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Skills, commissioning and the 6Cs

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Rita: Why the 6Cs and not some other initiative? What led you to the 6Cs?

Jane: The 6Cs were built on a programme I was running nationally before I was appointed as the chief nursing officer for England. It was based around improving excellence in nursing and midwifery across the board. When I was applying to become the CNO for England, I spent time talking to frontline staff and testing out ideas and what people thought was important. One of the things that came back significantly was the need for something that really described what the professions do, in a way that was simple and manageable. I began talking about 4Cs: care, compassion, commitment and communication. I heard Dame Elizabeth Fradd talking at an event and she used courage in a completely different way. Courage was so important at that point in 2012. So it became the fifth. We used a lot of social media and networking to test ideas and through that came competence. We ended up with the six 6Cs . Others were suggested, things like collaboration, but six is about as many as anyone can remember.

Rita: How will you measure the outcomes? Do you intend to measure the outcomes?

Jane: One of the things we are doing is looking at how organisations and individuals and teams are using the 6Cs to change practice and improve care for patients. At the end of the day, the important thing is whether they make a difference to patients and carers. We receive a lot of anecdotal evidence, lots of good-news stories. We run a story of the month online, recently renamed on to '6Cs in Action:Celebrating excellence'. People submit initiatives or work they have done and then we have a panel, which assesses them and chooses a winner. As we move forward we will probably collect more hard evidence.

We know some people are using 6Cs as part of their staff induction, and universities have been teaching the 6Cs. One of the things we are looking at is saying 'can we measure both patient experience and potentially the way staff provide care using the 6Cs?'. Some organisations are beginning to look at using the 6Cs as part of annual appraisals.It can be difficult to measure somebody's ability to deliver effective care. We are looking to see if we can bring in some harder nosed measures. Overwhelmingly, the feedback we have from frontline staff, and managers in different settings and from patients is that it really makes a difference.

Rita: Do nurses in primary care feel that the 6Cs are as relevant to them as hospital nurses?

Jane: They certainly are as relevant. Whether practice nurses engage as much I think is mixed. Some have engaged, some maybe not as much. I think for us it is about being able to get into that network of practice nurses across the country and we know that some find it difficult to step out of their day-to-day work in a GP practice to look at other issues that are going on outside of their immediate sphere. We have got some great examples, people who have done frameworks around practice nurses and how they can use the Cs. We have done it for community nursing. Each of the Cs is as relevant in a practice nurse's role, if not more so.

Rita: What do you think can be done to increase practice nurses' engagement?

Jane: We have appointed a practice nurse advisor in NHS England, working in my team. We have done that deliberately so we have more expertise in practice nursing that can help develop the contribution that this key group of staff can bring to care. We have also developed a network of commissioning nurses. We have now got a better opportunity to have contact with practice nurses than we have ever had. In the past, it really did feel like they were almost isolated, not forgotten but not as engaged. Now we have got the ability through both area teams and clinical commissioning group nurses to get together with practice nurses on a local basis. The other way we are engaging is through the continued use of social media. It has been powerful. People were saying there had been a lot of correspondence about my appointment so I joined. Now I have over 13,700 followers, I've got a huge network of people I can access. It makes a big difference being able to connect with people and use twitter to point people in the right direction. For example, when we hold 'weeks of action', certain things on the 6Cs website, being able to point people towards that on twitter and people being able to access information and share it is phenomenal.

Rita: Many practice and community nurses are set to retire over the next ten years. What is the DH doing to address this?

Jane: Health Education England's mandate identifies the need for students to have more community placements. That has proved really popular. I have spoken to many student nurses who have openly said they want to work in a community setting and last week met a newly qualified nurse who wants to be a practice nurse. That is incredibly positive. There is also a Community Nursing Advisory Group. We are working with the team at NHS England that is looking at primary care. Part of that is how we can enhance and support the role of practice nurses to deliver an increasing demand and focus on the importance of outcomes in primary and community care.

Practice nurses have a fantastic opportunity to increase health and wellbeing at a very early stage, as well as helping to treat people who are acutely unwell. Practice nurses love the breadth of that role. I think we need to do more to enhance it, which is why we have set up the working groups. Bringing someone on board with a specialist practice nursing role will help.

Rita: How can nurses' skills be used differently to enhance how primary care works?

Jane: It is about making sure nurses can use the skills they have. I believe that rather than having a professional hierarchy, we should find out what the individual's or group of patients' needs are, what skills are necessary to ensure they have the best outcome, and then who can best provide it. In many ways that would be practice nurses or other healthcare professionals.

A good example of that is a personal one. My dad was feeling unwell recently. He is 84 and my mum rang the GP surgery. The practice nurse, who is a nurse practitioner, came out to see my dad. She did an ECG and was able to give him advice and support, which enabled my mum and dad to feel much more comfortable with what they could do, what actions they could take and enabled him to stay at home. It is a brilliant opportunity to use the advanced skills that practice nurses have got to make appropriate assessments and to keep people out of hospital. I also know of some GP practices where nurse clinicians run their own sessions, run their own lists, have their own clinics. There are lots of opportunities for practice nurses to enhance their skills and expand what they do.

Rita: GPs are not always supportive of practice nurses. How can nursing address that?

Jane: One of the ways is to demonstrate and show what good work nurses can do in those settings. Write about it, speak up, show it, tell their stories, put articles in publications, which describe some of the work they do and what the outcomes are. Another way is to have some GPs who are really supportive. Professor Steve Field, chief inspector of general practice at the CQC, is really supportive of the role of practice nurses. We have the clinical leaders network, which runs across the country, chaired by GP Dr Raj Kumar, who works in Warrington. He has got some very forward thinking ideas about how his practices can work in different ways and that includes enhancing the role of his practice nurses. They are supported to get Masters degrees; they are supported to do advanced roles. He brings in consultants from secondary care to run sessions in the GP practice.

Rita: How can primary care nurses raise their profile and standing in the healthcare environment?

Jane: We have primary care nurses who become nurses at CCG level so that is a good way. If there are vacancies for nurses at CCGs I would encourage them to get the skills and experience to be able to do that. Hilary Garratt , who is the director of nursing for health improvement in my team, is helping to raise the profile of nurses as commissioners and how nurses can help commission different pathways of care. Practice nurses could be very influential in that field.

Rita: What would you say to demoralised practice nurses ?

Jane: That is a difficult question. GPs are independent contractors and can make local decisions. I suppose they should concentrate on why they do the job; they enjoy being a practice nurse. The majority of nurses I speak to love the contact with families, getting to know individuals incredibly well and then support them through many long term conditions through life. That has such influence on an individual's life and is one of the greatest motivators.

In terms of the issues around terms and conditions then there is something to be learned from the best. Looking at how other places practice, what options there are and whether there are positives to be gained by looking at contracts in a different way.

I would like to see primary and community care nursing as a leading career choice for nurses now and in the future and I will continue to work with the profession and key stakeholders such as Health Education England and the DH to enable this to happen on a much larger scale than at present.

Rita: Is there anything nurses wishing to move into leadership roles can learn from your experience?

Jane: Whatever job you do, you're a leader. As a newly qualified nurse or midwife, you are still a leader because you are making decisions about your patients, you are assessing them, you are planning care, and you are communicating with them. You quickly start to support junior staff, you will work with students, and you will work with healthcare assistants who aren't qualified and registered nurses or midwives. I think nurses are leaders at an early stage.

One of the things that I did was take every opportunity. I tried and tested a lot of different things over the years and initially my ambition was to be a sister, which I did, and then I wanted to be a nurse specialist, and then I took the opportunities as they came along. Always be true to your values, have integrity and build resilience. These jobs are tough. Be honest if you make mistakes, everybody makes mistakes. The key thing is being open to learning and to change, and to reflect and to move on. If you had asked me when I qualified would I see myself as chief nurse for England I would have said no. If you had asked me five or six years ago I would have said no. Having got here, it is a huge privilege and an amazing role.

We all have the same aim, which is providing the best safe effective care for patients and the best experience. The way you do that means something for patients.

http://www.england.nhs.uk/category/publications/blogs/jane-cummings/

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