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Primary Concerns: A survey of healthcare professionals

Primary Concerns: A survey of healthcare professionals


For anyone still hoping that the current NHS reform programme will deepen clinical engagement in the management of the health service, the findings of Primary Concerns:

A Survey of Healthcare Professionals

sound a clear warning: less than 7% expressed support for the policy. Plain opposition came from almost 60% of those polled, while the remainder were ambivalent or unsure about the direction of travel.

For those opposed to the changes, two reasons stand out. Almost two-thirds of those surveyed saw the reforms as a “distraction from caring for patients”. While the same number believed that the changes are a step towards privatisation of the health service.

In austere times, waste was a theme, too. There was a clear desire for a grownup debate about the use of the NHS budget with 61% of those polled believing that cutting the use of ineffective treatments should be top of the agenda.

Indeed, there appeared to be a call for greater respect for NHS resources in general. In total, 83% said patients should be forced to pay a fee for not attending appointments.

And 63% of those polled said patients should pay for Accident & Emergency visits that were the result of alcohol.

Amid all this, one might expect to find morale hurtling towards rock bottom. In fact, there was a mixed picture: just 43% of primary care staff polled said they would choose the career they are in again. But the average self-rating for morale, at 5.7 out of 10, will give the reform programme’s supporters a crumb of comfort that primary healthcare professionals are not on the brink of downing tools and, as a result, could yet be won round.

Publishing and research company Campden Health polled 1,122 primary healthcare professionals working in primary care: practice managers, nurses and GPs. by email between 6 February and 27 February. Nurses constituted the largest segment, with 718 respondents.

The title ‘nurse’ covers a broad range of functions. Within this category, 532 respondents classified himself or herself as a ‘practice nurse’.

The polling sample was strongly skewed towards an older demographic, with 539 respondents in their 50s compared to 108 in their 30s. To some extent, this reflects the career path of some healthcare professionals, which may start in a secondary care setting or in a foreign country, only to move into UK primary care a number of years later. However, with such a large proportion

fast approaching retirement, it also compounds long-standing concerns over staff shortages. Indeed, 471 of respondents said they would be leaving the NHS within the next five years, mainly due to retirement.

In July 2010, and following election campaigns which promised an end to repeated large scale restructuring of the NHS, the nascent coalition government announced plans for one of the most dramatic programmes of NHS reforms in the history of the health service.

The policies were outlined in the White Paper Equity and Excellence: Liberating the NHS, published in July 2010, and in the subsequent raft of consultations. They were given the necessary statutory support when the Health and Social Care Bill received Royal assent in May 2012.

The biggest structural reform was the abolition of primary care trusts (PCTs) and strategic health authorities (SHAs), with most of their commissioning responsibilities – and therefore approximately 73% of the £108.9 billion NHS budget – being handed over to 211 clinical commissioning groups (CCGs).

As a result, if the NHS reform programme is to succeed it is, according to NHS England, the body that oversees CCGs: “vitally important that CCGs are clinically-led.” Indeed, they should have the “full ownership and engagement of their member practices, so that they can bring together advice from the broadest range of health and care professionals to influence patterns of care and focus on patients’ needs.”

And yet Campden Health’s poll found that support for the reform programme was severely lacking. Plain opposition came from almost 650 of those polled, while 395 were ambivalent or unsure about the direction of travel. Just 76 respondents – less than 7% – said they supported the policy.

David Stout, chief executive of Hertfordshire and Essex Commissioning Support Units, says that addressing this fundamental “disconnect” is one of the most urgent priorities facing CCG leaders. However, he suggests that attempts to secure buy-in to the national agenda are far less important than those to strengthen the connection between frontline staff and CCG members and leaders.

“When you ask the public their views about the NHS, their views are far more negative than when you ask them about their own experiences,” he says. “In the same way, after 1 April, what will really matter is the level of confidence and trust staff have in their local CCG.”

This is a view echoed by Nigel Edwards, a senior fellow at the King’s Fund. Asked what advice he would give to local leaders hoping to improve engagement in CCGs, he says: “Don’t mention the reforms! It is not so much because they are seen as toxic, though that is a problem – but because for those delivering services, and those receiving them, what matters is how the structures can be used to make specific changes which will benefit patients.”

“The narrative needs to be about how changes to services will help Mrs Smith, who has congestive heart disease and Parkinson’s, not about the national agenda,” he says.

If Nigel Edwards is correct, however, the survey’s follow-up questions – that asks for reasons for not supporting the reforms – does not bode well. One of the most popular reasons cited, by almost two-thirds of those polled, was that the reforms would lead to them being able to “spend less time caring for patients”.

This is a long-standing criticism of the NHS reform programme, propagated by many of the organisations represent healthcare professionals, including the British Medical Association (BMA) and the Royal College of Nursing (RCN). Mike Farrar, chief executive of the NHS Confederation, a membership body for NHS commissioners and service providers says the “form-filling and box ticking” doctors and nurses might have to do because of changes to NHS structure is a growing problem.

“We need to strike the right balance of providing information which allows patients to have a clear picture of the standards of care, without spending a disproportionate amount of time providing the same information to numerous organisations in different ways,” he says. “We are concerned that patient care could be affected because organisations and staff are distracted by the burdens of administrative requests from external organisations.”

But while the administrative burden created by the reforms was a common complaint, so too were fears that the changes are a step towards privatisation of the health service. Again, this is similarly long-held complaint of the healthcare professional representative bodies – as wellas the government’s political opponents. But its profile has increased in recent months with the government having to clarify regulations under section 75 of the Health and Social Care Act 2012 that appear to make it compulsory for CCGs to use market mechanisms to commission health services. The Department of Health insists that choice of provider rests with lead clinicians.

In austere times, though, waste is a key theme, too. Among opponents of the reforms, 58% believe the reforms mean doctors will spend too much time on management, and 47 per cent believe the changes amount to a waste of money.

Indeed, there is a clear desire for a grownup debate about the use of NHS resources with 684 (61%) of those polled believing that cutting the use of ineffective treatments should be top of the agenda. Though slashing NHS managers’ pay and pensions came a close second (57%).

While the nation struggles with the burden of self-inflicted ill-health, the poll also detects a lack of sympathy from many of those patients affected. Bariatric surgery for the obese would also be in line for cuts, as would any surgery for smokers. If practice managers, GPs and nurses were in charge of their own budgets, the current health secretary’s fondness for homeopathy would not protect it from the chop, along with herbal medicine, and acupuncture.

The primary care community is also keen for charges for the nation’s boozers, or at least a reduced subsidy; 63% of those polled said patients should pay for Accident & Emergency visits that were the result of alcohol abuse.

There appears to be a call for greater respect for NHS resources, and their limits. In total, 83% said patients should be forced to pay a fee for not attending appointments. Dr Steve Field, recently appointed as deputy medical director to NHS England, as lead for addressing health inequalities, says the polling in these areas, which struck him as “somewhat judgmental”, surprises him. “I think some of these ideas are pretty abhorrent. Alcohol is a social issue and I don’t think we should be looking at charging people for care, or potentially driving patients away from seeking help,” he says. “We know bariatric surgery can reduce several co-morbidities, and we know smoking is very closely linked with deprivation – I think we need to understand the underlying causes of these problems, not find ways to punish patients.”

The survey found that primary and community care professionals are, by and large, very proud of job they do. 931 (83%) respondents categorised the quality of services they provide as ‘good’ or ‘very good’. Conversely, only 22 (2%) rated them as ‘poor’ or ‘very poor’.

A significant proportion (35%) of those polled thought that the level of service their practice offers to patients has worsened over the last two years. Of these respondents, there was no single, clear reason as to why, though ‘cuts to budgets’ and ‘organisational change’ were the most popular.

Just 54% of those polled said they would be happy for a family member to be treated at their local hospital, suggesting significant unease about the quality of services being commissioned.

“That really stands out,” says Dr Charles Alessi, chairman of the National Association of Primary Care.

“Yes, there will be some skew in a statistic like this, because people are always likely to think better of their own services than of those provided by others - but this does suggest real concerns around the quality of hospital services. And this is where the reforms should strengthen the levers for change.”

In the short-term, CCGs may hope for nothing more than maintaining a steady ship, and safely transferring commissioning arrangements in a very turbulent environment.


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