VOL: 97, ISSUE: 46, PAGE NO: 34
Jennifer Banks-Smith, BA, is project officer
Steve Gillam, MD, FRCP, is director, primary care programme;Cathy Shipman, MSc, BA, is research fellow, all at the King's Fund, London.Therese Dowswell, PhD, BSc, was senior research fellow, National Primary Care Research and Development Centre, University of Manchester, at the time of 'writingWhen primary care groups (PCGs) were established, the intention was that primary and community health care workers, including nurses, would be at the heart of the initiative, influencing decision-making and implementing change.
When primary care groups (PCGs) were established, the intention was that primary and community health care workers, including nurses, would be at the heart of the initiative, influencing decision-making and implementing change.
After more than two years, we thought it would be useful to reflect on how PCGs and primary care trusts (PCTs) are affecting nurses in primary and community care settings. To do this we have used data from the national tracker survey (Wilkin et al, 2000; 2001).
Nurse board members
The first PCGs had either one or two nurse board members, along with GPs, a social services representative, a lay member, a chair and a chief executive. As PCGs evolved into PCTs, nurses and the other board members were included on the trusts' professional executive committees.
The first tracker survey (Wilkin et al, 2000) obtained 106 completed questionnaires from a sample of 144 nurse board members (a response rate of 72%). Most believed that they offered a broad nursing perspective, rather than representing the interests of their specific nursing group. This contrasted with GP board members, who tended to see their role as representing the interests of GPs or their particular practice (Smith et al, 2000).
Most of the nurse board members in the sample were community nurses, who outnumbered practice nurses by three to one. Most were also women, yet they felt strongly that they represented all their nursing colleagues, regardless of their position or background.
Their combined experience was broad, including areas such as health service management, pharmacy, dentistry and social services. The sample also included nurses working in both the public and voluntary sectors.
Nurses are expected to inform and shape the decisions that PCGs and PCTs need to make to carry out their main functions. We found that many nurse board members believed that they could make a significant contribution to decision-making.
Asked what particular qualities they brought to the board, many replied that their experience and knowledge of a wide range of health care settings was of most value. The following quote illustrates what many expressed: 'I have the grassroots experience of the general public's expectations and needs. [I have the] ability to communicate well with colleagues. [I] appreciate the importance of health as opposed to health care. [I am] willing to ask questions, even if I feel I may look silly or ignorant.'
However, when asked if their qualities and experiences were used appropriately, only two-fifths of the sample felt that they were.
Although most nurse board members received a salary in recognition of their service to the PCG and said they had the support of their managers, two-thirds found it difficult to combine their nursing jobs with the work required by the PCG. This is supported by the results of a Nursing Times survey, in which 92% of respondents reported that they struggled to fit in their PCG work (O'Dowd, 2000).
In spite of being overwhelmed by the workload, many nurse board members had made a concerted effort to inform and consult with practice and community nurses through local meetings and newsletters, giving those working in clinical roles a voice.
In the first survey, very few nurses held senior office on PCG boards. No nurse board members were chairs and only two nurses were vice-chairs. The Health Service Journal reported last year that there were two nurse chairs nationally.
The second tracker survey found that one nurse board member held the position of chair on a PCT's professional executive committee. None the less there is evidence of increased involvement and integration of nurse board members throughout the various sub-groups and committees of the PCG/Ts (Box 1).
The most notable integration was in clinical governance. Nurses were either sole or joint leads of clinical governance sub-groups in many areas (Table 1). Lead responsibility was often shared with a GP, but in one case two nurses worked together as leads. Most PCGs had nurse representatives on their clinical governance committee or working group. However, clinical governance was still considered to be GP-dominated (Sweeney et al, 2001).
Very few nurses were leads in health improvement, which is surprising considering its implications for nursing workload and roles. For example, as part of their health improvement remit, many groups and trusts were carrying out health needs assessments and implementing smoking cessation initiatives, both of which require nursing input.
Commissioning leads reported that practice and community nurses were represented on their commissioning sub-groups (Table 2). Seventy-five per cent of the leads believed that nurses had been consulted on the commissioning of community health and hospital services.
With the introduction of nurse prescribing and rising numbers of nurse prescribers, nurse involvement in this area of PCG/T activity had increased (Skinner and Savage, 2001). However, in our sample no nurse board members were prescribing leads.
Provision of nursing services
The shortage of nurses, both nationally and in primary and community health services, is an ongoing problem. The government has set ambitious targets to combat such shortages. Most groups and trusts considered nursing staff to be a high priority for investment and had tried to tackle workforce issues by employing nurse practitioners and developing nurse specialists. Table 3 shows the proportion of groups and trusts at varying stages in workforce development. However, 18 had yet to plan any such initiatives.
The schemes set up to enhance the integration of community and practice nursing include joint meetings, training, shared records and common management. Others that aim to promote integration include:
- Common membership of PCG working parties (services/staff development);
- Shared participation in public education evenings - for specific conditions such as asthma;
- Strategic reviews of the workforce to improve training and retention;
- Nurse forums (monthly meetings);
- Monthly meeting with allied health professionals;
- Shared assessments and treatment.
The chairs described a range of similar initiatives set up by groups and trusts (some already under way and others still in the planning stages) to integrate the nursing workforce. However, while joint meetings and training were a regular occurrence, relatively few practice and community nurses had common management structures. Few areas had joint community/primary care records and this may act as a stumbling block to closer integration and more coordinated nursing care.
Nurse-led services were being used to improve patient access by 41% of the trusts and groups surveyed, and a further 29% were planning to initiate such services. Nurse-led services delivered across more than one general practice also increased access.
Although many community nurses have worked in more than one practice for many years, groups and trusts are actively increasing this form of collaboration. For example, in 51% of the localities covered in the survey community psychiatric nurses (CPNs) were working across practices. Plans to introduce or extend this practice had been made in a further 16 areas. PCG/Ts had initiated these developments in 23% of areas.
The social services board members indicated that there was little partnership between local authorities, district nurses, CPNs or any other community nurses. This is particularly apparent in the relocation and reconfiguration of teams or through transfers and secondments. There was also little evidence of changes in terms and conditions, roles and responsibilities within partnerships with social services.
The NHS Plan (Department of Health, 2000) set the target that all PCGs should become PCTs by 2004. One of the PCTs' main functions is to provide primary and community health services. For those moving to trust status the main motivation was to further integrate primary and community health services. Other reasons are cited in Table 4.
Of the six PCTs in our random sample, two provided district nursing and health visiting services, but none provided CPN services. These trusts employed 28-150 nurses (averaging 81 nurses per PCT). Three out of the six trusts considered the staffing levels for nurses inadequate. Twenty-seven PCGs employed nurses. However, the maximum number directly employed was two.
The tracker survey provides evidence that investment in nursing is considered a high priority for PCGs and PCTs. At the same time, current staffing levels are thought to be inadequate, even in PCTs employing more than 150 nurses. Many groups and trusts are planning a range of nurse-led service developments and many initiatives are under way to promote increased collaboration between GP practices through the provision of nursing services.
Primary care groups and trusts are in a relatively early stage of development and it is encouraging to see that nurses working in these organisations have integrated themselves well throughout the various sub-committees and working groups. Nurse board members who participated in our survey have taken lead roles in clinical governance and health improvement.
However, progress has been more limited in some areas. None of the nurses in our sample had lead responsibilities in sub-groups in the areas of commissioning and prescribing, and only a few were in senior positions on the boards.
Many nurse board members struggle to manage their PCG or PCT work alongside their clinical and other responsibilities. As they gain experience and confidence in combining these roles, the strain may be reduced. Nevertheless, nurses need training and support to enable them to maintain and develop their roles in PCGs and PCTs. They can make a real contribution to decision-making and primary health care policy development.
Nurse board members have the opportunity to represent nursing interests and to act as advocates for the populations they serve. It is important that they have the support they need to allow them to contribute fully to board discussions.
The first article in this series appeared last week