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National Nursing Strategy Implementation Plans: Don’t Ration Compassion

April 27, 2013

Does nursing finally have something to celebrate? After the shock of the Francis Report and the disappointment of the government’s response to it, last week’s publication of the National Nursing Strategy Compassion in Practice Implementation Plans saw a welcome return to common sense. Yes, there was the usual blind obeisance to Intentional Rounding, and yes, there was some eye-rolling stuff about ‘consider[ing] the implementation of supervisory roles to support staff in the emotional labour of care’. We all know that this kind of service, if it happens at all, will be patchy and uneven in its availability and quietly dropped when it turns out that no one ever uses it – either because they haven’t got the time or because they are afraid of giving the impression that they can’t cope. But before we throw out the baby with the bathwater, let’s take a moment to reflect. Because there’s plenty of good stuff in here too.

Most strikingly, there is the commitment to convene, by June of this year, an ‘acute expert development group to review current practices and metrics used, alongside an extensive literature review, in order to identify potential compassion specific indicators, or methods by which existing measures can be used to reflect compassion and the other 6Cs’. Well hallelujah! For once, let’s set aside all the gripes about how it’s been a long time coming and should have happened years ago. Instead, let’s seize the moment and be happy that it’s happening now. If it works as it should, it might finally give us the tools to show firstly, which nursing styles and workload organisation patterns produce the best outcomes in terms of patient wellbeing and satisfaction; and secondly, it could even shed some light on the old, old question of what it is about caring that actually makes a difference to people. If we can answer these questions, we can really begin to make a case for the power of nursing.

But before we get too carried away on an unstoppable tide of joy, let’s be clear: the Implementation Strategy contains six distinct areas. The real challenge will be to maintain a high level of co-ordination between the various conclusions and recommendations of all six of them as they are carried forward together. Nowhere is this joined-up thinking more vital than between Action Area 3 (‘Delivering High Quality care and Measuring Impact’) and Action Area 5 (‘Ensuring we have the Right Staff, with the Right Skills, in the Right Place’).

The national objective of Action Area 5 is ‘Work with NICE to establish adequate, and appropriate, staffing levels for all care settings’. As part of its National Nursing Strategy, NHS England has made a commitment ‘to review and refresh these plans on a quarterly basis [over the next three years], update the timescales and report on what has been achieved’. Grumbling Appendix respectfully suggests that one of the key areas for the spotlight of scrutiny should be the extent to which insights about achieving compassionate care are fed into the development of tools to predict staffing requirements. If this doesn’t happen, the whole exercise will have been completely pointless. Unfortunately, however, achieving co-ordination between the various Action Areas is only half the story.

The implementation of the Health and Social Care Act (2012) has consolidated the trend for decisions about health care provision to be devolved away from central and towards local providers; for this reason, the so-called ‘National Nursing Strategy’ may turn out to be something of a misnomer. Although the general framework of the six Action Areas is decided at national level, their implementation is firmly in the hands of local Directors of Nursing. In the case of Area 5 for example, it is their role ‘to agree appropriate staffing levels in all areas through the application of evidence based tools’.

The danger here is that local care providers will be free to put their own interpretation on the meaning not just of ‘adequate and appropriate’ but also of ‘evidence based tools’. What, one wonders, counts as an evidence-based tool? Will there be any obligation on trusts to incorporate the findings of the National Nursing Strategy? Or will they be free to invent their own tools to suit their own ‘local conditions’ (for which read, pockets), or (perish the thought), simply purchase some patented ‘nurse manpower optimisation programme’ from a commercial company?

This is not say that there won’t be examples of excellent practice. There definitely will be. The worry is that their distribution will be far from universal. On Sunday 7th April The Guardian website published short interviews with five doctors who were all taking lead roles in their respective Clinical Commissioning Groups. Under the terms of the Health and Social Care Act, these groups now have the freedom to decide on their local health priorities and commission services (including nursing) accordingly. Speaking of his group, one doctor commented: ‘we’ve saved hundreds of thousands of pounds in our £300m budget in the last year by reducing the use of drugs for which there’s no evidence that they work’. Another said that his local hospital ‘began having a consultant working in its medical assessment unit seven days a week, because we commissioned that’. As a result ‘patients now get earlier diagnosis and access to scans more quickly. And there are some early signs it has reduced our weekend mortality rate’. Leaving aside the mildly troubling revelation that the prescription of useless drugs in Tower Hamlets has been merely ‘reduced’ rather than eradicated altogether – these sound like great ideas. So great, in fact, that you’ve got to wonder why they’re not being rolled out across the whole NHS as of now.

Whilst it is true that every area of the country faces geographically-specific health challenges (for example, higher-than-average elderly populations, higher-than-average non-English-speaking populations, higher-than-average birth rates, higher-than-average rates of poverty or poor housing), the idea that only some communities should have access to initiatives like the ones discussed the The Guardian interviews seems ludicrous. For nursing, this could mean that interventions are dictated less by the patient’s health requirements than by where they live and whether their condition has been recognised as a priority by their local Clinical Commissioning Group. It’s nonsense. The National Nursing Strategy’s recommendations – whatever they turn out to be – have to be just that: national. Or are we going to say that compassion is a priority only in certain localities?

NHS Reforms: We need people to see why we have changed things; The Guardian: 07/04/2013
http://www.guardian.co.uk/society/2013/apr/07/nhs-reforms-clinical-commissioning-groups?INTCMP=SRCH

NHS England (2013): Compassion in Practice Implementation Planshttp://www.england.nhs.uk/nursingvision/actions/#plans

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