Seven-day services open new doors
In the drive to deliver seven-day NHS services, organisations have been told to focus on a number of initiatives centred on senior hospital doctors. This narrow focus does not take into account the skills and competencies of specialist nurses, who could be the key to delivering improved care outside core hours.
NHS organisations have been told to focus on a number of consultant-centred initiatives, such as directed interventions and the time when a consultant reviews a patient.
The RCN accepts that change is necessary. Head of nursing practice JP Nolan says: ‘There is a lot of evidence that people have worse clinical outcomes when they come into contact with the NHS at the weekend.’
But the college and others are arguing that the focus on a single staff group may be the wrong way to tackle poor care outside core hours and might not lead to the most cost-effective solutions.
The issues often relate to diagnostics, and senior clinical decision-makers being less available than they are from Monday to Friday. Providing extra doctors is likely to be extremely expensive, and might not have the effect the government wants.
Nuffield Trust healthcare think tank chief executive Nigel Edwards recently pointed out that, while there is evidence consultants matter, one study has shown weekend mortality for patients who have had a stroke is linked to the number of registered nurses per bed, not the frequency of senior doctors’ ward rounds.
Work by Healthcare Financial Management Associates has suggested moving to improved seven-day services could cost trusts 1.5-2% of their incomes.
Mr Nolan sees highly trained specialist nurses and midwives as a key part of any solution, and argues the issue is about using the staff member with the right skills at the right time. That right staff member could be a doctor, but it could also be a nurse providing care at an earlier stage, preventing the need for medical intervention.
London South Bank University professor of healthcare and workforce modelling Alison Leary says: ‘Sadly, the value of specialist nurses is still debated, despite the evidence that they are value for money and worth the investment. They are still seen as “nice to have”, not as “need to have”.’
The service, which is based at Homerton University Hospital NHS Foundation Trust in London, was pioneered by nurse consultant and former Nursing Standard nurse of the year Matthew Hodson (pictured).
It ensures patients whose condition deteriorates have a round-the-clock point of contact. Patients who might be struggling for breath can be assessed in their homes by the respiratory team, preventing unnecessary hospital admissions. The team can also co-ordinate with other services, such as ambulance and out-of-hours services, and if a patient calls overnight, they can be offered telephone advice.
Patients could be told to take medications stored at home for exacerbations of COPD, or they could be visited by a rapid response team that can put a package of care in place and arrange for equipment to be provided.
If patients do have to go to hospital, the respiratory team will be involved in their care and treatment decisions. If they have to stay overnight, a team member will see them first thing in the morning.
The service is staffed by physiotherapists and nurses, three of whom are usually on duty at weekends. If there is high demand (winter and hot spells tend to exacerbate COPD), more staff will be on duty.
Nurse Edmer Sayat says the team’s involvement means patients who are admitted to hospital can be discharged more quickly, and helping patients to remain at home after discharge has led to a fall in hospital re-admission rates.
Physiotherapist Laura Graham, who is part of the team, adds: ‘It is great for patients. They remain at home and yet always have a lifeline. Sometimes they just want a friendly voice at the end of the phone to reassure them that their symptoms are normal.’
Some patients do need the input of the medical team in A&E, but increasingly those patients who are being brought to hospital are really unwell. This means doctors are freed up to see the patients who need their input.
Professor Leary argues that this is not about role substitution, but about what specialist nurses can bring to care, particularly the care of those with long-term conditions. By intervening before a patient is at crisis point or coping with deterioration, advanced practice nurses can keep people out of hospital and help provide care closer to home, or even at home. A specialist nurse could assess patients in a district general hospital, for example, and decide whether or not they need to go to a regional centre and see a consultant.
‘There are many instances where nurses and midwives are already providing this senior decision-making input across seven days,’ says Mr Nolan. Examples include midwives making decisions during childbirth, respiratory nurses dealing with patients whose conditions have deteriorated, and mental health nurses who will often be the first point of contact for patients in crisis.
Mr Nolan says these services are safe and affordable, with good clinical outcomes and the ability to distinguish between what is urgent and what is an emergency. They are not universal, but by building on the good examples that already exist, they could be extended to provide a more comprehensive service.
‘But how do you make sure these successful models are invested in to make them first regional and then national?’ he asks.
Part of the answer may be telephone or telehealth consultations. Ambulance services are increasingly interested in having senior nurses, either as part of the ambulance crews – as happens in Sweden – or helping with calls. This is another part of a trend for ambulance services to ‘see and treat’ where possible, rather than simply conveying patients to hospital.
Mr Nolan says there are encouraging signs that thinking is now shifting away from the place of care to who is best able to provide care, with some vanguard sites – high-performing trusts chosen by NHS England to share their expertise with other hospitals in their region – beginning to take this approach.
The acute shortage of doctors in some specialties, coupled with the high cost of using doctors for tasks that could just as well be undertaken by other staff, would make advanced practice nursing roles especially valuable. But any large-scale spread of these models must be based on the confidence that nurses will have the skills and competencies to take on the more advanced work.
Steps have already been taken to ensure that competencies for some tasks are standardised across professions, and some of the medical royal colleges may be willing to accept nurses playing a greater role in sustaining services. The workforce planning officer of the Royal College of Paediatrics and Child Health, for example, recently suggested that advanced nurse practitioners could perform a greater part in providing services where doctors’ rotas were hard to fill.
Professor Leary points out that there has been little succession planning for specialist nurses – many of whom might effectively be working single-handed – and also that this is an ageing workforce. The RCN has found that the number of band 7 and 8 nurses has fallen recently, which could be due to posts being abolished or downgraded. Investment in training will be needed if specialist nurses are to play a larger part in improved seven-day services.
In midwifery, there has been a growth in the number of trusts offering midwife-led births, often in a unit alongside consultant-led maternity. Jessica Read, the local supervising authority midwifery officer in London, says this means doctors can concentrate on births where their particular expertise is needed, while low-risk women can have the option of a midwife-led birth that is likely to involve less intervention. Every trust in London, bar one, now has at least one midwife-led service.
New guidance in London has helped. ‘The idea is to make sure all women eligible to receive midwife-led care are able to access it,’ says Ms Read. This can relieve pressure on doctor-led services, as well as benefiting women and babies, and may make it easier to provide appropriate levels of consultant cover over seven days.
But in some parts of the country, these roles are being taken on by advanced nurse practitioners (ANPs). Mark Clement is part of the children’s acute transport service hosted by Great Ormond Street Hospital in London. The service transfers children across north London and East Anglia to Great Ormond Street and other London hospitals, as well as Addenbrooke’s Hospital in Cambridge.
As an ANP, Mr Clement sometimes leads the team, offering telephone advice to hospitals with sick children. If necessary, he travels to the hospital to stabilise the child and transport them by land or air ambulance to a paediatric intensive care unit.
‘Our philosophy is to get intensive care at the point of contact,’ says Mr Clement. ‘We are mimicking intensive care management, rather than just acting as a transport service, and it can be very emotional. Sometimes, the outcome is not as you would like. But at the time, your focus is on giving that chance to the child.’
The competencies to lead the team and provide care have been mapped, and they can be covered by doctors and ANPs who have undergone the appropriate education and training. Mr Clement says he has not encountered any resistance to a nurse leading the team, and that nurses add stability to a team as they are likely to stay longer than a doctor who may rotate to another role after six months. ‘We are good at forming relationships and working in teams, and managing children and parents,’ he says.
‘Most professionals have recognised this is a positive thing. It is not a threat. There are problems with filling medical positions and this is one way of plugging the gap. It is also a fantastic opportunity for nurses.’
‘This is about the sensible deployment of all of the workforce, and about liberating people,’ says Mr Nolan. ‘There are new opportunities for nurses and midwives’.