As Jeremy Hunt settles back into his role as health secretary, with a new cohort of health ministers to assist him, some of his ideas for transforming the NHS have been heavily debated.
Both Mr Hunt and prime minister David Cameron have said that they would like the NHS to become a seven-day service with practices open from 8am to 8pm.
In his returning speech as health secretary, Mr Hunt said that he wanted to 'prioritise out of hospital care.' He said 'we need a step change in services offered through GP surgeries, community care and social care. That is my mission, and I know it is the mission of the whole NHS too.'
One of those step changes is to create a system where patients can visit a GP practice on any day of the week. The logic behind this is that people do not stop being ill at the weekend, so services need to account for this.
However, this announcement was meant with derision from a number of senior healthcare figures. They have asked the politicians to think carefully about how they will plan for seven-day services when the primary care workforce is already
over-stretched.
Dr Chand Nagpaul, chair of the British Medical Association's GP committee, said: 'Ministers must halt their surreal obsession for practices to open seven days when there aren't the GPs to even cope with current demands. This would damage quality care by spreading GPs so thinly and will reduce GP's availability for older vulnerable patients. The newly elected government must wake up to this alarming reality not only because it will fail dismally in its manifesto pledge for 5000 extra GPs, but crucially because unless it turns this around we won't have a comprehensive general practice service in parts of the UK.'
While Dr Nagpaul speaks exclusively about GPs, the reality is that practice nursing is facing very similar pressures. Around 45% of the nursing workforce is over 45 1 meaning that many general practice nurses are heading for retirement soon. There has been a decrease of 3000 community nurses and a decrease of 4000 specialist nurses since 2010.1 Many of the nurses who do remain in practice are working at their limits.
Between 1995 and 2009 the number of consultations in general practice has jumped from 3.3 million to 21.9 million consultations.2 Data for general practice consultations has not been collected since 2009. Despite these numbers there was no mention in Mr Cameron's speech of increasing the practice and community nursing workforce. In fact, practice nurses did not feature at all in Mr Cameron's first speech as re-elected prime minister, despite him talking about general practice.
Practice nurses on Twitter expressed their dismay that the prime minister had omitted a key part of the primary care workforce from his speech.
Heather Henry, co-vice chair of the NHS Alliance, tweeted that 'primary care needs to evolve as a system and not just rely on (fab) GPs'.
Janet Gower, a nurse practitioner, said that 'we need a national programme and there are too many different things occurring over the country'.
The Royal College of Nursing (RCN) 'supports moves to ensure that any patient care is of the same standard at 9am on a Sunday morning as 9am on a Tuesday morning. To make this a reality, the health service needs sufficient resources to be able to provide enough staff when they are needed. This includes all nursing, diagnostic, imaging, medical and support services. We look forward to working with the government to identify what is needed and ensure that the NHS is safely staffed 24 hours a day, seven days a week.'
Paul Vaughan, the regional director of RCN West Midlands, says it is interesting that Mr Cameron was willing to put a number on GPs but not on the number of practice nurses needed. 'I think some of that is about what do people and politicians really understand about what nurses do, the value they bring and the difference they can make. We know that if you invest in highly-skilled nurses they will deliver an effective and efficient service for people. I would challenge that if [politicians] can be clear about the numbers of doctors [needed] they can be clear on the number of nurses.'
Mr Vaughan also says it is important that we look at the real reasons behind the proposals for seven-day services. 'One of the challenges is that there is no universally acknowledged definition of what seven-day services means. Some of the issues of the debate came from the Francis report on Mid-Staffs when he highlighted low staffing at the weekends in hospitals. With any of this kind of work, you can't then look at one part of the service because we have to take a broader view, which is why people are talking about the impact on general practice. We already know there is a challenge for people to get access to general practice. So it's quite right that we need more GPs but GPs don't work in isolation they work with registered nurses who ultimately deliver a bulk of the care in any general practice.'
Kirsty Armstrong, a senior lecturer and practitioner in primary care, agrees. 'Politicians do not consider [practice nursing] a specialist nurses role, but it is a general specialist role. You can't take a nurse from the hospital and put them in general practice without training them and vice versa. Practice nursing is so much more than just bandaging and things like that.
'I heard from someone that they thought that district nurses and practice nurses are interchangeable. This shows quite clearly that there is a lack of understanding of the practice nurse role.'
Professor Chris Ham, the chief executive of the King's Fund said that he believed seven-day services were 'the right thing to do.' However, with the caveat that politicians need to make sure that there is the money and the workforce to make this happen.
However, when the idea was first put forward, Peter Carter the chief executive of the RCN, stressed that increasing hours could lead to more industrial action from nurses.
He told The Independent that attacks to unsocial hours pay would be the 'red line' for nurses.
Mr Hunt responded saying that they had not yet set the terms and conditions for nursing pay for seven-day services. Speaking on Today on Radio 4, he went on to explain that in order to improve services 'we need to look at the skill mix of general practice.' He said at the moment GPs are doing things that could easily be done by nurses such as blood tests and test results. He did also say that there needed to be 'more nurses in practices to balance out the skill mix'.
Other politicians have also weighed in on the debate. Norman Lamb, the former Liberal Democrat health and social care minister, claimed that David Cameron's plan could not happen without increased funding.
Politicians and the public are still so unclear on the role that practice nurses have in general practice that their role is often ommitted when discussing the future of general practice.
There is national recognition of the shortages of GPs, yet very few people seem aware that the same challenges face the practice nursing workforce. If this is recognised and rectified, general practice just might be able to function the way Mr Cameron envisages it.
| Commentary |
| Professor Matt Griffths, advanced nurse practitioner and lecturer 'The current out-of-hours services struggle for staff at certain peak times. This includes not only doctors but paramedics, nurse practitioners and of course support staff. I think seven-day general practices are an ideal but someone has to pay for the staff, and nurse practitioners will be key members of the team. I do hope the government considers this when it comes to reviewing pay.' Lou Patten, chief officer at NHS Aylesbury Vale CCG and district nurse 'Practice nurses, with all their skills and experience of chronic disease management provide the backbone of support to patients in primary care – and we will need them to support seven-day working, so recruitment is an absolute must if we are to achieve our strategy for building out of hospital care.' Sir Sam Everington, GP Bromley-by-Bow partnership and chair of Tower Hamlets CCG 'It's more complicated than looking at just one profession in the workforce. The answer is to train up as many groups as possible to carry out many different jobs.' Rob Webster, chief executive of the NHS Confederation 'A move towards seven-day services for the NHS will provide a better, safer and more responsive experience for patients and could lead to a more efficient use of NHS resources. To achieve this, a wider culture change across the NHS is needed, in addition to resolving the financial, workforce and service design challenges.' Dr Nav Chana, chairman of the National Association of Primary Care 'Any increase in the number of GPs must be accompanied by more sophisticated approaches to recruitment and retention, as well as a fundamental review of the model of care in which GPs operate.' |
1. Frontline first The fragile frontline. The Royal College of Nursing. http://royalnursing.3cdn.net/9808b89b8bfd137533_krm6b9wz7.pdf. Accessed May 2015.
2. Trends in consultation rates in general practice 1995-2009. Health and Social Care Information Centre. http://www.hscic.gov.uk/pubs/gpcons95-09. Accessed May 2015.