Nursing in Primary Health Care

Policy into Practice

Ann MacKenzie, Fiona Ross

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136153006
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

The role and scope of nursing in primary health care is continually evolving as a result of changes in society. This book explores current issues from the perspective of nursing, showing how policy informs practice. The topics covered include: * health needs profiling
* assessment
* interprofessional work
* quality of care
* family carers
* new nursing roles in primary health careThe book is suitable for practioners in primary health care, students doing diploma, degree and postgraduate courses in nursing and health studies, and also post-registration courses. Nursing in Primary Care draws on research and examples from practice to encourage a questioning approach to policy information and the consequences of its implementation.

Chapter I

Policy overview

Summary

This overview looks at recent policy trends and current influences on primary health care services and nursing. Radical policy and organisational change in the 1980s and early 1990s are reflected in the shift in the balance of care and the decentralisation of services. This chapter addresses some of the current issues in primary health and community care, examines their origins, and their impact on nursing. These issues include consumerism, community care and care management, general practice, health promotion, the secondary/primary care interface and the shifting balance of care, and the tension between the management and caring cultures of nursing in primary health care.

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Pressures for change

The unfolding years of the twentieth century feature major change. There are the demographic changes in the population structure such as the rising number of old people, particularly the very old, the challenge of the major killers – cancers, heart disease and the life-style diseases – the threat of new risks to health such as HIV and AIDS and the re-emergence of old ones such as TB. There are the continuing care needs of people with long-term health problems, and the alienation and social malaise of a society with high unemployment and homelessness. The introduction of new technology and the shifts in political thinking that have challenged the post-war system of welfare require radical new approaches to the organisation and delivery of primary health care services. This chapter looks at the policy and organisational responses to these pressures with a particular focus on the framework of nursing in primary health care.

The context of the reforms

The health and social care reforms of the late 1980s and early 1990s must be understood within the political context and the broader programme of political change in the public sector at that time. Butler (1994) outlines three of the central tenets of the Thatcher government which strongly influenced the development of the reforms. These were: the primacy of a sound economy; the belief that nothing should be done in the public sector that could equally well be done in the private sector; and an underlying assumption that large organisations were inefficient. As Butler (1994) notes, the internal market in the NHS was the product of a political environment that valued wealth above welfare, markets above bureaucracies, and competition above patronage. In addition to health and social services, internal markets and decentralisation of management were introduced into public housing, state education and public road and rail transport.

Theory of internal markets

The term internal market is something of a misnomer, because markets in the classical sense cannot exist in a service sector. Bartlett and Le Grand (1994) identify a number of ways in which the community care market differs from classical economic theory. On the supply side, providers may not be motivated by the need to derive a profit from their work (e.g. voluntary organisations). On the demand side, consumer purchasing power is concentrated in state purchasing agencies – Health and Local Authorities. The term ‘quasi-market’ is frequently used to emphasise the distinctive context in which economic interactions take place in health care.

The terminology has softened since the early days. For example, purchasing is now more often called commissioning, and increasingly there is a questioning of the principles of imposing a market economy in health and social care. This chapter aims to introduce some of the current issues in health and social care and apply them to nursing in primary care. In particular it will attempt to highlight some of the inherent contradictions between policies which on the one hand promote collaboration between agencies, and on the other value competition; where choice is the political imperative, but where in reality the alternatives are limited.

The internal market in primary health care

This section looks at some of the issues relating to how the internal market works in primary care. Increasingly purchasing in primary health care is being carried out by combined commissioners of Health Authorities and Family Health Services Authorities. The purchasing role is to define the shape and level of local services to meet defined population need and to improve clinical and health-focused outcomes within a service framework of equity, responsibility and efficiency (Bosanquet 1993).

The necessity to develop a needs-led service which takes account of the needs of defined populations requires the involvement of front-line service providers. Historically the information base for planning community nursing services has been limited to crude measures of contact and restricted definitions of task-orientated care. In order to plan services effectively, purchasers need more sophisticated tools, including activity measures of workload and caseload, performance indicators, patient dependency levels, and criteria of clinical outcome. A more detailed discussion of these issues is presented in Chapter 2. All of this is in its infancy, and the challenge for nurses in primary care is not only to describe and articulate their arena of practice as outlined in Box 1.1 and Box 1.2, but to do it in quantifiable terms. Smith et al. (1993), in a small exploratory study of the views of providers and purchasers of district nursing, found that two views emerged from purchasers. At one end were the managers who tended to view nurses as biased reporters of clients' needs, supporting a self-regarding and protective professionalism. At the other end of the spectrum were managers who viewed the nurses' involvement in contributing to the purchasing agenda as inevitable and desirable, because of their closeness to the client and their advocacy role.

Box 1.1 Current strengths of nursing services in primary health care

●being available 24 hours a day, 365 days a year

●supporting individuals through major life events

●establishing close relationships with clients

●having knowledge of the local environment and social context

●providing care for sick people in their own homes

●caring for the chronically sick and disabled in their own homes

●taking part in health promotion

●providing a link between agencies and professionals

●working with at risk and vulnerable clients

Choice and the user

Government policy has emphasised the central position of the user in service planning and delivery. This objective is being addressed through several routes. Firstly, the market approach seeks to empower users by giving them a choice between alternatives and the option of exiting from a service if dissatisfied. Secondly, professionals are being urged to involve users in, for example, membership of user participation groups, and assessment and collaborative care planning. Thirdly, the opening up of complaints procedures, and the encouragement of patient satisfaction surveys through the patient charter initiatives, are additional but important ways of increasing the user's voice.

Box 1.2 Future focus of work

●being flexible and responsive

●working collaboratively

●evaluating outcomes

●working for innovation and change

●targeting care to those in need/at risk

●developing partnerships and networks

●developing clinical guidelines

●reviewing quality, client satisfaction and cost

Biggs (1993) points out the inherent inequalities that exist between users and professionals that limit the possibilities of true choice and participation. He identifies these as: different interests, priorities and cultural concerns, as well as effective exclusion from the negotiating arena of contracting. This then raises the question of the extent to which current policy is internally consistent, particularly in the discussion of choice and health care.

One of the ways in which the reforms are intended to provide greater choice and responsiveness to patients is in the implementation of a government strategy of charters for citizens and patients. The general principles of these charters are to ensure that standards, information, choice and complaints systems are promoted, and that helpful, appropriate and sensitive services are provided by receptive professionals at the sharp end of care. Examples of charters in primary care include that introduced for family doctor services, which requires GPs and primary health care teams to set quality standards in practices for care and health promotion, and the recent Community Care Charter designed to monitor the effects of the community care reforms. A patient charter standard on community nursing appointments was also published in late 1994.

The introduction of charters is potentially a device that could be used by nurses to encourage dialogue with user groups to contribute to standard setting and monitoring. One of the difficulties of this is the problem of arriving at sensible definitions of standards and agreeing a methodology for measurement.

Nursing in primary health care has always been patient focused. This comes from the individual one-to-one encounter in the patient's home, the personal and continuous relationship that develops over time through, for example, monitoring child development or caring for patients with continuing care needs. Finally, the nature of work in the community takes staff away from the immediate purview and supervision of nurse management. This creates differences in the role of a nurse working in primary health care compared to that of a counterpart in hospital, particularly in terms of autonomy and responsibility. Paradoxically, despite this close relationship with the patient the position of primary health care nursing is weak and marginal to the acute nursing sector. A parallel with this can be seen in the relationship that general practice has with hospital medicine, which is both resource rich and technologically powerful.

The issue of user-centred care raises the question: how do nurses in primary care know what users want? If these needs can be defined, what forms of response and developments in practice are possible and appropriate? One of the ways in which nurses are responding to users' needs is by setting up carer support groups. The issue of carers is discussed further in Chapter 6. The review of community nursing innovations in the UK, revealed a number of initiatives in the broad area of information giving (Ross and Elliott 1995). This reflects the fact that users and patients increasingly want more information, honesty and involvement in care. The Alloa continence centre was set up by a district nurse in a Scottish health centre to make continence information and advice more freely available. It has a help line, information and appliances available, as well as access to professional advice (Walker 1992). In addition a variety of nurse-led initiatives have resulted in information packs using different presentational media, for example accident prevention (leaflets); preparation of patients for continuing care on discharge (video); prevention of TB (audio tapes); raising awareness and understanding of disability among school children (structured teaching pack for use in a workshop format). Finally, there are other examples of innovative practice, such as a children's bereavement group and the use of ‘solution focused therapy’, which has been applied in psychiatric nursing to help clients find solutions by identifying areas of personal strength and ability (Queens Nursing Institute 1993).

Community care

The stated aim of the NHS and community care reforms is to create stronger incentives and to increase efficiency and responsiveness by opening up health and social care to competition (DoH 1989c). Since April 1993 social services have had the responsibility for purchasing social care, through care management and assessment. The most clearly defined change was a financial one in that Local Authorities were charged with the responsibility for the finance of all publicly supported long-term care outside the NHS. Social Security funding under income support arrangements has been run down and reallocated through the revenue support grant to Local Authorities. The majority of this reallocation is to purchase packages of care from the independent sector. Thus Local Authorities have become ‘enabling’ authorities involved with stimulating the independent sector, separating the purchaser and provider functions within social services departments and establishing more effective joint planning towards the objective of seamless care.

There are a number of issues raised by community care, which have been debated in various forums, and by different disciplines (Ross 1990, Lewis 1993, Hunter 1993). These include the conceptual separation between health and social care, joint working (Chapter 4), seamless care, quality care (Chapter 5) and the user view.

Health and social care

The community care reforms are based on the assumption that health and social care can be marketed, delivered, evaluated and funded separately. It is argued that primary health care workers deal in health, whereas social agencies are in the business of social care. This ignores the fact that most health problems are socially defined, and that the majority of people with continuing care needs require assistance from both services and often simultaneously (Hunter and Judge 1988). The community care proposals recommend that a designated care manager should be responsible for the assessment and care plan including the purchase of appropriate and co-ordinated services. In order to provide seamless care across health and social agencies it is essential to consult the user and carer in the development of the plan. The continuing and inevitable tensions at the margins of hea...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Acknowledgements
• Introduction
• 1 Policy overview
• 2 Health-needs profiling
• 3 Current issues in assessment
• 4 Interprofessional work
• 5 Quality of care
• 6 Family carers
• 7 New nursing roles in primary health care
• 8 Conclusion and future directions
• References
• Index