GPs have traditionally been self employed, initially working as private traders and, since the inception of the NHS in 1948, as contractors. In the 1960s, in response to an outcry over disparity of pay and expenses and a statement implying that GPs were second rate doctors lacking the ‘outstanding merit’ to become hospital specialists, high numbers chose to leave the profession. Negotiations for a new contract began and the outcome was the Family Doctor's Charter in 1966. This introduced a major change in the way GPs were paid, which saw improvements to practice premises and reimbursement for practice staff, thus enabling GPs to delegate work to practice nurses (Kmietowicz, 2006).
At this time, practice nurses were often also qualified midwives and they were largely concerned with antenatal care, child welfare, wound care and injections. A large proportion of this care took place in the patient's home (Cartwright and Scott, 1961).
Trends towards increased scrutiny and evidence-based medicine were consolidated in the 1990 GP contract, which launched an era of greater external management for general practice and the contract of 2004 ‘represented a new relationship between GPs and the NHS, putting an increased emphasis on performance-related pay, as measured by the quality and outcomes framework (QOF)’ (The King's Fund, 2016). These two contracts saw increasing numbers of practice nurses employed to undertake the nursing care of the practice population, with an ever-growing emphasis on the management of long-term conditions.
Agenda for Change
Nurses coming into the profession in the 1990s were likely to be employed on a ‘G grade’—a ward sister's pay for those employed on the then NHS Whitley pay scale. For many nurses at the time, this may have been a considerably higher salary than they were earning as a staff nurse on a hospital ward. However, in 2004 Agenda for Change (AfC) was introduced for all staff employed in the main NHS, with the exception of doctors and dentists. This ‘introduced a job evaluation scheme and harmonised employment terms and conditions for a multitude of jobs within the NHS’ (House of Commons, 2009). For most nurses, the introduction of AfC meant a significant increase in pay, with the potential for annual incremental pay rises and the ability to progress through pay bands with appropriate study and the undertaking of additional responsibilities.
However, the vast majority of GP employers did not adopt AfC. As independent contractors to the NHS, they were not obliged to embrace AfC and for such small employers, it was perceived to be a costly exercise. As a consequence, practice staff now have no nationally recognised payscale and have to negotiate pay, terms and conditions on an individual basis. As an article in Independent Nurse stated, ‘Not being on Agenda for Change means that practice nurse salaries can stagnate even with the acquisition of new skills or promotion’ (Bhardwa, 2016).
‘General practice needs to compete with all healthcare sectors to maintain our highly skilled primary care nursing workforce and therefore it is essential that we address the variability of pay, terms and conditions at a national level, to make general practice an attractive and viable career option.’
The First Practice Management website (2018) states that ‘Without Whitley, practices face a dilemma of what to do in order to determine fair salaries and other benefits, particularly as practices find themselves in competition with NHS employers (who will be offering AfC terms), or even other practices (who may also be offering AfC-related terms), for recruiting and retaining staff’.
In 2015, the Queens Nursing Institute (QNI) published a document entitled ‘General Practice Nursing in the 21st Century’. It stated that ‘there has never been a better time of opportunity for nurses working in general practice’, and that ‘general practice nurses have the potential to contribute significantly to the transformation agenda.’ The publication was based on a survey of practice nurses and generated an excellent response rate. Some of the headline findings were that 33% of practice nurses are due to retire by 2020; less than one-third of GP employers offered placements for pre-registration nursing students; and only a third of practice nurses felt that their salary reflected their role. A list of required actions stated:
- The need to promote general practice nursing as a viable career option
- A need to increase the number of student placements within primary care
- That consideration be given to the terms and conditions of the practice nursing workforce.
The General Practice Nursing Workforce Development Plan (Health Education England (HEE), 2017) stated that ‘Unless we keep general practice nursing at the centre of our workforce reconfigurations we will simply not develop robust enough teams with the necessary skills to bridge the increasing gap between capacity and demand brought on by an ageing workforce, lack of new entrants and increasing workloads’. However, none of its 17 recommendations mentioned improved and standardised pay, terms and conditions as a means of aiding recruitment and retention.
The District Nursing and General Practice Nursing Service: Education and Career Framework (HEE, 2015) outlined a specialised stepped education and career illustration with indicative academic levels. For the first time, practice nurses were presented with clear guidance on career progression within primary care. However the executive summary specifically stated that ‘Agenda for Change banding … is not within the confines of the HEE role.’
Last year saw the publication of a ten-point action plan for General Practice Nursing (NHS England, 2017). This describes the nursing element of the Five Year Forward View (NHS England, 2016) with its pledge to significantly expand the entire general practice workforce. In its introduction it states the need to ‘build and retain this skilled and adaptable workforce…while attracting new recruits to the profession’. Again nowhere in this document is there mention of standardised pay, terms and conditions as a means to either recruitment or retention of staff.
Pay survey—Lambeth Clinical Commissioning Group
The lead nurse team at Lambeth Clinical Commissioning Group (CCG) undertook a survey of general practice nurse and healthcare assistant (HCA) terms and conditions in 2015, receiving a 90% response rate. Unsurprisingly, huge variation in hourly pay rates was found ranging from £10.30/hour to £27.50/hour for general practice nurses and £6.72/hour to £13.00/hour for HCAs. Annual leave entitlement was variable — between 4 and 6 weeks, and occupational sick pay varied from nothing to full AfC terms. Maternity pay was similarly variable, although the response rate was lower, perhaps reflecting the mature age of this cohort of nurses.
The lead nurse team has been involved in discussions with practices about adequately remunerating nurses in their roles, either at initial employment or subsequently when they have completed additional training. The team has found a complete willingness on behalf of employers to receive guidance where pay is concerned, as practices are in as much confusion as nurses about what is appropriate and how best to negotiate.
In early 2016, the lead nurse team was involved in a round table discussion with senior nurses across all sectors in Lambeth. Recruitment and retention were discussed and the attrition rate affecting newly qualified nurses, particularly in relation to affordability of living and working within inner London. The team was made acutely aware of how all sectors of nursing are fighting over the same pool of nurses and how agency nursing rates of pay affect the ability of our acute sector colleagues to retain permanent staff.
Lambeth was fortunate to have recruited a few newly qualified nurses straight into primary care, and they wanted to be given an idea of their starting rates of pay and how this could be expected to increase with career progression. Rather than have individual discussions which are themselves inequitable, it was decided to develop a pay framework to map to the general practice nursing career framework (Table 1) (Marsden et al, 2017). This was fully endorsed by Lambeth CCG and Community Education Providers Network (CEPN) and was launched in June 2017 at the first South East London GPN Conference. It generated a great deal of interest in London and across a variety of primary care settings in England and staff have found it useful not only from the pay perspective but also as a recommended career pathway for practice nursing. The document also included recommended terms and conditions (Table 2).
The lead nurse team are also working to develop the HCAs, providing training at employment and helping them to move on to foundation degrees and nurse training. The team had similar discussions around pay as the HCAs progress on their pathway and decided to produce an HCA pay framework (Table 3) to aid discussions around salary increases. This was published in January 2018, and the lead nurses look forward to receiving feedback from practices locally and further afield.
Conclusion
It is widely known that one-third of practice nurses (approximately 8000) will retire in the next few years and that ‘the capacity of the system to fast track newly qualified nurses into primary care is only growing slowly’ (NHS Workforce Review Team, 2008). Added to this the profession is not providing adequate placements for student nurses to get a taste of primary care, and therefore newly qualified nurses are unlikely to view practice nursing as either a first destination or subsequent career option. General practice needs to compete with all healthcare sectors to maintain our highly skilled primary care nursing workforce and therefore it is essential that we address the variability of pay, terms and conditions at national level, to make general practice an attractive and viable career option.
Key points
- For most nurses, the introduction of Agenda for Change (AfC) meant a significant increase in pay, with the potential for annual incremental pay rises and the ability to progress through pay bands with appropriate study and the undertaking of additional responsibilities
- However, the vast majority of GP employers did not adopt AfC. As a consequence, practice staff now have no nationally recognised payscale and have to negotiate pay, terms and conditions on an individual basis
- The lead nurse team at Lambeth Clinical Commissioning Group developed a pay framework to map to the general practice nurse career framework
This article was originally published in Practice Nursing
Louise Ashwood, practice nurse, Paxton Green Health Centre, London; joint lead nurse, Lambeth CEPN
Anne Macrae, practice nurse, Herne Hil Group Practice, London; joint lead nurse, Lambeth CEPN
Paula Marsden, nurse practitioner, Binfield Road Surgery, London; joint lead nurse, Lambeth CEPN
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