What goes around...

What goes around comes around. Never is this saying more true than when it comes to nurse training. When I trained  in the New Wave era of the 1980s, it was basically an apprenticeship as it had been for generations before me. Our training was fully funded. We worked on the wards and were paid a pittance because we knew nothing but we were a pair of hands - an increasingly useful pair as we progressed. We learned in modules in the classroom in between each placement. Alongside us on the wards were enrolled nurses - doing two years to our three for a 'lesser' qualification. And there were degree course students - doing four years - who spent more time studying and less time in the sluice but came out as registered nurses like us. I had friends in all nursing streams and while I was envious of the degree course nurses - with proper recognition for their academic work - I understood the intent of the enrolled nurses, many of whom just wanted to qualify as quickly as possible and hadn't understood when they applied that they would get a 'lesser' qualification.

Gradually the profession learnt the folly of having two tiers of qualification - some of the best nurses had an enrolled qualification but their careers were stymied - they couldn't progress. Many 'converted' via extra training to become registered nurses. From the turn of the century diploma and degree courses ran side by side with many people opting for a diploma course because they couldn't afford to do a degree. By 2013, nursing was a degree only profession. The move was of course accompanied by the usual moans about nurses not needing to be educated and educated nurses meant compassionless care. Education doesn't make someone a bad nurse, although overwork, poor pay and lack of managerial support can make compassion hard to find.

Nurses, together with some other professions allied to nursing - physiotherapists for instance but not paramedics - currently still have their training paid for via an NHS bursary but they are no longer paid to work. They are supernumerary to the numbers on the ward. Again this can be a blurred line - the more skilled they become the more appropriate it is to leave them to get on without hovering over them - but is that exploiting them?

And now, just two short years later in a move Chancellor George Osborne describes as 'modernising' the profession, the government has announced that nurses will pay £9,000 a year for the privilege of training. All for a job with a starting salary at band 5 (staff nurse) of £21,000, rising to the dizzy heights of around £28,000 some eight years later (If increments are still permitted). And the majority of nurses will stay at band 5.

Not everyone can progress to higher levels - much as the police force needs its constables, the NHS needs its staff nurses.  Added to which  there are  few jobs around at band 6 - many of these are ward manager posts, downgraded from band 7. The latter (with a starting salary of £31,000) is now vanishingly rare amongst the nursing profession.  For more on nursing pay rates visit the RCN site here.

So there is every chance a newly qualified nurse will earn just enough to have to start paying back her student loan and, with the threat that hangs over incremental pay (on the junior doctors' list of grievances) they may never earn even a modest pay rise. MPs got their 10% rise on the back of their independent pay review body but the equivalent pay review body for nurses recommending a 1% pay rise was turned down in 2014 by the health secretary as too expensive. A 1% rise was granted in 2015 but was hedged with freezes to incremental pay.

A nurse may never move beyond staff nurse  - in 40 years of nursing her (and it is 90% likely to be a 'her') pay will hardly rise. This will do nothing to close the gender pay gap already present between male and female graduates - with 20% of male graduates earning £30,000 or more compared to just 8% of women.

Throw in that most of the nursing workforce are women (did I mention that?) and that women are still the only ones biologically able to give birth so their chances of career progression and better pay will be curtailed or at best postponed for several years by childcare. And all the time they must make sure they remain up to date, complete sufficient clinical hours and pay an annual subscription of £120 to the Nursing and Midwifery Council (NMC).

One of the arguments for student loans was that graduates would earn more than those who didn't go to university. That argument is now redundant. True if degrees are in civil engineering or mathematics as this article in The Telegraph shows but nursing doesn't feature here. Graduates will earn on average £12,000 a year more than non-graduates entering the job market who can expect to earn around £22,000. Nursing graduates are below this on £21,000. And yet they will be paying the same level of tuition fees for their training as someone starting on £30,000.

Not like other students
The reason why there is a shortage of nurses is because NHS Trusts, scrapping to get their books in order so they could apply for Foundation status 'miscalculated' the number of nurses they would need. this translated into fewer training places and now future nurses will be paying a very heavy price for this mistake.

At the time of Osborne's announcement, chief executive of the RCN, Janet Davies said: “Student nurses shouldn’t be the ones having to pay for it. Student nurses aren’t like other students. Half of their time is spent in clinical practice working directly with patients and their families and they have a longer academic year.

Davies also said "The proposal could deter the sizeable number of student nurses already owing significant amounts from a previous degree, Davies warned. “The average age of students on nursing degree courses is 29. They’re not all 18-year-olds.”


But now the idea of 'nursing associates' is being sold as the answer to those who can't afford to pay for a degree. Back to two tiers of nursing. Badged as nursing apprenticeships and hedged with sentimental quotes about nurses being the 'lifeblood' of the NHS (despite being so badly paid) this is a sell out by the nursing hierarchy who have argued for so long for an all degree profession.

Find out how to respond to government plans to scrap the NHS bursary here and use the RCN's online calculator to work out just how far nursing salaries are lagging behind

Travel sick - banning smoking in cars

Queuing in traffic around the north circular on the way to relatives was a feature of my childhood. As was my mother's stress at the combination of the length of the journey and my father's nose to tail break hard driving. Her need for a cigarette was pretty overpowering. I remember my brothers and I pleading with both our (health professional) parents not to smoke in the car - something they heeded as best as nicotine addicts can. We had to have the windows wound up to shut out the smell of traffic fumes only to be locked in the car with cigarette fumes. It was only the very real threat of me throwing up due to aforesaid breaking that stopped my mother lighting up.

This experience was probably pretty common in the 1970s and increasingly less common in the decades since - although Labour and co-operative MP Luciana Berger claims here that one in five children may still be exposed to smoke in cars. Whether it is out of ignorance of the harm they do or denial in the face of addiction, only legislation will force parents to confront what they are risking.

It's hard to know why banning smoking in cars is such a contentious issue. Yet it's a real fight - one that may well go down to the wire - just like banning smoking in public places - but we got there in the end with that. We have to hope that this government doesn't once again run scared of legislation to protect the public's health just as it did with plain packaging of cigarettes and minimum unit pricing of alcohol - although it may be tiptoeing back to reconsider the latter.

The House of Lords has backed Labour's proposal to ban smoking in cars carrying children. Ministers are now looking at how to implement such a ban. Disappointingly, however, deputy prime minister Nick Clegg said on his weekly LBC phone in that he was opposed to legislation that would allow the government to ban smoking in cars with children - calling it 'sub contracting parenthood'. But then I hadn't realised that Clegg was a smoker. Does he think car seats for babies is 'sub contracting parenthood' or is it just the smoking thing? Read the story here
Read @COPDdoc Nick Hopkinson's excellent dissection of Clegg's arguments here


There is widespread evidence here and here that second hand smoke harms those who breathe it in. That this is so was a strong feature of the argument for banning smoking in public places - those employed in pubs and clubs were forced to breathe in the cigarette smoke of punters hour after hour. Five years after the public smoking ban, there were reports of improved health amongst barworkers and it has been almost universally welcomed by them and by their customers. Although there are still hardy knots of people gathered outside pubs and clubs sharing nicotine and camaradrie with other smokers.

It was thought that the ban on smoking in public places would drive smokers back into the home to light up. But it seems this didn't happen. Many smokers took the opportunity to give up whilst many more at least took their smoking outside just as they had to when in a public place.

Of course, public health education must continue to be a big part of changing smokers' habits, together with support to help people give up. But we know from experience that public health campaigns are most effective in changing behaviour when they are backed by legislation. That was the lesson from introducing the law on wearing seatbelts, and the drink driving and smoking bans.

Children, of course, have no say in any of this but if they had, I don't believe one would say 'I wish Mum or Dad would smoke in the car.'

Blowing a gasket

Politicians hijacked the family doctor label and used it to sell the changes in the NHS to an uncomprehending, trusting public. Now secretary of state for health, Jeremy Hunt wants family doctors back in their surgeries doing what they do best as well as running the night shift in order to keep people out of A&E. It’s not going to work.

As a nurse who trained under the old order in what was basically an apprenticeship as well as under the new order in a return to practice course, I felt ‘qualified’ to comment in my last post about nurses. I decried the idea that student nurses should spend a year working as healthcare assistants before being allowed to train as student nurses. 

A month later I find myself writing about GPs – they being the latest professionals under attack from the coalition government. My ‘qualification’ here is more third party. As the daughter of a GP and also the sister of one, I’ve plenty of experience of how the job affects family life and, having worked professionally with GPs, I feel I have an insight into their workload and, to a certain extent, what drives them. And, of course, being a patient gives me the shop window view.

I confess to more than a little hypocrisy, having complained myself about the curmudgeonly, recalcitrant nature that is at the core of many a GP (with no one being more recalcitrant than my late father who took things to another level). However, GPs having long been on a pedestal must now feel they can’t do right for doing wrong. Having been given the keys to the  commissioning purse as part of the Lansley changes to the health service thus distracting them from their day job, they are now being castigated for having given up their night role 10 years ago which apparently has only now started to affect A&E services. Speaking at the King’s Fund recently, Secretary of State Jeremy Hunt, told GPs to take responsibility for the care of their patients out of hours http://www.telegraph.co.uk/health/10077146/Jeremy-Hunt-orders-GPs-to-take-charge-of-out-of-hours-care-as-row-escalates.html

Hunt complains that we have lost sight of the concept of the family doctor. We? I think he means politicians lost sight of the family doctor when they appointed them as head honchos buying services for their patients instead of referring to them; making GPs responsible for the health of the local population when their skill lay in the clinical needs of the individual patient in front of them.

My local GP surgery, may not implement with gusto all the various public health measures that I think would be a great idea just because they are ‘ideally placed’ in the community but, when push comes to shove, they have always been on the side of the patient. They have provided excellent care to me and my family, expedited appointments and been fantastic support at times of need.

Much has been written about the problems with A&E: the rising numbers of patients being admitted via their doors and the long waits which we thought were a thing of the past. Statistics have been bandied about with a variety of commentators offering their views and reasons.  The pressures on A&E have undoubtedly been caused by a range of factors – a cut in the number of inpatient beds means people back up in A& E waiting for admission. The cuts to social care mean that people may not cope so well at home and seek admission to hospital and, with less support in the community, it is harder to discharge people from hospital.  The whole system is under pressure and the gasket is blowing in A&E.

When it comes to the arguments over A&E numbers, I found the King’s Fund’s John Appleby’s blog the most compelling argument for why numbers were increasing and why there’s no need to panic: http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing

His logic has to make you wonder; is the media storm over A&E nothing but a stirring of the hornet’s nest creating an impression of a ‘failing’ NHS that needs saving by the private sector? Hmmm, can’t see that working either. If there’s one thing that presents at the door of A&E it is ‘difficult’ patients and that’s one thing the private sector doesn’t want. ‘Difficult’ patients with complex social circumstances, co-morbidities and distressed relatives are time consuming and expensive. Paying for care at the entrance of A&E would truly be the end of 60 years of care free at the point of delivery. I wonder when that idea will be voiced?

 

Cheap labour

Potential nursing students should spend a year working as health care assistants before they start training, says the government. A move described by the RCN as ‘stupid’ www.bbc.co.uk/news/health-22209634

I couldn’t put it better myself. The story first broke at the end of March but I hoped it had merely been suggested to test reaction and would not rear its head again. But no, here we are at the RCN congress www.rcn.org.uk/newsevents/congress/2013 and the government, dogged as ever, especially when it’s wrong, is going full tilt.

It’s an idea that completely misses the point of the recommendations of the Francis report and tries to lay the blame for the travesty of Mid Staffs on nurses, whilst Francis laid it on the NHS Trust Board and the strategic health authority. www.midstaffspublicinquiry.com/ 

How anyone thinks that unleashing untrained people, often teenagers straight out of school, on patients with multiple care needs, will improve the care of those patients is bewildering. It demonstrates a complete lack of understanding of nursing and, I would suggest, of education.  If you don’t believe me then read http://juneinhe.wordpress.com/  for a nurse who really knows her stuff.

Nursing is and should be a career, where educated people can be both caring and ambitious. The two are not mutually exclusive. Nurses can specialise and become expert in their field – increasingly a necessity in an advanced health service. There will always be room for generalist nurses but the days of a nurse being able to ‘work anywhere’ are about as realistic as expecting an athlete to be able to compete in any event just because they can run fast. Yes, nurses need to be caring and compassionate but they also need to be intelligent, educated and forward thinking.

How will a year spent as a wage slave facing the more grim aspects of life make someone compassionate and enthusiastic for more? Many young people will be more than up to the job and still want to go on to do their nurse training. But many, who would have made excellent nurses, will not. The ability to deal with the smell and misery and sheer grossness that comes with caring for the very sick, the very old and the dying takes maturity, understanding and compassion. The latter is not produced automatically like an inborn kindness duct present only in those who can be nurses. However, it will almost certainly develop as someone matures and is certainly something that can be learnt with the support of good tutors and good role models. 

The age old dichotomy between ‘educated’ nurses and ‘trained’ nurses is tedious and usually put forward by those who are not nurses or have been out of the profession so long that they can’t remember the bad old days.  Why would you not want your nursing workforce educated? At present student nurses spend more than 50% of their training in practical learning – on the wards, in the community and in skills labs. What will another year of hard graft at the minimum wage – making their training an unrealistic four years – add to the mix? 

Put young people fresh onto wards and into care homes and there is no knowing who their role models will be. Much of nurse training may be spent unpicking some bad habits and corner cutting learnt while on a year’s ‘compassion training’.  And anyone forced to do a year of apprenticeship might well see themselves above having to do any of the dirty work once they are trained – there is an army of untrained youngsters for that – thus having the opposite effect the government intended.

But of course this is not about nurses, nursing or patients. It’s about filling jobs cheaply with young people thus solving the care of older people and the young unemployed in one hit.

Learning unsupported and unsupervised will be bad for nurses, bad for nursing and bad for patients.

For more on the good old, bad old days: Remember when?

Positive about health

Recently, I attended the Public Health 2013 Achieving Positive Health Outcomes conference. Aside from the fact that the word positive in a health context is not always, well, positive, (think HIV positive) it was interesting and stimulating to be amongst public health colleagues. In particular, it was good to hear from the determinedly non-pompous head of PHE, Duncan Selbie who talked about ways of working and yes, positive attitudes to colleagues and others.

The purpose of the conference was to introduce local authorities to issues in public health now that, as Roy Lilley so eloquently put it in his blog conta.cc/WBWXgE, it is ‘stuffed up the back passage of the town hall’. So, there was a lot of hard sell from private companies hoping that local authorities would commission them to provide weight management services or active lifestyles at a price. Don’t know why; local authorities are strapped for cash and that lovely ring fenced public health money is not going to stretch to anything other than the most basic, but hopefully effective, public health interventions.

It was not all commercial sell and there was a presentation from the public health team in NHS Wiltshire and NHS South of England on the excellent work they have done on tackling unintended pregnancy in the region. This was through incentivising GPs to train to provide long acting reversible contraception (LARC) thus increasing access to contraception across the region. GPs had their training paid for and additionally, for each implant they are paid £61 (and the same for removal).  All funded by Improving access to contraception monies. Whether that programme will be sustained now that funding is coming to an end remains to be seen. Will GPs continue to provide the service if they are not receiving payment for it?

Ironically, the conference was held at The Brewery Conference Centre, which, when I was training as a nurse a million years ago at nearby Bart’s Hospital, was still a working brewery - dray horses and all - but is now a beautiful conference centre. However, its association with alcohol seemed slightly at odds with the promotion of public health or, as we were regularly reminded, the public’s health – as if we hadn’t thought about that before.

The alcohol link was not direct sponsorship more just an association so I got over it. But coming in the week that it did with minimum pricing for alcohol looking like it was taking a dive, it did make me think. Is alcohol advertising, promotion, branding, its very presence all around us as pernicious as we now consider that associated with smoking?

There was a time, not so very long ago, that tobacco companies sponsored a vast array of sporting events and no one thought anything of it but as smoking has slowly become almost as antisocial as, say, drink driving, is alcohol becoming the same? I don’t think there’s a lobby to ban alcohol completely - it is not quite the killer that smoking is and, let's face it, prohibition was a disaster.

However, there is no doubt that ‘something has to be done’, if only to rein in our enthusiasm for alcohol. Drinking is so easy. It’s easier, in fact, then smoking. It’s always been frowned on at work unlike smoking which was once a part of office life, and those employees who drink at lunchtime are a rarity these days, but buying alcohol and consuming at home is so easy and so cheap, compared to a generation ago.  And culturally, it’s acceptable. Smoking is no longer culturally acceptable. People might at best feel sorry for you if you smoke but they won’t joke and laugh about it and share their smoking stories like they do about drinking.

Studies show that minimum pricing does have an effect on drinking levels in the population with one Canadian study showing that a 10% increase in average minimum price for all alcoholic beverages was associated with an almost 32% reduction in deaths wholly attributable to alcohol. The study by Tim Stockwell, Jinhui Zhao and colleagues showed that there was also a time lag in the impact with fewer deaths from alcohol two or three years after minimum prices were established.

Certainly minimum pricing will not solve all alcohol woes but it might be a positive step towards acknowledging that we may have a problem. And that first step is important in any addiction, whilst a positive attitude is essential in public health.