At the vanguard of partnership working

The concluding part of our series on vanguards looks at how integrating services is prompting nurses to develop and extend their roles. If the NHS is to cope with rising demand and limited resources, staff in different sectors will have to work in partnership across traditional boundaries.

Vanguards are trying to build closer working between acute hospitals, primary care and community services. If they succeed, not only will it be better for patients, it will create new ways of working and extended roles for NHS staff.

So how are nurses in vanguard areas faring? The first vanguard sites were selected one year ago (March 2015) with the aim of developing and implementing the ideas set out in the Five Year Forward View, NHS chief executive Simon Stevens’ blueprint for the NHS. Some nurses in vanguards are already working in different ways or have been involved in devising and extending improved services.

Picture credit: Getty Images

In Dudley, community nurses are working more closely with colleagues from social care, mental health services, allied health professions and the voluntary sector to provide person-centred care. ‘It has made my job much easier – it brings us all together,’ says Janet Beddows, cluster lead nurse for one of the five areas served by Dudley clinical commissioning group. ‘We have identified a lot of people where the main issue is social isolation and have prevented them going into the emergency department. Voluntary sector workers are getting them out to clubs, or people are coming round to talk with them.’

She believes that face-to-face contact between those working for the different services has helped. ‘It is our team without walls,’ says Ms Beddows. All members of the team understand what other services are available to help support patients – which was not always the case in the past – and can help the patient gain access to them.

The Better Care Together project, in parts of Lancashire and Cumbria, has staff in an integrated rapid response team looking at how to introduce a ‘discharge to assess’ model. This has been pioneered in a number of places, including Sheffield Teaching Hospitals NHS Foundation Trust. It allows assessment of patients’ ability to cope in their normal surroundings, rather than the artificial environment of hospital.

Rachel Gibson, acting team leader of the integrated rapid response scheme in the South Lakes area of Cumbria, says its plans could result in better integrated care and working between different sectors. ‘It is about what would be best for our diverse population,’ she says. ‘It is about recognising people’s strengths and weaknesses.’

Ms Gibson says the vanguard should help pull together the many good services in the area. This will require working with different providers and local authorities – and she is mindful that ‘if an action does not happen, the rest will fall down like a pack of cards.’

Vanguards are testing the possibility that staff in different professions can take on elements of each other’s work. In Northumbria, vanguard status almost coincided with the opening of a specialist emergency hospital, relieving the area’s relatively small hospitals of emergency cases. Nurse practitioners at Hexham hospital already had acute assessment skills, and were able to prescribe. Now, at a time when junior doctors are hard to recruit, they are using these skills to take on a bigger role in looking after patients overnight.

More nurse practitioners have been recruited to hospitals at Wansbeck and North Tyneside because the opening of the new emergency care hospital has meant there are no junior doctors on the surgical wards on these sites. Nurse practitioners will do pre-op work ups and aftercare, and they have been trained in advanced lifesaving skills so they can deal with cardiac arrests.

Northumbria Healthcare NHS Foundation Trust vanguard programme manager Andrea Stoker says the trust recruited both externally and internally for these nurse practitioner posts while offering extensive training. ‘They had a depth of knowledge and experience. We gave them an opportunity to embed these,’ she says.

In the Wirral, vanguard funding is helping to reshape services in a sustainable way (see box) by encouraging people to seek urgent care at the right point and directing them to emergency department alternatives. The vanguard money effectively pump-primes this development, along with other changes that are still hard to fund from normal budgets.

A new twist on triage Picture credit: Alamy

Patients turning up to the emergency department at Arrowe Park Hospital in the Wirral will be greeted at reception by two nurses – one from the emergency department and one from the community trust.

They are there to make an immediate decision on where that patient is best treated. In the first few weeks since the joint approach was introduced in December as part of the Healthy Wirral vanguard, 15% of ‘self presenters’ to the emergency department were diverted to the walk-in centre, and 35% sent into the minor injuries stream. This freed up triage nurses further down the line to focus on more complex cases.

A second phase of the project will extend the hours that community nurses are in the emergency department and allow the front door practitioners to do some interventions. It will shape the emergency environment to guide people to the right service, says Wirral Community NHS Trust director of integration and partnerships Val McGee. The practitioners will also start to see children as well as adults. Emergency department matron Helen Morris adds that there is an element of patient education, as many were unaware of the alternatives available locally. ‘It has been good for us internally – it helps us to see people with higher acuity more quickly.’

The chance to work alongside colleagues from the other organisation also enables nurses to share learning ‘A&E nurses did not realise what services were out in the community, and community nurses did not always realise what services we had in house,’ says Ms Morris. ‘It has given us the opportunity to work with the community trust in a closer partnership… and helped us get the right people round the table.’

The hope is that other areas will be able to learn from these models and adopt or adapt them to meet their own challenges. If so, the vanguards will have reshaped the NHS across England – and helped nurses provide better care to many vulnerable patients.

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