioners to fill vacant posts. RCGP Chair Dr Maureen Baker commented ‘existing practice nurses aren’t simply sitting around waiting for patients to walk through the door’.³ We know that, of course, but it is nice to hear it acknowledged.

WHAT NEEDS TO BE DONE?

So, what is to be done? Also published in April was NHS England’s General Practice Forward View, which set out the investment and workforce plans needed to improve and sustain the future of general practice.⁴ It acknowledged that its ‘transformation plan’ could not be delivered without significant recruitment and expansion of the workforce and set out a multi-billion pound strategy to ‘get general practice back on it’s feet’.⁵ One of the aims of is to double the rate of growth in the primary care workforce over the next five years, by appointing an extra 5,000 doctors supported by a minimum of 5,000 extra non-medical staff, including nurses, pharmacists, physician associates and mental health workers. It accepted that its targets were ambitious in terms of recruitment but explained: ‘We must use every effort to try.’⁴ Expansion of the GPN role is clearly seen as an integral part of the success of the future of general practice with investment concentrating on attracting more nurses into primary care, developing more advanced nurse practitioner posts, employing practice nurses in Primary Care Access Hubs and promoting greater involvement of practice nurses in co-ordinating care for patients with long term conditions. Box 1 outlines NHS England and Health Education England (HEE) plans of practice nurse investment for the future.

PRACTICE NURSE RETIREMENT TIMEBOMB

The Forward View plans are ambitious to say the least. Last year the Queen’s Nursing Institute (QNI) published a survey of over 3,400 GPNs throughout the UK which was undertaken to support the QNI’s ongoing campaign of excellence in nursing in the community and primary care.⁶ The responses reflected both the positive and more challenging aspects of practice nursing at a time when you could argue the profession is on the cusp of significant change. A key finding to emerge from the survey, and which is of particular relevance, is the fact that a third of practice nurses are planning to retire by 2020. A third of the practice nurse workforce. Within 4 years.

Furthermore, the most recent Practice Nursing Forum annual pay survey, undertaken by 740 nurses, confirmed this finding: almost half the respondents (48.3%) stated that they intend to retire within 10 years, with a nearly quarter of those (24.2%) planning retirement within the next 5 years.⁷ These figures should be cause for alarm. Such planned retirements will cause a significant dent to the current workforce not just in terms of numbers but also in respect of the loss of arguably a significant percentage of the profession’s most experienced and skilled nurses. The figures don’t take into account the number of practice nurses who may leave primary care for reasons other than retirement. This clearly is something that commissioners will need to sit up and take stock of with regards to succession planning. Not only that, if the profession is struggling to recruit nurses that are planning to leave, how on earth will it start to meet the targets to increase the practice nurse workforce set out in the NHS England’s General Practice Forward View proposals?

RETENTION AND RETURN TO WORK INITIATIVES

RCN Chief Executive Janet Davies welcomed these proposals as a step in the right direction. Concentrating on retaining staff and supporting back to work initiatives for nurses through appropriate training schemes is seen as a vital component of swelling the workforce.⁸ Health Education England reinforced the message that it is more cost effective to ‘go all out’ to retain staff and offer return to practice schemes to non-practising nurses than it is to recruit and train from scratch – not to mention the time factor.⁹

The King’s Fund suggests that it costs in the region of £2,000 to train each nurse through a return to practice scheme compared with £51,000 to train a new nurse. Admittedly this is hugely relevant for stakeholders but it’s not simply all about the finances. What are the elements that keep nurses in practice and make us keep wanting to do the job day after day? And what makes us feel disillusioned and thinking about throwing the towel in? These questions have to be asked of practice nurses if any new model of service delivery is to have a chance of success. Continuous staff engagement and greater nurse consultation at both a national and local level are seen as being fundamental to grasping what is important in terms of retaining staff.¹⁰ In addition, exploring the views of the current workforce can be used to attract nurses back into general practice.

Another finding from the QNI survey was that nurses currently working in primary care need to have adequate support to do the job, opportunities for professional development, a recognised career structure, strong leadership, equality in the workplace and to be listened to. Consultation with and investment into the current workforce are vital if the plans to take general practice forward are to be realised (Box 2).

Workforce planning, raising the profile of general practice nursing as a specialty, improving student placements in primary care through collaboration with education providers, structured support for nurses new to practice nursing, mentorship training for current GPNs to inspire the next generation and staff engagement – all these are essential to securing the future of practice nursing. How many current GPNs, for example, however confident, competent and experienced, feel able to take on a mentoring role to educate, inspire and nurture the practice nurses of the future?

In Practice Nurse (May 2016) we learned of an innovative scheme commissioned by Scarborough and Rydedale CCG which is doing just that. This scheme has been successfully exploring the views of nurses, instigating a workforce development programme, and introducing a competency framework into practices, with preceptorship training for GPNs to help tackle recruitment and retention, and to promote general practice nursing to the next generation.¹¹

ADVANCED TRAINING PRACTICE SCHEME

Throughout Yorkshire and East Humber in collaboration with a number of CCGs and Health Education Yorkshire and Humber (HEYH), the Advanced Training Practice Scheme provides undergraduate student nurses with high quality, accredited training placements in primary care. The network of training practices involved are linked to local universities to provide student induction and training, mentorship training for practice staff as well as preceptorship for newly qualified nurses entering primary care. The scheme enables student nurses, who are developing their skills within general practice, to view primary care as a real career option and that is clearly key. The scheme is now able to place 350 student nurses a year in participating practices but admits that convincing practices, who are already pushed to their limits, to sign up to the scheme hasn’t been without issue.¹² However, the scheme does suggest that with the right support this can equally benefit practices as well as the students themselves and ultimately, and most importantly, the profession. The collaboration between commissioning groups, practices and educational institutions is at the heart of the scheme in order to bear fruit for the future workforce.¹³

NEW MODELS FOR DELIVERING PRIMARY CARE

As part of the evolution of primary care to address patient need and to protect the future of general practice, NHS England’s Five Year Forward View aims to ‘dissolve the boundaries’ of the traditional divide between primary care, community services and hospital provision.¹⁴ Newer models of care in the form of Multi-specialty Community Providers (MCPs) and Primary and Acute Care Systems (PACS) are two examples of the integrated care model which is being promoted. However, communities throughout the country have different populations with different health needs and new care models are not to be seen as a ‘one size fits all’. The emphasis on greater self-management and a focus on a co-ordinated approach to long term conditions are central to the vision of the future of the NHS. Optimising technology in practice, development of local hubs, amalgamation of practices to large group practices and new approaches to deliver care to our patients are what we will all need to be embracing in the future of primary care.

CONCLUSION

Clearly life in general practice is moving at a punishing pace and this in turn will inevitably have huge implications for the workforce in primary care, particularly for the roles and career development of GPNs. The study in The Lancet has highlighted the extent of the problem of current workload in general practice, and the fear is that this is unsustainable if primary care continues in its current form. It has even been commented that ‘if general practice fails, the whole NHS fails’.¹⁵ And although the study was undertaken in England, it is likely to be a similar picture throughout the UK.¹⁵

It is vital that substantial investment is made to revive general practice. With the emergence of innovative schemes improving recruitment and retention of nurses within the specialty, major changes in how primary care is delivered through collaborative models of care, the introduction of pharmacists and physician’s assistants to work alongside the increased numbers of nurses and doctors to provide that care, embracing technology and addressing patient expectations are all spokes in the wheel of the future of primary care. We know the problem, but can we overcome it?

Are you involved in a scheme to improve recruitment and retention of general practice nurses or to explore new ways of delivering primary care services? Tell us about it for a future issue of Practice Nurse

REFERENCES

1. Hobbs FDR, Bankhead C, Mukhatar T, et al on behalf of the National Institute for Health Research School for Primary Care Research. Clinical workload in UK primary care: a retrospective analysis of 100 million consolations in England, 2007-2014 The Lancet. [Published online] 5 April 2016. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00620-6/abstract

2. Ewbank L, Hitchcock A, Sasse T. Who cares? The future of general practice. 2016. Reform. http://www.reform.uk/wp-content/uploads/2016/04/Reform_who_cares_the_future_of_general_practice.pdf

http://www.univadis.co.uk/viewarticle/can-nurses-relieve-the-strain-on-gps-392238?s1=news

3. Royal College of General Practitioners. RCGP response to Reform report on general practice. 12 April 2016. http://www.rcgp.org.uk/news/2016/april/rcgp-response-to-reform-report-on-general-practice.aspx

4. NHS England. General Practice Forward View. April 2016.

https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

5. NHS England. NHS England backs a multi-billion transformation plan. 21 April 2016. Available at: https://www.england.nhs.uk/2016/04/gpfv/

6. The Queen’s Nursing Institute. General Practice Nursing in the 21st Century:A Time Of Opportunity 2015. Available at: http://qni.org.uk/docs/1%20FOR%20WEB%20GPN%2021%20Century%20Report.pdf

7. Practice nurse pay squeezed, retirement timebomb ticking. Practice Nurse 2016 April 46;(4): 8

8. Royal College of Nursing. RCN praises recognition of primary care nurses in national reports. 21 April 2016. https://www.rcn.org.uk/news-and-events/news/rcn-response-to-national-reports

9. Addicott R, Maguire D, Honeyman M, et al. Workforce planning in the NHS. Kings Fund. April 2015. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforce-planning-NHS-Kings-Fund-Apr-15.pdf

10. Health Education England. Growing Nursing Numbers. Literature review on nurses leaving the NHS. July 2014. https://www.hee.nhs.uk/sites/default/files/documents/Growing%20nursing%20numbers%20–%20Literature%20Review.pdf

11. Wollerton C, Swiers D. Where will all our practice nurses come from? Practice Nurse 2016;46(5):20-23

12. Lane P, Peake C. A scheme to increase practice nurse numbers. Nursing Times 2015;111(13): 22-25

13. Good Governance Institute. The nursing journey: recruitment and retention. A White paper from the Good Governance Institute (GGI). 2015. http://www.good-governance.org.uk/wp-content/uploads/2015/07/The-nursing-journey-recruitment-to-retention.pdf

14. NHS England. Delivering the Forward View. NHS planning guidance 2016/17 - 2020/21. 2015. https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

15. Thompson M, Walter F. Increases in general practice workload in England. The Lancet. [Published online] 5 April 2016 [cited 15 April 2016]. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00743-1/abstract