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The RCN's chief executive and general secretary discusses the focus on primary care nurses, their pay, and training and developing the workforce with Rita Som.

Q) What is the RCN's top priority for the year?

There are a number, not just one. The most pressing issue is to get the government to understand that there really have been cuts in the number of nurses on wards and in other settings. It is one of the reasons why, in some areas, there are big problems with the standard of care. All the research demonstrates that if you do not have enough staff, at times the standard of care is compromised.

We have had a plethora of enquiries (Francis, Keogh, Berwick, Cavendish). One of the common denominators in all of them is the need for enough staff. Sir Bruce Keogh said in his enquiry into 14 trusts that the government say are failing that the common denominator is insufficient nursing staff, the wrong skill mix, and a huge over-reliance on what he called 'unqualified staff'. So the RCN is asking the Government to do something about that, which could address the deficits in some places in standards of care.

We are also appalled that the Government has chosen to disregard the recommendations of the independent pay review body. This was affordable and the Government has chosen to ignore it. To say that nurses and their colleagues in other disciplines must endure another year of a pay freeze is wholly unacceptable.

Q) The majority of practice nurses are not on Agenda for Change (AfC), so the one per cent won't apply to them anyway. Does the RCN now accept that there is a mismatch in pay or would you like to see all nurses on AfC?

Whether it is AfC or any other formula, nurses should be better paid. That is my overall bottom line. Remember, the RCN has 423,000 members. A hundred thousand of our members, nearly 20 per cent, do not work in the NHS. This is a huge proportion of our membership. They are under a myriad different pay conditions and what we say is that all employers, whether independent or NHS, should pay nurses a decent wage.

Q) Would more standardised pay for practice nurses attract greater numbers into the profession?

Yes. We have some great GPs and some great practices that properly remunerate and recognise nurses as an integral part of the team. We have got others that, historically, have not recognised the role of the nurse. It is little wonder they struggle to recruit people into those posts. What we say to all GPs is 'recognise nurses and allow them to share some of the profit and you will end up with a more profitable business'.

Q) Why hasn't the RCN recruited a replacement for Rebecca Cheatle, the previous primary care lead?

We were very sorry to lose Rebecca. She was excellent. She took over from Lynn Young, who had a very long and distinguished career with the RCN. It has proved difficult to replace Rebecca. But I would rather an empty house than a bad tenant. While some good people have applied, no-one has quite fitted the bill. We would rather wait and make the right appointment.

Q) Is the RCN doing anything to find the right person?

Yes, we are. We are optimistic that in time we will find them. We were in the same situation with our educational adviser, which took some time.

Q) How can the pressure on the primary care nursing workforce be alleviated?

People have got to look at what is happening with society: more and more people are living longer than ever, but many of those people are not necessarily living healthier. Many of those people access healthcare via primary care, so we will need a larger and more highly skilled workforce. Now is the time to do it. The nursing workforce is an ageing workforce, 200,000 nurses are going to retire in the next two years. What we cannot do is rely on what the health service has done historically which is, when recruitment is down, go to developing countries and raid their already stretched nursing workforce. I do not have a problem with anybody who wants to come to the UK , but that is no way to run a health service.

Q) It has been suggested that the universities should be doing more to raise the profile of primary care nursing as a career option. Is that fair?

Absolutely. Primary care nursing has been hugely under-invested over the years. We know that with the changing face of healthcare, by investing more in primary care results will be seen. First, the pressure on acute hospitals will be ameliorated, as people are kept well and out of hospital. Secondly, people who are at risk of health problems can be managed to stay healthy. Primary care is good for the patient and the bank balance.

Q) Is the RCN doing anything to support the universities in providing better placements?

Yes, we have highlighted and encouraged it. We spoke to universities, and we talked to providers. But we have no statutory authority. Our role is often misunderstood. People sometimes write to us asking 'why don't the RCN do this' and I often write back saying 'well, if we had the authority, we would'. We are making it clear that good quality placements are necessary during the pre-registration nursing course in order to introduce trainee nurses to primary care and for them to see it as an attractive career choice.

Q) With so many nurses about to retire from primary care, is the RCN concerned about the future of the primary care workforce?

At some stage, the Government, nursing leadership, and others who are acutely involved, must realise that this cannot go on. We have been hugely encouraged; Steve Fields could not be a better advocate for primary care nursing. We hope that, in time, the political masters will understand that they are being given the right advice. Government must steer the employers and the way the health service works in order to get the investment, which is so badly needed.

Q) Does the RCN support the RCGP's general practice foundation nursing group's drive to establish a formal qualification and career pathway for primary care nurses?

We work closely with the RCGP. The fact that the RCGP are taking such an interest in nursing signals that they understand that originally a lot of practice nurses were enticed by the ability to balance family commitments and working hours. That was in the early days, but what is needed now is more rigour. You do need formalised qualifications, and we will be working closely with the RCGP's group on that. What we also need is the leadership of the four countries of the UK to champion this. The NMC need to be on board too.

Q) The government's recent mandate to Health Education England contained a recommendation to introduce a course to support the transition of nurses in the acute sector into primary care nursing. Are there many nurses in the acute sector that want to move into primary care?

We work well with Health Education England, and I think they are well intentioned. These jobs must be made attractive, be properly remunerated and people be supported.

Q) Traditionally, practice and community nurses have been under developed and struggled to access training. How can that be changed?

The RCN has to keep exposing this. It is about saying to politicians that they have to invest. You have got to give people the time [to train]. You invest in good quality training and education for practice nurses; it will pay dividends in the ways they work. They will become much more effective.

About 18 months ago, I went to an RCN conference in Kent on update training. There were over 100 practice nurses at this conference. Virtually every one of those nurses was there on a day off. That is no way to develop a workforce. Start by acknowledging that these nurses are keen, they are enthusiastic. People shouldn't have to come in for development on their own time.

Q) What are the RCN's thoughts on the funding gap for general practice?

The RCGP is absolutely spot on when it talks about the depletion in the investment in general practice. The public and some politicians think of GPs when they hear 'general practice'. Nurses play a huge role in general practice. I know that there has been a lot of criticism of the GP contract of 2004 but I think that criticism is ill-directed. What people forget is that, by 2004, doctors simply did not want to be GPs - the long hours, the huge strain. Things had to change. They might have changed too far in one direction but they certainly could not stand still. We need a similar initiative in relation to practice nurses.

There needs to be an honest discussion about how, in some places practice nurses are under strain, almost to breaking point.

What we say to the Government is: care can't improve until the Government comes to terms with the fact that in some parts, general practice is run on a shoestring and goodwill. There comes a stage when it will run out.

Q) What is the RCN doing to raise the value and awareness of primary care nurses with the public, as more care is moved to the community?

We need to get this message across to the public. The public tends to engage when either they themselves or one of their relatives has got an illness or a condition. I would say this in relation to what is increasingly becoming the parity, more care in the community and so on.

But care in the community costs. If you do not fund it properly, what you are going to end up with is the types of scandals that we had in the 90s, when we had all of those enquiries into failure in mental health. You will find people in their own homes being neglected if you do not have enough district nurses. You will find people developing conditions that, with proper primary care nursing could be prevented.

Noone wants to be in hospital, and if patients can be nursed at home, and cared for safely, that is what we all would want. But if it is done on the cheap, primary care nursing will end up in the mess that mental health was in during the 90s.

Q) How can we get from this to actually having more nurses on the ground?

One of this Government's techniques, in relation to health has been to have enquiries. What we have had so far is a lot of fine words. At some stage, we want to see these recommendations implemented. Of the 290 recommendations from the Francis enquiry, very little has been implemented. Yes, he talked about a culture change - we have got to change the culture - but what about the recommendations about developing evidence-based metrics in order to ensure safe staffing levels in all settings?

Q) Why did the RCN not take on board the Francis Report's recommendation that its two functions be split?

It did. Robert Francis said that we should consider whether or not we should split. The college was criticised for being locally ineffective, and we have never ducked that. We are not one of the organisations that have tried to wheedle their way out of it. We acknowledged that some things could have been done better. So we looked at the recommendation and debated it. Ninety-nine per cent of our members said they wanted the college to remain as one. If ninety-nine per cent of the members had said 'yes we want to split' we would have gone down that route. The membership understood that at times there are tensions and difficulties, but overall, the combined functions of the RCN makes it highly effective. That is what the membership wanted and that is what we will do.

Q) What does the RCN think of the NMC's proposed fee rise?

It disagrees with the fee rise. Eighteen months ago, it was £76. The NMC then raised it to £100. It also got a £20 million grant from the Government. The RCN negotiated that. We went and met with Andrew Lansley, and we said this huge hike that they were proposing was unacceptable. He saw the wisdom of what we were saying and he gave the NMC a £20 million grant. Eighteen months on, the NMC needs to raise the fee to £120. This is unacceptable, to go in a two-year cycle, from £76 to £120, for people who are enduring a pay freeze because of economic problems not of their own making.

The NMC should look at how it is funded. Some people have said to me: it is only another £20 a year. That is one way of looking at it. Another way of looking at it is this: the vast majority of the 675,000 registrants never have to use the NMC. Some of these nurses have paid thousands of pounds and they question what they get back.

Q) What do you think of the NMC's proposals for revalidation?

The RCN is in favour of revalidation. The basic principle, that a registrant should have their performance validated, is uncontroversial and everyone should get on board with it. Every nurse should have an annual appraisal. It is something we encourage people to do. And if a nurse, for whatever reason, thinks they are not doing well, the annual appraisal offers a chance to deal with it rather than letting the problem become chronic.

Q) Some primary care nurses have concerns about whether it will be a nurse doing their appraisal.

I do understand that in some employment situations, there may not be another nurse. I think that can be easily resolved, and I do not think people should get too caught up with that. If someone is working for a company, and they are the only nurse, they must overcome their fears and concerns and find a sensible way forward with their boss.

Q) What one key thing can the RCN can do to support nurses in primary care?

I think that, historically, we have done good things but we can do more. We have got to get a primary care adviser in post. We also have to do more to highlight the incredible contribution that primary care nurses make.