Of the 1.3m folk now
employed within the NHS over 400K are nurses. Nurses are literally everywhere
spread right across primary, community and secondary care. Nurses deliver the
majority of clinical care and the 'tribes' of district nurses, health visitors,
school nurses, midwifes, GP practice nurses and hospital nurses have recently
been added to with the appearance of 'modern matrons', nurse consultants and
growing numbers of clinical nurse specialists and nurses with special
interests. But the NHS Plan proposed even more new roles for nurses.
New Roles
Many other new roles are developing and more
seem to be being created almost every other week. More and more 'mega-nurses'
are doing new things in different ways. Prof. Sir George Alberti, reporting on
emergency services over this winter, has said that without emergency nurse
practitioners (ENPs) working in A&E and dealing with patients with minor
injuries and ailments as well as ordering tests, A&E targets would not have
been met. ENPs are also coming to primary care providing out-of-hours (OOH)
care and working with ambulance trusts. Other new roles being introduced
include the First Contact Practitioner and Physician Assistants. In secondary
care add pilots for nurse anaesthetists, surgical practitioners and medical
nurse practitioners and this particular pot is bubbling away quite nicely. One
key driver for the appearance of all of these new roles is the shortfall in the
numbers of both GPs and hospital doctors. The government has not been too
successful in increasing GP numbers and in hospitals the impact of the European
Working Time Directive will inevitably mean that even more work will be picked
up by nurses, further extending their roles. The vision for the nurse of the
future has been clearly spent out by the Chief Nursing Officer. Although some
doctors do feel threatened by all of this and there is some opposition, this is
surely now an irresistible force for change....... To get a fuller picture here
of the new enhanced roles for nurses, do please have a look at the
Modernisation Agency's Changing Workforce Programme.
Impact of
nGMS
The new GP contract will hugely impact on primary care nursing
and could mean radical changes in ways of working. Nurse practitioners will be
fundamental to the success of the Quality & Outcomes Framework and could
also become the main providers of additional services such as vaccinations and
contraceptive services, leading to more and more nurse-led services. We could
have nurse-led enhanced and extended services as well as for OOH care. The high
profile currently on chronic disease management could also see nurses across
primary, community and secondary care sectors working closer together with
enhanced roles for school nurses, health visitors working to reduce A&E
attendances and secondary care nurses moving into primary care. We will see
more nurse specialisation in primary care and nurses taking more responsibility
in the planning and delivery of care, possibly becoming full partners in GP
surgeries. The first nurse-led PMS pilot was set up some five years ago and PMS
will continue to provide a laboratory for experimentation in nurse-led
services. Watch out for too for Directors of Nursing in General Practice. These
will be key new customers. The first Wanless report predicted that nurses could
undertake some 20% of the work of doctors and a growing body of evidence seems
to demonstrate the success of these new models of care. The British Journal of
General Practice has reported (2004 54:207-210) that triage nurses in primary
care can reduce the number of face-to-face consultations with GPs by 40% by
effectively 'filtering' out those patients who really do not need to see a GP.
Nurse triage is also the basis of the growing numbers of Walk-in Centres,
largely nurse-led. Many nurses in Walk-in centres are also prescribing.
Latest Prescribing Moves
One of the key new tools for the
extending roles of nurses is of course the ability to be able to prescribe for
patients. The NPEF for independent nurse prescribers continues to rapidly
expand - more POMs are being added all the time along with more medical
conditions. Further extensions to include first contact care and emergency care
drugs, linked to nGMS and OOH services, are currently out for consultation from
the MHRA. Prescribing definitely enhances the nurse's role, allowing the nurse
to offer a more comprehensive package of care and is being seen as an essential
skill of the nurse of the future. Over the last 18 months approaching 2000
extended formulary prescribers have trained and registered and many of these
have also qualified as supplementary prescribers. Supplementary prescribing of
controlled drugs and unlicenced drugs are currently being deliberated, as is
independent prescribing of controlled drugs. And also don't forget the
increasing use of PGDs too (a new NPC publication now out here) as well as
Patient Specific Directions (PSDs) for named patients. Some Allied Health
Professionals and Optometrists will also be given new prescribing powers.
Non-medical prescribing is now moving into the mainstream.
Moving
Forward
Building on Best Choice emphasised the need to strengthen
the role of nurses and last year both the Health Service Journal and the
Nursing Times launched a new Manifesto drawn up by nurses. Many of the ideas
put forward were very innovative. "It is now time for all health service
managers to use the knowledge and experience of nurses to help shape the new
NHS," suggested both editors. Health secretary John Reid has said that nurses
should not only be in the frontline of delivering patient care but also at the
frontline of running the NHS. "Nurses need to be all that they can be," he
said. Last year too the DoH (with the RCN) published Freedom to practice:
dispelling the myths - this is about the barriers to developing new practice,
that nurses could be doing more to push forward the modernisation programme and
a strong need for NHS managers and doctors to be challenged about what nurses
can actually do now - both legally and professionally. Yvonne Sawbridge, Nurse
Lead for the NHS Alliance, said at their nurses' conference earlier this year,
"Nurses need to wake up to their value, stop asking permission and help create
better primary care services for their patients. There is no need to be
subservient any more and no need to wait for a doctor to delegate some task or
other".....
Taking Stock
So this is yet another fast
moving NHS agenda for companies to track! Nurses have of course always been
industry customers but perhaps only at the margin. Now they need to become a
key customer group in their own right in the same way as GPs and hospitals
doctors and with perhaps companies creating separate sales and marketing nurse
strategies. Nurses are being urged to become more entrepreneurial and nurse
leaders/managers to take the initiative, shaping as well as delivering care.
But who are the nurse leaders driving all of this forward? What are your levels
of contact with the main policy bodies (the RCN and the NMC)? What is your
strategy towards the RCN and the consortia they are involved in, such as the
national collaborating centre producing clinical practice guidelines for NICE.
What are your strategies regarding the new advanced nursing and management
roles? Who is tracking the development of these new nurse customers? The PCT
Director of Nursing will be a new KOL as will the Directors of Nursing in Acute
Trusts and SHAs. The workforce development confederations, co-ordinating nurse
prescribing training courses, have now been absorbed into SHAs. What are your
strategies here? Matt Griffiths, RCN joint prescribing adviser, has suggested
that companies should work on PGDs for their own products (with practitioners)
as well as helping supplementary prescribers to develop the evidence base for
clinical management plans. But do we know where nurses get their evidence-based
information from to inform their decision-making?
Having said all of
this, some nurses are strangely hesitant to move forward worrying about the
balance between providing patient care and influencing the planning of care.
Nurses do not yet appear to be as politically active and attuned as they might
be and they could usefully forge alliances with the pharmacist fraternity,
facing similar issues. Companies could help nurse groups here and perhaps
provide assistance to them in moving forward. However, there does seem to have
been a paradigm shift in nursing since the publication of the NHS Plan four
years ago and to keep right up-to-date do please add the regular CNO bulletin
(www.dh.gov.uk) to your
reading list. Next time we will return with some thoughts around pharmacists of
the future.
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CNO's 10 key roles for Nurses
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Article first pulished in Pharma Times - April 2004
