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Primary Concerns

4 December 2014

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Primary care workers feel the quality of patient care has worsened in the last 18 months according to research carried out by Cogora, publishers of Management in Practice. 

Data from our annual nationwide survey of 1,171 nurses, GPs, and practice managers have revealed that 63% of healthcare professionals believed the quality of patient care had worsened over the past year and a half. 

The data, collected between 4 and 21 August 2014, represent a dramatic worsening in healthcare professionals’ perception of the quality of NHS care; with only 35% of respondents in our 2013 survey stating that they perceived the quality of patient care to have decreased in the 24 months prior. 

A meagre 5% of respondents believed that quality of patient care had improved, relative to 34% in the 2013 survey.

The Health and Social Care Act still continues to be a sore point with 61% of respondents disagreeing that the reforms had resulted in better care – despite its stated aim of using GPs knowledge to drive the quality care agenda. This opinion was persistent across nurses (56%), GPs (63%), and practice managers (62%).

A key part of the Act, was the formation of clinical commissioning groups (CCGs) of which all GP practices must be members. They were given a poor rating for engagement scoring only two out of five, with five being very reflective, when respondents were asked if their CCG’s decisions reflected their views. 

When a sense of engagement was rated, CCGs scored three on a scale of one to five, where one represented feeling completely disengaged with their CCG. Interestingly, the extent to which respondents believed that CCGs’ decisions were reflective of their views or felt engaged with their CCG differed across professional groups, with practice managers being more significantly positive to their CCGs than GPs and nurses.

However, the results did not only show poor support for NHS England. There was also very negative perception of Welsh healthcare, which is devolved to the Welsh Assembly. Notably, 88% of healthcare workers in Wales, versus 63% nationwide, believed that quality of patient care had decreased over the past 18 months – showing that the current dissatisfaction among primary healthcare workers is not restricted to NHS England.  

In addition to highlighting a nationwide concern for the quality of care provided, it also showed low support for various government policies designed to increase quality of care such as the setting up of new regulator, the Care Quality Commission (CQC). The 2012 Health and Social Care Act granted the CQC the power to place practices considered to have such significant problems so as to put patients at risk under ‘special care’. However, healthcare professionals in the survey indicated that they had little confidence in the scheme’s ability to improve the quality of care, with the median respondent rating the effectiveness of the scheme as two (on a scale of one to five, where three represented very effective). Perhaps not surprising considering the business investments made by GP partners into their practices, support was lower among GPs than among nurses and practice managers.

The survey also highlighted resistance against government plans to rate the speed and accuracy with which GP practices refer suspected cancer patients to hospital, again proposed to help improve quality of patient care. Only a small minority of healthcare professionals stated that they ‘agreed’ (7%) or ‘strongly agreed’ (4%) with the plans. Again, the strongest objections came from GPs, with 81% of respondents in this professional group stating that they ‘strongly disagreed’ with the plans, relative to 26% of nurses and practice managers. 

Concerns relating to the proposal were also expressed by Dr Sarah Schofield, chair of West Hampshire CCG, who noted that “mistakes will be made whatever the system, and those doctors who repeatedly refer late, need support and education to improve their skills. 

Publishing rates of referral is likely to drive GPs to refer many more people into the cancer pathways, in order to avoid publicity. This will not drive up quality later in the pathway”. 

In addition to questions around the quality of care and NHS reforms, respondents were also asked about their current level of morale. On a scale of one to five, where one represented very low morale, the median primary healthcare workers only rated their morale as a two. The median rating was the same for all professional groups surveyed and all UK regions, suggesting the morale problem is widespread. 

Similar ratings were observed when respondents were asked about how hopeful they felt about the future of the NHS when, again, the median rating for all professional groups and regions was two out of five.

When asked about the impact of specific factors on morale, being ‘over-worked’ was given a median rating of four to five by GPs, nurses, and practice managers, on a scale of one to five (where five indicated being highly influential for poor morale). Bureaucracy was also perceived to contribute to poor morale, receiving an overall median rating of four. In both instances, there was a difference in the extent to which these factors affected healthcare professionals’ morale with GPs and practice managers rating them as having a significantly greater impact on their morale than nurses did. 

Not surprising considering the recent announcement of strike over pay, salaries were also rated as having a negative impact on morale (median rating of four). Interestingly, despite known differences in the salaries of nurses, GPs, and practice managers, there were no significant differences between the professional groups in terms of how much they attributed their poor morale to their current salary. 

Open-ended answers also shed light on additional factors for poor morale. A considerable percentage of respondents (approximately 13%) indicated that unfair criticism from the media and politicians contributed to worsened morale. Another commonly cited reason (approximately 12% of respondents) was unrealistic demand from patients, sometimes driven by the general media as indicated by one healthcare professional who stated that “the media and the politicians give the patients unrealistic expectations about what is possible. They are creating a ‘nanny state’. People will take no responsibility whatsoever for their own health”. 

Furthermore, NHS management and structural changes were also cited as reasons for low morale (approximately 13% and 9% of respondents respectively). Examples of poor management included poor communication, a perception of management as not appreciating their staff, and a feeling that decision makers did not have sufficient clinical expertise to make good judgements. Interestingly, our annual 2013 survey also highlighted a cultural problem in the NHS, with 35% of respondents then reported having received verbal or written abuse by a NHS colleague. Together, these findings suggest there is a long-term problem with the work culture within the NHS.