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A message to the Minister: the NiP survey results

In one of the biggest ever surveys of primary care nurses in the UK, Nursing in Practice has discovered that years of constant change has taken its toll on the general practice nursing population. Over 1,400 of you responded to our questions, and here are the results

Elaine Linnane
Editor-in-Chief
Nursing in Practice

Significant developments have taken place in the primary care arena over the last few years, which have inevitably affected the various roles of the primary care nurse. Nursing in Practice gauged opinion from over 1,400 primary care nurses on some of these leading issues.
In one of the biggest ever surveys of primary care nurses in the UK, Nursing in Practice has discovered that staff shortages, frozen PCT posts, an increasing workload and no recognition for the value of the role have left many health visitors feeling disillusioned with the current state of their profession. Sixty-two percent describe current morale as quite low or extremely low, 36% describe the amount of work-related stress they experience as unmanageable, and 60% would not recommend a nursing career in the primary care sector (see Figures 1-5).
Commenting on these figures, Cheryll Adams, Unite/CPHVA Acting Lead Professional Officer 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 on very poor NHS management philosophies which have allowed this culture to develop."

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Health visiting
Despite the recent government response to Facing the Future, the review of health visiting that aimed to give the profession a clear direction in keeping with the changes taking place in society and government policy, many health visitors feel that there have been too many recent changes to the detriment of the service. "There is too much emphasis on financial recovery, which limits our work rather than letting us address local population need," said one health visitor based in Leicestershire.
"The trust does not value health visitors - jobs are being frozen, skillmix is often inappropriate, stress levels are very high, work does not feel secure and there is poor support from management," explained another health visitor from Blackpool.
"Unfortunately, these survey findings are depressingly familiar and dovetail with our own research during the last 18 months," said Cheryll Adams. "We have been campaigning to reverse this sorry state of affairs since then, so that a career in health visiting and community nursing can be viewed as rewarding and fulfilling. For that to happen, primary care trusts need to employ and train more health visitors and community nurses, such as school nurses, and to cut down on unnecessary paperwork and bureaucratic time wasting."
Lynn Young, Primary Care Adviser for the RCN, is also concerned. "The fact that so many health visitors feel disillusioned is particularly worrying when you consider the recent health visiting review, the public health demands and the new initiative being led by Kate Billingham, which requires intensive health visiting support."
And the survey results 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.

Changes in PCT structures
For many in England the recent restructuring and merging of PCTs has been unsettling. Although the changes in PCT structures came into effect over 12 months ago, many PCT-employed primary care nurses are still awaiting clarity of what this means for their role and are uncertain about their future. In addition, a lack of skilled staff and resources along with an increased workload mean that many feel that patient care has got worse since the changes - 53% of health visitors, 36% of district nurses and 29% of community nurses (see Table 1 for a selection of comments).
A district nurse from Peeblesshire in Scotland told NiP: "I absolutely love my job. However, the current proposed changes in community nursing here in Scotland are very unsettling. No one seems to be able to tell us what the proposed changes are."
Lynn Young is not surprised at these 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."
In contrast to their PCT-employed colleagues, the practice nurses questioned seemed more content with their current situation. Despite the change in focus towards a more target-driven service since the introduction of the 2004 GMS contract, and the consequent increase in workload, 42% of practice nurses would describe their current level of morale as quite high or extremely high (for some district nurse views of the GMS contract, see Table 2).
One practice nurse from Halifax in west Yorkshire described how "despite lots of changes within the surgery, the changes have been managed with consideration for all staff working within the surgery. I feel that we are at last working together."

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QOF points
Fifty-six percent of practice nurses felt that the Quality and Outcomes Framework (QOF) had resulted in moderate improvements in patient care. However, not everyone was happy with the means of obtaining points: "There is too much paperwork for the sake of 'ticking boxes' for the PCT to obtain payment for our work with patients, which makes the focus of our job so much less patient-focused", commented a practice nurse from Brighton.
Criticism of the "ticking boxes" process was reflected in many other comments from practice nurses, for example:

  • "Too much time spent trying to achieve points."
  •  "Number crunching has taken emphasis away from giving the patient quality care."
  • "I have to put QOF first and patient care second."
  • "Time is wasted on just getting the boxes ticked."
  • "We only seem to concentrate on 'required' data."

And for some practice nurses the QOF had quite serious consequences:

  • "[GPs] give out computer-generated lists of patients who they need information on. I think it is disgusting that a patient should be rung up by a HCA and asked if they are feeling suicidal, or when they last had an epileptic fit."
  • "Especially towards the end of the financial year, there is a mad rush just to achieve the points rather than seeing the patients because they are due a check-up."

"Interestingly, the comments made by general practice nurses reflect those made in the early 1990s, when the community health sector was also experiencing fundamental change and therefore instability and insecurity," commented Lynn Young. "It is heartwarming to read of good news from general practice, but although many nurses report on improvements achieved through the QOF, negative remarks on the number-crunching aspect of the contract are familiar."
Obtaining QOF points was not, however, without its benefits - 38% of practice nurses who responded to the NIP survey had received a reward for their involvement in achieving QOF points for their practice. Rewards varied hugely, and included laptops, wine, cream cakes, meals out, parties, and a variety of financial bonuses, ranging from £50 to £3,000 each year.
Marilyn Eveleigh, Consultant Editor of Nursing in Practice, believes that this wide variation reflects where GPs, as small businesses, see their position. She commented: "The GPs' extending role as gatekeepers of patient needs, government expectations for opening times and PCT referrals will directly impact on the nursing role and rewards."
More skilled staff, more time, less admin, more pay and more support from management were the most popular responses from all nurses when asked for suggestions for what would improve their working life and the care they provided to patients.

Pay award
The recent staggering of the pay award for nurses in England has been one of the most commented on features on NursingInPractice.com, with most nurses, unsurprisingly, upset that for the second year running this government has given them a below-inflation pay award. This disappointment is also reflected in the NiP survey results.
Sixty-four percent of district nurses felt their remuneration was "unfair", and that as specialist practitioners who were being shouldered with more and more responsibility they should be on AfC band 7 or even 8, earning the equivalent of a head of year teacher or police sergeant. "As a firstline manager carrying a large caseload and also a prescriber, I feel our salaries should reflect these responsibilities. Therefore we should be remunerated on a par with other professionals in similar positions," commented one district nurse from Swindon in Wiltshire.
Fifty-six percent of health visitors said they were paid an unfair wage. Again most felt that they operated as "specialist practitioners", and considering the responsibility and accountability that came with the job, that all health visitors should be on AfC band 7.
Fifty-two percent of community nurses considered their remuneration was "unfair", with most feeling that band 6 would be more appropriate for their level of responsibility.
Fifty-three percent of nurse practitioners working in primary care considered their remuneration as "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, 61% of practice nurses felt that their remuneration was "fair" and reflected their current workload and level of responsibility.
"Yet again the different stories from practice nurses on how they are treated financially continue. Some practice nurses are quite satisfied with their pay and bonuses, while others clearly feel that they are underpaid and unrewarded," said Lynn Young. "Comments made on 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," she continued.

Practice-based commissioning
Practice-based commissioning (PBC), the policy intended to give more decision-making power over NHS resources to general practices, and allow them to design and deliver completely new services or commission others to do so, is going to change the face of primary healthcare. Indeed in those practices and PCTs where PBC is already up and running, results have shown it is possible to deliver significant improvements in patient care while also saving the NHS money (Commission accomplished: how practices are winning with PBC. MiP 2007;11:21-5, or online at www.ManagementInPractice.com). Nurses are pivotal to the success of PBC - how can commissioning decisions be made without the input of the primary care nurses?
However, it is obvious from the Nursing in Practice survey that nurses are significantly under-represented in the PBC arena. Seventy-three percent of practice nurses said they were not involved in their practice PBC plans, and more worryingly, 56% said that there were no nurses involved at all. There appeared to be three main reasons given for this:

  • The nurses "hadn't been invited".
  • "Only the GPs and managers are involved."
  • Responders "don't know enough about it".

"Clearly PBC is not developing in the way we would like to see," commented Lynn Young. "The RCN has been busy extolling the virtues of multidisciplinary PBC for some time now and we need to see far more progress achieved during 2008."
Donna Davenport, Professional Development Nurse from Stockport PCT, outlined the benefits for nurses getting involved in local PBC in her online blog "Practice-based commissioning: where are all the nurses?" (www.NursingInPractice.com/myweek) back in July:
"There are immense benefits to involving you in this process, such as:

  • Effective planning, service improvement and development.
  • The NHS will maximise the use of existing resources including knowledge and skills.
  • There will be more opportunities to achieve NHS priorities and targets, including health improvement and better patient-centred care.
  • Your involvement can contribute to a more robust governance structure and process."

Marilyn Eveleigh wishes to encourage those nurses who have been invited to respond: "This is how you will find out more about PBC. I am aware of several PBC groups that would welcome nurses but have had no commitment from them, and therefore are not bothering to ask anymore."
Hand in hand with PBC is the prospect of more involvement with the independent sector, in the form of alternative providers. However, 62% of all primary care nurses questioned felt that the introduction of private sector providers posed a major threat to the quality of general practice and to patient care.

Conclusions
The government has published its list of healthcare priorities for the next 12 months, which includes achieving the 18-week referral pledge, providing increased out-of-hours care, and reducing health inequalities, particularly by tackling the biggest killers - cancer, cardiovascular disease, smoking and suicide - as well as the old favourites - teenage pregnancy, obesity, alcohol abuse and sexual health problems. An extra £3.8bn is being allocated to help PCTs achieve this.
None of this will be possible without the primary care nursing workforce. Nurses are the heart of primary care services and general practice. "The RCN is not surprised at the results of the NiP survey, which does not in any way diminish our concerns at reading the comments from hardworking community nurses," said Lynn Young. "Unfortunately the RCN also constantly hears from nurses working in hospital that they, too, are feeling demoralised and are considering a career in community nursing."
Lynn believes it is time for the government to sit up and listen: "Health ministers should be interested in this survey and understand that unless we see a more highly motivated and rewarded community nursing workforce, their targets and health improvement agenda will continue to be policy, rather than patient-centred, personalised nursing care."
In a survey of this sort it is easy to focus on the negative, the areas where you, rightfully, feel disempowered. However, despite the many challenges being thrown at you, it was reassuring to hear how so many of you still love your job. At the beginning of a new year it is perhaps more inspiring to finish this feature with a list of some of the many positive comments that we received about working as a nurse in primary care:

  • "It is fantastically rewarding to get to know a person or family and to feel trusted and valued. If we were as well respected by the government and paid for the skills needed in such a very diverse field, the job would be perfect."  
  • "There is such a lot of scope to develop personal skills and knowledge, autonomy and confidence."
  • "I have been a practice nurse for 29 years, and have gone from handmaiden to a much more autonomous role as a clinician. The work is varied and interesting and never boring […] I get to know the patients and their families and feel I can make a real difference to their lives."
  • "Despite the odd moan I love my job and wouldn't change it for the world. Being involved in people's lives through the good, bad and ugly for 17 years in one practice has given me a perspective on health and what it means that I would not have otherwise understood. I feel privileged when people trust me with personal information and thrilled when I help someone make changes that improve their health."
  • "The boundaries are more blurred allowing for a proper career path and ability to develop professionally whilst remaining totally clinical."
  • "It is a time of great change with more care being undertaken in the primary care setting - yes there are bumps in the road at the moment but with courage and determination these can be overcome."
  • "I love my job. I work in a wonderful area with lovely caring people and I feel valued and appreciated by my colleagues and patients. They are like an extension of my family - corny but true!"

The Nursing in Practice survey was conducted online at www.NursingInPractice.com from 14 November to 7 December 2007. A total of 1,477 nurses completed the survey

Some other results from the NiP web survey:

How many of you are planning to retire in the next 10 years?
30% of practice nurses
40% of district nurses
52% of health visitors
24% of community nurses

24% of practice nurses have been graded according to Agenda for Change
60% of community nurses do not undertake regular clinical supervision (as defined by the NMC)
53% of health visitors believe that patient care has got worse since the changes to the PCT structures
10% of district nurses would like a career change as soon as possible

Out-of-hours care
50% of community nurses, 52% of health visitors and 57% of district nurses believe that we should go back to the pre-2004 arrangements, and money should be reinvested in general practice to allow GPs to support out-of-hours care
74% of nurse practitioners and 65% of practice nurses believe that the 2004 out-of-hours arrangements have had mixed results, but PCTs should continue to provide the service and improve upon it where necessary

Practice-based commissioning
28% of practice nurses, 21% of community nurses, 40% of health visitors, 23% of nurse practitioners and 12% of district nurses are unclear about what exactly PBC means.

Your comments: (Terms and conditions apply)
"Whilst understanding that experience and skills gained over years of practice are valuable and quite rightly should be respected, and in many cases does not stop the practitioner delivering excellent care, the problem is that it is not an objective way of assessing a person's ability to do the job. With a registered qualification any employer has an understanding of what they can expect in terms of under pinning knowledge
and skills. With a background in practice nursing myself, I resisted the pressure to have a specialist practitioner degree because I initially resented the fact that a degree seemed the only way in which my abilities would be acknowledged. I have found however that it drew together 20 years of nursing expertise in a way that employers understood and made them sit up and listen to me. I think that we perhaps have to embrace formal recognition rather than resisting it especially as many of the formal educational paths now allow us to use daily experiences to base our learning on. Practical skills are celebrated alongside the academia aspects of learning. With regard to the idea that there is no difference in what formally trained practitioners are doing that is true, because it's their thinking that is changed and that is what nurse development is all about and what many employers are looking for" - Name and address supplied

"I think Community Nurses with experience, skills and knowledge are of the same level with Healthvisitors, Practice Nurses and District Nurses. An experienced qualified General Nurse should be at the same level with Public Health Specialist Nurses. They are just fortunate to get specialist training. There is no difference in the job District nurses, Health Visitors and Community Nurses are doing. The pay band is also different in some PCTs. I suggest this should be equal. Some PCTs pay their Health visitors Band 7 agenda for change while some pay band 6-equal payment should be applied to all staff. Some staff hold degrees in nursing studies. Where does Agenda for Change group this cadre of staff? Are they generalists or specialists?" - Name and address supplied