Published: 13/05/2004, Volume II4, No. 5905 Page 26 27 28

Last year HSJ and Nursing Times brought nurses together to imagine new roles for the profession.Six months on, Adrian O'Dowd assesses what progress has been made

Six months on from a ground-breaking experiment in which nurses were asked how they would run the NHS, several of the ideas they came up with are now being implemented. In a joint edition of HSJ/Nursing Times which reported on four seminars across England (feature, pages 32-35, 13 November 2003), many practical, common-sense solutions were put forward by four groups of nurses who were invited to write and present their vision of a 'nurse-envisaged'NHS.

Those ideas made up a manifesto presented to chief nursing officer Sarah Mullally. Several steps have now been taken to put some of those good ideas into practice.

Four organisations took part in the project: University Hospital Birmingham trust, Northumbria Healthcare trust, Homerton University Hospital foundation trust in east London, and Bradford South and West primary care trust. Relevant health authorities were also invited to attend the seminars.

Six months on and Homerton is pushing ahead with change, which is made easier by it being one of the first foundation trusts in England, allowing extra clinical and financial freedoms. Senior nurse in medicine and rehabilitation at the trust Jennie Negus recalls: 'After the meeting, our director for nursing at the North East London strategic health authority asked us what our priorities were.We met with her several weeks later to discuss them.'

One priority was a mental health nurse specialist post permanently based on an acute ward, which looks likely to receive the green light for a six-month pilot (see case study, opposite). It is hoped the pilot will improve care for patients with dual physical and mental health diagnosis, make better use of nurse specialists and cut agency spending.

One of the more controversial ideas from Homerton was for medical students to spend a year as nurses as part of their training, in order to gain better caring and communication skills. One spin-off is that North East London SHA - which took part in one of the seminars - is planning talks with the deans of medical schools to discuss matrons or senior nurses playing a role in medical training.

Matrons would meet undergraduate medical students at appropriate levels of their training with the aim of fostering a better understanding of matrons' and senior nurses' roles, explains SHA director of nursing Trish Morris-Thompson. 'This might be in the form of matrons giving talks to the students.'

With some of the ideas barriers are inevitable, he adds.

'There has been a tremendous pace of change going on at the trust as it has now got foundation status.None of the ideas from last year's seminar have been lost, but some are less achievable, such as free public transport for nurses and medical students spending a year of their training as nurses. Those are difficult to implement, but most of the ideas are feasible at some point.'

A theme of all the seminars was for a shift away from national targets, with more of a focus on locally set priorities.

'We really want to take forward nursing and midwifery initiatives and there is a feeling we can do that now, ' says Ms Negus. 'On targets, we are led by what is out there nationally, but often there is a match nationally and locally. Tuberculosis is a priority here. It is a big problem in east London and it does not seem to be a high national priority.Our SHA nursing director is to meet with TB nurses across the region to discuss raising their profile and see what support she can give them.'

As a result, the existing London TB nurses network has been given£10,000 by the SHA to help fund educational needs such as training days.

Ms Morris-Thompson says the managers were impressed by the seminar they attended. 'What the event did was bring about a very dynamic dialogue between directors and clinical nurses.We got a tremendous understanding between the two groups about the value of nursing.One real value of nursing is being able to interpret patients' needs in a way that no other professional group can do.'

Tangible results have come out of the University Hospital Birmingham trust meeting, including three new nurse consultant posts in nutrition, gastroenterology and coronary heart disease, which have been approved in principle by the trust and health authority.

Maggie Bayley, head of nursing division two at the trust, explains: 'The key thing for us in the past six months has been development of nurse consultant posts.

With the nurse consultant post in coronary heart disease, for example, the nurse will review the delivery of care for all chest-pain patients who now come in under the care ofa general physician rather than a cardiologist.'

Ms Bayley believes the seminar last year was a big step forwards for the trust's development of nursing; there will be new freedoms soon if it gets full approval to become a foundation trust in July.

'It was really exciting and challenging. I absolutely loved it. It was very thought-provoking and a real opportunity to think outside the box and be able to put our own stamp on where we might take the health service in the future, ' she says.

'It is good for chief executives to be challenged in a positive way. They wouldn't normally have that kind of debate with their own staff.'

Northumbria Healthcare trust director of nursing and emergency care Rosemary Stephenson says the trust has many initiatives in development and the discussion last year has helped some of those reach fruition.

One of the schemes it has helped to cement is an ongoing training programme for nurse practitioners at Hexham Hospital where, since February, they have taken on much of the work normally done by junior doctors.

Northumbria Healthcare trust deputy director of nursing Debbie Reape says the programme has been a success and a second cohort has started training already, with further intakes on the cards. Twelve nurses had three to four months 'in the classroom' followed by 10 weeks' training alongside third-year medical students, and then further instruction in clinical areas.

'It is working well, ' she says. 'They are working closely with the consultants and our second cohort of 12 started training in March. The training has been very much clinical scenario-based.

'We had a nurse, Helen Maughan, present at the HSJ/NT seminar last year who was doing the programme and she was able to say how the course could be developed. Fundamentally, these groups of nurses are demonstrating to us what is possible.'

The trust has also set up what is believed to be the first nurse-led chemotherapy service for local patients with cancer. There are two clinics a week at Hexham General treating up to 10 patients a day, rather than them having to make a 50-mile round trip to Newcastle for treatment.

Bradford has also been moving ahead since last year's seminar. Bradford South and West PCT director of nursing and operational services Philomena Corrigan says one idea in particular has grown out of the meeting she attended and others were firmed up shortly after event, following further discussion.

'We want to create four new posts - advanced primary care nurses - to look at the more complex elderly patients, those that need more active help.We want to stop them going into hospital and make sure they do not just end up in a nursing home.'

The posts are in line with the Evercare model of care for the at-risk elderly, developed in the US by United Health Care and being piloted in the NHS. The model relies heavily on specially trained nurses who plan appropriate care with patients and their families. It is hoped the four posts will be operational by July.

'The idea was discussed at the seminar and after that we said this is a really good one, let's do something about it.We have also appointed a nurse consultant, who is a prescriber, to run a 15-bed intermediate care unit in Bradford. It was run by a medical consultant before. It is fantastic.'

A trainee nurse practitioner had also been appointed for mental health in a health centre in Allerton on a trial basis.

'The seminar last year was a thought-provoking exercise, ' adds Ms Corrigan. 'It was interesting to see how aligned our thinking was with national perspectives.'

Nationally, the Department of Health has been very interested in the HSJ/NT manifesto and approved its distribution to all delegates at last November's chief nursing officer's conference in Brighton.

'All the suggestions were interesting and gave me and my colleagues food for thought, ' says chief nursing officer Ms Mullally.

'The idea to make nurses the lead professionals in primary care is certainly something that the DoH has been looking at for some time.'

Nurse consultants, nurses becoming care managers for those with long-term conditions and the extension of nurse prescribing are all aspects of the DoH's drive to give frontline nurses more power. l Nursing ambitions: campaigning for a specialist Jennie Negus is a woman with a mission: to improve patient care while developing nursing at her trust.The two should not be mutually exclusive.

The senior nurse in medicine and rehabilitation at Homerton University Hospital foundation trust has been championing the need for a permanent mental health nurse specialist in acute wards since the HSJ/NT seminar.

'There are many occasions when our patients have dual diagnosis and traditionally these tend to be cared for in a unispecialist service, 'she says.'The nurses at Homerton are almost exclusively registered general nurses and their expertise is in physical health.

When patients present with an existing mental health problem or display mental ill-health there is a lack of awareness, knowledge and expertise.'

She continues: 'Currently, staff can refer for a psychiatric assessment or access emergency support and advice, but there is no provision for ongoing support or advice regarding care planning for mental health patients; therefore the care is not patient centred.

'This lack of quality results in reduced efficiency in terms of the patients staying longer, non-concordance, re-attending and re-admissions. In addition there is a high use of one-to-one registered mental nurse (RMN) agency nurses in an attempt to contain mental health problems.'

Final approval is expected soon on a part-trust, part-strategic health authority funded six-month pilot of an H-grade RMN in acute wards whose roles will include:

acting as gatekeeper for all psychiatric nurse 'specials', through undertaking a comprehensive assessment of patients'mental health needs and risk to themselves and others;

reviewing the nurse specials on a daily basis to re-assess their need;

developing care plans for managing mental health needs within an acute setting;

providing counselling, anxiety management and behavioural support;

devising an education programme for ward staff.

'The post could significantly improve the quality of care that we deliver to patients at Homerton who have concurrent mental health needs, 'argues Ms Negus.'We predict that nurse specials will be used more effectively, with a resultant reduction in the level of agency spend.'

Speaker's corner: why it really is good to talk University Hospital Birmingham trust Head of nursing division two Maggie Bayley is becoming used to receiving invitations to official events where she speaks on how nurses would run the health service.

Ms Bayley took part in one of last year's HSJ/Nursing Times seminars and says she is now explaining the process and the benefits to others.

'I have been invited to speak at the national Developing Nurse-Led Healthcare conference next month. It is linked to the HSJ/NT meeting as the conference organisers said they had read about that.

'I am also chairing a workshop there where I will explain how the seminar happened and what we discussed. I want to look at how they can do the same thing, ' she adds.'I want them to start their own debates at their own trusts.'

Ms Bayley continues: 'After we did the seminar members of the nursing team, including chief nurse Dame Catherine Elcoat, were invited to a [Labour Party] Big Conversation event in Birmingham in February, when we had the chance to speak directly to prime minister Tony Blair and health secretary John Reid.Because I had been involved in the HSJ/NT discussion Dame Elcoat asked me along.We want to see how we can continue to influence politicians. It is exciting being asked to talk about this to other people, ' says Ms Bayley.

It is perhaps no coincidence that another speaker at the June conference is Homerton University Hospital foundation trust matron in acute medicine Louise Olley, who also happened to take part in another of the HSJ/NT meetings.

Ideal world: what the nurses called for lnurses to be the lead professionals in primary care;

doctors to spend a year of their training as nurses;

a case manager for every patient;

the NHS to consider co-payment for some treatments;

consider changing the name of the NHS to be more partnership orientated;

fines for missed appointments;

nurses to have preferential treatment over the general public;

trusts to provide a 24-hour test service;

encourage volunteers to take on additional responsibilities;

full integration of primary care trusts and social services.

Key points

Trusts that took part in a series of seminars last year are implementing ideas for a 'nurse-envisaged' NHS.

Results have included new nurse consultant posts in Birmingham and ongoing nurse practitioner training in Northumbria.

A Bradford PCT is introducing advanced primary care nurses in line with the Evercare model of care.