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Freeing up nurses to improve care

Have nurses been freed? Exclusive survey on a year of NHS reforms


In the second part of Nursing Times’ investigation into the government’s NHS Next Stage Review one year on from its publication, nurses give their opinions on its impact and progress. Steve Ford reports

The NHS Next Stage Review has begun to have an effect in some areas but has yet to achieve its aim of putting frontline staff in control, suggest the findings of research by Nursing Times.

The review – High Quality Care for All and its associated documents – ushered in the government’s latest plans for future direction of the NHS. It included a focus on improving quality of care by putting patients at the centre of decisions and using indicators to measure standards, as well as a wide range of workforce reforms – some of which deal specifically with nursing.

To mark the forthcoming first anniversary of the publication of the review Nursing Times has carried out a follow-up survey on nurse views on the review. This follows last week’s exclusive interview with the review’s architect health minister Lord Darzi.

The new survey aims to provide a yardstick with which to gauge whether opinions have changed on the reforms since Nursing Times carried out similar research last year. The new survey also included extra questions asking nurses about the progress and impact that the review had had on them over the last 12 months.

One of the key themes of the review was to increase the quality of services in the NHS by allowing nurses and other staff more control over the services they provided. One of its chapters was called ‘Freedom to Focus on Quality’.

Lord Darzi suggested last week that this was starting to happen. ‘Some of the feedback I have from frontline staff is that they have found the next stage review liberating,’ he told Nursing Times.

However, this does not chime with the views of respondents to the survey, which on one hand suggests there is frustration with the slow pace of change, while on another that changes that have happened so far have had a negligible impact.

Just under 70% of the more than 500 respondents said the government’s drive to increase quality of care had not had any noticeable positive impact on health services so far.

More than a third of respondents said that some of the policies in the review had already had a direct impact on the way they worked. But – Lord Darzi may be unhappy to hear – 30% of those that had seen such an impact said it had made things harder for them.

Additionally, more than eight of ten nurses said they did not agree with Lord Darzi’s comments that the reforms have ‘liberated’ frontline staff to lead improvements on quality.

A large number of respondents cited managers and their continued focus on meeting targets, both clinical and financial, as barriers to progress on freeing up clinicians to lead improvements.

One said: ‘Lots of talk but still no real changes. Management say staff involved but still don’t really listen.’

‘The basics are still missing. With ongoing reductions in support staff in admin roles, more and more of this falls to nursing staff. Time is spent chasing notes, filing and on the phone – taking away from patient contact time,’ said a further respondent.

‘Whilst the intention is admirable there is no back-fill to allow this to occur so how can front line staff be released to provide this. Patients still require nurses on wards,’ said another.

While, these comments seemed to reflect the majority view, some respondents did agree with Lord Darzi. One said: ‘I feel as a staff nurse more at liberty to take decisions and help my line manager in my day to day clinical work with patients.’

When compared to Nursing Times’ previous survey in November, the new survey results show some similarities on some issues but also some interesting changes on others.

As one might expect, more members of the profession are now aware of the review, with 73% saying they have heard of it compared to 65% in the previous survey.

In November, we also asked nurses whether they thought the review would benefit nursing in general and also as an individual at work. The new survey suggests that nurses are becoming increasingly disillusioned about the impact of the review for themselves and also its impact for the profession as a whole.

The percentage of respondents who think the review will either be of ‘great benefit’ or ‘some benefit’ to nursing is now 47% compared to 62% in the earlier survey – representing a 15% drop.

Additionally, only 33% of respondents currently think the review will benefit them as an individual while 67% said it would not. This compares to a 50% split last time round. 

The two surveys also allow us to compare views on specific policies in the review that affecting the profession – namely the introduction of nursing metrics and the government’s wish to encourage more nurses to set up social enterprise schemes.

There has been almost no change in the percentage of nurses that back the idea of introducing nursing quality indicators, so-called metrics, with just under 80% still welcoming the idea. This is one area where progress has been made on a national and local scale (see box 4).

Just over half of the respondents to the new survey said their organisation had done some work on developing or introducing nursing quality indicators.

Additionally, one in ten said they had taken part in the government’s recent consultation on potential NHS quality indicators.

However, there has been an interesting change in views on social enterprise schemes, which are organisations set up as independent of the health service but are then commissioned by it to provide services (see box 3).

The government has been keen to promote them as innovative and entrepreneurial but they remain contentious with some stakeholders, particularly nursing unions, because they result in nurses leaving the safety of the NHS and exposing themselves to market forces.

In November a quarter of respondents said they would consider setting up a nurse-led social enterprise scheme. This has now risen to a third of respondents.

Answers to a new question that did not appear in the earlier survey also suggest a move towards a more popular view of entrepreneurialism. More than 60% of nurses responding to the latest survey said they would consider setting up a nurse-led service within the NHS itself.

‘This is where the impetus of nursing enterprise should be directed. Unfortunately it’ll be directed into some form of private sector healthcare,’ said one respondent.

Another new question included in the present survey asked nurses to identify the greatest threat to the success of the next stage review – in light of events such as the recession and the possibility of a change of government next year.

Interestingly, neither of these two examples were judged to be a major factor in the success or failure of the plan. The majority of respondents cited nursing shortages, apathy among NHS staff and lack of leadership as the three biggest threats to the review’s eventual success.  

Staffing shortages, which are predicted to be made worse by a future funding squeeze – the NHS Confederation recently forecast that the health service would be facing a £15bn shortage within two years – were a recurrent theme throughout the survey findings.

One respondent said: ‘Nothing will improve until there are enough frontline staff in place. I am a specialist nurse and recently visited a 27-bed ward in my trust, which was that day being staffed by two qualified nurses and an HCA with every other ward so short there was no possibility of assistance. In situations like these nothing will be achieved until staffing is appropriate.’

Overall the survey shows that, one year on, the changes discussed in the review have mostly yet to materialise. Nurses have observed some impact but, far from feeling liberated to lead improvements, largely feel constrained by staff shortages.

It would appear a national nurse recruitment campaign, which Nursing Times understands is due to begin early next year, cannot come soon enough.

As one respondent said: ‘Staff are working hard to keep the existing service running. Innovation is being stifled because, although the ideas are there, the time to implement is not. Many of those in a position to lead are filling the gaps in the service.’



Box 1: Progress report – preceptorships

The review backed the widespread introduction of one-year preceptorships for newly qualified nurses and pledged a threefold increase in investment. 

Ministers confirmed that this would mean an increase in funding from £10m in April 2008 to £30m over the next three years. As reported exclusively by Nursing Times a national framework for such schemes should be ready for roll-out by the end of the year, with a set of standards due soon after.

At the end of last month, a Department of Health spokesperson said: ‘We are developing a national framework for preceptorship and that is being led by West Midlands SHA and will be completed by the end of the year.

‘The NMC will publish standards in 2010 on preceptorships which will be used within our framework.’


Box 2: Progress report – all-graduate entry profession

The process of moving to an all-graduate entry profession had already been set in motion by the NMC prior to the publication of the next stage review.

The review itself said the government would ‘explore’ the potential impact of the shift to all-graduate registered nursing workforce while ministers awaited the outcome of the NMC’s work.

However, the Department of Health is yet to make public any of the research that it has commissioned on the issue.

At the end of last month a DH spokesperson said: ‘We are working with the NMC, strategic health authorities and other stakeholders to identify the preferred option for implementation.’

Meanwhile, the NMC is engaged in the second phase of its review of pre-registration education, which is due to be published in the autumn.

‘The first all-degree programmes are expected to be in place by September 2011 – discussions are taking place with UK government health departments to agree timescales for their introduction,’ the regulator said.

Last week Nursing Times also revealed that a national apprenticeship scheme for nursing would be introduced later this year to provide a route into degree-level nurse education for those without A-levels.


Box 3: Progress report – social enterprise

The review said it wanted to encourage nurses to set up social enterprise schemes to support the development of ‘vibrant, successful community health services’. Such schemes are independent of the NHS but commissioned to provide services by it.

The government promised to change pension arrangements to allow NHS staff who transferred to social enterprise schemes to retain their NHS pension scheme membership.

Earlier this month, the government took further action to get more NHS staff interested in social enterprises. It announced an extra £70m to be pumped into a special fund to pay for loans and grants available to support existing schemes and to help new ones start up. The government had previously invested £20m in the fund since it was set up in 2007.


Box 4: Progress report – quality performance indicators

One of the key parts of the review is the planned introduction of performance indicators, often referred to as metrics, on areas such as safety, effectiveness and compassion.  

The Department of Health launched a consultation in November on 400 possible indicators for the NHS and last month unveiled a list of 232 metrics. These, however, are not mandatory, and clinicians will be able to choose which are most appropriate for their unit or service.

Over the next three to five years more metrics will be added to the list to ‘improve depth of coverage across all care pathways and quality dimensions’, the DH said. Within the next few months, the DH is also set to publish benchmarking data that will enable comparison between clinical teams as a basis for local quality improvement.

Additionally, chief nursing officer for England Dame Christine Beasley is understood to be working on a set of quality indicators for nurses and midwives. These are likely to be based on those suggested in the State of Art Metrics for Nursing report, compiled by the National Nursing Research Unit at King’s College London.

A number of organisations, including NHS North West and the Heart of England NHS Foundation Trust, have already developed and introduced their own nursing metrics.


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Readers' comments (2)

  • I am a lecturer in nursing and have strategic and operational links with a number of NHS Trusts. There are two issues that I think need to be further investigated, the first being the financial restraints imposed by NHS Trusts who are aiming for Foundation status. It would seem that in their aim to meet the financial requirements for Foundation status one area of financial restraint is in limiting the substantive appointment of nursing staff and reducing the provision of addititonal 'bank' or 'agency' staff to ensure adequate staffing levels. It is evident that these 'cuts' are not going to be demonstrable in the financial accounts but it is the experience of senior nurses and clinical managers in trying to ensure adequate staffing levels.

    The second is in relation to the industry of some qualified staff. I have regular contact with newly qualified nurses and 3rd year students in their final placement at two large NHS Trusts and have consistently been alerted to profesionally unpalatable reports of qualified nurses in a wide range of clinical areas who feel they 'work so hard' that they are 'entitled', during their working hours, to spend at least some of that time sitting at nurses stations socialisng with colleagues. I have been in nursing long enough to know that this is fact not fable and the excuses of paperwork, telephone queries and admin tastks do not always justify the time spent at the 'nurses station'. I agree that leadership is fundamental but we also need to ensure these appointments at an operational level, that necessarily include management roles, are populated by senior nurses who have the management skill to address the day to day performance issues of staff in their remit of responsibility. Whilst I would not condone a move to a totally authoritarian approach to management there is a lot to be said, and often a high level of support from other staff ,for a manager who is prepared to challenge nurses performance, for example the nurses frequently found at the nurses station, as to what they are actually achieving in their work time. I know that I speak not only for those nurses who are frustrated by some of their colleagues attitudes and performance but also the patients and their families, of which I have personal experience of both roles, whose experience of nursing care in the NHS is sadly less than optimum.

    I know there are executive nurse leaders who are very committed to supporting senior nurses in performance managing their staff both through positive reinforcement of good practice, enhancing practice and identifying and taking direct action on sub-optimal performance, however there appears, too often, to be a hiatus between the aims of the nurse executive and the leadership and managment activity of nurse managers in the clinical areas. Perhaps nursing should be looking much more closely at what is actually happening in some clinical areas and responding professionally to the challenges of managing those performance issues that will enhance team work and more importantly patient care.
    There are so many areas in the NHS where proactive management of all nurses to ensure optimum performance results in excellent clinical standards and therefore, and most importantly, high levels of patient care and satisfaction. Perhaps it is about learning lessons and empowering those with managerial responsibility to performance manage their staff in a positive, fair and consistent manner.

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  • L’union fait la force (Unity is strength).

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