All practice nurses interviewed were female and had been practice nurses for between 5 and 17 years. The distribution of practice QOF achievement by practice socioeconomic profile is shown in Table 1.
Three broad themes were identified from the data: roles and incentives, workload, and impact on patient care.
Roles and incentives
Roles and incentives were discussed in relation to two issues: professional development and professional status. Most practice nurses felt they had expanded their role and taken on new skills, particularly in chronic disease management and data recording, since the implementation of the new GMS contract. This view was consistent across practices, regardless of the level of QOF achievement or the socioeconomic profile of the practice population:
‘I think the contract has enhanced the nurses’ role rather than hindered it.’ (PN8, QOF Q4, affluent)
However, this focus on contract areas led several nurses to voice concerns at having fewer opportunities to work and train in non-contract areas, such as minor illness:
‘I think it could have a detrimental effect on the development of the practice nurse's role because you could very much be here to just do the contract work and not be able to stray from that into areas that you have trained for.’ (PN9, QOF Q4, deprived)
‘I would just like to see more minor illnesses and to have more clinic time for that. My clinic is always full and I cannot see any more patients. I hope I could have less chronic disease management clinics and more minor illness. I probably would like that, but at the moment we need the chronic disease management in relation to the contract requirements but I don't know whether that will change or not.’ (PN17, QOF Q1, deprived)
Table 1 Practice distribution by QOF point achievement and socioeconomic profile.
There was a general opinion that the new contract had enhanced their perceived status within the practice somewhat, with more autonomy, independence in organising care, and a greater centrality of role in the practice:
‘Before the contract we used to just do the mundane things and we were really just a GP's handmaiden sort of style, but now we are working a lot on our own and doing a lot of things [so] that we get out of it more job satisfaction.’ (PN14, QOF Q3, deprived)
However, for some, this increase in autonomy and role expansion was in response to the GPs' needs for work to be conducted in the area of chronic disease management to meet QOF targets, rather than in response to nurses' clinical interests:
‘Yes, they directed that there had to be more clinics for whatever they were targeting and needed to improve upon in relation to the contract but I think they had that power [to direct nursing work] anyway.’ (PN17, QOF Q1, deprived)
For some, this focus on achieving targets meant that team working had improved within their practice to maximise QOF achievement; others perceived that they had carried out most of the work required themselves:
‘I do in fact do most of the work for the contract and in many ways that's not a good thing as it is supposed to be team work.’ (PN1, QOF Q4, affluent)
‘Well [pause] I think that they have basically left it to me.’ (PN8, QOF Q4, affluent)
Although most nurses felt that their professional status had improved, many felt there were few tangible benefits in terms of salary, with only one nurse reporting a salary increase as a direct result of her practice's high point achievement. A substantial minority was openly critical of the GPs in their practice, feeling that while they (the nurses) did most of the work, the GPs were the ones who benefited financially. This view was not related to the QOF achievement:
‘I'm not comparing it [GP salary] to what the papers say they were walking off with, but [they got] financial rewards for a lot of the work that has been done by nurses.’ (PN18, QOF Q2, deprived)
‘The GP's role in the contract is picking up the points and getting the money.’ (PN1, QOF Q4, affluent)
‘… we do the work, the doctor gets the rewards and it is up to him whether he decides to pass it on or not because he gets a global sum now. So that is a bit of conflict with a lot of nurses at the moment. So our role and responsibility has expanded but at the same time the wages are staying much the same.’ (PN12, QOF Q2, deprived)
Although salary increases, while remaining on the same grade, were unusual, approximately a third of interviewed nurses had been promoted to a higher grade since the inception of the new GMS contract — which would, of course, improve salaries. This appeared to be associated with higher-achieving QOF practices, but it was unclear if these promotions were as a direct result of QOF achievement. No nurse had been offered the possibility of becoming a partner, despite this being allowed under the new contract. However, it was unclear whether this was due to GPs not offering nurses such opportunities or to the nurses themselves feeling reluctant to grasp them:
Interviewer:‘What about the partnership idea between GPs and nurses?’
Practice nurse:‘I don't see GPs going for that.’ (PN12, QOF Q2, deprived)
‘… we discussed [partnerships] as well, before the contract started. We discussed it recently due to a partner retiring, I am not sure if I would consider that at this time. Yes the option is there — whether I would consider to do that or not?’ (PN9, QOF Q4, deprived)
Indeed, when some nurses were explicitly asked about nurse partnerships, most did not want to take on that level of responsibility, at least at that time:
‘Well if it's your business it should then become, it's your source of income and you become, well you have got to make the money, you have got to make the money to dish it out and that includes our wages. Me personally, I wouldn't want to be a partner, it may well be a thing of the future.’ (PN13, QOF Q3, affluent)
Practices often offered practice nurses incentives at the end of the contract year, in the form of a monetary bonus or extra holidays. Opinion as to the appropriateness of the incentive varied, with no obvious association between QOF points and the incentives offered:
‘I am happy [with the incentive offered] but I have spoken to other practice nurses who are not, I think a lot depends on who you work for.’ (PN5, QOF Q1, deprived)
‘I made the suggestion that I got a percentage of the total. I could never work out what the percentage should be and in fact it was one of the GP's who came up with a figure, which was acceptable to me, so I agreed to that.’ (PN1, QOF Q4, affluent)
One practice nurse in a high-achieving practice, was aware of the business side of the practice and felt that, although she received a monetary bonus, it was diminutive in comparison to the money awarded to the practice for the QOF points attained:
‘I suppose if you look at it as a percentage of the actual money that comes in … [wry facial expression and nervous laughter]’ (PN9, QOF Q4, deprived)
Such situations contributed to a general feeling of inequity in the workload/remuneration balance between the nurses and GPs. Indeed, occasionally, the use of an inappropriate incentive was perceived to be worse:
‘The practice in total were all taken out for a meal, I don't like Chinese, we were all sick. A financial incentive would have been better.’ (PN2, QOF Q1, deprived)
Workload
Workload had increased for all nurses in terms of clinical commitment (particularly in contract-driven chronic disease management and preventive care), bureaucracy, and data collection:
‘Well we always did the asthma but we have now to do the diabetic clinic, you know more health promotion, coronary heart disease, stroke clinic, epileptic clinic, and mental health patients. These have all increased and a lot of what the doctors did, such as the epileptics and mental health patients, you know, the practice nurse is doing them now. The workload is heavier now than what it was before the introduction of the new GMS.’ (PN14, QOF Q3, deprived)
Even those nurses who felt that the type of patient they were seeing hadn't changed complained that the volume of work had increased dramatically. Most felt pressurised by this, with time being a particular constraint:
‘You know you are trying to do something that realistically will take three quarters of an hour and you have just quarter of an hour to do it in. Something goes, you either run late, which I frequently do, or you take a note of what has to be entered on the computer in your head and put it in after the patient has left the room, either way your surgery runs late.’ (PN2, QOF Q1, deprived)
Although workload had increased, most nurses agreed that the contract had systematised and standardised care. Those in low-achieving practices were particularly likely to mention this:
‘It has become much more structured and I have recall systems in place for all the chronic disease areas, before it was a bit scrappy.’ (PN5, QOF Q1, deprived)
By contrast, high-achieving practices were more inclined to report that the contract represented an extension of previous ways of working:
‘It really hasn't made that much of a change to our work as a practice nurse because everything that has come up in the contract and every box that has to be ticked we have always ticked before the contract, it is made no difference to how we practice but probably we are seeing more patients coming through because more patients are being chased up to come down but it has not made any difference to their care.’ (PN11, QOF Q4, affluent)
Some nurses felt that there was more of a focus on population health than on the needs of the individual. They were particularly frustrated by the rigid protocols for reviewing patients and the call and recall system:
‘Some of the things that should be included in it aren't and some of the tick boxes are quite ridiculous… And also insistence on three letters to patients. We are constantly hounding them and patients should be allowed to choose whether they want to cancel themselves out.’ (PN1, QOF Q4, affluent)
‘I think it is a bit one-dimensional and shallow and not overly impressed with the way it has made us work.’ (PN3, QOF Q1, deprived)
Impact on patient care
Although there was general agreement that the new contract had improved some aspects of patient care, there weremany concerns that the target-based nature of the health care provided had negative impacts too:
‘It is very top heavy and at the end of the day what I think the NHS should be asking is what gain to the patients does it afford. Sometimes I am standing at the door holding the door open for them while I speak to them — not good care.’ (PN2, QOF Q1, deprived)
‘But I am not sure how collecting all this data and reaching targets is going to help patients perceive their own locus of control by way of health in its holistic sense.’ (PN3, QOF Q1, deprived)
‘… a bit resentful, in as much that the contract seems to have taken over and it is all admin and tick boxes and taking away from the patient care side of things and no incentives. You wonder sometimes if it does improve patient care or whether you are just ticking boxes for the sake of it.’ (PN8, QOF Q4, affluent)
The requirement for systematic data collection using the computer, particularly during the consultation, was also criticised as creating a barrier between the nurse and the patient:
‘I find I am not looking at the patient, it's almost an afterthought. I better look at the patient to see how they are. “Oh my goodness you are looking awfully pale today.” That should be something that's noticed as soon as they come into the room. “Good morning Mrs So-and-so come in and sit down; my you are looking a bit peely wally, [off-colour] how are you feeling?” But no, you are too busy on the computer and it is an afterthought.’ (PN2, QOF Q1, deprived)
‘Well it is quite labour intensive, very labour intensive, and there were many people coming in to see me but we are more interested in what is on the screen and it is hard to sit and listen to somebody when my computer is over here, the logistics of it cannot be carried out easily, do you know what I mean?’ (PN12, QOF Q2, deprived)
Much of this was due to a lack of time during the consultation. Some tried to complete the data collection after the consultation, but this also resulted in feeling pressurised. There was also a widely held view that time spent inputting data meant less time to provide clinics:
‘Well, say this morning I have had a diabetic clinic, I will sit for hours this afternoon putting all the information in the computer. I would not see one patient; I will just sit and do that until 5 o'clock tonight.’ (PN15, QOF Q3, deprived)
Some nurses were concerned about the ethical dimension of collecting patient information for the specific purpose of achieving QOF targets and, hence, practice payments, with patients not fully aware or informed of the reasons behind this new way of working. There were some suggestions that this was deceptive:
‘I feel that patients don't realise that this is going on as no one had actually told them and no one has explained to them why we are asking them so many questions and gathering so much data.’ (PN6, QOF Q4, affluent)
