HC Deb 28 March 2000 vol 347 cc315-22

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Dowd.]

9.50 pm
Mr. John Healey (Wentworth)

I am grateful for this chance to raise the issue of discretionary pay points for practice nurses. The matter was raised with me by four local practice nurses, who skipped lunch to see me at my constituency office a month ago.

These are senior nurses at the top of their profession. They manage their own case load, run clinics and lead service delivery teams on family planning, women's health, asthma and chronic obstructive pulmonary disease, which is a legacy of the coal mines that is only too common in south Yorkshire. They are responsible for health promotion, Medical Research Council-sponsored research and the training and professional development of other primary care staff.

Practice nurses are developing new quality standards, audit work and clinical governance systems. They are, to all intents and purposes, making prescription decisions, although of course because they are not health visitors or district nurses, despite the fact that they have the same qualifications, those prescriptions are still countersigned by GPs. In other words, practice nurses see and manage patients who would previously have been seen and managed by GPs.

That part of the nursing profession is the backbone of the GP service at present and the base on which we will build a better, more multidisciplinary primary care service in the future. Ministers have therefore rightly given strong support to the expansion of practice nurse numbers and roles.

The nurses who came to see me are highly experienced and have been at the top of their pay scale for many years. Their annual salary is between £18,000 and £19,000 for a full 34-hour week, although, as many surveys confirm, practice nurses, like other nurses, often work extra hours unpaid. They are also very committed to their work. Care of their patients is their first, second and third priority. They are the last people to make complaints on their own behalf, but they have been driven to do so, first, by the mishandling of their position by Rotherham health authority and, secondly, by the muddle over their position generally as nurses employed by GPs, who are independent small business people.

In 1998, the Nurses and Midwives Pay Review Body recognised a serious problem of career progression for such senior nurses. Three quarters of nursing staff in G, H, and I grades were at their grade maximum, and the pay review body stated that there was

little, if any, scope to reward the taking on of extra responsibilities or the acquisition of new skills. We were also aware of the deleterious effect that limitations on career progression could have on recruitment and retention. Nurses, including practice nurses, at the top of their grade were getting extra responsibility without extra reward or recognition.

The 1998 pay review body report, therefore, introduced the concept of a discretionary points system to allow the most senior nurses with the greatest responsibilities to apply for up to three additional increments, each worth between £375 and £400. As the pay review body made clear, those were introduced as an interim solution, and not a long-term answer to the problems.

National agreement was reached between the parties in September 1998 on implementing the discretionary points. The NHS executive issued an advance notice on 11 September 1998, and the Nursing and Midwifery Staffs Negotiating Council was charged with agreeing criteria for the operation of the system, which it published in November of that year.

The review body expressed the firm expectation that, to quote the NMNC guidance,

initial awards of discretionary points locally will have been achieved by the end of December 1998, backdated to 11 September 1998. In Rotherham, our General Hospitals NHS trust set up and operated such a scheme, as required, from September 1998. To date, 126 midwives and nurses—none of them practice nurses, of course—have applied and been assessed for discretionary points, and 111 such points have been awarded.

Our Priority Health Services NHS trust employs two practice nurses, although other nurses and health visitors have used the scheme set up by that trust in November 1998. Under that scheme, 64 discretionary points have been awarded.

By the early summer of 1999, Rotherham health authority had set up arrangements to deal with applications from practice nurses employed by GPs. During the summer, a number of nurses went through lengthy efforts to prepare applications, which were assessed by the health authority's panel.

Eleven nurses were awarded discretionary points. In August or September, they received confirmation of their awards in writing from the health authority's professional nurse adviser, who, quite reasonably, had been co-ordinating the assessment system. In the letter, the nurses were informed that a report would

now go to the Executive Team who will need to approve the awards. Any money approved will be backdated to September 1998. In November, out of the blue, the nurses received a letter from the health authority chief executive, Mr. John Hinchcliffe, which stated that since the time that the practice nurses received the letter about discretionary points from the health authority,

we have been considering how to proceed and seeking advice from the Department of Health. We have come to the view that the process that was used to award the points did not follow nationally-agreed guidelines and we have therefore decided that we need to rectify this situation. To do this, we will, in fact, need to run through the process again. I do apologise for this but it is important that this system operates properly and that it is seen to be fair and equitable for all involved. The letter continued:

We will put in place the appropriate procedure as soon as we can and any awards made under the new procedure will be backdated to the date of your original application. Understandably, the practice nurses were extremely disappointed, demoralised and demotivated, but they are determined professionals, and they pressed Mr. Hinchcliffe for the reasons why he thought that the process introduced by the health authority had been flawed. Mr. Hinchcliffe explained that

GPs need to be involved in the process not least because they will be required to part-fund any awards. According to Mr. Hinchcliffe, the authority's arrangements had not followed national guidelines in four areas. He stated that

GPs have not ratified applications; staff representatives have not been involved in developing the local procedure; the executive team of the health authority—

was not clear what decision-making process had been used; there is no clear indication of how any appeal should be handled. I met Mr. Hinchcliffe 10 days ago to discuss the problem, and I made it clear to him that I did not accept his arguments that the process was unsound, or that it needed to be redesigned and rerun from scratch.

I shall deal with Mr. Hinchcliffe's points one by one. First, practice nurses had to raise the question of their application with their GP employer before it was submitted. Certainly in the cases that I have examined, the GP either endorsed the application, or at least confirmed the accuracy of the description of the practice nurse's role contained in—

It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put. Motion made, and Question proposed, That this House do now adjourn.—[Mrs. McGuire.]

Mr. Healey

I was not quite prepared for that, Mr. Deputy Speaker, but I am grateful for the opportunity to continue.

Secondly, Mr. Glen Turk of the Royal College of Nursing, representing staff, was involved in the arrangements, and was a member of the assessment panel. Thirdly, I have not asked to examine the paperwork records of the panel process, but the criteria for the process were clearly set out in the NHS Executive's advance letter of 11 September, then exemplified in the guidance of the Nursing and Midwifery Staffs Negotiating Council. I therefore simply cannot accept that the executive team could have failed to grasp what was involved in the decision-making process if it had taken the trouble to check, either during or after the process.

In any event, the Office of Manpower Economics survey conducted in autumn 1999 on behalf of the pay review body to monitor the progress of the scheme made it clear that trusts were interpreting the guidance flexibly. Fifteen of the 74 trusts that had agreed a scheme had departed from national guidelines, and half the 26 that were still negotiating their schemes were thinking of doing the same. There is clearly considerable scope for local variation and discretion within the guidance, and within the discretionary points system.

Fourthly, the official guidance gives, in fact, little guidance on appeals, beyond a reference to local grievance procedures. If that was not made clear to applicants at the start, there may be an argument for refining the scheme in the future, but it is hardly a sufficient argument to justify re-establishing and rerunning the whole process.

I fear that our practice nurses have fallen victim to some senior management wrangle. Such treatment of nurses by the health authority does it no credit; they deserve better. I have some sympathy for the authority, however, and suspect that others around the country are in a similar position. Paymaster but not employer of our practice nurses, the health authority stepped in last year to try to fill a void. Individual general practices can hardly be expected to set up their own process for determining discretionary points; primary care groups were still finding their feet, and, in any case, they are not employers of practice nurses. Moreover, no guidance has been issued on how practice nurses should be handled, given their special employment status in relation to GPs as independent contractors to the NHS.

I shall say more about that shortly, but, before dealing with national issues raised by the constituency case, let me ask my hon. Friend the Minister some questions. Will he consider investigating the situation in Rotherham? In particular, can he offer Rotherham health authority a second opinion—perhaps from the Nursing and Midwifery Staffs Negotiating Council, or the NHS Executive—on whether the scheme seriously breaks the national guidelines, and is therefore fundamentally flawed?

If we can avoid the waste of time, effort and cost for all involved, I believe that we should do so. That would deal with the frustration and demoralisation of 11 practice nurses who, understandably, are fed up with the way in which they have been treated.

The position of practice nurses in Rotherham highlights two wider national problems. First, I gather from our experience in Rotherham, and from further research that I have undertaken, that practice nurses are vulnerable to GPs' veto on their participation in the process. One local practice nurse reports that her GP said "no way" to discretionary pay points unless the health authority footed the entire bill.

In practice, GPs can first discourage practice nurses from participating, and also discourage applications. Secondly, they can resist confirming the responsibilities that practice nurses have to set out in their applications. Thirdly, they can refuse to pay any increment that a practice nurse may be awarded.

The Royal College of Nursing believes that GPs who pay for the discretionary points are the exception, not the rule. That means that hundreds of practice nurses are likely to be losing out on the opportunity for career progression and recognition. That is unacceptable.

Let us consider the second wider national problem. Although practice nurses are professionally qualified and indisputably covered by the pay review body, GPs—their employers—are not. As independent contractors to the NHS, they are not bound in the same way as trusts or health authorities to pay review body settlements. That means that practice nurses are left in limbo on discretionary points.

That is not surprising because practice nurses are not mentioned in the pay review body reports on discretionary points, the NHS Executive's advance letter, the Nursing and Midwifery Staffs Negotiating Council's guidance or the Office of Manpower Economics survey, which covered 106 trusts and no GPs.

The hard question for Ministers is whether the Government want practice nurses in or out of the discretionary points system. If the Government believe, as I do, that the pay review body is right to say that the problems are of practice rather than principle, and that the system should continue, they should consider issuing guidance, albeit non-binding. It should include advice on arrangements that mention GPs and make clear the position of practice nurses. Will the Minister consider clarifying the position in that way?

The imperative to do that will increase in four days' time when the first of the 23 primary care trusts comes into operation. The new trusts will include community nurses, health visitors, district nurses, midwives and practice nurses working alongside each other. They will be encouraged to work together in teams. If Ministers do not move to ensure that the problem is solved, the fact that practice nurses currently lose out will become increasingly clear.

10.8 pm

The Minister of State, Department of Health (Mr. John Denham)

I congratulate my hon. Friend the Member for Wentworth (Mr. Healey) on securing the debate on access to discretionary pay increments for nurses in general practice. By pursuing a constituency case, he has aired some important wider issues.

I recognise from my hon. Friend's comments that some of the nurses involved—probably all of them—have had their expectations raised and then dashed in a most unfortunate way. I cannot promise to provide a ready-made solution this evening. The issues involved are complex and, as with so much personnel and employment practice in the national health service, there have been some arcane custom and practice, rules and regulations and professional demarcation. We must change some of those matters in future. However, there are not always easy solutions to the immediate problems.

There should be no doubt that nurses have a vital role to play in the modernised and revitalised national health service: in hospitals, in community health services and in general practice. That role will become more important as the NHS breaks down some of the artificial professional barriers and begins to build a service that uses all the talents of its staff.

That is why the Government attach such a high priority to ensuring that we make nursing an attractive and fulfilling career. We have put doctors and nurses, as well as other health professionals, in the driving seat on primary care groups, for example, and nurses in leading roles in NHS Direct—the nurse-led helpline—and in our new walk-in centres. In all those roles, new and traditional, fair pay and conditions of service are important. Our strategy for nursing is paying off: a 25 per cent. increase in the number of people registering for nurse training this year is only one example of that.

Modernised primary care is at the heart of a modernised NHS. That depends on the people working in primary care—not only the doctors, but, crucially, a properly rewarded, fairly paid, motivated and well-trained nursing work force who have access to high-quality continuing professional development and family-friendly terms and conditions of employment that allow them to give of their best.

On pay in the wider sense, we have set out a strategy to modernise the NHS pay system so that it is fit for the 21st century. We have to undertake a root-and-branch modernisation of complex pay systems that have grown up over 50 years. The negotiations are going well, but they will take time, which is why a system of discretionary points was introduced for some senior nurses in 1998 as an interim measure. My hon. Friend referred to that. The agreement on discretionary points was made in the Nursing and Midwifery Staffs Negotiating Council and applies to all staff working in the NHS on national Whitley contracts. Essentially, it provides for three discretionary points at each grade, valued at about £400 at scale F and £435 at scale I. They are, in turn, subject to recommendations made by the nurses pay review body.

As with all such agreements, the recommendations do not apply automatically to staff employed under locally negotiated terms and conditions, including nurses employed by GPs. Although my hon. Friend suggested that practice nurses, by definition, are covered by the pay review body and that agreement, that is not the case because GPs are self-employed contractors to the NHS. There are about 29,000 GPs in England who comprise some 9,000 separate, independent practices ranging from single-handed to large multi-partner practices. Each is responsible for employing its own suitably qualified staff, including practice nurses.

Although many GPs base their employment contracts on national agreements and the recommendations of the nurses pay review body, they are not obliged to do so. With 9,000 practices operating in different circumstances and with different case loads and case mixes, variations in terms and conditions of employment are inevitable. That is reflected in pay levels. If GPs do not pay an appropriate salary, there are likely to be implications for the retention and recruitment of practice nurses at local level. I would hope that individual practices carry out their employer functions responsibly and with regard to the position of all in the primary health care team.

Most GPs, as independent contractors, operate under cost-plus arrangements for general medical services. Under those arrangements, the NHS guarantees to return to the profession all expenses incurred in delivering patient services. About two thirds of total expenses are directly reimbursed to the practice that incurs them. The remaining third are reimbursed at the average for the profession as a whole through capitation and other fees and allowances.

That mixed economy of direct reimbursement of all or some of a particular expense and the indirect reimbursement of the remainder on an averaged basis has been developed over many years in consultation with the profession. It recognises that GPs are independent contractors with responsibilities for ordering their own businesses, settling their own bills and hiring the staff they need to support them and also helps to ensure good value for the taxpayer by giving the individual practice some incentive to exercise due economy in the use of NHS resources. In fact, most of the cost of staff salaries is paid directly to the practice that incurs the expense—typically, about 70 per cent. The individual employer will then have to meet any balance from the amounts built into NHS fees and allowances.

There is an element of discretion for health authorities, primary care groups—and, in future, primary care trusts—in how much they use the funds centrally available to them to support the primary care improvement plan; how much to support premises improvements; and how much to develop and to expand primary care teams. The Government have agreed that the amount of the unified budget spent on practice infrastructure in 1998 must be increased year on year in line with inflation.

Wages and salaries are a substantial cost to practices. Health authorities receive a unified budget annually, which includes an element for GP practice staff. The health authority can reimburse a GP up to 100 per cent. of any proportion of the various elements that go towards the costs of employing staff: salaries, national insurance and pension contributions, staff training, including course fees, and so forth.

As I understand the position in Rotherham, the health authority convened a process to assess the suitability of practice nurses for discretionary points—even though, as I have explained, the arrangements do not automatically translate to them. Unfortunately, the nurses were informed that they had been successful—or unsuccessful—in advance of discussion with their GP employers, who would have been liable for part of the cost of any such awards.

My understanding is that, although there may have been proper discussions on the merits of individual claims for discretionary awards, the health authority had not discussed whether, and how, the GPs as employers would fund any increases in pay. It is perhaps surprising that the authority did not address funding as part of any discussions. It was at the point at which nurses were informed whether they had been successful that the health authority suspended the process, to avoid putting practice nurses into a situation where they were in conflict with their employers.

The current position is that one of the health authority directors is working with one of the PCG chief executives to design a clear and robust process to address the issue. The health authority has asked the three local PCG boards to persuade local GPs to support their nurses' applications for discretionary points. Some GPs have already indicated that they are willing to contribute to the pay uplift. In those cases, the application will be fast tracked.

My hon. Friend asked me to investigate the situation in Rotherham and to express an opinion as to whether the health authority scheme falls in line with national guidance on discretionary points. I am willing to look again at my hon. Friend's excellent speech and to find out whether there are any issues in it that I have not been able to address this evening. I will happily pursue those with the health authority. However, it follows from what I have said—and from the nature of GPs as independent contractors—that the notion of a scheme that is purely a health authority scheme and does not engage with the GPs as employers is perhaps not sensible and may not stand up.

I believe that Rotherham, working with primary care groups, is seeking to resolve the matter. I hope that the nurses whom my hon. Friend has represented so well will soon be able to put their disappointment behind them. I will take a close interest, as my hon. Friend asked me to, in the way in which the situation in Rotherham develops.

It would be appropriate to say a few words about some of the new developments in primary care. Although they cannot be enforced on individual practices, they may provide alternative ways in which to address the employment of practice nurses and to resolve some of the issues that we have discussed.

New ways of delivering primary care allow primary care practitioners to respond flexibly to patient needs and to service delivery. Known as personal medical services pilots, those arrangements are individually negotiated, rather than developed at the centre. They allow practitioners, doctors and nurses to develop new models of employment that are as flexible as the service delivery arrangements.

In personal medical services pilots, one of the most popular options—popular with doctors and with other members of the primary care team—is the practice-based contract. In the traditional general medical service model, the contract is between the NHS and the individual GP. Additionally, as I said, the members of the team are employees of the GP. However, practice-based contracts can involve all the players, with nurses and doctors being equal signatories to the contract. There is also a small number of nurse-led pilots, in which we have seen perhaps a total transformation of the relationship between doctors, nurses and the NHS.

Such arrangements have the scope to change radically the roles of the individuals involved and to develop true partnerships of equals—each bringing their own skills to bear in serving the needs of their patients. In doing so, they move beyond the so-called red book governing how practices are usually remunerated. Instead, it is possible for pilots and health authorities to negotiate directly on a total package of health care services for patients and on what is a fair price to all concerned to deliver that total integrated package.

My hon. Friend quite rightly asked about the future. In partnership with the professions, we are examining the role that primary care trusts should have in the development of practice staff. Clearly, PCTs will continue the functions of primary care groups in developing primary care investment plans, but they are new bodies with new powers and new opportunities. I hope that one of the opportunities that PCTs will seize is that of helping their constituent practices to develop more integrated human resource policies.

One of the spheres in which PCTs may develop is to employ staff with particular skills. It might be possible, for example, for PCTs to employ a bank of nurses for an area, establishing a skills pool so that nurses with different specialist knowledge and experience could be available to all patients in the PCT area, rather than just in their employer's own practice. Staff employed by a PCT will be directly employed by an NHS body, because that is what a PCT is. They will therefore be integrated into the wider NHS human resources framework, while all the time being essentially practice nurses at the front line of patient care in GP surgeries.

Those developments may well occur in the future. Although they are not being imposed on practices, some PCTs are certainly keen to develop them.

As I said at the beginning of my speech, I cannot produce a ready-made answer. I hope that I have been able to assure my hon. Friend that practice nurses have a very important role to play in the modernisation of the national health service. Some flexibilities are already available in the system that could help to address the issues that he raised. Moreover, in the way in which the NHS is moving forward, there are certainly opportunities for the development of different models of employment of nurses.

As I said, I shall take a close interest in what happens to my hon. Friend's constituents, and I shall look carefully at the report of the debate to ensure that all the issues that he has raised are properly addressed.

Question put and agreed to.

Adjourned accordingly at twenty-three minutes past Ten o'clock.