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A strategy for the future of nursing

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The government's principal advisor on public health nursing says she wants to banish the negative image of the profession propagated by recent reports, and bring nursing into the 21st century.

Professor Viv Bennett was unveiled as the DH's first ever director of nursing at the turn of the year, and works closely with ministers to ensure public health nursing is central to government policy. Along with Jane Cummings, chief nursing officer (CNO) for the NHS Commissioning Board, Prof Bennett's position replaces the old CNO role, which previously sat within the DH.

Nursing presence
'When the new health system was being designed, an important thing to establish was where clinical advice and professional leadership responsibilities would lie in the new landscape,' Prof Bennett explains.

'There was a lot of discussion in various journals about where there should be senior nursing presence. Out of those discussions came the view that we needed to have a CNO in the NHSCB responsible for nursing in the NHS and NHS-funded services (Ms Cummings), and we needed to have a very senior nurse within the DH to provide that clinical advice into public health and into social care (Prof Bennett).'

One of the first tasks to be undertaken by the country's two most senior nurses is the development of an overarching nursing strategy; a 'vision' on the future of nursing, based on six 'Cs' (see box, right), due to be published in the autumn. It follows a number of high profile reports drawing attention to cases where nursing care has fallen short, particularly with regard to the level of compassion shown.

'I think every nurse feels very bad when we see those kind of reports, and of course we need to acknowledge and address those bad things that happened,' says Prof Bennett. 'What we also need to do is get some visibility around the great things that happen every day too.

'(The vision) is to have a narrative about nursing that looks forward. We sometimes get drawn into looking back to some imagined age when things were different, and in some people's perception, better.

'But healthcare isn't like that any more. People are in hospital for a very short time, and we need to significantly develop our primary and community practitioners. It's about really being able to take it forward to what nursing is going to look like in five, 10, 20 years time.'

Community nursing
Moving more care from acute to primary settings has been part of government rhetoric for years. However, data for 2011/12 from 61 PCTs, published earlier this year, show that investment in primary care fell by £11.34 million during that time.

Prof Bennett says that although the shake-up of care delivery 'sounds like a simple thing to do', it will take time to introduce. 'What do we need in the community? We need active rehabilitation, and chief professions officers leading the work about recovery and rehabilitation,' she says.

'I think we have seen changes in healthcare. But the bit where we still have to do more, and where people are very committed to doing more, is how we support excellence in the care of older people both inside and, very importantly, outside the hospital.'

Key to improving care of older people at home is securing the future of the community nursing workforce, particularly district nurses, who have seen their number steadily decline over the last 10 years. Independent Nurse revealed the first details of the government's proposed Community Nursing Strategy in May, and Prof Bennett has been working closely with ministers on its development.

'The view was that we should do some work on district nursing, but it would be more helpfully positioned within an overall piece of work about nursing in the community. That would be a whole range - at the one end, the work of practice nurses where community meets primary care, and other places where community nursing interfaces with social care, and do a kind of overarching piece of work,' she explains.

'Additionally, we are doing a piece of work with carers around the nursing contribution to identifying and supporting carers, so it was sensible to do all of theses things together, and that's the work that's being done now.'

Defining the role of district nurses will be central to the strategy, Prof Bennett pledges.

'Sometimes people struggle to explain why district nursing is so important, and resort to a list of tasks, whereas we know that the skill and knowledge that a district nurse brings is very much more than a list of tasks. The first thing we need to do is set out very clearly what the district nursing contribution to excellence in care and high quality health and wellbeing outcomes is.'

Boosting nurse numbers
Although the director of nursing believes an increase in district nursing numbers will be required if care is to be transfered from acute to community settings, there are no plans to include a recruitment target. This is in contrast to the health visitor strategy, which set out to recruit 4,200 extra health visitors by 2014.

'That's an incredibly unusual policy actually, because very little policy has a target attached to it today,' says Prof Bennett.

'Do we have sufficient qualified DNs? I think we have to look at that very carefully because we have such an increasing older population and we have an aspiration to deliver care that (requires) much less time in hospital, so logically you would say we're going to need more nurses who can work in hospital and out of hospital, or out of hospital. It would seem logical that if we have more people and more care in the community, then we will need more district nurses in the future.'

Effective skill mix is central to achieving the best care, Prof Bennett asserts: 'Are there parts of the process that can safely be delivered by support workers? Yes, within that overall framework of delegation. I think that if you ask older perople particularly what they value, they value having (their care delivered by) someone they know.'

The community nursing strategy will draw on both the health visitor programme and the school nursing vision. The latter was published in January and sought to define the role of school nursing and its future.

'The aim is very much to do what we did for the other two professional groups: raise visibility, raise public awareness of the skills and knowledge of district nurses and what they should expect.'

However, unlike school nursing and health visiting programmes, the community nursing strategy is to be produced following the passing of the Health and Social Care Act, which sees the responsibility for commissioning of community health services passed from PCTs to clinical commissioning groups (CCGs).

'We know already that there is great variation across the country in community services. What we wanted to be able to do was offer the best of evidence to those commissioning groups on which to base some of their thinking,' Prof Bennett continues. 'This programme will be slightly different in that the systems change will have happened, and also it is not a public health programme. So what we agreed with Jane (Cummings) was that the DH will lead the first tranche of the work - producing the model and pulling together the evidence - and then it would be passed over to the NHSCB for implementation from 2013.'

Clinical commissioning
Away from policy development, Prof Bennett is keen to ensure nurses are at the forefront of the existing policies introduced by the coalition - namely, the work of CCGs, which will take over the bulk of local commissioning from April next year.

Independent Nurse research shows that fewer than half of CCGs currently have a nurse on the board, while anecdotal evidence suggests that many are put off getting involved in other capacities of perceived conflicts of interest.

'Last year, when I was the lead for nurses in commissioning, we did a lot of work with nurses - wrote a lot, published stuff about why it was so important that we had multi-disciplinary, clinically led commissioning and how nurses can help enact that.

'There's something about really stepping up to the plate. If we want to change health services, or to be part of that change, or deliver care in a different way then we have to be part of making that change happen. So nurses working with CCG boards or allied health professionals working with commissioning boards can really get a strong service redesign.'

However, joining the board is not the only way in which nurses can help commissioning groups to flourish. 'If you had a specialist nurse in partnership with someone with a long-term condition significantly effecting the redesign of a long-term condition care pathway, then it might look very different,' says Prof Bennett. 'Nurses have a great deal of skill and knowledge around safeguarding, which will be very important for commissioners - both local authorities and CCGs.

'It is absolutely vital that there is a strong nursing contribution across all the elements of commissioning. And that may be through being part of the CCG board, or part of commissioning support organisation, or working to lead or support service redesign, or working with your Health and Wellbeing Board. I think there are lots of ways of doing it. It is vital that we do.'

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