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'Excellent' nurses should be paid more, says Francis

The Agenda for Change pay framework should be adapted so nurses who “demonstrate a commitment to patient care” are paid more than others, under recommendations made by Robert Francis QC.

His landmark report from the Mid Staffordshire Foundation Trust public inquiry suggested nurses should be rewarded and “incentivised” for showing the right skills, such as compassion and good care.

Mr Francis said that as well as showing a commitment to patient care nurses who also recognised the priority that dignity and respect of patients deserved could be rewarded under the existing Agenda for Change pay framework.

This could also include nurses who seek training to develop their leadership skills.

The report concludes: “The leadership required for the delivery of excellent nursing care should be recognised and incentivised in the remuneration structure by a more explicit reference to the delivery of excellent care, and by use of professionally formulated and accepted performance measures.”

He said more effort was needed to promote professional development within nursing and recommended the knowledge and skills framework could be amended to reflect the skills nurses should show and be used to reward those who meet standards.

Mr Francis suggests in his report that this could be done when nurses reach the gateways in their pay bands under the Agenda for Change framework.

He accepted the KSF had seen “variable take-up” across the NHS and while good patient care and developing skills were “implicit” in the framework he said “neither necessary characteristics are explicitly headlined or highlighted specifically for every nursing post.”

The report said: “In Stafford, wards that were well led generally provided an acceptable standard of care. The terrible experiences of which the various inquiries received so much evidence came largely from wards lacking in strong, principled and caring leadership.”

Prime minister David Cameron welcomed the idea of performance related pay in his speech to the Commons responding to the report.

He said: “Another issue is whether pay should be linked to quality of care, rather than just time served at a hospital.

“I favour this approach,” he said.

But Peter Carter, chief executive and general secretary of the Royal College of Nursing, said: “I want to see the details…what does it mean?

“We’ve got the kind of headline, but now we’ve got to wait and see how it drills down. It will be interesting to get the detail on that,” he told Nursing Times.

Readers' comments (30)

  • Or how about you just get fired if you are clearly unable to manage a ward effectively or and you are being paid to do so? It is too difficult to sack bad staff in the NHS.

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  • I think you'll find that this is just an easy way for Trusts to close down the increment/gateway on the pay bands. That said I'd be quite happy to see those who do "just enough" or less sit and stagnate on the bottom of their pay band whilst those who consistently go the extra mile be rewarded as such. Trouble is you'd need a hell of a leader/local manager to make the system work.

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  • Another excuse to cut the pay of nurses,no one is being blamed for staffordshire but the nurses? what about the managers who implemented the cuts etc? Cameron hates nurses he always has a go any time he can.
    If the pay of nurses is cut then unfortunately the better qualified and caring staff will leave and you will get the type of nurse working in the NHS that no one wants,if you pay them peanuts you get monkeys

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  • How naive is that?

    I can just see it happening. the bosses darling who leaves everybody else to run round doing all the work would get the reward and those who really work hard caring for the patients unnoticed in the background would be ignored. This is exactly what happens in organisations and how many of the former get promoted!

    It is not sour grapes I have seen it happen very blatantly all too often, but I know which type of nurse I prefer to be and which I would prefer to look after me.

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  • As others have commented, how about dismissing those who are unable to do the job...

    The problem in this scenario is those with power to hire and fire are in some cases unable to do the job themselves...

    How about doing the correct thing and re-inventing the wheel? Why not retur to Whitley Grades where a Nurse worked for her/his advancement through Nursing related, skill enhancing courses and patient contact rather than the right; hair and eye colour and night out jollies with 'senior' staff.

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  • Organization do promote muppets into junior management roles. Primarily to serve as cannon fodder, taking the flak from frontline staff, when there's not enough resources, as well as from more senior managers for not implementing their strategic visions into a workable form.
    Also these muppets can't go anywhere else, as everyone knows they're useless, under trained + lack real expertise in anything, however still as a manager they have authority to be a plank. More importantly they prevent better people from being promoted.

    At first glance, its good not to pay for lazy, ineffective and inactive staff. However it also sounds like a performance related pay freeze.

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  • No nurse should ever be rewarded and “incentivised” for showing the right skills, such as compassion and good care. This is the minimum we should expect of every nurse, however they should be rewarded for additional skills, developing new services etc.

    The NHS has long paid GPs incentives for various characteristics of "good" practice through QOF etc but principally it increased costs as the good ones just got paid more, the gad ones were still bad, they sometimes delivered what was needed to get the points but overall care did not improve and in some cases non-QOF care deteriorated.

    Nursing is a CARING profession, therefore if you don't care you should be dismissed. The NMC is superfluous as negligent nurses should go through the legal process. The regulatory bodies have failed to protect patients and should be abolished, since this was their purpose.

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  • Organisations want yes wo/men who they will reward generously and can mould to conform with their culture. they do not want people who are independent thinkers who will try to bring about change, show initiative and speak out. to get on and get paid for 'excellence' you have to play their game even if patients and colleagues suffer as a result.

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  • It would be good if it was carried out in a totally unbiased and fair way, but I have to agree with some of these comments. I have seen far to often that those who climb the ladder do so by treading on others. Those often in management make life very difficult for those who have more about them than they do. It is open to abuse, a free ride for the ones with brown knees and a career block for those who are the innovative, caring and compassionate ones. It saddens me to admit this is NHS culture and hard to challenge as the ladder upwards consists of these individuals watching the backs of each other.

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  • Oh my god has no-one got anything positive to say? All this saddens me at the end of the day we should be out there caring for patients giving them the care and respect we would want for our own families and communicating with families. If we are all going to blame ' the management' all the time we will get nowhere. Nurses are powerful group instead of moaning go and inspire some change that or come & work for Nottingham University Hospitals where we really are trying to do the right thin under enormous pressure from the top down & bottom up

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  • Anonymous | 8-Feb-2013 9:23 pm

    Like what? I've heard nothing about Nottingham University Hospitals.

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  • I would love to reward hard working caring nurses better. But this is so had to measure, and so subjective. Which puts people at the mercy of their manager, good or bad. I am not a nurse, just a manager but Whitley Council was just before my time. Could anybody have the patience to explain how that worked please? I would like to see if we can adapt our KSFs locally. Thank you.

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  • Why not, simply have 'EXCELLENT' nurses, in all departments?

    The NHS should be promoting a standard of care based on a Quality of Excellence!

    Anyone performing below that standard can, in my opinion, be dismissed on the grounds of incompetency

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  • Iama Cynic | 9-Feb-2013 0:49 am

    Agreed. All nurses should be of a certain standard and should not be singled out for doing a good job! those below standard should be supported and given chances for improvement and if this does not happen in a reasonable amount of time they should be dismissed, as should anybody immediately if their practice proves unsafe.

    As for singling out people for special rewards for just doing their job properly (so typically British and breeds contempt), I remember during my first year on my own with a third year in charge of a surgical ward on nights. She proudly wore a gold medal as student of the year. She was very efficient, although not over friendly, and appreciated by senior staff. I was keen to consolidate the skills of basic care I had learned in the school of nursing and my tutor made regular assessments to ensure I was carrying out the care exactly the way we were taught otherwise we failed our assessments.

    This gold medal miss told me I was quite good but I was too slow. She had never seen me do a bed bath but chose to use this as an example and to my amazement said patients don't get dirty in bed and behind curtains nobody sees whether you are doing a full bed bath. All they need is a face and hands wash!

    Once qualified would it be fair, give somebody like this nurse a higher financial reward as she is perceived to be delivering excellent care and the ward looks spick-and- span under her command yet the basics are being ignored, and another excellent nurse being passed over for reward who takes more time to keep her patients safe, clean and comfortable and listens to their concerns whilst the ward is slightly less orderly and she does not manage to finish all her work on time?

    Another senior staff nurse I encountered told me to fill in the four-hourly obs book for thirty patients instead of going round actually taking the obs because sister was about to come on duty. Whilst she was explaining to me how you look at the previous readings and modify them slightly
    I fortunately found a pretext and left her to do her own dirty work!


    In the old days as a new student one was very quickly put in one's place and learned not to complain. Hopefully something one would no longer get away with now.

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  • The culture of rewarding + incentivising starts from an early age. At school teachers now have to praise children for doing the right thing, which should be expected in any case. Parents giving sweets to their kids to keep them quiet or money otherwise they won't do household chores. No wonder why some kids gain pounds.

    I have seen excellent managers, kept from doing their jobs well and had differing points of view with the senior team. One in particular (not in nursing) was 'forced' to go onto gardening leave, before allowed to work elsewhere. As someone with excellent reputation getting next job was very easy, especially when directors from another organization knew he was free. During same period his juniors (including managers + team leaders) planned + implemented their exits to join their colleagues. Clients were informed by someone else, they also transferred their business / custom as the dust settled. Now that's loyalty and am sure there are comparable nursing examples. The new firm allowed this manager to create a new department from new + existing staff, and offered better all round package.
    Excellent staff, with great knowledge, skills, experience and right attitude will be recognized by others, and managers who recognized them will only be too happy to poach them from managers that don't.

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  • Unfortunately, the lunatics are running the NHS, therefore, as I have found at great cost, you will never be able to apply your own nursing expertise to its full capacity, because, in doing so it will 'force' your peers and significant senior nurse managers to ' up their perfomance too; And, that will never happen.

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  • how do you measure care and compassion? who will set the standard and monitor attitudes? do managers even like good hard-working nurses? why are so many bullied for being efficient and caring?

    nurses seem to be actively punished for caring, being accused of being too slow and for 'spoiling' people. how many of us have been told by colleagues (HCAs through to the ward manager) that we need to 'speed up', 'haven't got time for that'.

    there are always going to be brown-noses who don't give a hoot except when they think the 'right' people are around.

    instead of rewarding people who are good at their job, maybe we could just pay nurses a better wage and not employ the ones who don't give a damn. being uncaring is not the same as being incompetent, you can be technically excellent, get everything done, blah blah but if you are bossy, thoughtless, don't care about either the patients or the staff then perhaps you shouldn't be in the 'caring' profession.

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  • paying on merit, pay by results, incentives and bonuses are just more General Management gimmicks which should have no place in healthcare. This is not what genuine care for the sick is all about. Better salaries for all and support or sanctions for those unable to perform would be a far better and fairer solution.

    I certainly did not go into nursing to be in competition with my colleagues or to suck up to any managers.

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  • 'excellence' seems like a highly inconsistent and subjective value judgement!

    precision is achievable and can be measured

    perfection is an obsessive narcissistic personality trait which can never be achieved. Even in nature there is no such thing as absolute perfection.

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  • it is very easy to spot poor work and things left undone and to point it out criticise it but achievements are rarely notice and praised.

    sometimes nurses are so busy achieving the impossible and making their patients comfortable and well that some things are omitted or short cuts taken giving the impression that they are slapdash and do not care.

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