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Frontline nurses' low morale threatens Brown's health plans

Staff shortages, frozen PCT (Primary Care Trust) posts, an increasing workload and little recognition of the value of their role have left many primary care nurses disillusioned with the state of their profession.

That is the stark conclusion of one of the largest surveys of nurses in primary care ever carried out in the UK, with over 1,400 respondents in a survey conducted by Nursing in Practice.

Earlier this month Prime Minister Gordon Brown announced a raft of new health initiatives, including better access to primary care and health screening for all. Nurses are central to the delivery plans. So it's bad news for the government plans that the survey reveals 62% of health visitors describe their current morale as low, 36% feel the amount of work-related stress they experience is "unmanageable", and more than half - 60% - would not even recommend a career in the primary care sector.

Unite/CPHVA Acting Lead Professional Officer Cheryll Adams said: "It is enormously worrying, but predictable, that 60% of those polled would not recommend a primary care sector nursing career - and this is a searing indictment of very poor NHS management philosophies which have allowed this culture to develop." Unite/CPHVA (Community Practitioners' and Health Visitors' Association) is a section of Unite, the third-largest trade union in the NHS.

Survey results also showed that it is not just health visitors who are feeling discontented - 55% of district nurses and 45% of community nurses would also describe their current level of morale as low.

Lynn Young, Primary Care Adviser at the Royal College of Nursing, is not surprised by the survey results: "Community nurses and health visitors are tired of constant organisational change, which in itself achieves little improvement in patient care. In fact, quite the reverse - public funds are used to support irrational change, rather than frontline services."

For practice nurses, the ticking-box process involved in achieving QOF (Quality and Outcomes Framework) points - the annual reward and incentive programme detailing general practice achievement results - was the biggest complaint.

One practice nurse described how "number-crunching has taken emphasis away from giving the patient quality care", while another expressed disgust that, to achieve maximum points, "a patient should be rung up by a HCA [Health Care Assistant] and asked if they are feeling suicidal, or when they last had an epileptic fit".

Pay was another emotive subject, with most primary care nurses feeling underpaid and undervalued:

•    64% of district nurses felt their remuneration was "unfair" and that, as specialist practitioners being shouldered with more and more responsibility, they should be on Agenda for Change (AfC) band 7 or even 8, earning the equivalent salary of a head-of-year teacher or police sergeant.

•    56% of health visitors said they were paid an unfair wage and that, considering the responsibility and accountability that came with the job, all health visitors should be AfC band 7.

•    52% of community nurses considered their remuneration to be "unfair", with most feeling that AfC band 6 would be more appropriate for their level of responsibility.

•    53% of nurse practitioners in primary care considered their remuneration "unfair". As one nurse practitioner said: "I see patients with undifferentiated and undiagnosed conditions, I am a nurse prescriber and I do not think AfC pay bands reflect clinically on this level of work." Most were looking to be on AfC band 8.

However, in contrast, and perhaps because they are not paid by the NHS (they are paid directly by GP employers), 61% of practice nurses felt that their remuneration was "fair" and reflected their current workload and level of responsibility.

"Comments made [in the survey] by PCT-employed nurses on pay are harsh, making the RCN even more aware that a 2008 pay deal needs to be far more generous than that awarded in 2007," said the RCN's Lynn Young.

This was echoed by Nursing in Practice Editor-in-Chief Elaine Linnane: "We are keen to investigate our readers' views and feelings and to represent them and their interests in our media and the media at large. That's why we took advantage of our large readership to canvass their opinions in the survey and obtain a true representation of them.

Click here to read the survey article in full.
Click here to download a pdf of the survey article in full.

Your comments: (Terms and conditions apply)
"I am also surprised that 61% of the practice nurses polled felt that their remuneration was "fair". Given that none of the PNs I know get the inner London weighting, annual leave entitlement based on length of service, or the sick pay entitlement that our directly employed colleagues get. I got no pay rise at all this year, and know others in the same position, this in spite of achieving maximum QOF points" - Name and address supplied

"Only 53% of primary care nurse practitioners rate their salary as "unfair"? Does that mean that the other 47% are better paid, happy or married to one of their GP/PCT employers?  Or is the remaining 47% rating their salary as "GROSSLY unfair?" I am fed up with earning under the local "average" pay and feeling envious towards others without qualification or higher education who are earning far more than I am for less responsibility and weekends off" - Name and address supplied

"I love my practice nurse job, and although my GP employer pays me top level 6, I am frustrated by the restrictions in expanding my role. It is the interesting changes that I find encouraging, but cannot take part. The government actually want nurses to take a lead, but how, when my employer believes nurses should not prescribe and it is down the GP to decide on my professional development? I think nurse training choices should be down to nurse managers, not GPs or practice managers, and if nurse prescribing is to take off, we need a free central training and support for nurses willing to expand their knowledge and skills but do not have professional support of the medical team that restricts them. I would be willing to do further training in my leave, but cannot access it because their is no medical supervisor willing to take the time" - Name and address supplied

"This does not take into account the feelings of the nurses who are constantly having to change working practices and revert back to the old way as voiced by our managers when it suits them. They are not working the frontline, they just attend all these meetings that us community nurses do not get told about. Surely, if they are changing locations within the team we should be given 90 days notice. Does anyone consider the service users when making these decisions? I cannot begin to think that they are considered. Have they done a patient questionnaire and quality audit and analysis? If so where is the evidence? These services should let the patients make the
decisions and let the service be patient-led" - Name and address supplied

"The role of Nurse Practioner/prescriber is indeed vast. Most are qualified to Masters level - often at our cost. Why should the medical world recognise our extended skills when our own profession is still reluctant to so! If primary care is to be frontline why is there not a significant movement to be professionally recognised - the afc is very difficult to apply to our role in this environment/experience" - Name and address supplied

"61% of practice nurses felt that their remuneration was "fair" and reflected their current workload and level of responsibility. Fair or unfair? Hard to believe" - Name and address supplied