Impact of the 2004 GMS contract on practice nurses: a qualitative study.

BACKGROUND: The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF). AIM: This study investigated how practice nurses perceive the changes in their work since the contract's inception. DESIGN OF STUDY: A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores. SETTING: Glasgow, UK. METHOD: Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach. RESULTS: Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient-nurse relationship, which were regarded as a core value. CONCLUSIONS: The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.

Stakeholder perspectives on new ways of delivering unscheduled health care: the role of ownership and organizational identity.

RATIONALE, AIMS AND OBJECTIVES: To explore stakeholder perspectives of the implementation of a new, national integrated nurse-led telephone advice and consultation service [National Health Service 24 (NHS 24)], comparing the views of stakeholders from different health care organizations. METHODS: Semi-structured interviews with 26 stakeholders including partner organizations located in primary and secondary unscheduled care settings [general practitioner (GP) out-of-hours cooperative; accident and emergency department; national ambulance service, members of NHS 24 and national policy makers. Attendance at key meetings, documentary review and email implementation diaries provided a contextual history of events with which interview data could be compared. RESULTS: The contextual history of events highlighted a fast-paced implementation process, with little time for reflection. Key areas of partner concern were increasing workload, the clinical safety of nurse triage and the lack of communication across the organizations. Concerns were most apparent within the GP out-of-hours cooperative, leading to calls for the dissolution of the partnership. Accident and emergency and ambulance service responses were more conciliatory, suggesting that such problems were to be expected within the developmental phase of a new organization. Further exploration of these responses highlighted the sense of ownership within the GP cooperative, with GPs having both financial and philosophical ownership of the cooperative. This was not apparent within the other two partner organizations, in particular the ambulance service, which operated on a regional model very similar to that of NHS 24. CONCLUSIONS: As the delivery of unscheduled primary health care crosses professional boundaries and locations, different organizations and professional groups must develop new ways of partnership working, developing trust and confidence in each other. The results of this study highlight, for the first time, the key importance of understanding the professional ownership and identity of individual organizations, in order to facilitate the most effective mechanisms to enable that partnership working.