More attention on nurses needed in NHS reforms

This is the Accepted Manuscript version of a Published Work that appeared in final form in Practice Nursing, copyright © MA Healthcare, after technical editing by the publisher. To access the final edited and published work see, Originally published January 2011


The government’s highly anticipated Health and Social Care Bill 2011 was published on 19 January, and ensuing debates inside and outside the health professions have been fierce. ​

The Bill proposes to abolish primary care trusts (PCTs) and strategic health authorities in England and hand over the commissioning of health services to GPs.

The result: a loss of more than 20,000 health staff jobs and the responsibility of an estimated £80 billion of public money in the hands of GPs. Questions are being asked about what this means for general practice and patient care, and where it leaves the 25,000 nurses working in general practice in the UK who appear to have been overlooked in the proposals.

Despite arguments voiced in reaction to the Bill, many agree with the overall aims of the reform, which are to give patients more choice and give the professionals most in tune with patients’ needs greater decision-making power over their care.

Every practice in the UK will need to form part of a consortium that will be overseen by the NHS Commissioning Board. Secondary care has been largely disregarded in much of the discussions.

Nor, has there been any mention of a requirement for nurse representation in the consortia, which Janet Davies, Executive Director of Nursing and Service Delivery at the Royal College of Nursing (RCN), finds disappointing. ​

‘Nurses have such a wealth of information about the population’s needs. There should be an absolute requirement for their involvement,’ she says.

However, Lynn Young, Primary Care Policy Adviser at the RCN, stresses there is also nothing to stop nurses from taking the opportunity to get involved with their practice’s consortium.

‘My biggest worry is the practice nurses who will no longer have access to PCT practice nurse leads,’ she says. ‘They’re an important resource and we need to start thinking about where we can get that function.’

In addition to issues associated with the removal of the PCTs, handing the commissioning role to GPs may pose a strain on their already limited time. If GPs are spending time in a managerial role, who will replace the hours lost? ​

It may mean more GPs; it may mean that nurses take on some of that work; but then again, it may not mean anything at all, says Ms Young, who warns against making assumptions. No one knows how much time the commissioning entails and it is highly likely it will be contracted out.

‘We’re very unclear right now but the reforms are insignificant compared to the fact that the NHS has got to find £20 billion.’

There’s no denying the immense challenge of the Government’s £20 billion efficiency savings target. Nonetheless, the concerns associated with reaching it through the avenues outlined in the Bill are difficult to ignore.

Tough decisions
GPs will become the public face of tough decisions, leaving them vulnerable to public scrutiny. Working together in consortia opens the possibility of clashing opinions and friction between GPs. Perhaps the most worrying of all, practices will choose what services they offer, competing with each other and with private organisations as the cap for private patient income is removed.

Miss Davies says she’s worried that if GPs are competing with one another, they may not want to be transparent in the sharing of information and that will have its own repercussions. ​

‘When communication is poor, you impact the quality of care,’ she says.

GPs may have the knowledge to make decisions regarding patient services, but allowing them to hold the purse strings will likely call into question the motivations behind their decision-making. The pressure for consortia to achieve budget targets and the monetary rewards for doing so may lead them to acquire the cheapest health services at the expense of quality care.

Equally, although patients will have the freedom to choose their GPs, allowing practices to decide what services they offer opens up the likelihood those services will become highly fragmented.

This is the area where Miss Davies believes practice nurses’ roles will be most affected—in helping patients navigate the system. Patients with complex health problems will find it difficult to seek out different service providers and will need direction.

‘When nurses get more involved and take on more responsibility, patient care is better because of it,’ Miss Davies says.‘But how do we make sure nurses are equal players in the game and are rewarded?

‘That’s something that needs attention.'