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Making it pay

As the burdens on the NHS increase so do the pressures on nurses, but where is the recognition of that in terms of pay?

With some nurses, midwives and other healthcare workers in England and Northern Ireland staging strikes over the proposed 1% increase suggested by the NHS Pay Review Body, the pay awarded to NHS workers is again in the spotlight.

However the picture for primary care nurses is more complex and in itself reflects how the wider landscape of primary care provision is changing. Although the number of private, non NHS, providers in primary care is small, they are present. In addition a small number of social enterprises have entered the market.

And of course general practitioners, though generally providing NHS care, are essentially able to set their own terms of pay and conditions as independent contractors and are not obliged to pay the national pay system for NHS staff, Agenda for Change (AfC) (see box 2). This is pitched against an ageing practice nurse workforce that is believed to have reduced by around a third since 2008 and a current workforce who frequently change jobs, leading to a high turnover of staff.

A number of private providers Nursing in Practice contacted for this article declined to comment on their pay arrangements for staff. However Virgin Care - the company runs services including urgent care centres, minor injury units and GP practices - head of public affairs Russell Elliott says: “The vast majority of health services we run are where we have taken over existing services. In those cases staff are usually TUPEd over [TUPE rules protect employees' rights when the organisation or service they work for transfers to a new employer], although it depends on the contract, which will say what it expects staff to be paid. But if you want to recruit you have to pay the going rate. The market dictates that. Indeed we may end up paying more than some NHS providers.”

Professional officer, health sector, for union Unite Rosalind Godson points to the education sector for comparison.

“We already know what happens when schools set their own pay rates, as private schools are far more unlikely to value their school nurses and often pay substantially less than NHS rates.

“Any employer who abandons AfC rates needs to ensure that the pay scales do not discriminate. What tends to happen is that the staff do come over on TUPE - it would be disruptive and bad publicity to do anything else - but then the employer starts to chip away at the extras, such as holiday pay rates. Also new staff will not always be paid the same as existing staff. It is done by stealth.”

Ms Godson says there is considerable variety in the pay rates offered by GPs.

“There is a lot of variety, not just on pay rates, but on terms and conditions such as mileage, holiday allowance and pay and maternity pay. Also, GPs may want nurses to work 'split shifts' ie in the morning and then the evening, but not want to employ them for the few hours in the middle,” she says.

A trawl through the practice nurse jobs currently advertised on job web sites such as NHS Jobs shows adverts describing numerous roles as offering 'competitive' or 'dependent on experience' rates of pay - or offering salaries comparative to AfC rates. Others advertise hourly rates.

But NHS Alliance general practice nursing special adviser Louise Brady says even when roles are advertised as paying AfC rates, what often actually happens is that the role will pay a rate at the bottom of the said band, but without extra payments for extended hours - and then not increased for a number of years. 

With an, albeit slowly, increasing number of large, multi practice players entering the field - small GP practices continue to be the dominant form of provider - there is speculation about how well organisations will pay staff, but Ms Brady believes the size of provider does not tend to alter their pay rates. 

“Very few practices pay AfC rates and some practice nurses don't even get a cost of living increase annually. It is very much up to the practice nurse to negotiate their salary on an annual basis, with the GPs and practice manager,” she says.

“Nor do they automatically get extra payments for the increasing number of evening and Saturday morning surgeries that are being established by practices. So practice nurses do move around a lot as every practice works in a slightly different way. It's a competitive market and one that is currently on the nurses' side.”

Director of resources and performance management of Phoenix Primary Care, which runs general practices and walk in centres across Bedfordshire and the West Midlands, Ian Rose, agrees practice nurses are in a strong position to negotiate. He says the firm chooses to follow AfC pay scales - though not contracts - so as to reduce local negotiations with staff.   

“We didn't want 40 nurses each negotiating their own pay. So we do pay well by primary care standards but it is all about supply and demand,” he says.

“Primary care nurses do move around to get the best deal or to get a job in a clinical area they are interested in. Often we offer a salary to a prospective nurse employee and they will go back to their current employer and use it as a bargaining tool.”  

Commentators agree that recruitment in primary care nursing suffers from both not having a co-ordinated national recruitment campaign - though there are local campaigns - and no standardised training pathway into the sector.

Ms Brady says national minimum standards for pay would help encourage new recruits and reduce the turnover of instability in the sector.    

“One of the things that attracts nurses to primary care is the more family friendly hours and the fact that no two days are the same. It is also the more personal approach to both patient care and with colleagues. When you move around a lot the patients lose that stability too.”