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More power to practice nurses

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As a new wave of large, independent providers competes for GP contracts, Richard Staines looks at the future for practice nurses

In february practice nurses finally received official confirmation about something they had all known for years – that they were doing more work for less pay.

A National Audit Office report showed that England’s practice nurses were doing 34% of consultations in 2006, compared with 21% in 1995. At the same time, figures gathered by the government-funded Personal Social Services Research Unit found that the basic salary of a practice nurse had fallen by 9.6% – from £23,355 in 2005 to £21,118 in 2006.

The findings come at an uncomfortable time for GP businesses – a time when they face increasing competition from larger independent sector health firms for both contracts and staff.

Just last month UnitedHealth, the US independent healthcare giant, has taken over running three GP practices in Camden, London, which followed its earlier acquisition of two GP practices run by Derby City PCT.

There are other newcomers to the market too. ATOS Origin, formerly an IT firm, has taken over a GP practice in Tower Hamlets, London, and there are other smaller firms competing for GP service contracts.

But what exactly are these firms like to work for as a practice nurse?

Some nurses claim they can be better employers than GP surgeries. Kate Howie, clinical lead at UnitedHealth UK and chairperson of the RCN’s practice nurse forum, says: ‘For many years I have been saying that practice nurses need decent terms and conditions and job descriptions. We really need to be recognised for the work we are doing.

‘Where I am working now, I am delighted to say that is what our practice nurses receive.’

UnitedHealth offers Agenda for Change terms and conditions to all of its practice nurses. Those who are starting out begin on band 5, while senior practice nurses are on band 7 to 8a.
Staff working for UnitedHealth also receive at least five days’ training leave each year.

So how does this compare with GP-owned practices? Anecdotal evidence suggests that terms and conditions are variable.

Because GPs are themselves small independent employers who are sub-contractors to the health service, they are under no obligation to sign up to AfC.

This means practice nurses may not receive pay rises every year, even though average GP pay has soared since the introduction of their new contracts in 2003.

Sara Richards, practice nurse at Berkshire East PCT, says: ‘I don’t think the majority of practice nurses are on Agenda for Change or receive increments.

‘There are some very good practices that will listen to practice nurses. But there are a lot of practice nurses who don’t feel they can ask for more because they are happy with the part-time hours the job affords.’

And this situation does not look set to improve. Last year, government funding for GP practices did not increase, which resulted in less money being available for practice nurses, and this year, the amount of money given to GP-owned practices is set to increase, on average, by just 0.2%.

Sue Nutbrown, former chairperson of the RCN’s practice nurse forum, says: ‘[Lower pay awards] have eaten into practice profits. The practice nurses who are not on Agenda for Change have to do a lot of negotiation on pay rises.’

The disparate nature of practice nursing means that many are left to their own devices to negotiate with GPs on pay rises.

‘It is really difficult. It is not something that they are trained to do. The RCN forum does try really hard to give nurses the tools to give them confidence to do their own pay deal but it is not easy,’ she says.

But the new wave of independent providers may offer good career development opportunities for nurses. A trend for more work to be done by practice nurses will be more pronounced in independent providers, Ms Nutbrown predicts.

‘With independent providers, I think nurses will be doing a lot of the work that GPs would previously be doing, with GPs there for more complex medical-type issues,’ she says.
Ms Richards backs the idea of different primary care providers but adds that good GP-owned practices still have a lot to offer in terms of career development.

At the Cranborne Practice in Dorset, Susie Cooper has recently been promoted from practice nurse to sister and now has a role almost identical to that of a modern matron, except without the prescribing powers.

She says: ‘I look after vulnerable patients in the GP surgery, with regard to their medical, social and psychological needs. This morning I did a wheelchair assessment and I do minor visits for the GPs. My work is all about trying to support people and keep them out of hospital.’

She adds that GPs at the surgery are receptive to her ideas and opinions. ‘We have wonderful GPs here who are supportive. If I make recommendations about something that needs to be done, they listen to my ideas. Everybody works as a team, right from the bottom to the top.’

One of Cranborne’s practice nurses Laura Liddiard says another of the practice’s strengths is its use of its nurses in the triage system. Following an initial GP telephone consultation, the nurses then deal with appropriate cases.

‘We have all done additional training,’ explains Ms Liddiard.

‘Most patients are happy with this because they get more time – they get 10 minutes with us, compared with five minutes with the GP,’ she adds.

Ms Liddiard also carries out routine medical procedures and consultations. She says: ‘It is mainly about chronic disease management – asthma, diabetes and spirometry but we also do baby immunisation, travel vaccines, well-woman checks, well-man checks and contraceptive advice. And we help with minor surgery, like the removal of lesions, skin tags and cysts.’

Clearly good development opportunities are available in both types of practices. As Ms Richards says: ‘I think it is no bad thing to have several ways in which a practice nurse can be employed because it promotes choice.’

But not everybody is as convinced that independent providers will ultimately be good for nurses.

Jim Fagan, chairperson of the pressure group Keep Our NHS Public, says: ‘In the short-term, companies want to enter a market and to attract staff they need to provide excellent terms and conditions. In the longer term, this may be different,’ he warns.

Large, independent providers are new to the market and it is unclear what impact their presence will cause. But one thing is clear – GPs who are not competitive and fail to provide decent terms and conditions could face losing key nursing staff.

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