Published: 01/04/2004, Volume II4, No. 5899 Page 36 37

NHS and social care roles are being transformed by the changing workforce programme. Paul Dinsdale examines what this means at ground level

Changes to the roles of NHS professionals have been a constant theme of the last few years, and never more so than now as trusts attempt to reconfigure services to match shifting patient demands.

Health ministers have been very keen to be seen to be leading the work and have championed the Modernisation Agency's changing workforce programme as one of the engines for change in the NHS.

The programme is designed to help NHS and social care organisations test and implement new ways of working to improve patient services, tackle staff shortages and increase job satisfaction.

Its aims are to help redesign staff roles by combining tasks differently, expanding roles or moving tasks up and down 'a traditional uni-disciplinary ladder', and to remove any obstacles to change to ensure new ways of working become embedded in the NHS.

As part of its programme, it has set up 13 pilot sites in trusts around the UK and has run workshops for trusts to give advice on developing and implementing new ways of working at local level.

One unit focuses on new ways of working and aims to help modernise the workforce by providing the right numbers of staff in the right locations.As part of its work, it helps to implement: the Agenda for Change strategy, which will tie pay more closely to extended roles for nurses and other NHS staff, the consultants' contract, which will provide services to patients at guaranteed times and in a more convenient way, and the European working time directive.

The directive is leading to major changes in the ways that trusts distribute the workload of patient care. Pilot schemes are:

developing medical support worker roles - these staff are given extra training to carry out basic medical tasks;

extending nursing and other healthcare practitioner roles (see below);

making better use of healthcare assistants.

Acting director of the employers' organisation service at the NHS Confederation, Alastair Henderson, says the evolution of roles in the NHS is 'absolutely fundamental' to the development of services.

'These roles need to be developed at a local level, with agreement between managers and clinicians, and there are some really exciting projects going on around the country.

'They are about delivering services in a more effective and efficient way. If these changes make savings, That is good, but It is not the main reason for implementing them.'

Mr Henderson says that decisions on changing roles need to be left to local level, to provide what works best in a particular trust, but the lessons learned should be disseminated widely so other trusts can learn from them.

Acting head of employment relations at the Royal College of Nursing Josie Irwin says the Agenda for Change package makes this an exciting time for nursing, but that all the changes to nurses' roles need to be managed carefully.

'All of the changes have unlimited potential for nurses but we have to ensure that they are implemented properly and that there is fair remuneration for extra work, ' she says. 'The early implementers of Agenda for Change will be evaluated in the coming months and the job evaluation package will be reviewed in the light of the lessons learned. They might need some tweaking, but so far the early implementers are saying that it seems to be going well.'

Healthcare practitioner projects The European working-time directive pilot at Birmingham Heartlands and Solihull trust has nurses taking on extended roles in medicine and orthopaedics.

The project has introduced senior nurses to replace doctors in training from 5pm-9am on weekdays and all day at the weekend. It covers the acute medical wards at Birmingham Heartlands Hospital and elective orthopaedics at Solihull.

The senior nurses provide clinical advice to ward nursing staff and carry out clinical duties that would otherwise be done by junior doctors.

Project manager Linda Freeman said in an evaluation that it has succeeded through a structured training programme with defined objectives and clear communication with all stakeholders.

Consultant nurse for vulnerable children Christine Durance is the UK's first consultant nurse for vulnerable children, based at Mansfield District primary care trust in Nottinghamshire. She leads a team of 13 nurses working with a range of vulnerable children, including those with learning disabilities, behavioural problems and those who are looked after by social services.

The PCT is based in an area of major social deprivation, including former mining and manufacturing communities, with high crime rates, a lower birth weight for babies and higher rates of teenage pregnancy and poor health than in the county as a whole. It decided to appoint a consultant nurse for vulnerable children to coordinate services across several PCTs in 2001, although she is employed by Mansfield PCT.

The team accepts referrals from the social services departments of several councils in north Nottinghamshire. These are coordinated with the health services provided by PCTs. The team also works closely with GPs, the police and designated social workers.

'The team works across the boundaries of hospital and community services so we can make an intervention at different stages of the child's journey through the healthcare system, ' says Ms Durance.

'For example, if a family in crisis is referred to us by a social worker, we can assess the child or children's healthcare needs in tandem with their assessment with social services.We then work with the social worker to monitor the child's progress, so we can be seeing children regularly for months - even years in some cases.'

Generic health and social care workers South West Dorset PCT and Dorset social services have set up an 'intermediate care' project, which trains domiciliary care staff in delivering basic healthcare to elderly and vulnerable people at home.

The impetus came from the difficulties the council was having in recruiting and retaining domiciliary care staff, but the service also has the broader aims of facilitating earlier discharge of hospital patients, to help prevent avoidable hospital admissions of older people and to reduce the incidence of re-admissions.

PCT intermediate care coordinator Kaye Hoare says: 'Members of the team are allocated to clients who are involved in inpatient rehabilitation, in community or acute hospitals, or in one of the two rehabilitation schemes in residential homes run in the area.

'The health and social care assistants can also contribute to preventing avoidable hospital admissions. They can pick people up at home, following an event which adversely affects independent activity, such as a fall, but which can be restored with a limited period of supportive rehabilitation.'

She adds: 'As part of the PCT's intermediate care agenda, the health and social care assistants are located firmly within the health team with which they work. And because the teams are distinct from conventional homecare services, the client does not face the usual means-tested charges for the limited intermediate care treatment period of up to six weeks.'