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Strategy of mistrust?

1 September 2009

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Primary Care Consultant

Elizabeth is a primary care training and development consultant. She has worked in primary care in Wales for more than 30 years. She is a member of the Welsh Practice Management Conference Committee

Someone on the radio recently said that in future we will be valued for knowing what information not to use rather than the other way about. In the current climate of trying to filter the information we do need, this statement has given me something to think about.

In February, the Welsh Assembly forwarded a document entitled A Community Nursing Strategy for Wales to local health boards.(1) This was duly forwarded to GP practices for comment. Now, as I am sure you will agree, in practice this may not have fallen under the “urgent” category of priority for many managers, who may have put it to one side while more important issues were addressed.

A Community Nursing Strategy for Wales is a lengthy document of some 200 pages. Yet within this document there is a hidden bombshell: the proposal that practice nurses are taken out of the control of general practice and become the responsibility of the trusts.

Practice nurses play a vital role in general practice. Their skills and attributes have been developed over years to make them an integral part of the clinical team. Patients find the nurses approachable and appreciate the continuity of care provided by them. Practices have invested quite considerable sums of monies and time for specialised nurse training and development, and practice nurses have become highly qualified and specialised in certain clinical areas. Taking them out of general practice control can only be a reverse step.

How would this be managed? For a start, employment law issues are involved, regarding contracts and changes in job descriptions, working practices, times and shiftwork. Many practice nurses would leave the service rather than make this change. Many came to general practice because of the work patterns. The attractive prospect of working Monday to Friday, with no night/weekend shifts and being close to home in a small patient-friendly environment, brought some highly skilled people into general practice.

Practice nurses undertake many areas of the Quality and Outcomes Framework; certainly the district nurses I have spoken with do not have the skills to undertake the specialised areas of this work.

Recently, in many areas of Wales there have been changes to the district nursing services that have had a detrimental effect on patient care. Indeed, I have seen a number of nurses take early retirement in my locality. This led to different nurses covering different localities and lots of new faces; it has been unsettling for housebound patients.

But my main gripe is that the proposed change to practice nursing in Wales could have been missed. This change, should it happen, would have a phenomenal effect on general practice services, but was included in a document that wasn’t actually aimed specifically at primary care.

This is coming in through the back door. It was spotted by a small number of Welsh practice managers, who immediately informed others and asked them to respond. I have spoken with quite a number of managers who have all sent strongly worded letters to the Assembly.

None of these managers view this proposal as anything but a retrograde step for primary care. Some feel it is another move towards clipping the wings of general practice. But this is the plan the Welsh Assembly thought worthwhile bringing to the negotiation table, and it is my understanding that the Royal College of Nursing was part of the discussion group. Primary care was not.

I wonder if this is just an example of what is to come. Will we now have to be even more vigilant in our information handling? Have we enough time to trawl through every single document, however tenuous the connection to primary care, to ensure that nothing like this slips through the net?

Most managers have to decide what is important to their practice and sort through all the information that comes their way. This is one example of what might have been missed. Perhaps the high value placed on information “we know not to use” will bring about a new generation of need-to-know-everything managers. I don’t envy them their task.

1. Welsh Assembly Government. A Community Nursing Strategy for Wales. Consultation Document. Welsh Assembly Government; February 2009.