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Primary care nursing in Scotland

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As Scotland readies itself to vote for or against independence, the NHS is becoming a clear battleground in the run-up to next years general election. The NHS in Scotland is already devolved from the English NHS, and there is a general belief among health professionals that the day-to-day running of the NHS will not change in the event of a 'yes' vote.

The Scottish have traditionally placed emphasis on the NHS. It is currently the only country in the union to have accepted the Independent Pay Review Body's recommendations on awarding NHS staff a one per cent pay rise, and the government spends more of its budget on healthcare than on other sectors.

As well as funding, changes in policy have also emphasised the focus that the government places on the NHS such as the amendment of two pieces of legislation. These have led nursing organisations to lobby the government on behalf of the workforce to improve training and recruitment into primary care nursing.

The Children and Young People's Bill has enhanced the focus on school nursing and health visiting workforces and has led the Scottish Government to pledge to refresh the workforces to ensure that all children in Scotland have a named professional. The second was the Public Health (Joint Bodies) Bill that encourages integrated working between health and social care which will also be enacted from next year.

These have provided nursing organisations such as the RCN in Scotland and the QNI Scotland with the drive and the resources to carry out vital work to support primary care nurses and to enhance the workforce.

Ellen Hudson, the associate director of the RCN in Scotland, believes government policy has given Scottish primary care nurses a louder voice, as a greater emphasis is placed on increasing the amount of care carried out in people's homes. The community care situation in Scotland echoes that of the English - patients are living longer with more long-term conditions needing more and complex care in the community.

Scottish primary care nursing faces a very similar situation to that faced by its counterpart in the English NHS. There is a retirement crisis looming in the workforce: many of the advanced nurses and nurse practitioners are approaching retirement and too few newly qualified nurses are being recruited to fill the gaps.

Gill Dennes, chair of the Scottish Practice Nurse Association (SPNA), says that studies have shown that the vast majority of nurses in Scottish primary care are headed for retirement in the next five to 10 years. 'We are concerned that there is no one to replace them in terms of skill, but this is something that NHS Education for Scotland (NES) is working towards.'

To address this, the Scottish Government has placed an emphasis on improving training pathways for primary care nurses, including practice nurses, health visitors, school nurses and district nurses.

It previously set up focus groups for health visitors and school nurses in response to the amendment of the Children and Young People's Bill to ensure that there is a named professional for every child under five.

The government has now just given the green light on developing a focus group to improve the training and careers of district nurses.

The Scottish Government released its '2020 vision' in 2011, which set out its priorities for the Scottish NHS until 2020. The vision for the route map was to ensure that 'by 2020 everyone is able to live longer healthier lives at home, or in a homely setting'. It identified primary care as an area requiring improvement. The 2020 vision and the focus on improving care in the community has been the catalyst for investing time and money in primary care nurses to ensure the workforce can cater to the increasing demands of the community.



Debbie Coulter, a Scottish practice nurse, says:

[The programme] has given me so much confidence to do the job. Although I already had certificates in cardio vascular disease management, spirometry and cervical screening and had training in NHS Lothian's Weight Management programme, I gained so much more knowledge on the programme as well as the competence to do my job better. I also gained more insight into what I could do such as implementing projects to support awareness and uptake of screening for breast and bowel cancer; encouraging patients to take up walking challenges for better health; producing leaflets (funded by the Community Development Trust) on medal routes (walks) in the village. The GPs and Practice Manager were also extremely supportive.


Refreshed education

To ensure that enough nurses are being recruited into the practice nursing workforce, a post was created for a national practice nurse co-ordinator for NHS Education for Scotland with two remits: to set up a vocational training scheme and to set up a network for practice nurses across Scotland.

NHS Education for Scotland (NES) worked with the co-ordinator to create a practice nurse training programme, which began in September 2012. It is aimed at nurses already working in general practice to further their education within the field.

A series of consultations were held with nurses across Scotland to find out what they wanted from the programme, how long it should take, what level of education was required and what should be included.

Susan Kennedy, the NES national co-ordinator for general practice nursing, said that they wanted to create something that would be generic for all practice nurses across Scotland with less than a year's experience. 'Before practice nurses used to learn through taking diplomas in specialist subjects and this was just taking too long to prepare practice nurses for their role. This meant that it was difficult to replace the very experienced practice nurse quickly.'

'After asking practice nurses across Scotland the kinds of things they wanted included in the course we adapted it accordingly. We have included things such as long-term conditions, supporting self-management, and communication and consultation skills. The programme has concentrated heavily on these aspects.'

The programme is currently free and is funded by NES. Candidates are selected by the programme leaders. Ms Kennedy says that they hope to build on the numbers that are currently being recruited on to the course. 'We started with 12 in the first year, 15 last year and this year we will have 16. We are looking at ways to make it more cost effective without reducing the quality.'

Ms Kennedy set up a practice nursing learning and development network to look at the issues surrounding practice nurses. The network has a sessional education advisor in each Health Board area who considers things like how to support pre-registration nurses. 'This is difficult because of cost and something that we haven't been able to resolve yet, but we are keen to encourage and promote it,' says Ms Kennedy.

Ms Dennes, says that the SPNA is working alongside to ensure that they are working with NES and the practice nursing leads on the health boards. 'We try to cover the areas where there is no lead nurse, by representing these areas through the SPNA so we can ensure that we have links with all of the localities. We are also working with the RCGP in Scotland to ensure that we have representation within the [organisation].


The 2020 Vision for Health and Social Care

In 2011, the NHS in Scotland released a document to outline the changes to service that will be required to meet the needs of the changing population.

The key features are:

  • recognition of the importance of the public service reform agenda
  • maintaining the focus on improving quality at scale across Scotland (building on success, e.g. Family Nurse Partnerships, Scottish Patient Safety Programme etc.);
  • pursuing opportunities to work with other public sector and business partners
  • identifying particular areas for accelerated improvement and enhanced roles in unscheduled and emergency care, in primary care, and in services for people living with multimorbidities providing a whole system response to improve the patient pathway in order to reduce pressure on A&E departments;
  • supports our commitment to shift the balance of power to, and builds up and on the assets of, individuals and communities through a focus on achieving social change
  • developing our strategy for engaging and empowering our workforce, providing our response in Scotland to addressing many of the issues raised by the Mid-Staffordshire/Francis Inquiry


Named person for children

Alongside increasing the attention on practice nurses, there has also been a renewed focus on health visitors resulting from the amendment of the Children and Young People's bill.

As part of the 'Getting it right for every child approach' and the updated bill, the RCN in Scotland investigated what preparation was required for health visitors, what their optimum caseload numbers would be, and how they would work out visiting schedules.

The Scottish Government also announced in June 2014 that an extra 500 health visitor posts will be created in Scotland over the next four years to ensure that all children have a named professional. This will cost £40m. In March this year, Scotland's health visiting workforce stood at a total headcount of 1624 (whole time equivalent of 1339).

Nursing organisations then used the Children and Young People's Bill to drive forward improvements to education and ensure that the workforce was fit for this role.

Gavin Fergie, professional officer for Unite/CPHVA in Scotland, said at the time of the announcement: 'There is work to be done in making this a reality and the devil will be in the detail as to how this will be implemented.

'We view this four year plan, which runs until 2018, not as an end in itself, but a first constructive step in a continuing programme to develop the profession into the 2020s.'

The second strand of the Getting it Right for Every Child approach involved the work of school nurses. 'This meant updating the role of the school nurses, looking at refreshing their education needs, to ensure that there is a universal pathway into the career,' says Ms Hudson.

She also stated that there needs to be clarity on the school nursing workforce, and a clearer vision of what needs to be done in the future to ensure that all school-age children can access a school nurse.


Enhancing community services

The Scottish Government will now concentrate on the role of district nurses to maintain the workforce to meet future demand.

Theresa Fyffe, director of RCN Scotland, has said the RCN is currently working to invest in the district nursing workforce towards the end of this year. 'The government has now agreed to kick-off the work on district nurses, which we need to do. There is a need to work on the training and education development to become a district nurse and to adapt to that difference.

'We need to look at their education programme, look at their CPD in respect of post-registration framework. If district nurses are going to enable frail elderly people to stay out of hospital, they need to be able to make the right clinical decisions and use the right resources to provide safe care for people in the community.'

Clare Cable, chief executive of QNI Scotland (QNIS), says that the organisation will be engaging with the government's action plan. 'The group hasn't started yet, but I imagine it will focus on looking at the future workforce and how to configure it for the future. We want to look at how to engage with district nurses to be able to keep people well for longer. We want to look at an asset-based approach, what do individual families need from nurses.'

This report will be released in June 2015, after it has been fed back to and approved by health ministers.

Ms Cable also highlights the QNIS is currently working with the QNI in England, Wales and Northern Ireland, to conduct a review looking into the standards of education in district nursing and to ensure that the workforce remains fit for purpose for the future.

Ms Fyffe has promised that regardless of the outcome of the vote, all of this work will continue to ensure that primary care nurses in Scotland remain supported. 'This doesn't meant that policy won't change but there will be no sudden swerve from what has been policy already. The Chief Nursing Officer's review into nursing education was put together under the devolved government so whatever the outcome of the referendum, these things will still go ahead.'

The activity around primary care nursing reflects the government's agenda wider agenda.

Primary care in Scotland, as in England, will be where most patient care is focused in the future. It will be the skills of nurses that enable the government to deliver, making sure patients receive the best care they can, regardless of the outcome of the vote on September 18.

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