Labour should listen carefully to nurse

GPs are the last people who should direct the future of the NHS, says Jane Salvage

Last week, in front of an audience of nurses, doctors and managers, the Labour Party unveiled its proposals for "a health service for a new century".

The audience were hoping for a visionary new policy, and almost nobody disagreed with the principles on which the new proposals to replace the NHS internal market were based, such as equity, quality, and responsiveness to need. Rhetoric, however, is easy.

The core of the NHS is its 500,000 nursing staff. Despite being undervalued for years, their commitment to the Health Service is still strong, though many are now leaving for the greener pastures of private healthcare or other sectors. Their current problems, stemming from low pay and rock- bottom morale, include a crisis in recruitment, in retention (not enough nurses stay in the NHS) and in return (not enough come back after having children).

Nurses and midwives have nevertheless managed to improve patient care by insisting on better education, more research, stronger professional regulation and major advances in practice. All this has been achieved at great personal cost, in a climate mostly hostile to innovation.

Most nurses are hoping for better times, perhaps under a Labour government. They know only too well that the Tories have no vision, comprehensive policy or strategy for nursing. But would Labour do any better? So far the answer, sadly, has to be no. Labour's details of implementation are deeply flawed, and carry through neither the logic nor the values of the Party's strategic vision.

Tarnished and shabby the NHS may be, but the jewel in Labour's crown is beloved by the public and health workers. It's also a voting issue. So why hasn't Labour got it right?

Without a firm promise of new money, its pledge to divert funds to patient care by cutting red tape is not enough. Conspicuous by its absence is any plan to revitalise the service by paying attention to the needs or views of its staff. Adding insult to injury is the spectacularly wrong- headed centrepiece of its plan - to replace GP fund-holding, and the resulting two-tier service, with groups led by GPs who would decide what treatment to organise on behalf of patients.

In its efforts to remove market mechanisms from NHS planning and funding, Labour has reverted to an antediluvian vision of healthcare run by your friendly family doctor. How can it have missed such a golden opportunity? Maybe Chris Smith, the shadow health minister, should watch Staying Alive rather than Dr Finlay's Casebook.

Ignorance as well as nostalgia might also explain Labour's failure to move with the times. It doesn't understand the subtle but crucial difference between public health, primary healthcare and general practice. Smith promised to base care priorities on epidemiological and demographic evidence of need, and on clinical evidence of effectiveness. This is all fine, but his notion that it should be led by GPs is way off-beam. He talked of strengthening GPs' commissioning skills, but seems not to realise that health visitors, community physicians, epidemiologists and others are already trained in these skills and have been using them in the reformed NHS.

Besides, the greatest desire of most GPs is to get back to their patients, not to spend more time on management and planning. They give individual, curative medical treatment, not community-based, primary healthcare. What they think matters most will often differ from what others think - patients, nurses, community workers, voluntary organisations and so on. So, like good care, planning must be based on partnership and on co- operation: Labour watchwords in principle but not, it seems, in practice.

Smith argues that GPs are "normally the health service professional closest to the patient". That's not what most people feel after their average eight-minute consultation. It's certainly not the view of the thousands of patients who rely for survival on daily visits from the district nurse or the home help, or pour out their fears to the practice nurse because they are scared of wasting the doctor's time, or talk to the school nurse about their unwanted pregnancy.

Why hasn't Labour noticed the countless team-based projects which tackle health needs but do not set professional against professional, or put the doctor on a pedestal and the nurse in the sluice? Such projects are based on community participation and respect for everyone's perspectives and skills.

Perhaps Labour thinks that sucking up to GPs will buy off the opposition. If it is terrified of the medical establishment, it's forgetting that the power of doctors isn't what it used to be. Don't they realize that nurses, the biggest group of NHS staff, can no longer be relied on as a safe Labour vote if they see no end to their exploitation?

Perhaps they have just lost their nerve. Labour says it does not want to cause unnecessary upheaval, but NHS staff don't want a cuddly version of the status quo. They will welcome change in the right direction because they care deeply about the Health Service and want it to work.

Labour needs to think again if it is to win the confidence of NHS staff. Chris Smith should remember that policies and structures, however good on paper, can only be made to work by a well-motivated, highly valued and secure NHS workforce.

The writer, a registered nurse, is editor of `Nursing Times'.