Feature

But will the doctors buy it?

Allowing GP fundholders to purchase community nursing may reverse years of achievement, argues Jean Orr

Health visiting and community nursing are facing their biggest ever challenge from the development of GP fundholding. Since 1 April 1993 selected community nursing services can be purchased by GP fundholders from district health authorities or trusts. After the first year, fundholders will have the right to negotiate some reallocation of resources. They will have the right to change the skill mix of the community nursing services and, where there are savings from employing less skilled nurses, GPs will be able to spend this money on other services. Legally once the provision of community nursing services to patients is added to the lists of goods and services purchased by the fundholders, health authorities cease to be responsible for the provision of this service. These changes have very serious implications for the future of community nursing.

First, GPs will have control over health visiting and community nursing services in a totally different way from the past. The GP’s view of what constitutes a comprehensive nursing service will, of necessity, play an important part in the contracts drawn up with the community unit.

Second, there is concern about the implication that money saved by any changes in skill and grade mix can be reallocated according to the decisions of fundholders, either to increase the level of nursing services, which is unlikely, or to increase the level of practice nursing or other practice services. Those of us who are rather sceptical about how some GPs operate find it difficult to believe that any fundholder would not wish to expand their own practice using money saved from externally purchased services. The amount of money is considerable: in one practice the community nursing budget was said to be £200,000. As this is public money, we have a right to ensure that GPs are accountable for how it is spent.

The current obsession with introducing skill mix throughout the NHS leads me to believe that some GPs may want to purchase less expensive staff than qualified district nurses and health visitors. But it is difficult to see how a quality service can be offered if the ratio of unskilled to skilled staff becomes too great. In order to monitor and provide a service there is a need for effective management. Fundholding control over the service may mean the growing marginalisation of all community nursing management. This has implications for the support and professional advice available to staff on matters such as child protection.

My concern is that the service to clients will be affected. The major concern for health visiting is that preventive work may be cut in favour of a more task-oriented service geared to meeting targets for general practice. In particular, there are fears that the universal service offered by health visitors to all children aged 0-5 will be lost in favour of services limited to those in crisis. This would result in such visits being seen as stigmatising and would deprive so-called ‘non crisis’ families of the support and guidance of health visitors in the pre-school years.

Third, as both GP-attached and patch-based health visitors now fall under the service umbrella of the fundholders there is likely to be an end to health visiting within geographical patches. It will no longer be compatible with requirements for identifiable funding of the service. For example, a patch which has patients from six practices could hardly qualify for six separate purchases of community nursing services. Patch-based health visiting and community nursing have been developing ways of delivering care in community settings, linking with community groups, providing outreach services and health promotion in ways which are meaningful to local people.

GPs are concerned with primary health curative services and, although there have been moves to involve them in prevention, the ethos is still one of medical care. But services like health visiting centre around social aspects of health care, working with communities and families to prevent illness.

As community nursing is absorbed within general practice what choice will exist for clients in terms of well baby clinics and well woman clinics? Who will work with groups on the margins of health care such as homeless people, travellers and women in refuges?

No doubt there are GP practices which want to purchase a high quality district nursing and health visiting service and we are already hearing of the difficulties these practices face because of the reduction in training for health visiting and district nursing. Evidence from England shows student intakes for both falling markedly. For district nursing numbers dropped from 824 in 1989/90 to 569 in 1991/92, a fall of 30 percent. Health visitor intakes fell in the same period from 826 to 684, a drop of 17 percent. There is no shortage of applicants for courses; the problem is one of secondment.

What is really worrying about GP fundholding is that so much will depend on the approach of the GP and how she or he views the importance of community nursing. This seems a rather hit and miss way of delivering services which, with the current changes in community care provision, are going to be key to the health and well being of the population.