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Celebrating 30 years of Primary Health Care

Looking back at the stories Primary Health Care has covered on its 30th anniversary, recurring themes appear along with nurses quietly working in innovative ways to make a difference to the lives of individuals and communities against a shifting backdrop of policy initiatives
Picture of Nahla Walker (centre), with nurses Helen Drury (left) and Joanne Leivesley. When Nahla, aged six, told them she wanted to be a nurse, they ordered a special outfit for her with the name badge ‘Nurse in training’.

Looking back at the stories Primary Health Care has covered on its 30th anniversary, recurring themes appear along with nurses quietly working in innovative ways to make a difference to the lives of individuals and communities against a shifting backdrop of policy initiatives

  • Then and now: we warned of community nursing in turmoil, but is there more optimism today?
  • Recurring themes: safety of community nurses and sterling work of school nurses and health visitors
  • False dawns: shift in care from hospital to home heralded 25 years ago remains incomplete
  • Looking ahead: rising workload in general practice is not matched by workforce growth

In 1990, Kenneth Clarke was

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Looking back at the stories Primary Health Care has covered on its 30th anniversary, recurring themes appear along with nurses quietly working in innovative ways to make a difference to the lives of individuals and communities against a shifting backdrop of policy initiatives

  • Then and now: we warned of community nursing in turmoil, but is there more optimism today?
  • Recurring themes: safety of community nurses and sterling work of school nurses and health visitors
  • False dawns: shift in care from hospital to home heralded 25 years ago remains incomplete
  • Looking ahead: rising workload in general practice is not matched by workforce growth
Picture of Nahla Walker (centre), with nurses Helen Drury (left) and Joanne Leivesley. When Nahla, aged six, told them she wanted to be a nurse, they ordered a special outfit for her with the name badge ‘Nurse in training’.
When Nahla Walker, six, said she wanted to be a nurse, Helen Drury (left) and Joanne
Leivesley ordered a special outfit for her with the name badge ‘Nurse in training’

In 1990, Kenneth Clarke was health secretary in a Conservative government, nurse prescribing was in its infancy and the first issue of a new-look, relaunched Primary Health Care was rolling off the presses.

The editor then and now, Julie Sylvester, warned in that first issue that community nursing services of the day were in turmoil, with government reforms giving rise to a ‘whole set of new problems for district nurses (DNs) and that rapidly growing sector – practice nurses’.

Some might say that government reforms have continued to cause turmoil ever since, but other aspects of 1990s-style nursing and healthcare may be less familiar to today’s nurses.

Primary Health Care editor Julie Sylvester. On the journal’s 30th anniversary Daniel Allen reports on a browse through back issues.
Julie Sylvester

Project 2000, for example, was big news at the time and heralded the wholesale shift of nurse training out of hospitals and into universities. This revolutionary development, which was to change the face of nursing, was finding its feet in 1990 having been agreed by the profession’s regulatory body four years earlier.

Some felt having a GP as employer increased the danger of ‘handmaiden syndrome’

Change was definitely in the air back then, with discussions also under way about the possibility of some DNs being employed directly by GPs.

Lynn Young, then a community nursing adviser at the RCN, said DNs could not agree whether having a GP as an employer was a good idea or a bad one. Some felt it would increase the danger of ‘handmaiden syndrome’, Ms Young wrote, adding briskly: ‘My response to this is that those DNs who wish to behave as handmaidens will probably do so whoever employs them.’

The following year, staff shortages, a problem that seems to have plagued nursing for decades, was in the spotlight.

Health minister Virginia Bottomley launched a plan to attract ‘mature’ nurses back into the profession. Alongside a Come Back to Caring campaign, Ms Bottomley announced a learning package designed to attract health visitors to return.A past cover of Primary Health Care, which is marking its 30th anniversary.

Initiative sought to increase the number of women in senior NHS roles

Developed in association with the Health Visitors’ Association, the scheme was part of a wider Department of Health initiative called Women in the National Health Service, which also sought to increase the number of women in senior NHS roles.

In 1994, the journal was taken to task by the chair of the Yorkshire Practice Nurse Association, Karen Gupta, for an ‘unpleasantly titled little news item’ in an earlier issue.

The article in question had reported on the first national census of practice nursing and was headed ‘PNs “unqualified for” job’.

‘The future is primary care’

‘We all know that training is inadequate and ad hoc, but PNs have displayed far greater enthusiasm for post-registration training than almost any other group of nurses,’ Ms Gupta wrote.

An ‘editor’s response’ included beneath her letter said the offending news article did not reflect the journal’s views ‘but was included to show the findings expressed in the census report’.

Today’s emphasis on, and investment in, primary care is a measure of the importance the government attaches to it. But an editorial from 1995 suggests we have been here before and that nurses working in the sector would be wise to wait to see whether real change results. Public Health Alliance project manager Maggie Winters, writing 25 years ago, stated boldly: ‘The future is primary care.’A past cover of Primary Health Care, which is marking its 30th anniversary.

She said the mid-1990s emphasis on needs assessment, community care and health promotion ‘points to a change in focus from hospital-based health services to a primary care-led NHS’.

It sounded as though a new dawn was breaking for primary care, but the shift in care from hospital to home does not, even now, appear complete.

Nurses can play a part in helping young people prepare for life after school

The valuable contribution school nurses can make, when resources allow, to the health and well-being of young people has featured regularly in the journal.

An article from 1998 describes an initiative in a Lincolnshire boys’ school that helped pupils prepare for university. A course was devised offering sessions on topics such as avoiding debt, drugs awareness and, with input from the Red Cross, dealing with potentially life-threatening situations such as epilepsy and alcohol poisoning.

School nurses contributed to the course with sessions on safe sex, healthy lifestyle and healthy eating on a low budget.

A past cover of Primary Health Care, which is marking its 30th anniversary.The course went down well among pupils and, said the authors, showed how nurses can play a part in helping young people prepare for life after school.

Looking back through archive copies of Primary Health Care, it is clear that ‘reform’ has been a constant theme. Politicians love to tinker and over the past 30 years the way primary care services are organised and delivered has always been subject to someone’s idea of improvement, some more successful than others.

Under the 1997 NHS (Primary Care) Act, pilot schemes were set up to test different models for providing personal medical services, with nurses leading some of them.

Patients’ perceptions of a nurse-led general practice

Two years after the act was passed, research associates Alison Chapple and Wendy MacDonald, from the National Primary Care Research and Development Centre at Manchester University, described their study of patients’ perceptions of a nurse-led general practice in Salford.

The research found that patients were hazy about the reasons why a nurse was leading their general practice and about the government policy that had given rise to the pilot sites. But, said the researchers, almost all of those interviewed spoke ‘enthusiastically and positively’ about the care they had received since the nurse took over running of the practice.

‘As more parts of the country, particularly deprived areas, experience a shortage of GPs, it is likely there will be other opportunities for nurses to lead family practices,’ the article concluded.

A new decade and a new millennium, and in March 2000 what lay ahead for practice nurses was being explored in Primary Health Care.

Picture shows a nurse talking to an older couple. On Primary Health Care’s 30th anniversary Daniel Allen reports on a browse through back issues.
Picture: iStock

Rheumatology nurse practitioner Kym Kibble, who worked in hospital and community clinics, noted the ‘haphazard’ training opportunities for nurses in general practice. She argued that as a result, wide variations existed in the practice nurse’s role, which could compromise patient care.

Nurses are professionally and legally accountable for the care they give, she said. But declining to undertake tasks they did not feel clinically competent to perform could cause conflict if the nurse’s role was perceived differently by a GP employer.

Picture of a pub where men can have health checks. On Primary Health Care’s 30th anniversary, Daniel Allen reports on a browse through back issues.Practice nurses were therefore in a challenging position, Ms Kibble argued. But, she concluded, responding to patient need in an innovative and professional way ‘is surely a development worth aspiring to’.

RCN policy adviser and Primary Health Care associate editor Mark Jones took up the theme of the scope of practice in a column later that year. ‘The trick is to push your practice as far as you can without breaking the law or totally ignoring your job description,’ he wrote. But balancing those dynamics could be ‘pretty hard’, he acknowledged.

Obesity has featured more, smoking cessation has fallen away

Some of the many clinical issues explored throughout the journal’s history have often reappeared as new treatments or approaches have been developed. Among the recurring topics are pressure ulcers, continence and sexual health, reflecting perhaps the frequency with which they crop up in primary and community nursing practice.

Obesity has featured more, while smoking cessation appears to have fallen away since the four UK countries began introducing workplace bans from 2006.

Men’s health has also featured often, including an article in 2004 which reported on a new scheme in Bradford where men could order ‘a packet of crisps, a pint and a health check’ in local pubs. Men’s health coordinator Phil Arnold explained that the tests included blood pressure, weight, body mass index, blood sugar and cholesterol levels.

The safety and security of community nurses has also received due prominence at different times over the past 30 years.

In 2009, then health secretary Alan Johnson was praised by the Community and District Nurses Association (CDNA) for his decision to issue 30,000 personal alarms to NHS staff who worked alone. ‘There is a duty to care for the nurses who care for all of us,’ the CDNA said.

Involving patients in the delivery of care

The past three decades have seen a growing awareness of the importance of involving patients in the delivery of care. But in 2010 an article cautioned nurses against seeking patient involvement in developing their general practice without considerable preparation.

Andrew Craig, a partner in a ‘user involvement consultancy’, urged practice nurses to begin by ensuring colleagues were on board with any proposed shift towards giving patients a stronger voice.

‘Patient participation is not sustainable on the enthusiasm of one person,’ he said. ‘No matter how keen, a sole enthusiast faces isolation and burnout without wider awareness and peer support.’

But the potential benefits made perseverance worthwhile, he argued. ‘Successful user participation is a lot like cultivating pearls. The NHS oyster needs a bit of grit to produce anything: no user grit, no pearls for the practice.’

A past cover of Primary Health Care, which is marking its 30th anniversary.Mixed legacy of policy initiatives

Policy initiatives churned out over the past 30 years by successive governments have produced a mixed legacy. GP fundholding came and went, as did primary care trusts. White papers outlined visions and promised much; quangos, inspectorates and government bodies were born, died or turned into something else. And no one sorted out social care.

But against that shifting backdrop, nursing staff all over the UK have quietly continued to work in innovative ways to make a difference to the lives of individuals and communities.

A 2012 article described how nurses were partnering with lay health trainers to address persistent public health challenges in disadvantaged communities. Health trainers originated in a 2004 white paper, Choosing Health, and were intended to offer ‘support from next door’ rather than ‘advice from on high’.

A radical ‘neighbourhood care’ model

Judy White and Jane South, respectively a senior lecturer and professor from Leeds Metropolitan University, described how, under the direction of nurses, health trainers could increase the support available to people living with long-term conditions. Walking groups, fitness sessions, befriending groups and cooking sessions all evolved out of the scheme, to the benefit of participants.

‘Managing a lay workforce presents challenges but this is an effective service for clients who struggle to change without support,’ the authors concluded.

While primary and community nursing have gone through many changes in 30 years, none has been as radical as a model developed in the Netherlands that featured in Primary Health Care in 2014.

Picture shows a district nurse calling on a patient. On Primary Health Care’s 30th anniversary Daniel Allen reports on a browse through back issues.
Picture: Neil O’Connor

The Buurtzorg or ‘neighbourhood care’ model was developed by district nurse Jos de Blok in response to a system that had become overly bureaucratic and fragmented. His solution? To introduce a flat organisational structure without hierarchies.

Instead, managerless community nurses, working in teams of 12 and supported by a network of carers, volunteers and social workers, plus an innovative IT system, coordinated their own schedules and workloads.

‘When you focus on patients’ needs it leads to better outcomes and nurses feel satisfied’

Mr de Blok said: ‘When you have management, you focus on managerial goals without focusing on patients’ needs. When you focus on patients’ needs it leads to better outcomes and nurses feel satisfied because they are getting the best out of what they are doing.’

In 2018 the journal’s long-serving associate editor, Sue Thomas, issued a call for nurses to act on innovative approaches to type 2 diabetes, urging readers to ensure patients are aware of the evidence base and understand the implications of developing the disease from a health outcome and economic value perspective.

As Primary Health Care moves into its fourth decade, how does the future look for nurses in primary and community healthcare settings?

Reasons to feel optimistic about nursing in the community

Towards the end of last year the journal reported that despite recent dire predictions and many challenges there were reasons to feel optimistic about nursing in the community. The number of district nurses with a specialist practitioner qualification was rising; and a new International Community Nursing Observatory planned to build an evidence base to demonstrate the case for district nursing.

Picture of Primary Health Care associate editor Sue Thomas. On the journal’s 30th anniversary Daniel Allen reports on a browse through back issues.
Sue Thomas

With regard to practice nursing, however, there was disquiet. A growing workload in general practice was not being matched by a growing workforce, experts told the journal.

And while media attention had focused on GPs and the struggles they faced, the demands on practice nurses were being ignored. ‘There’s a lack of understanding of our role, the training we have done or how we can work independently,’ one practice nurse said.

Community and practice nursing clearly need all the new recruits they can get – and they are never too young. The last issue of Primary Health Care for 2019 reported on six-year-old Nahla Walker who, because of scarring on her lungs and treatment via a port-a-cath device, has had plenty of contact with community nursing.

When Nahla told nurses Joanne Leivesley and Helen Drury she too wanted to be a nurse, they ordered a special outfit so she could dress like them. It came with a name badge that said ‘Nurse in training’.


Daniel Allen is a health writer

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