Tens of thousands of nurses working in primary care are to be transferred to hospital and mental health organisations within the next six months.
By the end of March 2011, primary care trusts must split their commissioning from their provider arms. Research by Nursing Times’ and sister magazine Health Service Journal shows that nearly half plan to merge with acute or mental health trusts.
You have to ask, ‘what do the [hospital] leadership know or understand about community services?
Analysis of the plans for 149 PCT provider arms show 39 have been pencilled in for transfer to acute organisations and 31 to mental health trusts.
The moves mean primary care nurses, district nurses, health visitors and midwives will face radical changes in their working conditions and managerial culture.
A PCT director of nursing told Nursing Times the worst outcome would be merging with a weak hospital trying to “prop up” its foundation trust application by absorbing primary care services.
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She said: “Nurses recall community services [in previously integrated trusts] having to bail out overspending bits of the acute [hospital].
“You have to ask, ‘what do the [hospital] leadership know or understand about community services? Are they humble enough to learn?’ The sector has moved on a lot and the politics is often different. There is not the hierarchical relationship with consultants.”
She said community nurses enjoyed strong professional relationships with GPs, voluntary sector organisations and council social care providers. But there was a danger those relationships would be supplanted with an overly medical model of patient care, especially in acute hospitals.
Nursing Times has been told that most community nursing staff would prefer to see their organisations become community foundation trusts. Thirty three of the 149 plan to do that. The second most attractive option would be a merger with a mental health trust.
The PCT nursing director said: “Mental health trusts have quite a small bed base already and their philosophy is to keep people out of hospital.”
Community services and mental health trusts also use the same RiO patient record system.
Royal College of Nursing policy director Howard Catton said there would be challenges in adapting but also opportunities.
“With the right clinical leadership these [challenges] are surmountable,” he said. Changes in the hospital tariff to prevent hospitals from being paid if patients were readmitted too soon after discharge could help underline for acute hospital managers how important high quality community services were.
However, acute nursing leaders would find community nursing practice very different to manage.
“You have a workforce that works out often, works alone, you are not going to see them as much,” Mr Catton said.
There could be “questions” and power struggles over which nursing team - the community or acute - retained the senior nursing positions at each merged organisation, he added.
Despite ministerial support for the social enterprise model, community providers have largely shunned this idea, with only 16 provider arms opting to take that route.
The model had been seen by some as the best opportunity to create nurse led organisations. A well known example is Central Surrey Health, which was set up in 2006.
Central Surrey Health co-director Jo Pritchard spoke at the Conservative party conference last week and Andrew Lansley has spoken of turning the NHS into “the biggest social enterprise sector in the world”.
The union Unite welcomed the low social enterprise take up.
Professional officer for health Dave Munday said: “We’re pleased the majority of organisations are remaining in the NHS. A grave concern is that they [social enterprises] are a very large step towards privatisation.”
The RCN’s Mr Catton said: “At the moment there doesn’t appear to be the appetite on the ground for social enterprise that there is politically.
“All credit to Central Surrey Health for what they have achieved - but let’s not believe that great clinical leadership and patient engagement can only be achieved through social enterprise.”
Queen’s Nursing Institute spokesman Matthew Bradby said: “A very diverse picture is emerging. I don’t think we should be too surprised to see relatively few social enterprises in the picture. Not everyone will want to launch a new venture during a period of such economic uncertainty - but nurses who do establish social enterprises deserve to be well supported to give them the best chance of success.”