Community and Public Health Nursing

David Sines, Sharon Aldridge-Bent, Agnes Fanning, Penny Farrelly, Kate Potter, Jane Wright, David Sines, Sharon Aldridge-Bent, Agnes Fanning, Penny Farrelly, Kate Potter, Jane Wright

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118426883
• Edition: 5
• Topic: Medicine
• Subtopic: Nursing

"An extremely popular and valuable resource to students, practitioners and managers in community health care nursing" - Journal of Advanced Nursing

The fifth edition of Community and Public Health Nursing is an essential source of information for all those working in primary and community healthcare. Comprehensive and accessible, it draws on the knowledge of a wide range of experts and conveys all the information and skills nurses working in modern primary care settings require. It includes material on policy developments, research perspectives, health visiting, practice and district nursing, team working, advanced nursing practice, non-medical prescribing, inter-professional practice, and user involvement.

• New edition of the definitive textbook on community healthcare nursing
• Covers learning disability nursing, caring for patients with mental health conditions, and community children's nursing and school nursing
• Written by experts in the field – providing authority and insight
• Thorough, comprehensive, and up-to-date with the latest policy guidelines

Community and Public Health Nursing is an invaluable resource for novice and experienced practitioners, and for all healthcare professionals who work in the primary care and community setting, including practice nurses, nurse practitioners, district nurses, community staff nurses, health visitors, school nurses, walk-in centre nurses and sexual health nurses.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from iTunes, Google Play or the MedHand Store.

1

The Context of Primary Healthcare Nursing

David Sines

Faculty of Society and Health, Buckinghamshire New University, Uxbridge, Middlesex, UK

The changing context of service provision

The population of the United Kingdom is projected to increase by 4.9 million from an estimated 62.3 million in 2010 to 67.2 million over the 10-year period to 2020. Projected natural increase (more births than deaths) will account for 56% of the projected increase over the next decade, resulting in an overall UK population increase to 73.2 million over the 25-year period to mid-2035. The population is also projected to continue ageing with the average (median) age rising from 39.7 years in 2010 to 39.9 years in 2020 and 42.2 by 2035 (Office for National Statistics 2011).

The key drivers for population growth within the United Kingdom relate to greater life expectancy and migration, particularly from Eastern Europe (migration being expected to account for 68% of population growth during this period). Over the 25-year period to 2035, the number of children aged under 16 is also projected to increase from 11.6 million in 2010 to 13.3 million in 2026 before decreasing slightly to 13.0 million in 2035, whilst the population is projected to become older gradually, with the average (median) age rising from 39.7 years in 2010 to 39.9 years in 2020 and 42.2 years by 2035. As the population ages, the numbers in the oldest age groups will increase the fastest. In 2010, there were 1.4 million people in the United Kingdom aged 85 and over; this number is projected to increase to 1.9 million by 2020 and to 3.5 million by 2035, more than doubling over 25 years (Office for National Statistics 2011). The age of the working population will also increase during this period, demonstrating unforeseen lifestyle patterns, which in turn will impact on those people of state pensionable age.

According to Mathers and Loncar (2006), the ten leading causes of death by 2030 will be ischaemic heart disease, cerebrovascular disease, upper respiratory tract and lung cancers, diabetes mellitus and chronic obstructive pulmonary disease (COPD). Within the top ten leading causes of death will also rank dementias, unipolar depressive disorders, alcohol use disorders, stomach and colon cancers and osteoarthritis. The combination of longer-term physical disorders and psychosocial challenges will demonstrate the importance of integrated service provision and workforce capability and capacity to respond to presenting co-morbidities. Other worldwide challenges relating to infectious diseases, such as HIV and tuberculosis, will provide additional pressures on our healthcare systems.

So how do society and its associated health and social systems respond to such challenges? In the first place, it can be assumed that societal change moulds the institutions that are created to respond to the needs of the population. Demands change over time, and in so doing, socio-demographic factors drive the process of change that in turn requires the National Health Service (NHS) to adapt its operational base. Examples of such changes relate to the needs of an increasingly demanding and complex population, a reduction in the number of available informal carers, advances in scientific knowledge and technological innovation and a heightened awareness of ethical challenges (such as gene therapy, stem cell research, embryology and euthanasia). In addition, the 2010 Coalition Government’s quest to locate healthcare delivery as ‘close to home’ as possible has placed greater priority on primary and community service developments.

Such changes were enshrined within the context of the Government’s inaugural healthcare White Paper ‘Equity and Excellence: Liberating the NHS’ DH (2010a). The 2010 White Paper placed much emphasis on sharing decision making between clinicians and patients, leading to their empowerment and ultimate engagement in sharing responsibility for their own care:

Too often patients are required to fit around services, rather than services around patients.

This is a key component of the Government’s ‘Big Society’ mandate, encouraging a move to self-care and a reduction in dependency on State-sponsored healthcare delivery.

The resultant ‘care closer to home’ initiative has been influenced by a range of external forces, driven by government pressure to drive down NHS costs and to reduce dependency on hospital admission (DH 2008a, b). Such changes however come at a price in their own right, and if the NHS is to succeed in responding effectively to the demands of the new community care culture organisation, then it will have to be prepared to face the demands of a changing environment of care practice and delivery (Buchan 2008).

Care closer to home has been defined by Nancarrow et al. (2006) as ‘shifting all resources and expertise to primary care trusts’. This somewhat simplistic definition was adopted throughout the NHS 5 years ago and became the foundation for healthcare reform in the United Kingdom (Ham 2011). For example, NHS London announced in September 2008 that it would develop a new community-focused workforce plan for the city by 2013 (Workforce for London – NHS London 2007). The Health Authority advised that it wanted to see a 50% shift of hospital-based activity into community and primary care. This ambitious plan included a 10% reduction in inpatient bed admissions and a 41% increase in outpatient attendances in community healthcare service facilities. In order to achieve this, the workforce was challenged with the need to work more flexibly alongside patients, across care pathways in a variety of settings closer to home (DH 2008a, b). The workforce strategy that accompanied the SHA plan (NHS London 2010) advised that 15 000 healthcare workers would need to be trained or retrained to work in the community. More specifically the community nursing workforce would need to expand from 22% of the total nursing population in London to 40%. This presents a major challenge for the NHS and its educational providers (Buchan 2008) and represents three decades of investment in community-focused health service reform.

Other influencing factors were emphasised by Professor Stephen Field (DH 2012) in his healthcare ‘Listening Exercise’ for the Coalition Government (as a prelude to the implementation of the 2012 Health and Social Care Act). He identified the importance of promoting self-care and in encouraging patient and user involvement in healthcare prediction and co-treatment and service design. In his report he noted the major challenges facing the health of the population regarding obesity, smoking and alcohol/substance abuse, all of which place a heavy burden on the state healthcare system and contribute to the incidence of dual diagnoses and longer-term, complex healthcare conditions.

The expectations of higher service response from the health service and its professional workforce also continue to rise, particularly as service users engage more fully in the determination of the shape and scope of local healthcare provision. The Government received a final report from Professor Steve Field (DH 2012) that advised the Secretary of State for Health to continue to position care closer to home and to accelerate the transfer of care from large acute hospitals to the community through a new process of ‘clinical commissioning’, to be led by general practitioners (GPs) (through new Clinical Commissioning Groups). The Government accepted these proposals and has now advised that NHS employees should be involved in the design and commissioning of new services, supported by new workforce training arrangements to prepare them for the transition. These changes will undoubtedly herald the way for a major transformation of the NHS workforce as it prepares to support care closer to home and reduces dependency on secondary care hospital-based services.

There are some risks attached to this shift in emphasis however since the concept of GP-led clinical commissioning (the new vehicle through which services will be commissioned) is untested and untried. Similar issues relate the nature, structure and deployment of the existing non-medical workforce in the NHS (Buchan 2008). Indeed, many practitioners remain defensive and tribalistic and tend to divide labour on the basis of historical or traditional trend rather than on the basis of actual customer or market need (Cipd 2010). A relationship also exists between professional groups and the State (Nancarrow et al. 2006), and in this regard the reshaping of the nursing workforce (with emphasis on community care) might provide an example of how government policy is driving change in how the professionals train and work.

Whatever the rationale for change, the impact of change, stimulated by a growing demand for flexible, high-quality services provided within local communities, will inevitably remould the NHS of the future. Resources are already being moved to the community at a rapid rate, and health service commissioners and providers are now required to demonstrate that the care they purchase and deliver is effective and responsive to consumer need. Field (DH 2012) has also written of the important role that members of the public are now making to the governance of the NHS, mainly through ‘Ownership’ of NHS Foundation Trusts and through engagement with Expert Patient programmes. NHS Trusts in turn are now responding more purposefully and seriously to user and patient expectations and are required to publish action plans in response to local and national patient satisfaction surveys and to demonstrate compliance with local service user requirements and feedback. Associated with the rise in consumerism and user engagement is a marked improvement in the capacity and capability of the NHS to respond to user complaints and to enhance governance procedures. Even more challenging to the NHS, however, is the increased number of litigation cases presented by patients, seeking recompense for less than satisfactory care experiences. It is perhaps therefore unsurprising that it is in the primary and community care sectors that change has been most rapid, demanding the creation of innovative workforce solutions and service reconfigurations.

The changing face of the community healthcare workforce

In this chapter, we have noted that more healthcare provision needs to be delivered through primary and community-based care with public involvement in health improvement in order to enable a shift away from over-reliance on acute care. This will help the healthcare service to evolve to meet the increasing challenges of an ageing population and an increased need for case management of those with long-term conditions in a way that allows patients to retain and regain an active role in society.

The NHS reviews of the last decade (Wanless 2004), the ‘Prime Minister’s Commission on Nursing and Midwifery’ (DH 2010b) and the Royal College of Nursing (2011) have all recognised the need to upgrade the role of community nursing in order to respond to government policy. The Royal College of Nursing expresses agreement for this view and have advised that ‘80% of the nursing workforce will be working with local people to improve their health, rather than working in the hospital fixing the preventable, resulting in the safe reduction of a large number of hospital beds’. Changes in Government policy will enable this to happen over the next decade, providing opportunities for the production of a competent, capable and confident workforce of community nurses and health visitors. Key changes in the new healthcare system [following the enactment of the Health and Social Care Act (Parliament 2012a)] will include:

A shift of power over health budgets to patients and GPs. The Government will allow patients the ‘choice of any qualified provider’ following a policy of ‘no decision about me without me’. Patients will be supported whether they want a service from a hospital, from a GP, from a community health service or from a voluntary provider. This shift in policy towards patient choice has the potential to drive and reward innovation evidenced within community health services.

Promotion of a mixed economy of service provision, including an increased role for local authorities and voluntary and independent sector care provision; social enterprises will also be encouraged, in line with the Government’s vision of the ‘Big Society’.

Greater opportunity for clinicians and front-line staff to develop, design and deliver services that are responsive to the needs of local people and their GP commissioners.

Freedom for practitioners to innovate and to provide services and outcomes that improve the health and social capital of their local neighbourhoods.

In order to realise these aims, we argue in this book that:

1. There will be a continued demand to expand the community nursing and health visiting workforce and their role in delivering health provision over the coming decade.

2. The nature of community nursing and health visiting will change as a result with community practitioners taking on a greater role as expert clinicians, leaders, innovators and entrepreneurs.

3. There will be a major need to transform the delivery of care so that there is greater emphasis on public health and management of long-term conditions in the community as dependence on the acute sector is reduced.

4. Community practitioners will need to acquire additional skills in evidence-based practice and to create a community service with leadership, innovation and entrepreneurship as central skills. Emphasis will also need to be placed on enhancing patient safety (and safeguarding), on improving clinical effectiveness and on working productively and efficiently. Such skills will be needed to modernise the service.

5. The number of nurses working in the community who have specialist/advanced community nursing qualifications (health visitors and district nurses) will need to increase significantly over the next 5–10 years.

6. Key features of our contemporary society suggest that a much greater focus on health promotion and public health is required since people are living longer and healthier lives and are better informed about their needs and expectations of the health service with particular regard to promoting self-management.

7.Increasing emphasis will be placed on increasing social inclusion and valuing diversity for socially excluded groups, that is, those least likely to access healthcare, and on the reduction of health and social care inequalities experienced by significant groups within our population (geographical diversity will also demand local adaptation of national healthcare solutions, particularly within the context of devolved government to the four countries of the United Kingdom).

8. Practitioners will require greater competence and capability to work with assistive technology in areas such as tele-health, tele-care and tele-medicine; consumers and practitioners are also becoming increasingly dependent on e-based information systems and smartphone usage.

In order to ensure that the workforce is appropriately skilled and aligned to the needs of the new healthcare delivery system, the Government produced a consultation paper on education and training in the NHS – ‘Developing the Healthcare Workforce’ (DH 2010a) (The full paper is available at http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_122590).

As a result of this paper, a national statutory body was created to determine the nature, structure and focus of the healthcare workforce in England (and its educational commissioning requirements) – Health Education England. This new statutory board will provide national oversight and support to Public Health England and all healthcare providers on workforce planning and the commissioning of education and training.

It is intended that the new system will fit with the Government’s requirement to develop care closer to home and will be supported by a series of Local Education and Training Boards, so that employers have greater autonomy and accountability for planning and developing the workfor...

Table of contents

• Cover
• Title page
• Copyright page
• Notes on Contributors
• 1 The Context of Primary Healthcare Nursing
• 2 Community Development and Building Capacity
• 3 Multi-Sector Working and Self-Management, Community Health Care
• 4 Moving Care Closer to Home
• 5 Evidence-Based Practice and Translational Research Applied to Primary Health Care
• 6 Integrating the Children’s Public Health Workforce
• 7 Community Children’s Nursing
• 8 Public Health Nursing (Adult): A Vision for Community Nurses
• 9 Caring for the Adult in the Home Setting
• 10 General Practice Nursing in Context
• 11 Occupational Health Nursing
• 12 Caring for the Person with Mental Health Needs in the Community
• 13 Caring for the Person with Learning Disabilities in the Community
• 14 Leadership: Measuring the Effectiveness of Care Delivery
• 15 Social Innovation and Enterprise
• 16 Adult Vulnerability in the Community
• 17 End-of-life Care
• 18 Interprofessional Learning and Teaching for Collaborative Practice Community
• 19 User Involvement, Self-Management and Compliance
• Index