Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
"Be Healthy!" if Every Child Matters
- Woody Caan (10 December 2006)
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Mistakes all round?
- John D Temple (11 December 2006)
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Make Primary Health Care Teams Stronger and Integrated
- Professor Mayur Lakhani (12 December 2006)
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Practice Nurses say new GMS contract reduces quality of patient-nurse relationship
- Stewart W Mercer, Wendy McGregor (12 December 2006)
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Re: Mistakes all round?
- Christopher J Derrett, Lydia Burke (13 December 2006)
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Time to review rewards for practice nurses
- Liam P Benison (15 December 2006)
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The nursing equivalent of the Poll Tax - coming to a PCT near you?
- Robert Hoskins (15 December 2006)
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Woody Caan, Professor of public health Anglia Ruskin University, Chelmsford CM11SQ, UK
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It is most timely, with a growing policy emphasis on practice-based commissioning, that Derrett and Burke [1] have highlighted the widespread cutbacks in the UK health visiting posts associated with home visits to families, outreach to excluded groups (like the homeless people with TB, traumatised refugees and persecuted gypsy travellers) and community groupwork for parents and parents-to-be. This withering of a century-old skills base must be reversed, urgently. However, our research on health visiting workload shows that it is very little to do with 'patients with acute and chronic diseases'. [1] The two main roles are public health nursing (at family, household and neighbourhood levels) and positive parenting support (including safeguarding children at risk of harm). Both these roles take professional training and systems of clinical supervision to act effectively: where skilled home visiting has been dispensed with, child protection problems accumulate and fester, and early interventions for disabilities or immature parenting disappear from the health economy. The key decision for general practitioners to make, soon, is how they will work as clinicians, gatekeepers and commissioners with the new Children's Trusts responsible under Every Child Matters initiatives for children to 'be healthy' in their long term development as citizens. [2] This will determine how they employ and deploy specialist public health nurses. [1] Derrett C, Burke L. The future of primary care nurses and health visitors. BMJ 2006; 333: 1185-1186 [2] Caan W. Discussion Forum, British Journal of General Practice. 2 March 2006. http://cms.rcgp.org.uk/staging/journal_/bjgp/discussion_forum.aspx Competing interests: Unpaid public health advisor to two Children's Trusts |
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John D Temple, Part-time lecturer in general practice University of Nottingham Medical School, Nottingham NG7 2UH
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It’s a shame that the editorial on this important subject has been made difficult to follow by apparent editing errors - surely it should say primary care team in the first paragraph, not primary care trust, and primary healthcare team, not primary health care trust, in the 6th, 7th and 9th paragraphs? Health visitors play an invaluable role in supporting and advising parents in the care of young children, and over my 30 years as a general practitioner have been key members of the primary healthcare team in the care of children. It is desperately sad to see them being detached from primary healthcare teams, and the downplaying of their role makes no sense at all at a time when families and children are supposed to be a Government priority. Competing interests: None declared |
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Professor Mayur Lakhani, Chairman Royal College of General Practitioners, SW7 1PU
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The discussion about the future of primary care nursing is welcome (BMJ 2006; 333:1185-1186). General practitioners are reporting that community nurses are being distanced from existing practice based teams. Teams remain the arrangement of choice for people when working in primary health care. The break up of primary health care teams is therefore of concern and will tend to exacerbate fragmentation of care. The result is that care may be delivered by nurses according who their employer is rather than the clinical needs of a patient. The RCGP believes that a model of integrated primary health care teams, consisting of healthcare professions delivering care in the community, can best address the challenges of an aging population with an increasing burden of long term conditions and co-morbidity. Although team members may not always be co-located, they should be united through their common goal on the delivery of high quality healthcare facilitated by strong working relationships. Such arrangements will require support and effective professional leadership and communication. However current policy and financing is not geared towards this model of care. High workloads and competing priorities may make it difficult for health care workers to adopt a team approach. The RCGP urges NHS primary care organizations to adopt a policy of ensuring that both old roles (such as health visiting, midwifery, and district nurses) and new ones (such as mental health therapists and community matrons) are integrated with existing primary health care teams and primary care practices. Such an arrangement is essential to bring about a much needed improvement in the coordination and integration of care – an issue that has repeatedly been shown to be of concern to patients and one which is a crucial function of primary care. Professor Mayur Lakhani FRCGP
Competing interests: None declared |
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Stewart W Mercer, Senior Clinical Research Fellow University of Glasgow, Wendy McGregor
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Editor - The editorial by Derret and Burke[1] raises important questions about the future for primary care nurses and health visitors and the potential for negative effects on patient care. We recently carried out a small study on how practice nurses (PNs) perceive the changes in their role since the introduction of the new GMS contract. 9 PNs were interviewed individually, from practices in areas of high or low deprivation in Glasgow (upper and lower quartiles of Practices in Greater Glasgow, based on Scottish Index of Multiple Deprivation) achieving high or low points on the Quality Outcomes Framework (QOF)(upper and lower quartiles of total QOF points per practice in Greater Glasgow) in 2004- 2005. Transcripts were transcribed verbatim, and analysed using a thematic approach. The results indicate that PNs generally feel their professional roles and status are developing under the new contract. However, views on incentives (financial reward) were mixed, with many (even from high QOF practices) feeling under-rewarded. All reported substantial increases in work-load, with a much greater use of IT and with less time to spend with patients. All but one nurse (who had negotiated 30 minute appointments) felt the new arrangements damaged the nurse-patient relationship, and most nurses reported a decrease in job satisfaction. The new GMS contract has undoubtedly changed the role of the Practice Nurse within primary care, with the potential for a far greater degree of control over working practice and professional development. However, from the limited data in this small pilot study, this may be at the expense of the ‘human factor’[2]. 1.Derrett C and Burke L. The future of primary care nurses and health visitors. BMJ 2006; 333: 1185-1186 2.Mercer SW and Reynolds W. Empathy and quality of care. BJGP 2002; 52 (Supplement): S9-S12 Competing interests: None declared |
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Christopher J Derrett, General Practitioner London N16 9JT, Lydia Burke
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John Temple is correct in spotting the typographic errors in our recent editorial. We apologise for the confusion caused .A corrected version is available via email on request from the first author. Competing interests: None declared |
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Liam P Benison, Editor, Practice Nursing MA Healthcare Ltd, St Jude's Church, Dulwich Road, London SE24 0PB
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Editor – Derrett and Burke’s editorial[1] is a timely discussion of the future of the primary health-care team. It was particularly encouraging, from a nursing perspective, to see rewards included along with power and responsibility in their recommendations for reshaping primary care. Practice nurses have achieved a substantial increase in clinical skill and responsibility over the last two decades, and their roles continue to develop, but the question of rewards is more rarely discussed. The findings of Mercer and McGregor’s small study of practice nurses’ perceptions of changes since the introduction of the new GMS contract[2] suggest that it may be time for a systematic review of the way in which practice nurses are remunerated. A study published in Practice Nursing[3] provides further grounds for a such a review. Martin and Young’s snapshot of practice nurses’ terms and conditions suggests that many practice nurses have been rewarded with a small bonus for their contribution to meeting practices’ QOF targets (although many have not). The interesting finding was that bonuses appeared not to reflect hours worked, salary level, nor the QOF points achieved by the practice. Contrary to Mercer and McGregor, Martin and Young found that job satisfaction was relatively high. Full implementation of Agenda for Change has been rejected by the majority of general practice, and Martin and Young found that many practice nurses do not want Agenda for Change either. What is needed now is an in-depth, nationwide review of practice nurses’ terms and conditions, perhaps along the lines of the York Report[4], to provide evidence for achieving a fairer system of remuneration for practice nurses. Such a system should strengthen general practice by rewarding contribution to the practice and the acquisition of skills and experience. A fairer system of rewards is needed to support the continued development of practice nurses who are so vital to the primary health-care team. 1.Derrett C, Burke L. The future of primary care nurses and health visitors. BMJ 2006; 333: 1185-1186 2.Mercer SW, McGregor W. Practice Nurses say new GMS contract reduces quality of patient-nurse relationship. BMJ 2006; Rapid Response, 12 December. Available online at: http://www.bmj.com/ cgi/eletters/333/7580/1185#151335 3.Martin J, Young L. Practice nurses’ terms and conditions: A survey. Practice Nursing 17(11): 570–572 4.Atkin K, Lunt N. Nurses Count: A National Census of Practice Nurses. Social Policy Research Unit, University of York, 1993 Competing interests: None declared |
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Robert Hoskins, Lecturer Divison of Nursing & Health Care , University of Glasgow, 59 Oakfield Avenue, G12 8LW.
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Derret & Burke [1] rightly alert readers to the recent Scottish proposals to end the role of health visitors and school nurses in favour of absorbing these functions into a new generic community health nursing service instead [2]. As Amicus [3] have pointed out, the review is heavily skewed towards managing chronic disease in the community with little weight given to the important public health preventative work that health visitors and school nurses do. The decision to end 110 years of health visiting and 100 years of the school nursing service in Scotland appears ill conceived for a number of reasons. Firstly, it was only 5 years ago that the review of Public Health Nursing - Nursing for Health [4] identified that public health nurses (school nurses and health visitors) were major players in the effort to tackle health inequalities. Amongst other measures Nursing for Health recommended strengthening the public health nursing role by providing a new public health nursing course to increase capacity in deprived communities [4]. Secondly, it makes no sense at all to do away with the only branches of community nursing that specialise in upstream public health nursing when Scotland’s health is the worst in Europe [5] and health inequalities appear to be getting worse not better[6]. Thirdly, and most baffling of all, in marked contrast to the recommendations outlined in Nursing in the Community [2] we have Delivering for Health [7] published by the Scottish Executive only a year ago, advocating the continuation of the health visitor role citing the effectiveness of Public Health Nurses ‘undertaking preventative health promotion in North Ayrshire, substance misuse services in East Renfrewshire and sexual health projects for young people in Dundee’ as gold standard practice. As it appears that the health visiting service in England & Wales is being left to wither on the vine with numbers at a 12-year low [8] it is not beyond the realms of possibility that the abolition of the health visiting and school nursing service is also being considered at the Department of Health. Remember the Poll Tax – 1st piloted in Scotland, then imposed on the rest of Britain! [1] Derrett C, Burke L. The future of primary care nurses and health visitors. BMJ 2006; 333: 1185-1186. [2] Scottish Executive. Visible, Accessible And Integrated Care. Report Of The Review Of Nursing In The Community In Scotland Scottish Executive Edinburgh 2006. [3] Amicus. Response to Improving Health by Providing Visible, Accessible, Consistent Care The Review of Nursing in the Community in Scotland 2006 [4] Scottish Executive. Nursing for Health: A review of the contribution of nurses, midwives and health visitors to improving the public's health in Scotland. Scottish Executive Edinburgh 2001. [5] Leon DA; Morton S; Cannegieter S; Mckee M. Understanding the Health of Scotland’s Population in an International Context. A review of current approaches, knowledge and recommendations for new research directions. A report by the London School of Hygiene & Tropical Medicine. Commissioned and funded by the Public Health Institute of Scotland 2003. [6] Shaw M, Davey Smith G, and Dorling D Health inequalities and New Labour: how the promises compare with real progress BMJ, Apr 2005; 330: 1016 – 1021. [7] Scottish Executive. Delivering for Health. Scottish Executive Edinburgh 2005 [8] Amicus. Hewitt ignored warnings on health visitor crises. 2006. www.amicustheunion.org/default.aspx?page=3826 Competing interests: None declared |
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