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GPs and nurses: the best of managers?

Lynn Young
Primary Healthcare Adviser for the RCN

It is a most unsettling time in the NHS in England these days - especially in primary and community healthcare. On top of the demand to make financial savings, the health service is being told that the coalition government wishes to remove primary care trusts (PCTs) and strategic health authorities.

If the proposals go ahead, in place of the huge gap left by the demolition of our current structures will be 500 GP consortia, which will have responsibility for most of the commissioning of healthcare services on behalf of their local population.

To say that many nurses and doctors have concerns about this direction of travel would be a great understatement. A significant proportion of GPs are voicing alarm at such a development, and with good reason. GPs, after all, are clinicians who have chosen to work in the most personal part of healthcare and are horrified at the prospect of taking on the role of commissioner on top of medical responsibilities. While it is generally agreed that nurses and doctors should inform commissioning, the process itself is a managerial one and we need the very best of managers to make the process valuable to the public and cost-effective.

A number of white papers were released by the government in the summer and the deadline for responses was early October. We are yet to learn how much attention politicians will pay to the comments made by the various organisations and individuals who chose to respond.

As much as people dislike government intentions, there is no doubt that David Cameron and Andrew Lansley are on a mission - to get the nation into better financial shape and successfully introduce market forces to the health service, in the belief that patient choice will drive up quality and reduce cost. Such a move has been attempted before, in 1990 by the Tories, and in a more subtle way through a number of reforms introduced by the Labour government during the early years of the 21st century.

Some commentators have suggested that the Lansley landscape for NHS England is merely another step forward in terms of developing an NHS underpinned by market forces. In some ways this is true, but if Mr Lansley succeeds with his reforms the direction of travel will not be evolutionary but a tremendous lurch forward into a different climate altogether.

We are now dealing with the language of Any Willing Provider, Social Enterprise and freedom for the new organisations to set their own pay and conditions of services. The fact is that, theoretically, foundation trusts have always had the ability to ignore nationally agreed pay and conditions, but have chosen not to. General practice, along with the rest of the independent sector, is not duty bound to employ its staff according to
Agenda for Change; and yet it still manages to attract talented professionals.

Nurses working in the community have had to deal with upheaval since August 2005, when the former Chief Executive of the NHS, Nigel Crisp, issued the infamous letter, Commissioning a Patient-Led NHS. Basically, the letter ordered PCTs to separate their commissioning and providing functions, and hive their community nurses off to another organisation. Five years on, community nurses are heading towards social enterprises, their local hospital and a small minority to community foundation trusts.

There is a glimmer of light. The call for the NHS to do more to prevent disease has become louder. The drive to offer patients their place of choice to die continues, and we all hope that, whenever that choice is home, community nurses will be there to provide fantastic end-of-life care.
 
Many of us have great concerns over the future of health inequalities. During a time of economic downturn the health gap between those in well-paid employment and people who are unemployed or in low-paid work widens. If we allow this to happen, England is destined to see a generation of people who are likely to die younger than their parents.