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Nursing in the 1990s

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The introduction of clinical grading caused chaos before Project 2000 revolutionised nurse training. Adrian O’Dowd looks back at the final decade of the last millennium

The fifth decade of the NHS saw nursing develop even faster than before and although there was less industrial dispute than in previous decades, the profession still had some major battles on its hands.

The decade began with one of the most controversial changes to nursing ever – the introduction of clinical grading in 1988.

The system moved all nurses on to grades such as D, E and F and worked on the basic idea that pay should be dictated by tasks performed rather than rigid job titles.

Its introduction was commonly seen as having been botched as tens of thousands of nurses appealed, saying they had been wrongly graded.

The system was not properly funded and there was no agreement between staff and management on the criteria for different levels of seniority.

Ann Seal, an enrolled nurse from Portsmouth, says she had an eight-year appeal against her C grading at the time.

‘I appealed with six other nurses,’ says Ms Seal. ‘In the end we had ACAS help us sort it out and they ruled in favour of us being graded higher. I got £8,000 in back pay and moved to D grade. I felt it was a matter of principle and not just about the money.’

Gail Adams, Unison’s head of nursing, who qualified in 1987, says when clinical grading came in, she was on full-time trade union relief for two years to be able to do all the appeals.

‘The overwhelming majority appealed,’ says Ms Adams. ‘Having two different sets of interpretations on definitions of “supervision” and “being in charge” didn’t help. It was divisive between staff as some people doing the same job were being put on a higher grade than their colleagues.’

It took until 2003 for all of the 100,000 claims to be dealt with.

The start of this decade was also blighted by industrial unrest as, in 1988, 26 nurses and 11 auxiliaries in Manchester went on strike over clinical grading. This was followed by a wave of strikes and protests from nurses who feared the NHS would collapse because of low pay, staff shortages and lack of investment.

Ultimately, around 6,000 nurses took part in a protest (with just 600 actually going on strike), clashing with prime minister Margaret Thatcher who said strike action was ‘hitting out deliberately at patients’.

When, in 1989, the Conservative government published its white paper on NHS reforms, Working for Patients, there was almost universal hostility from all health service unions, leading to a coalition between the RCN, the BMA, Royal College of Midwives and medical royal colleges who were all opposed to the resulting NHS Bill.

A revolution in training came with the implementation of Project 2000 – a strategy that came from nurse regulator the UKCC. The training, started in 1990, based nurse education in universities and colleges and focused training on academic preparation.

It created a common foundation for all nursing students followed by specialisation in one of four branches of nursing – adult, children, mental health and learning disabilities. A newly qualified nurse would become a registered general nurse (RGN) rather than a state registered nurse (SRN).

Nursing students became supernumerary when working on clinical placements.

It also heralded the end of enrolled nurse training. It was felt at the time that enrolled nurses were being exploited so no more would be trained, although existing ENs could remain and were ‘encouraged’ to do a conversion course to become an RGN.

Rosemary Cook, director of the Queen’s Nursing Institute, became an enrolled nurse in 1980 and did a conversion to become
a registered nurse in 1989.

‘There was a lot of pressure on enrolled nurses at the time to convert and a view that we were going to be phased out.’

When Project 2000 started to be rolled out, Ms Cook says: ‘My thought was that I wouldn’t have gone into nursing if I had to go to university.

I wanted to quickly get down to work, get on the wards and see patients, and I would have been put off by the idea I was just a student.’

The 1990s saw a fundamental cultural shift with the introduction of the ‘internal market’ into the NHS, under the NHS and Community Care Act 1990. NHS trusts were created in 1991 as part of a restructuring that made them independent bodies encouraged to compete to raise standards. Health authorities stopped running hospitals directly and ‘purchased’ care for their population from providers such as hospitals. Ms

Adams says these changes had a real impact on nursing and redundancies became common.

‘We were moving towards PFI schemes and there was a whole privatisation of NHS services agenda at that time,’ she says. ‘Our cleaning contract went out to tender.

‘When trust status came in, that led to financial problems. There were hospital closures, redundancies and job freezes. That was partly due to the internal market but also the NHS was not receiving sufficient funding from the government.’

Primary care was undergoing large change as well with the launch of GP fundholding, under which doctors had their own budgets to buy healthcare from trusts. The system was eventually dropped after complaints from the Labour Party, some doctors’ groups and the Audit

Commission that some doctors were keeping the profits for themselves in the form of massively expanded practice premises.

Practice nursing boomed during this decade, according to Ms Cook, who became a practice nurse in the community.

‘There weren’t that many practice nurses at that time but the GP contract of 1990 was the first one that began to pay GPs for doing health promotion, screening and preventive work,’ she says, which led to a boom in practice nurses.

‘As a practice nurse, I was allowed to do things I would never have been able to do in the hospital such as vaccinations, ear syringing, smear tests and immunising babies. There was much more autonomy.

‘Nurses were running their own clinics, admitting and discharging patients, prescribing, and ordering investigations like X-rays. The 1990s was the decade when a lot of “sacred ground” was claimed and trodden on by nurses that had previously been entirely medical.’

Local pay variation flared up in 1995 when trusts were allowed to give an optional extra percentage to nurses’ pay. This led to protest demonstrations and the RCN voted to drop its no-strike policy.

Post-registration and Education and Practice (PREP) was introduced by the UKCC in 1995 as the system for ensuring nurses kept up to date with their practice.

Despite all these changes, nursing was still one of the best jobs, says Ms Adams. ‘As a student, one of the loveliest areas I worked in was care of the elderly. You had time to talk to patients and get to know people. The pace of work now is so frenetic.’

‘You had more time and it was more about patient contact’

Variety and flexibility define the career of Gary Doherty, aged 37, who qualified in 1996 in Belfast and who is typical of many nurses from that decade.

Mr Doherty, now ward manager at Shaftesbury Square Hospital, part of the Belfast Health and Social Care Trust in Northern Ireland, recalls that in 1996, newly qualified nurses weren’t guaranteed jobs. After moving to Dublin to seek work, he got
a general nurse postgraduate certificate on top of his RMN qualification to broaden his work opportunities.

‘After qualifying with the general I went to work in London doing agency work. Your ordinary nurse’s wages would not bring in enough money to buy a house and the only way to do that was to go to London.’

Mr Doherty worked in London for about two years and says he was typical of a modern nurse in that he tried different kinds of nursing to get by.

‘I worked 60 hours a week for eight months and I only went out socialising five times in that time while I was in London. Everything else was put away in the bank. I had to make sacrifices.’

He returned to Belfast in 2002 and later became the country’s first designated alcohol liaison nurse – a role that won him the RCN’s Northern Ireland Nurse of the Year award in 2006.

Nursing has changed even in the 12 years of his career so far, he believes, adding: ‘Nursing is different now – it’s very driven. When
I qualified, you had more time for your patients and it was more about patient contact.

‘Being a ward manager now, it’s all about making sure my budget and staffing levels are okay, my staff training days are up to date and statistics correct.

‘I don’t want us to take our eye off the ball – patient care is the main priority. But I wouldn’t change being a nurse for the world.’

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