Issue | Response |
1. The move towards generic skills versus specialisation among community nurses | It is neither feasible (because of workforce issues - i.e. there will be a serious shortage of nurses in the future as pressures are exerted on both demand and supply) nor desirable to continue with the current (and increasing) level of specialisation that exists within nurses working in the community. Many countries - notably Slovenia, the Republic of Ireland, Finland and the Netherlands - community nurses work as generalists and provide services across the spectrum of care, from illness prevention to cure, and from the cradle to the grave. In Scotland the Family Health Nurses (FHN) work to a generalist model, delivering clinical care, promoting families' health, and organising community health initiatives. FHNs work with all generations, mainly in home and community settings. Although FHNs worked within the current system with district nurses and public health nurses acting as specialist resources, it is considered to be a model where the underpinning principles can be built on. The model is similar to that of the GP, i.e. seeing everyone who presents with a range of health problems, dealing with complex issues and referring others on to more appropriate agencies if required. In Parfitt et al's 2006 evaluation they found that FHNs claimed that working to a generalist model had enabled them to pick up on health issues and individuals who otherwise would not have received attention, and was highly acceptable to service users and carers. However, the success of the generalist model is contingent on a network of specialists to support practitioners where a presenting problem is outwith their knowledge and skills - complex child protection issues might be an example of this. The generalist/specialist interface is one of the key areas that will explored in the Development SItes. Recognition of limitations and identifying when to refer individuals to a more appropriately qualified person is a central aspect of professional accountability. |
2. Would the "clinical" nature of a model which endeavours to give equal weight to health promotion and illness prevention as well as clinical care of unwell patients mean that the needs of the sick individual would always be prioritised over the health promotion work? | Health improvement is one of Scotland's priorities and is integral to the proposed model. In a similar way to the FHN, it is envisaged that the proposed Community Health Nurse (CHN) would have a dual health improvement and disease management remit, which would be delivered through an integrated team network. The FHN works with families and communities as a whole, to identify the health care needs of the collective members of the community, rather than beginning with a set of specialists who work selectively with particular client groups according to age or underlying disease which risks fragmentation with individuals and communities 'slipping through the net'. |
3. The uni-disciplinary focus on nursing vs. a focus on multi-disciplinary integrated services | The focus of the Review has naturally been on nurses working in the community. The team approach in this model should not be seen as made up exclusively of nursing staff. This model offers CHPs the opportunity to construct teams which respond directly to local health needs and to introduce skills to the team which can best support the needs of their community(ies). The model also lends itself to further develop integrated working and may contain social work skills as deemed appropriate. The team approach allows flexibility to meet the needs of the local population rather than the rigidity of a service structure or organisation's focus. Thus, in the proposed model the CHN will work within integrated teams. However, instead of identifying a health visitor or district nurse that would be part of the team, it will be a CHN. One of the strengths nurses consistently identified in the workshops (which is supported in the literature review) is that they establish collaborative working relationships with other care providers. This model aims to build on those strengths |
4. The place of children and young people within the proposal (child protection issues) | As a generic worker it is anticipated that the CHN would be able to meet the health needs of the majority of children in the community. It is important, however, that the role of the specialist children's nurse and how it interfaces with the new model is further explored and a review of the role of the children's nurse is proposed. It is proposed that this review would take place in parallel with the Development Sites. Child protection is obviously the responsibly for all health care staff but at the moment many HVs spend large amounts of their time on child protection issues. The model emphasises everyone's responsibility towards child protection and vulnerable people but it offers an opportunity to explore in more detail the expert skills required of a specialist service and where they best fit. This would be explored jointly with the Scottish Executive Education and Health Departments and with the Hall4 Implementation Network in the Development Sites. |
5. The place of Practice Nurses within the model and lack of acknowledgement of their central role in managing Long Term Conditions etc. | Practice nurses have a crucial role in the delivery of care to communities and will be important partners of those working within the new service model. It has not been possible to incorporate practice nurses in the model due to the particular nature of their employment circumstances; it is recommended, however, that local systems embrace their particular skills and expertise and include them in team approaches to meeting the health needs of local communities. |
6. The impact of such radical proposals on the morale of an already demoralised, change fatigued workforce with concerns that some would leave the nursing profession | During the workshops nurses talked about feeling that they had lost their sense of professional identity and needed to be given a clear direction. This model proposes to do that. The model is not about devaluing the traditional community nursing roles but it builds from those foundations to capture the essence of nursing in the community. It describes a new nursing role that is modern, priority focused and fit for purpose. It defines nursing as a central player in delivering the new health policy agenda, with a strong focus on delivering services closer to home and addressing the twin challenges of an ageing population and a rising incidence of long-term conditions. Importantly, it describes a role that will play a vital part in developing the community services individuals, their carers and communities demand. Implementation will be phased over a period of time, utilising the Development Sites to flesh out the operational details of the proposal and to ensure that full implementation builds on the lessons learnt from these sites. |
7. A lack of evidence for the recommendations and proposed model | The review has based the model on evidence from · The workshops which explored what nurses from all branches of community nursing are good at and their frustrations, as well as what they could do in the future in terms of Delivering for Health · Workshops with users and carers · A consideration of the current model of service delivery as well as other models of nursing roles, namely Family Health Nurse and Community Matrons · A consideration of the policy drivers of care provision · The literature review · Results from WHO Europe researchers who conducted a multi-national evaluation across all countries that had implemented the Family Health Nurse Role · Two conferences involving a range of practitioners, nurse other managers, educationalists and other stake holders |
8. Transferability of qualifications between Scotland and the other UK countries and vice versa | During the process of implementation there will be work with NMC and colleagues across the UK to explore the issues of registration, building on lessons learnt from FHN project around registration. Agenda for Change offers health care workers the opportunity to develop a portfolio of skills based on capabilities and competences rather than being limited to the more traditional pathways. Increasingly there will be a shift away from defined professional qualifications distinct occupational groups to one that is defined by skills and competencies is centred on the patient /client (Malhotra G (2006) Grow your own. Creating the conditions for sustainable workforce development, Kings Fund, London). |
9. Too little consultation time around the recommendations and proposed model for such far-reaching changes | The consultation time frame reflects constraints of the original deadline in Delivering for Health. Consultation with key stake holders has been an integral part of the entire Review process. The operationalisation of the model in the Development SItes will allow for a fuller testing out of the implications of the model, highlight further work that needs to be undertaken and enable practitioners across Scotland to explore with their managers their PDPs to identify learning needs. |
10. A lack of awareness or acknowledgement in the report of the wider policy context and other national initiatives | A list of the policy taken into account was on page 16 of the Draft Report. The review of Social Work in Scotland, 21st Century Social Work informed the Review, to try to ensure that both health and social care needs of individuals, families and communities are addressed. Nursing for Health (2001), in particular, was a key document that was considered, but implementation of its recommendations was found to have been sporadic and inconsistent throughout the country. There has been close liaison with colleagues in Community Care, Joint Futures and other Departments at the Scottish Executive as well as recognition of the Care 21 report on unpaid carers. Delivering for Health sets out Scotland's health priorities. This review is an action point from Delivering for Health responds directly to the challenges laid out in that document. |
11. Geographical based teams versus attachment to a primary care practice | The Review had tried to make it explicit that the SEHD were not stating a position on this. It will be a matter for individual NHS Boards to determine whether group attached/aligned or geographically based services are selected for their areas. The size and skill-mix within nursing teams will need to be responsive to local need and determined by local geographic, demographic and other health and social service configurations. |
12.Training and competencies of nurses both initially and maintaining skills for the new role with consequent concerns around patient safety | The Review recognises that the educational needs of both new CHNs and current practitioners who will need to broaden their skills to acquire the competencies of the CHN are challenging, although Skills for Health will have already done some of this work. HEIs and NES will be central to this process. Additionally, work will need to explore the most appropriate ways to register practitioners affected by the implementation of the model. An integral part of the work of the Development Sites will be ensuring that that Clinical Governance standards are monitored. |
13. Management issues - particularly how the consultant nurse role fits within the CHP structure and the CHP Lead Nurse along with the affordability of the proposed new structure | Nurse consultants were identified in the Transition Plan as being facilitators of the changes required for the implementation of the new model. They would work closely with the CHP lead nurses, but their role would primarily be strategic and clinical rather than the more managerial focus of CHP lead nurses. It is proposed that Nurse consultants should be appointed in all NHS Board areas to facilitate the transition to the new service model and to lead ongoing developments. Additionally nurse consultants were seen as being an important development for nursing teams to provide clinical leadership and expertise as well as a more structured career pathway for nurses working in the community. |