Although practice nurses are taking on more consultations and responsibilities than ever before, their pay rises have been minimal while GPs’ profits have rocketed.
Jo Carlowe says it is time nurses were fairly recompensed for their invaluable contribution.
‘GPs are doing quite nicely, thank you very much, because they have become great negotiators. We need to become red-hot negotiators too.’
This is the message from Lynn Young, the RCN’s primary care adviser. She is referring to the contentious issue of why, since the introduction of the new general medical services contract in 2004, GPs appear to have done so well, while nurses have not.
Since the contract was introduced, GPs have enjoyed substantial pay rises. By contrast, the only increase reported by most practice nurses is one in workload.
A report published by the Commons committee of public accounts last month shows that GP partners’ pay has increased by an average of 58% since the introduction of the GMS.
The average pay of GP partners increased from £73,000 in 2002–2003 to £114,000 in 2005–2006. Over the same period, practice nurses have received only inflationary rises, while their workload has increased. Figures from the NHS Information Centre show that nurses undertook 21% of consultations in 1995 and 35% in 2007.
On average, a practice nurse performs 60 consultations per week, compared with 87 by GP partners, and they are now carrying out more routine consultations such as asthma and diabetes reviews. At the same time, GPs have seen a reduction in their working week. A National Audit Office report in February showed that GPs worked an average of 35.9 hours per week in 1992–1993 and 36.3 hours in 2006–2007. However, when out-of-hours work was factored in, GPs were found to work 7.2 hours per week less than in 1992.
The NAO says the large increases in average pay for GP partners has arisen not only from increased practice income but also from a smaller increase in expenditure. The report says it is not known whether the reduction in expenses is due to ‘GP efficiency or reduction in spending in the practice by GPs’. It adds that the average practice nurse income has been reduced in real terms, while salaried GPs’ income has increased by only 3%. The inference is that GP partners are enjoying a higher income at the expense of their practice staff.
Certainly, this is how a number of MPs have interpreted it. Addressing the Commons committee of public accounts, Austin Mitchell MP said: ‘They [GPs] are making more profit because expenses are down… the practice nurses are working harder; they are being exploited so the practice can make a profit.’
Ian Davidson MP was even more outspoken. ‘The evidence here is that nurses are now worse off in real terms. In the first two years, salaried GPs got 1.5% and the partners filled their boots and every other orifice with gold,’ he said.
Unions have long been calling for practice nurses to be paid at rates comparable with those of Agenda for Change. Gail Adams, Unison’s head of nursing, says: ‘They can no longer be allowed to profit on the backs of their hard-working staff.’
At the sharp end, such disparity is leading to much ill feeling. A University of Glasgow study published in the British Journal of General Practice last month reveals ‘considerable disharmony’ among practice nurses because of a perceived inequity between workload and remuneration.
Typical comments from the practice nurses surveyed included: ‘They [GPs] got financial rewards for a lot of the work that has been done by nurses.’
Indeed, although around one-third of interviewed nurses had been promoted to a higher grade since the GMS contract was introduced – which would mean they had higher salaries – incentives were often thought to be diminutive compared with the money awarded to the practice for quality and outcome framework (QOF) points attained. Moreover, not one nurse questioned had been offered the possibility of becoming a partner, despite this being allowed under the new contract.
While nurses talked about increased autonomy, this was within patient consultations rather than in the reorganisation of workloads, which remained under the control of GPs.
The authors warned that, unless tensions were resolved, effective teamworking would be difficult to achieve.
So how has this situation come about and what can nurses do about it?
Put simply, the situation exists because there is no mechanism to prevent it. The pay of GP partners is based on practice income when all deductions, including practice nurse salaries, have been made.
In negotiating the contract, the Department of Health placed no cap on the proportion of income that GPs could take as profit, which has contributed to the discrepancy in pay. The DH claimed its hands were tied as GP practices are classed as independent businesses so it is up to the partners to determine how much money can be taken as profit. As a result, practice nurses often feel that no one is fighting their corner.
‘The unions have no teeth as far as general practice is concerned. GP employers do as they like,’ says one nurse, who has more than 20 years of experience.
‘It’s about time the unions joined together and backed this properly. The unions don’t support us as well as they could, nor does the nursing leadership,’ says a 53-year-old nurse practitioner from Yorkshire.
Ms Young explains, however, that it is impossible for the unions to represent all 20,000 practice nurses in their individual practices. ‘There is no national negotiating system for general practice,’ she says.
Agenda for Change has gone some way in trying to create parity but only 75% of practice nurses are signed up to this, the RCN’s 2007 employment survey shows.
Dr Richard Vautrey, vice-chairperson of the British Medical Association’s GPs’ committee, told NT that any attempt to make Agenda for Change mandatory would require additional resources, which seems unlikely in the current financial climate.
None the less, nursing unions are in discussion with the BMA with the aim, says Ms Young, of ‘helping GPs to become better employers’.
And Ms Adams says Unison is pressing for PCTs to be more aggressive in their commissioning and in requiring GPs to demonstrate that their pay levels for nurses are comparable.
Ms Young believes the battle cannot be won by the unions alone. She says nurses need to help themselves by ensuring that their voices are heard and by letting GPs know what value they bring to the practice. ‘Not all 20,000 practice nurses are miserable,’ she says. ‘Some nurses have achieved very satisfactory terms, with the best practices dividing profits between all their staff,’ she adds.
Six steps to negotiating a better deal
GPs, in the meantime, refute many of the claims that have been levelled at them.
Dr Vautrey says that, rather than working longer hours, nurses are now working in different ways with greater freedom, and that GP partners are mindful of ‘incentivising staff’. ‘In a competitive market, it is in their interest to retain their staff,’ he says.
Moreover, he adds that the apparent discrepancy between GP and nurse pay will now be less, as the figures are two and a half years out of date.
‘Individual [GP] incomes have fallen by 8–15% from those headline figures. One of the reasons for this is that practice expenses are rising largely because of increases in staff pay. So, while nurses may not have received the very large rises that GPs saw in the last three years, pay would have increased at the same time as GP pay was falling. When the new figures are published in another two years, you will see a levelling out of the disparity between nurses’ and GPs’ pay.’
In its evidence to the committee of public accounts, the BMA also refuted claims that GPs were failing to invest in their staff, noting that in 2004 when the GMS was introduced, staff costs increased by ‘a fairly significant’ 17%.
‘The areas where expenses grew slowly or fell were business expenses and car and travel costs, together with depreciation on capital assets. GPs value their hard-working staff and have honoured the pay increases put forward by the national body that decides nurse pay,’ the association said.
GPs are also keen to point out that it is the GP partners, not nurses, who carry all the financial risk.
Dr Vautrey, emphasises that, while some practices have linked staff bonus schemes to QOF points, QOF income can drop as well as increase.
‘That is what has happened to GPs. So this becomes less palatable when linked to those types of risks,’ he says.
This issue of risk was raised in evidence to the committee of public accounts by Professor David Colin-Thomé, a GP and national clinical director for primary care at the DH.
‘You might want to quibble about the percentage of extra money but, if you are running a practice in times when it has not been as good, the partners would not get any gain at all, whereas the salaried employees like nurses would, because they were on a salary… Running the business is not an easy pattern – it is not always profit. In the past, we have had staff who decided not to be partners when offered,’ he said.
Perhaps it is true that nurses are not natural risk-takers – but Ms Young says practice nurses can afford to risk asking
‘I get calls from nurses who feel mistreated but, once they have gone to the partners, they have achieved a bit of success,’ she says.
‘Sometimes nurses are more nervous than they need be. Practice nurses should not allow themselves to be seen as victims.’
‘I WAS ALWAYS EXCLUDED FROM THE PRACTICE MEETINGS WHEN THEY DISCUSSED MONEY’
Jane Smith*, 51, works for a GP out-of-hours provider and as a bank practice nurse for a PCT. She has over 20 years’ experience as a practice nurse but left GP employment three years ago.
‘When I was a nurse team leader in a GP practice, I was always excluded from the parts of the practice meetings where they discussed how much money the GP partners were making.
‘The nurses were working extremely hard towards the chronic disease management targets as well as taking over the INR monitoring, including dosing patients, but we were expected to undertake training in our own time.
‘There was brief discussion about incentive bonuses for hitting QOF targets for the nurse team but this never got further than the discussion stage. The GPs were grabbing payments for the QOF targets while practice nurses were putting in all the hard work to earn it.
‘The GPs were not even prepared to pay us nationally agreed pay rises and I never managed to negotiate Agenda for Change terms of employment.
‘I have no idea why GPs are allowed to get away with this stance but I think many are so arrogant that they do not even see the need to justify their position.
‘GP employers do as they like and, sadly, nurses are often their own worst enemies. They need to stand up and be counted.
‘However, my refusal to back down resulted in my GP employer deliberately making my position untenable. I was able to vote with my feet and get another job. Some nurses are not in a position to put themselves at risk of losing their jobs by speaking out.
‘When they are not the employer, generally speaking, GPs are fine but, as employers collectively, sadly they cannot be trusted to be anything other than draconian.
‘I would not consider working in general practice again.’
*The name has been changed to protect this nurse’s identity.