Despite their success, clinical nurse specialist roles are coming under scrutiny in the search for cost savings. But expanding specialist roles instead of losing them has the potential to reshape the delivery of healthcare, argue Annie Young and colleagues.

The role of the clinical nurse specialist is one of the successes of modern healthcare. However, amid cost cutting, there are reports that these specialist vacancies are being left unfilled, and that many of those in post are required to spend time working shifts on wards, in a general nursing capacity.

Not only is this a serious loss to patient care, it may also be a false economy. Astute managers would be wise to wake up to the potential cost savings that these specialists can achieve for the NHS and the potential for income generation at trust level.

Where a decision is made to invest in clinical nurse specialists, there are several ways that managers can make sure they reap optimal benefits.

Broad financial picture

A clinical nurse specialist post, at Agenda for Change band 6, 7 or 8, is not a low cost option for any service. However, by providing high quality, one to one care directed at each patient’s individual needs, the specialist can contribute to cuts in overall healthcare costs, such as those associated with emergency admissions, follow-up appointments and use of primary care resources.

Savings can be achieved, for example, when clinical nurse specialist-led services replace consultant-based care and as a result of nurse specialists devoting time to helping patients to self manage where appropriate.

In a financial report compiled for the Department of Health, the consultancy Frontier Economics estimated that around 1,200 new posts — a combination of specialists and support staff — are required to provide one to one care for all patients in England with cancer. The cost of this expansion in the workforce would be about £60m per year.

Based on evidence that 12 per cent of the associated workload is administrative rather than clinical, and assuming that this portion of the work could be handled by lower grade staff, the report indicates that the annual bill of £60m would be more than offset by savings of £89m per year.

In addition, if the specialists’ time is accounted for through coding of activity, the role can be seen to generate income at trust level. Changes may be required at local and national level to take full advantage of the income potential. For example, the tariff for a nurse specialist-led clinic may need to be unbundled from that of an associated consultant-led clinic, and methods are needed for costing and charging for nurse specialist support given by telephone.

However, with the advent of consortium commissioning, nurse specialist expertise in discharge provision, handover of care and community based support may allow managers to deploy them in a way that maximises efficiency and the quality of service.

Management and administration

Adequate administrative resources are essential to optimal provision of nurse specialist based care. For example, tasks such as data collection and the development of an effective data management system for trusts will help to provide accurate costings for the new breed of commissioners.

Data on clinical outcomes, including patient-reported measures and nurse specialist-sensitive outcomes, should be collected by the multidisciplinary team.

A policy for holiday and sickness cover for these posts, organised within the trust or across a broader service, such as a cancer network, will help to support continued care.

These specialists will need support to maximise their potential, for example through study days, mentoring and sharing of information across the country.

By developing their skills, specialists will be able to extend their roles and contribute to emerging national priorities, such as the recommendations of the national cancer survivorship Initiative and the quality, innovation, productivity and prevention programme for management of long term conditions.

Changes in the health service will provide established clinical nurse specialists with a timely opportunity to evaluate their roles and tailor them towards the government’s Improving Outcomes cancer strategy, for example holistic needs assessment, shorter hospital stays, value for money and fulfilment of QIPP.

The community nurse specialist will have an important role in coordinating the patient pathway between community and hospital care, offering a profound understanding of the value of the patient’s quality of life as well as the cost effectiveness of interventions. 

Clinical nurse specialists

Clinical nurse specialists bring a high degree of clinical expertise, innovation, leadership and continuity of care to their one to one work with patients, and a commitment to clinical governance, audit and meticulous documentation.

While the details of the role vary, it is increasingly clear that these nurses are taking on responsibilities that were formerly the preserve of their medical colleagues, such as pre-treatment and follow-up clinics, diagnosis, treatment decision making and management, and prescribing. They also provide mentoring and education and training for other clinical staff.

In cancer care, their contribution was singled out in December 2010 by national clinical director for cancer and end of life care Sir Mike Richards.

Commenting on the findings of the 2010 national cancer patients survey, he said: “Patients with a clinical nurse specialist reported much more favourably than those without on a range of items related to information, choice and care.”

The government’s cancer reform strategy also points out that patients repeatedly emphasise the vital role of the nurse specialist in improving their experience.

 

Caring for Patients and Families

The breast care clinical specialist nurses at University Hospital Coventry and Warwickshire Trust provide specialist care not only for patients, but also for their families, in line with the cancer reform strategy and other government initiatives.

An important aspect of their role is support after discharge from hospital, through contact at critical points in the treatment pathway, and through educating and empowering patients to recognise the signs and symptoms that warrant self referral back into acute care.

Regular surveys have shown that with comprehensive information provision from the specialist nurses, in addition to a strong supportive ethos, patients feel prepared for the treatments and procedures they receive, which contributes to a positive patient experience.

Income is generated by the specialist nurses following an agreement between the trust and the independent Meriden Hospital for provision of surgical breast care nursing services.

Innovation is another key aspect of the role. The breast care specialist nurses are working in partnership with MidTECH (part of the local NHS innovation hub) to develop and market a medical device. In addition, their system for managing anxiety among patients recalled to the breast screening assessment clinic has been published by the National Cancer Action team.

 

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