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Shortchanged in primary care

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As practice nurses progress through their careers, As practice nurses progress through their careers, they may not receive pay increases to match their skills

Practice nurses should add the art of negotiation to their already many stringed bows, if they seek fair pay for their skills. Not being on Agenda for Change means that practice nurse salaries can stagnate even with the acquisition of new skills or promotion.

The government agreed to a 1% pay rise for nurses and all healthcare professionals on Agenda for Change. GP practices are not bound by this model and can instead set their own terms and conditions as independent employers.

That’s 23,832 nurses, according to figures from the Health and Social Care Information Centre1, potentially missing out on pay rises and annual incremental increases.

Of course it is expected that all practices pay their nurses in line with the Agenda for Change pay bands. The official line from the BMA is that ‘nurse pay should increase by 1% in line with the Doctors and Dentists Review Body’s (DDRB) recommendation and our contract agreement. Practices don’t have to use Agenda for Change, but are very aware of the need to offer good pay arrangements, terms and conditions in comparison to community and hospital employed nurses in their areas.’

They state that retaining and attracting skilled practice nurses is very important, particularly with the shortage of GPs affecting many areas of the country.

Unfortunately research by the Queen’s Nursing Institute (QNI) has found that this is not always the case. While many practice nurses starting salaries do usually align with the pay bands in Agenda for Change, practices often forego increasing pay when a nurse changes role, adds to their skills or becomes more specialised.

Ellen Nicholson, an advanced primary care practitioner, says that this can often leave nurses in primary care behind their secondary care counterparts. ‘Practice nurse pay is usually affiliated to an Agenda for Change pay band when they start a job. But you don’t get the automatic annual increment that those on Agenda for Change receive. And again as there isn’t a standardised approach you’ll have some nurses on £12 an hour and others on £14 an hour and variances in people doing the same job. This is why we need standardisation.’

The QNI survey of 3405 practice nurses revealed that 81.5% said that they were not awarded increments based on their performance.2 One of the nurses commented: ‘Within general practice the majority of staff have to fight for any form of salary increase/enhancements/increments.’

Another said that in trying to negotiate a pay rise: ‘I rang around several other local surgeries to find that practice nurses, who are all doing the same job get very different salaries and remuneration’.

Jenny Aston, an advanced nurse practitioner from Cambridge and a member of the RCGP practice nurse forum, conducted a survey in her local area asking nurses basic questions about their pay and holiday allowance.
‘I found that there was a massive range of pay for nurses whether they were practice nurses or advanced nurse practitioners. I think we have to be more honest about what people are paid and what they are worth basically,’
she said.

Surveys in other areas could be conducted to reveal the extent of the variation in practice nurse pay. Ms Aston says this could take us one step closer to understanding how to ensure that practice nurses receive a fairer pay deal across the board.

How are nurses being supported on this?
The BMA states that practices should align pay to the Agenda for Change pay bands and this appears to be the case for the majority of practices in England. However, the concern comes from the variation in pay across similar roles and the fact that many practice nurses are not seeing the steady increments attributed to Agenda for Change, should they change role or become more specialised.

Instead Ms Nicholson says it is down to the practice nurse to negotiate pay when they progress in their job roles. ‘But obviously some people are better at negotiating then others and it depends on how much you value the skills you have as well,’ she says. It seems that if a nurse does not negotiate pay, there is a possibility they might never see any kind of uplift.

Gary Kirwan, senior employment relations advisor at the Royal College of Nursing (RCN), says that they provide guidance for nurses to negotiate better pay.3 The resources advise nurses about fair pay structures, how to make a pay claim and holiday allowance. ‘We would like those nurses in GP practices to use these resources to help make a case for their pay,’ he says.

Similarly other nursing unions, state that the only thing they can do at this point is support nurses and investigate cases where nurses feel they are being unfairly paid.

UNISON’s head of health Christina McAnea says: ‘Private healthcare providers should be paying staff at the very least the rates agreed under Agenda for Change. So they should be increasing pay from 1 April. If they don’t do this then they will find it difficult to recruit and retain nurses. We’ll be taking action by putting in claims for Agenda for Change uplift where we have recognition agreements with employer.’

Suggestions for change

Ms Aston says that Agenda for Change isn’t a good model for practice nursing pay bands as it is more suited to larger organisations like hospitals. ‘We’ve tried to implement Agenda for Change before but it didn’t happen. No one has the power to make GPs do that because they are independent employers,’ she says. However, Ms Aston does state that there could be opportunity for a more standardised approach with the creation of federations and increased cross over work between other sectors and general practice.

Ms Nicholson suggests a CCG wide approach could be adopted as it is currently too difficult to impose a national standard for all practices across the country. ‘From a practical point of view, having a pay structure at a local level within one CCG could work and then other CCGs could follow suit. This could be the starting point.’

Mr Kirwan says that to create a national framework for practice nurse pay would be a question of expecting over 7000 small businesses (each GP practice in the country) to adhere to the same conditions which is ‘quite a huge task’.

‘There’s hundreds of different GP practices so we couldn’t set one base rate for them, it wouldn’t be feasible because there are different arguments for different types of employers,’ he says.

Creating a similar model of pay for practice nurses appears to be a question of collaboration on a mass scale. Ms Aston says that in order to standardise pay for practice nurses, GPs would have to work with their local medical councils (LMCs) the BMA and the RCGP to collectively agree on a model that would fit all practices.

At this stage, implementing a standard pay structure across all general practices seems unlikely, given just how many different organisations would need to be involved. The results from the QNI survey show that this is a very real issue among practice nurses and in order to sustain the workforce this needs to be addressed.

As practice nurses take on more and more clinically complex roles, pay must escalate to match their competencies. Ms Nicholson says research has found that nurses in senior positions and in prescribing roles actually save practices money in GP appointments and follow up consultations.

It might be time for GPs and the government to subscribe to the adage of ‘spend more to save more’. IN


1. Health and Social Care Information Centre. 2014.

2.The Queen’s Nursing Institute. 2016. General Practice Nursing in the 21st Century.

3.The Royal College of Nursing. 2015. Fair Pay in the Independent Sector.

What do you think? Leave a comment below or tweet your views to @IndyNurseMag

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I think there's a long way to go before it could be standardised in any way, as nurses have such diverse roles in practices these days. Furthermore, nurses practitioners are taking on more and more of what were traditionally doctors' roles. Their level of accountability is sometimes greater than in ward situations. I have been a ward sister myself and am now a practitioner and prescriber. In some cases, the nurses are teaching the junior doctors, and certainly comparing and sharing information with long qualified doctors.
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