Bleating up the wrong tree

Who does the government consult when it wants evidence of 'shortage' and the need to increase pay? The usual source is the Royal College of Nurses, one of whose purposes is to raise nurse pay. Obviously the RCN and working nurses will argue that the central issue is pay.

Perhaps the government should survey more thoroughly those nurses who leave the profession at different parts of their career.

Why are so many trained nurses not involved in nursing? Why did they leave their chosen profession and why are they reluctant to rejoin it? The RCN and surveys of working nurses cannot answer these questions. The government seems determined to base policy on incomplete evidence and in so doing may produce daft solutions for ill-defined problems at high cost.

Nurse recruitment is difficult in part because of the changed nature of the role. During the past 10 years healthcare policy has involved significant increases in patient activity and sharp reductions in the length of stay.

These changes have resulted in nurses having to care for patients who are acutely ill.

Previously they had had 'hotel' patients in their beds and this enabled staff to focus their efforts on the very ill. As length of stay declined, all too few managers sought systematically to increase nurse staffing in wards and even fewer could afford change.

Inarticulate and weak nurse managers, combined with performance targets and 'efficiency gains' which demanded cost squeezes, resulted in nursing workloads being increased.

This patient load appears to have increased unevenly between and within hospitals and to have been often poorly managed. In part this is a product of the differential management skills of ward sisters. It seems some cope marginally while others create structures and a work ethos which ensures excellence. Often there tends to be little cross-over learning as the care system is fragmented within institutions.

American healthcare managers responded to reduced lengths of stay by increasing nurse staffing.

This ensured that the new population of acutely dependent patients were not only well managed but discharged with care so as to avoid readmission and the associated costs for the hospital and patient. British nursing did not learn from this, and instead its leaders collaborated with financially driven chief executives who reduced nurse staffing and, in so doing, made the job onerous and unattractive for many.

About the same time the 'wise' opinion leaders in the profession pressed for changes in the training of nurses. They consulted academic nursing colleagues who recommended academic training: this had the nice effect of increasing their power, influence and income. By moving to a more academic system of nurse training, the profession was disadvantaged in a number of ways.

First, the pool of people from which trainees could be drawn was restricted. Second, by insisting on more classroom and less ward experience, many vocationally oriented people were demotivated.

This is not to say that academically trained nurses are not needed. Such people could acquire invaluable practice and management skills which in the near future may provide much needed improvements in the leadership of the profession.

However, the policy issue is one of balance or appropriate horses for courses: we need academic nurses to manage complex care processes by teams and we need caring, patient and tolerant nurses who will clean up a distressed incontinent elderly person on the ward at 3am and who will care for the terminally ill patient. Why the profession backed the academic horse so strongly is unclear, but it appears to have been of ambiguous benefit.

The quality of nursing care remains as uneven as that provided by doctors.

Systematically, nurse managers and nursing staff ignore evidence about effective wound care practice, management of incontinence and infection control. Some argue this is due to the pressure of work. But in reality it is due to gross failures to prioritise effectively and adopt styles of care which reward better the patient and the practitioner Properly trained nurse practitioners can carry out most of the roles of the GP effectively and in user-friendly ways. They could, if doctors let them, make up for allegedly inadequate staffing levels, particularly in rural and deprived city centre areas. With such substitution the bleatings about 'shortages' of GPs could be mitigated and patients could be given access to effective care.

The policy challenge is clear.

There appears to have been little evaluation of nurse staffing levels in relation to changed patient needs over the past decade and more. Squeezing budgets as practised by the Conservatives and by Labour has distorted nurse staffing levels.

With nursing costs making up 35 per cent of a trust's budget, they have been the victim of undue savagery and this has created unpleasant working conditions for many nurses.

The resulting recruitment difficulties will not be remedied by further large pay increases. The rate of return over the lifetime from investing in nurse training is quite high. New nurses are paid more than many university lecturers and other skilled groups.

The challenge for the government is not to fritter away increased expenditure on nurse pay hikes unless there is demonstrable evidence that it will draw back nurses into the NHS.

Instead of spending on high pay hikes for these voting 'angels' in 2001, it might be more efficient to improve staffing levels and job characteristics for nurses.