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Practice nurses and PCTs: better times ahead?

Lynn Young
Community Health Adviser
Royal College of Nursing

Primary Care Trusts (PCTs) are a bold and brave part of the current radical health and social reforms. Some people see their development as little more than reconstruction for the sake of reconstruction, but many primary healthcare (PHC) enthusiasts believe that they hold the potential for achieving improved community health and a better deal for frontline PHC workers.

PCTs are indeed the vehicle for transforming the culture of a truly archaic healthcare system, and hold a significant key to beneficial modernisation, reduced health inequalities and improved public health. It was certainly a brave move by politicians to pass legislation that, for the first time in history, moves independent general practice towards more corporate organisations in which information has to be shared and a common framework for clinical governance implemented. All this action (and turbulence for some) has major implications for that most important member of PHC - the practice nurse (PN).

The time is right for PNs to become intrinsically involved with the local discussions and political intrigue currently taking place, and to work towards shaping their destiny. This is crucial because so much energy is needed to implement these changes - it would be pretty tragic if neither the NHS workers nor the public felt any benefits as a result.

So what do PCTs mean for the practice nurse population in England?
First, it must be said that the PNs working in the presently established PCTs have not felt the "big bang". My information sources tell me that so far little difference has been felt. But these are early days, and  while moving the structures and furniture can be done fairly quickly, more profound change takes time.

The trouble with traditional general practice is that the standards vary from inspirational to pretty poor. With this huge variation comes enormous differences for the PN workforce in terms of clinical practice, employment conditions and resource allocation for continuing professional development. And this is the main reason for the drive to PCT-land by the end of 2003. It is essential to public health that we take appropriate action to raise the standards of poor general practice to the heights of the very best. If we achieve this then PNs will feel the benefits as much as the patients they work so closely with.

But there is much to do - this is not a quick fix, and PNs are advised to focus their attention on what really matters to them and their patients, rather than become engrossed in meaningless detail.

At present, ministers have not advised PNs, or their fellow GP-employed colleagues, to immediately transfer their contracts of employment to the new PCTs. A more softly, softly approach is being advised, with statements such as "when the time is right", "if the PNs want to" and "if there are agreed benefits for all" being used, and this line is strongly supported by the RCN.
The issue of PNs transferring their employment to PCTs is now one of formal consultation, and the RCN is working closely with its Practice Nurse Association to collect as many PN views as possible. The RCN is also collating a formal response for the Department of Health, and at present we have no reason to believe that ministers will give PNs the "hard" push into joining an organisation they do not wish to be employed by.

But PNs cannot be complacent - they must be involved and take the lead in stating clearly what should be in place to make PCT employment attractive. The following needs careful consideration, and discussion will be enriched and more meaningful if PNs engage with their fellow community nurse colleagues in order to gain a wider perspective.

Services to patients
Many people believe that improved integration of the PHC team is more likely if all community nurses enjoy and share the same employer. While integrated teams have been forging ahead since 1997, maybe barriers and unhelpful boundaries will melt more quickly when the issue of "different employers" is no longer an issue. Developing integrated PHC teams is seen as a way of enabling patients, particularly those with complex pathology and needs, to more easily flow with harmony through the healthcare and social care system. Services need to share information, information technology, accepted best practice and local health strategies.

So, ask yourselves: could PNs make a bigger contribution to the development of truly integrated care if employed by a PCT?

Clinical governance
It is very clear and unpalatable that many PNs find it very difficult to get adequate "time out" for their professional and personal development. The RCN has heard many stories regarding how prohibitive PN Primary Care Group/Trust executive members have found being "allowed" the appropriate time for their executive duties. Statute requires that each NHS organisation (including PCTs) has within its systems a clear framework for the implementation of clinical governance.

PNs need to benefit from this aspect of health reform, which can be hard when working within a very small organisation. So, think clinical governance when discussing the merits (or not) of moving your contract of employment. Find out what the philosophy is of your PCT Board and Executive regarding lifelong and shared learning, dedicated time-out for personal development, and how they plan to ensure that a culture of "only the very best practice will do" can evolve. You might also ask how the resources for continued professional development are to be shared throughout the PHC workforce. There has always been inequity among community nurses, and PNs and the PCTs should urgently address how this can be fairly - and with best patient care in mind - be addressed.

Employment conditions
The RCN believes that ministers genuinely want to see improved working conditions in the NHS. However, we face profound difficulties in having a workforce that is equipped and able to address their local health demands and needs while still able to enjoy a fulfilling personal life! We now have an NHS framework - Working Together - that should guide the employment changes essential to the success of PCTs and could help to improve the recruitment and retention of the PHC workforce.(1)

The policy Agenda for Change, which intends to modernise nurses' pay, will soon be implemented in a number of pilot sites.(2) PNs, presently employed by GPs, will not have access to this new and hopefully better way of paying nurses, but would if employed by their PCT.

Agenda for Change removes the nurses' clinical grading system and replaces it with an improved job evaluation system, which appears to be extremely nurse-friendly, and the RCN is optimistic that the profession will in the future feel the benefit.

In the past, too many PNs have not received annual pay rises in harmony with their community nurse colleagues employed by the neighbouring community trust, and the issue of pensions has still not been truly sorted out in the way we would all wish for.

At this crucial time of PHC development, the advice is for PNs to indulge in reasoned debate and discussion. Look at the merits, the downside and all possible implications. Think what is in the best interest of your patients and the PN workforce and try to reach a local compromise, having given voice to dissidents and enthusiasts alike. What will suit one PN may not suit another, and remember a mixed economy of different employment models may be the best way ahead for the time being.

PHC is facing a time when traditional general practice is being transformed. PCTs and PMS (Personal Medical Services) pilots are playing their part, while at the same time a large number of new GPs are choosing salaried status rather than that of self-employment.

It would be difficult to imagine a PHC without a strong and elegant practice nurse workforce. While I have a passionate belief in the value of integrated teams, I am still not convinced that sharing employers is an essential element to their success - but it can certainly be of positive help.

The RCN can guide you through your dilemmas and hopefully offer a little wisdom and experience. Forget the "big bang"; think "slow evolution" with all the stakeholders thoroughly engaged in the process and signed up to the ultimate dream - better working lives and improved community health for all!


  1. Department of Health. Working Together: Securing a Quality Workforce for the NHS. HSC 1999¦. London: HMSO; 1999.
  2. Department of Health. Agenda for Change: Modernising the NHS Pay System: Joint Framework of Principles and Agreed Statement on the Way Forward. HSC 1999—. London: HMSO; 2001.

Further information
Practice nurses who are RCN members can obtain more detailed information on
PCTs by phoning RCN Direct
T:0845 772 6100
Ask for PCTs - a radical change in primary health care and PCTs in England: the knowledge and skills nurses need to make them a success.