Workforce productivity and the role of consultant nurses, allied health professionals and pharmacists

An evaluation commissioned last year by the North West NHS examined the role of the consultant nurse, allied health professional and pharmacists. It produced a report called Ten Years on – An Evaluation of the Non-Medical Consultant Role in the North West. The study was the first comprehensive review of the impact of the role in the North West since its inception in 2000.

The successful consultant practitioner in nursing midwifery, allied health professional and pharmacy role is complex and integrated by nature. While small in number the consultant practitioners role in the North West has had a demonstrable impact on service development and delivery. The level and function of the role is affected by both the individual and the organisation. 

The experienced, well supported and committed consultant practitioner clearly has the potential to support the current and future NHS agenda. However we found there was little evidence of workforce planning in terms of succession planning to sustain roles and service, and or develop new roles and a continued lack of understanding of the consultant (N.AHP.P) remit.

The NHS is in one of the most financially constrained periods in its history and central to its survival is improved productivity and much of the room for improvement lies within the workforce. In reality this requires renewed focus and engagement with staff to harness their real potential. 

Productivity is being driven as part of the quality, innovation, productivity and prevention agenda, geared towards modernising the NHS and meeting the wider economic challenges facing the public sector. The NMCs have made a significant contribution locally and in some cases nationally over the last 10 years to the delivery of service with many practical illustrations of personal drive and commitment to supporting the quality improvements, innovation, and productivity and prevention agenda.

It is suggested that the consultant practitioner role has the potential to make a valuable high level impact in organisations to support the current and future modernisation and associated QIPP agenda.

Commitment to the QIPP agenda was re-emphasised in the Department of Health’s most recent and challenging proposals outlined in Equity and Excellence – Liberating the NHS, and the Health and Social Care Bill which stated that: “over the next few years, the wider health economy and the public sector generally face significant challenges, an ageing and growing population, new technology and higher public expectations and continuing growth in demand. Through developing their Quality, Innovation, Productivity and Prevention (QIPP) plans, the NHS has been planning for some time for a tighter financial environment, with the ambition of achieving efficiency savings of up to £20bn for reinvestment in front-line care. Healthcare staff account for the majority of NHS spending, so having the right mix of skills and empowered professionals will be essential in meeting these challenges.”

In the King’s Fund report NHS Workforce Planning: Limitation and Possibilities it is recommended that providers need to focus on workforce productivity particularly ensuring that current staff are able to work flexibly and have the ‘skills’ to deliver services both now and in the future.

This article advocates that closer examination of existing roles, and their impact, could provide evidence of significant contribution to the productivity improvement agenda that is potentially not being recognised or measured.

Background to the consultant role

The nurse, midwife, allied health professional and pharmacy consultant posts were first introduced in 2000, starting with Nursing and Midwifery, followed by AHPs and more recently pharmacists. The aim of the consultant role is to:

• To strengthen clinical leadership;
• To provide better outcomes for patients by improving services & quality;
• To provide a new career opportunity to help retain experienced and expert practitioners in practice.

The Department of Health guidance’s on these consultants outlined four broad core functions:

• Expert practice;
• Professional leadership and consultancy;
• Education, training and development;
• Practice and service development, research & evaluation.

The main focus of the role was identified as the delivery and practice of clinical care, with the expertise in practice underpinning each of the other functions. These posts are the highest level within the health care system for front line clinicians wishing to stay in practice and are for many the pinnacle of a practitioner’s career.

The NHS North West Evaluation Study – 10 years on

The North West NHS commissioned the evaluation in 2010 to:

a) Provide an overview of the make-up and spread of non-medical consultant roles across the North West region.

b) Illustrate the consultant’s contribution/engagement across the four core functions and to provide illustrations of the impact of the consultant practitioner role on the care and service provided by the clinical team.

In order to fulfil the remit of the project brief the study included a combination of qualitative and quantitative methods which are summarised below:

• Desk top literature review;
• Focus groups with key stakeholders; consultants, directors of nursing, allied professional leaders, and pharmacy leaders;
• An Electronic questionnaire all the known consultants in the North West;
• A questionnaire to identified stakeholder champions.

Questionnaires were distributed to all the consultant practitioners on the North West register (130) and the response rate of 73 per cent (95) was excellent. This resulted in confidence that the study’s responses were fully representative professionally of the consultant practitioner cohort across the North West.

The study’s findings

The study demonstrated that the consultant practitioner had been established in all four sectors of healthcare: primary care, mental health, acute and specialist services. 

Across the North West the average number of consultants practitioner per trust was two-three per organisation and a very small number of organisations (6 per cent, n4) had larger numbers of consultants practitioner ranging from nine and 12 per organisation. However there were 30 per cent (n19) of providers in the North West that had no consultant practitioner posts.  

The study also identified that the North West had a turnover of consultants practitioner of 1.5 per cent per year - (n1 or 2 per year). This indicates that contrary to expectations the role is not a job for life and some consultants do move on to other jobs, particularly associate and or director posts in service, education and or research.   

The study found that the consultants practitioner were actively engaged in the four core functions and, following discussion with the consultants (N.AHP.P.), additional broader activity was analysed for the first time, through the use of a unique framework developed by the evaluators: The NMC Interactive Impact Framework (see figure 2 - right).

The framework enabled the complexity and breadth of the consultant role to be analysed separately, whilst also recognising that in practice the functions are inextricably intertwined.  The broader areas examined in particular were:

• Partnership working and networking;
• Empowerment of others;
• Clinical practice both direct and indirect which has not been specifically examined in other studies;
• Service and practice development;
• Evidence of the consultant contribution to QIPP.

The model enabled the study to examine more broadly the true scope and influence the consultant practitioner had on the experience and care of patients. The original Department of Health guidance stipulated 50 per cent of the role should be spent in practice which many interpreted as “direct hands on care”. 

In reality, the framework used in the study showed that every aspect of the consultants practitioner activities i.e., direct care, indirect care, education and development, research, and service re-design, evolved around and focused on the experience and or care of patients. In other words the consultant practitioner spends 100 per cent of their time in activities impacting on practice.

The consultant practitioner’s impact on quality, innovation, productivity and prevention

The study analysed the data using the QIPP framework to assess the consultants input and impact on practice, staff and the organisation’s performance. It was found that the consultant practitioner’s impact was achieved through the following key activities:

• providing strategic clinical leadership and expert advice;
• developing and empowering others;
• creating new roles and new ways of working;
• driving service development;
• identifying and influencing the education and training of others;
• participating in practice based research;
• generating partnership working.

The study’s findings build on previous studies (Guest and Redfern 2004, Humphries et al 2006, 2007, Manley 2000, Woodward et al 2005) and particularly built on the evidence on the consultant practitioner’s contribution to service development, applied research, evidence based practice, influencing education, working with others particularly universities and other providers, and the development of policies and protocols. Some of the impact findings are described below.

Quality

Consultant practitioners clearly perceived that they were improving service quality by influencing others through their use of evidence based practice, and provided a large range of examples (over 100) that supported this. The consultant practitioners primarily influenced the quality and experience of patients through:

Changing and challenging local clinical practice

“Took service through customer service excellence in 2009, one of first NHS organisations to achieve this, involved all staff and patient groups in setting the Agenda for this. Culture of autonomous decision making embedded in organisation”

Developing new standards and guidelines

“Trust wide standardisation of tracheotomy care”

Working across health economies to develop and deliver seamless pathways of care

“Promote partnership and cross boundary working and promote evidence based practice in paediatric palliative care”

“Presentation of evaluation of findings of serious case reviews and agreeing priorities across health economy”

Empowering and educating patients, carers and families in their care and or in engaging users in service developments

“Provide extensive training to patients and families regarding the care and management of their feeding device. These empowered patients/carers adapt their lifestyles to cope with managing a feeding device, keep well and ultimately stay out of hospital”

Innovation

Innovation was evident in a number of the examples provided by the consultant practitioners particularly in areas of practice where no precedents exist through the development of:

• Standards and policies;
• New ways of working, including medical teams; and
• Service redesign.

In these areas of activity the consultant practitioner demonstrated high levels of engagement, high levels of expertise and clinical leadership particularly around risk management and statutory regulations related to practice.  Some examples are shown below:

Working where no precedents exist

“The specialty I work in is probably the most legislated area of the NHS as it involves working with ionising radiation and the manufacture of sterile medicines. My role has involved the interpretation of this complex legislation (which is sometimes conflicting) both at a local and national level which has been put into guidelines, policies etc. My role has involved setting up a comprehensive quality management system, sops, documentation etc which is required for licensing of the service by the MHRA and setting the standards for others to practise and operate in the specialty”

“The services I have developed are operating where no precedent exists. We are currently in negotiation with several national institutions regarding developing an evidence base on the back of the models implemented”

Service development and service delivery often influencing at Trust Board and service level

“Set up a very successful Children’s Observation & Admissions Unit (COAU) mentioned on DH website as an example of good practice + won national awards. Had many visitors/enquiries and helped others establish similar units. Had article published 2001 + presentations at conferences since”

“Worked with breast screening services…to relocate mobile unit to a more central location to improve uptake of breast screening especially in minority ethnic community. Negotiated with… town centre retail park to have unit based on…Centre car park. The planned move was agreed and the next time the unit was in…this site was used”

New ways of working

“Proactively enhanced the role of nursing whereby they can independently clinically examine, diagnose and treat patients”

Development of standards of best practice nationally, regionally and locally

“My PhD work was the development and testing of the ICU Recovery Manual. This has now been adopted by the National Institute of Clinical Excellence as part of the guidelines for rehabilitation following critical illness”

Productivity

The study findings indicated that the consultant practitioners significantly add value and improve productivity locally particularly in relation to:

• supporting the delivery of performance targets;
• improving both workforce and service efficiency reducing waste;
• raising income;
• improving and changing practice;
• improving the patient experience through service re-design.

This was further demonstrated by illustrations of the dissemination of the Consultant Practitioners efforts locally and nationally often demonstrated through recognition of their work and their practical collaborative initiatives nationally.  Some of the examples are shown below:-

Supporting the achievement of performance targets

“Redesign existing respiratory pathways to provide better outcomes for patients and the health economy e.g. Care closer to home  through oxygen therapy review with saving of over £100k, sleep service review – streamline pathway resulted in reduced waiting time for treatment from six months to four weeks”

“My role was brought in to facilitate redesign of the pathway for patients with musculoskeletal pathology to enhance quality and reduce waiting times. This led to the creation of the MCAS which has now been fully operational for five years. The MCAS is a triage and treatment service which has resulted in large scale reduction in waiting times to both orthopaedics and rheumatology and has helped achieve the 18 week referral to treatment target”

“Undertake role of consultant doctor in breast unit so introduction of role has enabled unit to run more clinics, meet government targets and reduce waiting times for patients. Part of unit management team influencing all aspects of service”

Reducing waste and improving the patient experience

“Redesign of community weight management services in 2005 - extending scope of dietetic practice in relation to home enteral feeding - preventing unnecessary hospital admissions”

“Redesign existing respiratory pathways to provide better outcomes for patients and the health economy e.g. Care closer to home  through oxygen therapy review with saving of over £100k, Sleep service review – streamline pathway resulted in reduced waiting time for treatment from six months to four weeks”

Raising income

“I have raised approximately £5 million pounds in external funding since coming into post which has enabled me to recruit additional staff to help us promote the public health agenda in midwifery. Currently we have over 10 full time equivalent community midwives working as a result of additional funding I have secured and a number of other specialist posts”

Improve both workforce and service efficiency

“We have changed the practice in leg ulcer management through the research projects we have done. Now have very competent practitioners who diagnose leg ulcer aetiology. Evaluated Topical negative Pressure- now have a quicker healing and earlier discharge with using this practice has changed both medics and nursing views and practice. I have devised a robust monitoring pathway for collecting pressure ulcer incidence for the Acute and PCT”

“Enabled … nurses to expand their field of practice and get involved in cases that would previously have been dealt with by physicians”

Prevention

The findings indicate the consultant practitioners had a significant impact on the practice of others, particularly staff and patients, through their use of, and influence on, education and training, research development and the development of policies in their day to day practice which was contributing to reducing risk and preventing errors.

Practical examples showed the work of the consultant practitioners impacted on staff and the organisation by, increasing practitioner’s confidence and competency through:

• Ensuring consistent practice;
• Improving patient safety; and
• Reducing risk.

Illustrations of this include:

Policy development to reduce risk

“Development of Trust Medicines reconciliation policy -reducing risk of errors and noncompliance”

“Development of mattress replacement policy resulting in reduction in risk of pressure sores and infections”

Education and training of staff and patients ensuring consistent practice

“Delivered tracheotomy training and reduced number of clinical incidents relating to these patients” (trust wide)

“Patients have been empowered to recognise their symptoms and manage their conditions by making changes to their lifestyle”

Research development to improve patient safety

“Impacted nationally on practice in observation through published research Developed NIMHE toolkit for suicide prevention. Developed toolkit for self-injury”

Discussion on the Benefits to organisations

The study findings provide evidence of the valuable impact a successful Consultant Practitioner can have within organisations.    Due to time constraints the evaluation was not able to measure quantifiable cost effective benefits but further work in this area is being considered as a next stage.  Despite this limitation, the study does demonstrate that the Consultant Practitioners role adds value to organisations, often through and with others particularly in relation to QIPP.  These benefits are summarised below:-

1. Patient benefits through:

a) Improving patient care and standards of practice

b) Providing education to patients and or their families or carers

c) Empowering patients through information and choices about their care

2. Organisational/Service benefits through:

a) Re-designing services that support improving the patient’s experience and achieving key organisational performance targets/ goals

b) Leading improved productivity through re-design of services

c) Improving productivity through better utilisation of staff

d) Improving productivity through active education, developing staff and introducing skill mix changes

e) Raising income through successful research bids

f) Improving performance through delivering clinics and services where relevant

g) Improving safety through reducing untoward incidents and or complaints as the proxy measure for the development and implementation of policies, guidelines, and protocols

h) Raising the organisations profile and reputation through achievements in research and practice via publications, presentations, and networking locally, regionally and nationally

i) Providing an attractive vehicle for organisations to  recruit and retain highly trained expert specialist practitioners

j) Demonstrating an organisations commitment to leadership in practice

3. Staff benefits through:

a) Providing staff with support in practice from an expert in the field

b) Providing staff and teams with education, research and challenge focused on best practice

c) Providing staff with mentorship, supervision, training and development

d) Providing career opportunities for clinicians wanting to progress and develop within practice

e) Developing new ways of working and new roles to make best use of staff and resources

f) Creating policies and procedures to provide guidance and support safe practice

Workforce challenges for organisations   

In conclusion the findings suggest the effective consultant practitioner can make a significant contribution to improving productivity and the wider QIPP agenda which is potentially not being widely articulated, recognised, measured and/or effectively capitalised upon. This article has attempted to illustrate some of their potential.

One of the most frequently cited issues in the study was that the majority of consultant practitioners perceived there to be a lack of understanding of the role within organisations across a variety of staff, professions and levels. In some cases this led to tensions and a lack of awareness of the scope and high level at which the role functions, which created barriers to the consultant fulfilling their full potential. As a consequence some consultants were not as effective across the four key functions and in some cases they believed it reduced their ability to influence and impact within the organisation and externally with key partners. Some of these factors have been highlighted in other studies and despite it being the tenth anniversary year, it is concerning that these issues were still present today.

We also found very little evidence of workforce planning in terms of succession planning to sustain roles and/or of the development of new posts.  The lack of workforce planning and understanding of the consultant practitioner role is short sighted in light of the need to maintain successful services and improve staff productivity in the NHS.

The study found that a number of key factors are required to ensure the consultant practitioner role is effective, efficient and productive.  The factors critical to success are:

• A supportive culture, and director level accountability with formal meetings;
• Clarity of role with clear expectations and outcomes;
• Organisational understanding of the role and staff support;
• Adequate administrative support;
• Formal clinical supervision.

The study provides organisations with information and evidence on the breadth and complexity of the consultant practitioner role and how it can and does impact on the QIPP agenda.  It is recommended that organisations read the full evaluation (Mullen C. and Gavin-Daley A. 2010) to get more insight in to the background and functions of the effective consultant, and take the opportunity to ensure the current Consultant Practitioner workforce is enabled to maximise their impact.  We would also recommend that organisations review their workforce plans ensuring that they consider the consultant practitioner role, taking in to consideration the benefits that these roles can bring to patients, staff, and organisational performance.

References

Department of Health, Nurse Midwife & Health Visitor Advanced Letter DH AL (NM) 2/99), September 1999.

Department of Health, Nurse Midwife & Health Visitor Consultants – Establishing Posts & Making Appointments, HSC 1999/217, September 1999.

Department of Health, Approval of Nurse Midwife & Health Visitor Consultants, Professional Letter; DH PL (CNO) 2003(5), May 2003.

Department of Health, Meeting the Challenge: A Strategy for the Allied Health Professions, DH, November 2000.

Department of Health, Guidance for the Development of Consultant Pharmacist Posts, DH, March 2005.

Department of Health, Arrangements for Consultant Posts – for staff covered by Professions Allied to Medicine PT ‘A’, Whitley Council, DH September 2001.

Department Of Health, Health and Social Care Bill, 2011.

Department of Health, Equity and Excellence:  Liberating the NHS, July 2010.

Department of Health, The NHS Constitution, March 2010.

Guest D. & Redfern S., An Evaluation of the Impact of Nurse Midwife & Health Visitor Consultants, Kings College London Management Centre, 2004.

Imison C., Buchan J. & Xavier S., NHS Workforce Planning Limitations and Possibilities, Kings Fund 2009.

Humphreys A. Richardson J. Stenhouse E. Watkins M. Cummins E. (2006) Assessing the Contribution of Nurse and Allied Health Professional Consultants - A feasibility study, Faculty of Health and Social Work, University of Plymouth July 2006.

Humphries A., Johnson S., Richardson J., Stenhouse E., & Watkins M., A Systematic Review & Meta-Synthesis: Evaluating the Effectiveness of Nurse Midwife & AHP Professional Consultants, Journal of Clinical Nursing 2007, 16, 1792-1808.

Manley K., Organisational Culture & Consultant Nurse Outcomes, Part 1 Organisational Culture, Nursing Standard, May 2000a.

Manley K., Organisational Culture & Consultant Nurse Outcomes, Part 2 Nursing Outcomes, Nursing Standard, 14, 34-39, 2000b.

Woodward V.A., Webb C. & Prouse H., Nurse Consultants: Their Characteristics & Achievements, Journal of Clinical Nursing 2005.

Woodward V.A. Webb C., & Prouse H., Nurse Consultant Organisational Influences on Role Achievement, Journal of Clinical Nursing 15, 272-280, 2005.