Submission to the Prime Minister’s Commission on Nursing and Midwifery August 2009

The Socialist Health Association was founded in 1930 to campaign for a National Health Service and is affiliated to the Labour Party. We are a membership organisation with members across the UK who work in and use the NHS. This includes nurses, doctors and other clinicians, managers, board members and patients. We have been involved in a series of debates recently about dignity and respect for patients and this submission is informed by those debates.

1.Is this commission conducted from the point of view of the NHS as an employer? Or in terms of the training and regulation of nurses? If the former then how does it take account of migration both from inside and outside the EU? If the latter then how is the rest of the UK involved? It appears some people still imagine that the NHS is a monopoly employer of nurses. This was never true.

2.Why are health visitors excluded from consideration? Does the government really have a policy on the future of universal health visiting? The response to Facing the Future was distinctly lukewarm on this point. Most PCTs seem to think health visitors are a very expensive resource and should only be used for specialist roles. There is a lot of talk about school nurses, but they still seem to be thin on the ground. In family centres, which should be jointly funded and supported by PCT’s local councils etc,. health visitors/school nurses etc should be part of the team. Targeting resources on the most at risk sounds good, but actually most deprived people do not live in deprived areas. We think there is still a need for universal visiting of young babies and that health visiting has an important role to play in what we would like to see as a more flexible team. If the pledges make in the NHS constitution about a universal service mean anything they should apply here. There needs to be urgent consideration of the development of a public health workforce to which recruitment and career progression is not restricted to those with nursing or medical qualifications. The remit of that workforce should not be restricted to babies and children, but extend to elderly people and to many more settings. Nurses or health visitors are the right and flexible professionals to provide training for carers, and public healthcare.

3.Nurse pre and post registration nurse education and continuing professional development should be based on human rights principles: Freedom, Equality, Dignity. These principles should be enshrined in the NMC code of conduct. Nurse training needs to ensure that shared decision-making with the patient is at the centre of all consultations and care management. The code of conduct should be enshrined in NHS job contracts and terms and conditions. There should be much more emphasis on dignity and the way nurses actually care for patients and relatives. It is implicit in the code of conduct but not explicit. It should be in both the code of conduct and the contract. Then the whole business of dealing with poor practice could be an employment issue not a fitness to practice issue. In that way poor behaviour in this area would be an issue for employers and need not be dealt with by the NMC.

4. We want to see a more unified framework for the regulation of all the health professions and we welcome moves to enhance the role of the Council of Healthcare Regulatory Excellence and a more professional approach to regulatory hearings. If we can provide a National Clinical Assessment Service for doctors and dentists in trouble, why can we not do the same for nurses? Has there been a proper cost-benefit analysis of this? The professions need to develop a symmetrical approach to quality, to be as ready to criticise and help root out poor practice as they are to trumpet the good. All the regulators should be focussing on raising the standards of their professions, working together through CHRE to ensure that professionals can cross over in terms of work and there is guidance from their regulators to enable this to be done safely and well, and that they provide support, guidance, standards and keep up to date with changing practice, clinical issues, research and the implications of emerging technologies for their individual professions, and then set appropriate standards, and guidance. Finally they should be making every attempt to include lay people in assessing education and training programmes, entry points on to the registrar, CPD, etc, so that patients views are taken into account. We strongly support the proposal to transfer adjudication functions of all the health regulators to the Office of the Health Professions Adjudicator and to harmonise sanctions across all the health professions regulators.

5.For nurses the way to better pay and conditions is too often to move away from nursing into management. There are very few posts for nurse consultants and there is a very widespread view that direct patient care is not well rewarded. The registration conditions encourage this. People who are no longer competent to empty a bed pan can still be registered nurses. In fact the move to an all graduate profession appears to presage a situation where nurses will no longer actually deliver care for patients. Doctors, by contrast, as Lord Darzi pointed out to the President of the Royal College of Surgeons recently, have to carry on practising if they are to be taken seriously as doctors. Management is an important part of a health service, but it should be distinguished from nursing or doctoring. We suggest that a registered nurse should be required to maintain actual clinical practice. Directors of Nursing, like Medical Directors, should still be doing the business, and be seen to be doing so by their peers. They should not spend all their time in offices and meetings. We think the possibility of making health management a regulated profession should also be given proper consideration.

6.We need a professional regulatory structure which encourages dissent, innovation and good practice and challenges the culture of conformity and hostility to whistle blowing which has become widespread. There should be clear pathways between the complaints system and referral for a fitness to practice issue and employers should be obliged to use them. In several high profile cases recently the whistle blower has been the subject of disciplinary processes while those neglecting and abusing patients were not. If there is any distinction between a registered nurse and an unregistered assistant it must be that a nurse is an autonomous professional. We don’t see much evidence that this is accepted by employers. Nurses appear to be tightly controlled by management and used to ration care, particularly in the community. It should be a very clear obligation on all nurses that they report concerns about unsafe or unprofessional behaviour and support colleagues who do so, and there should be a national agency to which expressions of concern can be directed, to give nurses confidence that their concerns will be properly handled.. Suppression of honest criticism or whistle blowing by a a nurse should be regarded as unprofessional. There is a clause in the standard doctor’s contract: “A practitioner shall be free, without prior consent of the employing authority, to publish books, articles etc., and to deliver any lecture or speak, whether on matters arising out of his or her NHS service or not.” We think a similar term should be included in the contracts of nurses and all other registered health professionals. Nurses should have adequate professional and legal protection to ensure their central role of maximising the quality of care for their patients and other health clients.

7.There should be clear developmental pathways for people to move from less qualified roles to more qualified roles but the assumption that hospital nurse training is the bedrock of all professional competence may not be sustainable. As the workforce becomes more diversified that assumption is less justified. If the much heralded shift of care out of hospital into the community ever happens then we will need very different skills, development pathways and approaches to the work, and it may no longer be appropriate for the vast majority of nurses to train in hospital. So, for example, we cannot see why health trainers could not progress to be health visitors without having to be trained in clinical skills which they won’t use. It should be possible for staff to move from one field to another if there are transferable skills. All clinical practitioners should have access to specialisms once their core skills and competencies have been assessed. We think a common basic education for all clinical professions would have a lot to be said for it.

8.The situation of nurses varies with the context in which they work. Nurses in acute hospital medicine lead very different lives from mental health nurses in the community. There are particular problems in mental health nursing. The unique contribution of the nurse is difficult to identify, and it is not obvious where the line is between health and social care or other therapies. Nor is it obvious that the distinctions are important as the NHS Careers website asserts that “Your main tool as a mental health nurse will be the strength of your own personality “. All health professional training needs to be in the context of the indivisibility of social and health factors in achieving “wellness”. Nursing is the profession that always crosses these boundaries.

9.Pay is relevant. Nurses are asked to do what doctors used to do because they are cheaper, and ancillaries are asked to do what nurses used to do likewise. Of course they may also do it better, but the motivation for the organisation is usually economic, not quality. We think pay should be based on the expertise and quality of what is delivered and not on some assumed professional competence through the possession of a prior qualification. Nurses do not seem convinced that even within their own profession this is true, and it is not clear that Agenda for Change has standardised promotion, job grading, recruitment & selection or training opportunities. Both quality and cost effectiveness are affected by excessive use of agency and bank nursing and by inappropriate decisions about skill mix. It is always possible to save money in health care by substituting highly skilled and expensive staff by people who are cheaper and less skilled. Our payment systems need to reward the quality which is a result of a more stable workforce. We hope the development of patient reported outcomes will provide an incentive to improve the quality of nursing and we look forward to their extension into community services including health visiting. Until that happens we think that the ratio between registered and non-registered nurses, and the difference between the nursing establishment and the number of nurses actually present should form part of quality monitoring systems.

10.Hospital nurses don’t seem to spend much time actually nursing. The Productive Ward programme (which we welcome) claims success in increasing the proportion of nurse time spent caring for patients from 40% to 50%. That is a step in the right direction – but what are they doing the rest of the time? According to our members’ reports, filling in forms and writing notes – but not reading the notes made earlier. As with some other professions it appears that nurses spend a lot of time feeding the computer’s demand for information, but that the technology does not help them to do their job. Nursing Informatics in the NHS seems to be in its infancy, and encouraging investment in this area seems to be one of the most useful things the Commission could do.

11.Teaching hospitals should offer research options for nurses, and universities should do the same for community services.