In June last year, the DH amended the Health and Social Care Bill, making it compulsory for each clinical commissioning group (CCG) to appoint a nurse to its governing board.
It followed a recommendation from the NHS Future Forum, the body established to conduct a 'listening exercise' around the government's controversial NHS reforms; and similar calls from the Health Select Committee and the RCN.
In practice, this means each CCG must appoint an executive nurse to its governing body. This candidate must be an experienced clinical leader able to 'bring a broader view, from their perspective as a registered nurse, on health and care issues to underpin the work of the CCG, especially the contribution of nursing to patient care'. Other nurses (including those working in general practice) can have CCG roles, but the executive nurse cannot come from general practice (see box).
Inconsistency and confusion
A year on, the Bill is an Act; however the picture emerging from shadow CCGs regarding nurse representation is one of inconsistency and confusion with nurse input in commissioning varying widely between localities.
A total of 65 CCGs have so far responded to an Independent Nurse Freedom of Information Act (FOI) request, asking whether they have appointed an executive nurse to their governing body, and the time commitment stipulated.
More than half (51 per cent) said that, to date, they had not appointed a nurse to their board (in an executive position, or any other role). A separate IN survey of CCGs, published in February, found that 54 per cent had yet to make an appointment, suggesting little progress has being made in the last four months.
Five of the CCG respondents (8 per cent) currently have a practice nurse as their only nurse representative, which is non-compliant with DH requirements.
Andrea Gupta, consultant practice nurse and chair of St Helen's Health shadow CCG admits she is unsurprised that many groups have yet to make a nurse appointment.
'The official guidance regarding nurses on the board has changed so many times, and the final version has not been out long,' she says, adding that many groups are still in the process of deciding whether to share certain board members and resources with other local groups.
More than a third (35 per cent) of CCGs are unable to state the number of hours per month the key nurse role entails. Just 14 per cent said they had appointed, or planned to appoint, a lead nurse on a full-time basis, with a third (32 per cent) saying the nurse on their board would be employed for up to 10 hours a week.
Some 14 per cent of nurses board members will work for a maximum of five hours a week.
RCN assistant head of nursing Tim Curry says: 'We've seen recruitment adverts for CCG nurses stating the job is for two days a month. 'In what way are they going to be able to contribute, except at two meetings each month?'
| Attributes of the CCG executive nurse |
The candidate should:
Be a registered nurse who has developed a high level of professional expertise and knowledge.
Be competent, confident and willing to give an independent strategic clinical view on CCG business.
Be highly regarded as a clinical leader, probably across more than one clinical discipline/ specialty - demonstrably able to think beyond their own professional viewpoint.
Take a balanced view of the clinical and management agenda drawing on specialist skills to add value.
Contribute a generic view from the perspective of a registered nurse, putting aside specific issues relating to their own clinical practice or employing organisation.
Bring insights from nursing and perspectives into discussions regarding service re-design, clinical pathways and system reform.
Have no conflicts of interest (not be employed by any organisation from which the CCG secures any significant volume of provision).
Bring significant additional perspectives beyond primary care.
Not be a general practice employee. This does not preclude practice nurses from being members of the governing body in other capacities, for instance as the health professionals acting on behalf of member practices.
Source: CCG Governing Body Members; role outlines, attributes and skills, April 2012
Sharing nurse expertise
In some areas, CCGs have appointed a lead nurse, dedicated to an individual group. By contrast, three groups in Nottinghamshire have appointed a single full-time nurse to work across them, a decision replicated in Suffolk, where two CCGs (West Suffolk and Ipswich and East) will share one nurse lead, committing 15 hours a week to each group.
The DH suggests the time commitment for lead nurses should be a minimum of one day per month; however, the RCN - among other critics - believes the minimum commitment should be greater.
'There should be a full time lead nurse,' says Mr Curry. 'Two days a month will not be able to affect a change on the board culture and they will get very frustrated.'
While guidance makes clear that the lead nurse 'should bring significant additional perspectives beyond primary care and should not be a general practice employee', it expressly states that 'this does not preclude practice nurses from being members of the governing body in other capacities, for instance as the health professionals acting on behalf of member practices..
Despite this, only four CCGs out of the 65 that responded to IN's FOI request currently have more than one nurse on their boards. These include Merseyside CCG, St Helen's Health, which plans to appoint a 'CCG practice nurse development lead' in addition to an executive nurse, to ensure practice nurses have sufficient input and representation. Ms Gupta, who chairs the group will be a third nurse with a role on the governing body.
'I prefer a model where an executive nurse isn't full-time, alongside a practice nurse board member or representative to help with nurse development and engagement,' explains Ms Gupta.
'If one nurse is in place for the right reason that is great, if it's three for the right reason, even better.'
Although the first 35 CCGs to enter the authorisation process has already been announced, the DH says it is 'too early' to draw conclusions about the make-up of boards as many shadow groups are still finalising management plans.
Latest guidance about authorisation, published earlier this month, states only that 'it is likely that regulations will require that: the governing body has at least six members: CFO, AO, two lay members, hospital doctor and a nurse'.
However, a DH spokesman pledged: 'In line with our agreement with the independent NHS Future Forum, there will be a nurse on every CCG governing body and we would encourage all health professionals to involve nurses in decisions around designing care for local patients.'
CCGs' progress is a cause for concern, warns Barrie Brown, lead nursing officer for health union Unite.
'It's pretty slow stuff,' he says. 'April is only nine months away - nothing in terms of the biggest shake up in the NHS's history and CCGs should be better positioned. Ideally we would see some centrally-driven guidance, but that's not part of the ethos of this government.'
But NHS Alliance chair Dr Michael Dixon (pictured), warns it would be a mistake for groups to appoint board members too quickly.
'Some are waiting to choose the right person, rather than appointing the first person who comes to mind,' he says. 'One problem we have seen is people choosing the same old suspects. It is sensible to bide time a bit.'
'You'll find, come 1 April (when CCGs take over commissioning from PCTs) most - if not every - CCG will have a nurse on the board.'
For now, however, it is clear that, in many areas of the country, nurses are not yet influencing commissioning at a crucial time in the evolution of CCGs, during the biggest shake-up in the history of the NHS.
Independent Nurse's No Tokenism campaign fights for nurse influence in clinical commissioning.