Art & science service development
Developing a community multiple sclerosis nursing service Quinn D, Adams J (2014) Developing a community multiple sclerosis nursing service. Nursing Standard. 28, 37, 46-50. Date of submission: September 10 2013; date of acceptance: October 31 2013.
Abstract Reforms to the NHS following the passing of the Health and Social Care Act 2012 have created new purchaser organisations with responsibility for planning the configuration of healthcare services in their geographic areas. If a community multiple sclerosis (MS) nursing service is to survive in this environment, it must demonstrate its ability to contribute to achieving the purchaser organisations’ objectives. Evaluation data, such as hospital admission avoidance and patient satisfaction, will be crucial in demonstrating the community MS nursing service’s clinical and economic effectiveness. A strengths, weaknesses, opportunities and threats (SWOT) analysis of the issues facing a community MS service in this environment is provided.
Authors Debbie Quinn, Queen’s Nurse Multiple sclerosis specialist nurse, Northamptonshire Healthcare NHS Foundation Trust, Wellingborough, and nurse adviser, Multiple Sclerosis Trust. John Adams Temporary lecturer, Anglia Ruskin University, Peterborough. Correspondence to: [email protected]
Keywords Community nursing, multiple sclerosis, multiple sclerosis nursing service, specialist nurse
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
MULTIPLE SCLEROSIS (MS) is a disease of the central nervous system in which white matter in the brain and spinal cord becomes inflamed and then scarred. The cause is unknown, but it is believed to involve interaction between genetic and environmental factors. MS usually presents in the early adult years and is more common in women than men (National Institute for Health and Care Excellence 2003). For most people with MS, the disease runs a relapsing and remitting course and around 15% of individuals are diagnosed with progressive MS (MS Trust 2013a). The prevalence of MS in England and Wales is approximately 100-140 cases per 100,000 people, with higher rates in Northern Ireland and Scotland (MS Trust 2013a). It is estimated that around 100,000 people with MS are living in the UK (MS Society 2014a). MS is an important issue in Northamptonshire because it is the most common disabling condition in young adults, and local GP caseloads are higher than the national average (Northamptonshire Primary Care Trust 2010). MS is an unpredictable and variable disease that affects each person differently. Common symptoms include visual disturbances, neuropathic pain, fatigue, spasms, depression and cognitive impairment. Many people with MS do not experience symptoms severe enough to stop them working, however studies have estimated that 80% of people with the disease are likely to be unemployed within 15 years of diagnosis (MS Trust 2012). Self-management of MS is crucial to enable individuals to cope with this lifelong condition.
Background Many nurses entered the nursing profession at a time when the NHS was a monolithic organisation in which service provision was determined centrally and in which services, and therefore employment opportunities, could be unchanged for long periods of time. There was little opportunity or incentive for nurse managers to respond to changing patient needs by creating services based on new nursing roles (Leech et al 2011). Therefore, the introduction
46 may 14 :: vol 28 no 37 :: 2014
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of market-driven reforms that encouraged competition between ‘provider’ organisations represented a major cultural shift (Maynard 2005, Leech and Matthews 2008). ‘Purchaser’ organisations increasingly used their new power to demand service configurations, with an emphasis on patient-centred care in the community. Specialist nursing roles have been developing internationally since the 1960s, and this cultural change in the NHS provided the opportunity for their development in a wide range of specialties in the UK (McDonald 2012, Pattenden and Ismail 2012, Whayman et al 2012). It was recognised that specialist nursing support could have an important role in helping people with MS, and since 1999 the MS Society (2014b) has spent nearly £6 million on specialist nurses. There are an estimated 250 MS specialist nurses in the UK (MS Trust 2013b). Research has consistently shown that the service offered by MS specialist nurses has been regarded positively by patients (Somerset et al 2001, Forbes et al 2007). The high level of support afforded to patients with MS has had an effect on the purchasing decisions of primary care trusts (PCTs). The funding of MS specialist nurse posts is also attractive to purchasers because of the scope for avoiding unnecessary hospital admissions. GPs and emergency department staff may have limited knowledge of the optimum management of MS symptoms or relapses, and so admission to an acute hospital may be considered the most appropriate decision (Quinn 2011). While the rationale for establishing and continuing to fund MS specialist nurse posts may appear clear, the reality is more complex and demands an entrepreneurial approach to renegotiating service developments. The local PCT in Northamptonshire, Rockingham Forest Trust, made a successful bid to the joint Department of Health (DH) and MS Society scheme in 2004 to fund a community-based MS specialist nurse. When that funding ended in 2007, the PCT took over the funding because the service developed to include one MS specialist nurse (0.6 whole time equivalent (WTE)) and a support nurse (0.4 WTE). In September 2009, the MS nursing service in Northamptonshire established a pilot care pathway with the local district general hospital and the GP out-of-hours service. This pilot aimed to reduce unplanned admissions through the emergency department and GP out-of-hours service by using an MS care pathway to ensure that people with the disease could receive treatment at home with additional support from MS specialist nurses. This service reconfiguration received strong support from service users, including a local representative of the MS Society.
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Service user input was crucial in ensuring that patients’ voices were heard, and it was a constant feature of the development of the community MS service. The MS care pathway was negotiated and developed with the emergency department and the local GP Pathfinder site to assist clinicians with their care of people with MS. It involved purchasing an extra seven hours of Band 6 nursing time, as agreed with the PCT. At the end of the pilot, which was conducted between September 2009 and February 2010, eight admissions had been avoided at the district general hospital and 28 potential admissions had been avoided by liaising with GPs in the community. This amounted to an estimated financial saving of around £75,000 based on the cost of treatment in the community versus a hospital stay of three days (Quinn 2011). The MS pathway was continued through local internal funding, and by March 2013 it had prevented a further 144 admissions by GPs and ten emergency department admissions. This equated to an estimated financial saving of around £300,000 based on the cost of treatment in the community versus a hospital stay of three days (unpublished data). These savings convinced the PCT to continue funding the extra nursing hours. This successful arrangement looked set to continue, but the NHS in England had been transformed in 2010 with the publication of the white paper Equity and Excellence: Liberating the NHS (DH 2010). It became clear the survival of a community MS nursing service would depend on adapting to the new organisational arrangements.
Health and Social Care Act 2012 Equity and Excellence: Liberating the NHS (DH 2010) provoked consternation throughout the NHS (Timmins 2012). Central to the Secretary of State for Health Andrew Lansley’s vision for the NHS was the abolition of PCTs and their replacement by clinical commissioning groups (CCGs), which would purchase health services on behalf of all GP practices in their area. Publication of the white paper was followed by 14 months of political dispute before the Health and Social Care Act became law in 2012 (Timmins 2012, Howieson 2013). Under the new system, CCGs are required to appoint nurses, and secondary care and lay representatives to the commissioning board, but this does not alter the reality that GPs now have a major influence on local purchasing decisions. The services they commission include planned hospital care, urgent and emergency care, rehabilitative care, and most community health, maternity, may 14 :: vol 28 no 37 :: 2014 47
Nursing Standard 2014.28:46-50. Downloaded from journals.rcni.com by University of British Columbia on 11/23/15. For personal use only.
Art & science service development mental health and learning disability services. The Health and Social Care Act 2012 also seeks to overcome the long-standing divisions between health and social care by requiring CCGs and local authorities to agree on commissioning priorities to meet local needs. Services more appropriately commissioned at the national level have become the responsibility of a new body, NHS England. In addition, NHS England is responsible for ensuring that the whole system works effectively (DH 2013). CCG boards have the primary responsibility for monitoring the safety and quality of services they have commissioned, while the Care Quality Commission monitors all health and social care provision on a national basis. Another organisation, Monitor, regulates NHS Foundation trusts to ensure that ‘health care services are provided effectively, efficiently and economically, while the quality of services is maintained or improved’ (DH 2013). Although PCTs were not formally abolished until March 31 2013, CCGs began to take shape in the preceding year when their organisational structures were established, their priorities were reviewed and preliminary negotiations with service providers were commenced. When the new arrangements began to emerge, it became clear that Northamptonshire would be served by two healthcare commissioning organisations: Nene CCG (2013) and Corby CCG (2014).
Community multiple sclerosis nursing service Before the Health and Social Care Act 2012 had come into force, a study of NHS organisations in England had found evidence of the effects of increased competition (Leech et al 2011). Examples included the appointment of marketing managers and commercial directors; an increasing focus on external communication and engagement with the main commissioners and stakeholders, for example PCTs and service-user groups, that most influence them; the development of ‘market share’ analysis as routine board reports, and a greater focus on understanding what neighbouring organisations (competitors) were doing (Leech et al 2011). In Northamptonshire it was realised that if the local community MS nursing service was to survive in the new environment, it must be seen to connect with the market-oriented agenda for health. The first requirement was to ensure that the community MS nursing service was aligned with the Northamptonshire Healthcare NHS Foundation Trust’s objectives to embed the service within the new NHS, and assisting the trust to meet vital objectives enabled this to occur. The 48 may 14 :: vol 28 no 37 :: 2014
four relevant objectives were (Northamptonshire Healthcare NHS Foundation Trust 2012): To be a patient-oriented organisation that treats people with compassion, values diversity, prevents ill health and personalises care to the needs of patients and carers. The goal is to be in the top 20% of NHS providers in terms of patient ratings. To provide services that are safe, oriented around evidence-based practice, delivered by empowered clinicians and that offer continuously improving service standards. The goal is to be in the top 20% of NHS providers for clinical and quality outcomes and performance against national targets. To provide services in modern, safe and clean environments that are accessible to the communities and populations they serve, designed around patient needs and ecologically sustainable. The goal is for buildings and facilities to be in the top 20% of NHS providers for environmental sustainability and efficiency. To provide an increasingly comprehensive, complementary and integrated range of services within Northamptonshire and surrounding counties. This includes primary and community services, local hospital services and specialist tertiary services. Based on these objectives, the community MS nursing service needed to focus on meeting the needs of its main purchasers, and examination of relevant policy statements was essential. One example that was examined was the Commissioning Intentions for Long Term Conditions document produced by Nene CCG (2013), one of the local purchasing organisations. It stressed the need for organisations to work with the local population to improve services, and specified objectives for health care in the locality (Nene CCG 2013). A strengths, weaknesses, opportunities and threats (SWOT) analysis provides a readily adaptable framework to assist an organisation in meeting the challenges of developing a service.
Strengths
Nene CCG (2013) highlighted the development of evaluation tools to assess the performance of integrated care for patients with long-term conditions, with the aim of achieving a 20% reduction in emergency admissions. This is one of the strengths of the community MS nursing service because admission avoidance is one of its demonstrated outcomes. This needs to continue to be a focus, with data available to demonstrate effectiveness of the service. Another strength of the service is the high level of patient satisfaction demonstrated by patient evaluations. Local
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Nursing Standard 2014.28:46-50. Downloaded from journals.rcni.com by University of British Columbia on 11/23/15. For personal use only.
evaluations confirmed the positive findings of national studies (Somerset et al 2001, Corry et al 2011). Since CCGs are required to commission services that meet the needs of patients and provide high quality care, the collection and publication of evaluation data must be regarded as important for the service. In addition, the important role that GPs now have in commissioning services means their feedback is crucial. An initial small-scale survey of local GPs, which is awaiting publication, indicated a positive response to the service (Table 1).
Weaknesses
In contemporary health care, groups representing patients with particular conditions need to use the resources of media and political campaigns to ensure that their concerns are heard and their needs are met. Priority setting has helped to focus effort in the NHS, but a concentration on some aspects of care removes the spotlight from others, because not every patient group can have equal priority. While targeting patients with long-term conditions such as coronary heart disease, stroke and diabetes has resulted in major improvements in care provision, the relative neglect of neurological conditions in national and local policy documents (Quinn 2011) may affect the priority they receive in the medium and long term. Another long-term issue is the need for organisational and educational support for the MS specialist nurse role. In the absence of succession planning, nurses will not be encouraged to make the care of people with MS their career focus.
Opportunities
Collaborative working with colleagues in secondary care should ensure that people with MS receive appropriate care tailored to their needs, so that those who could be managed in the community avoid unnecessary hospital admissions (Burgess 2011). In addition, there are potential opportunities to improve liaison with nursing colleagues in the local care home sector. Enhanced working with the two CCGs that serve Northamptonshire holds promise for extending the current community MS nursing service for the benefit of patient care.
Threats
If opportunities are not grasped, they could be transformed into threats to the existence of the community MS nursing service. Hospital-based neurology services are potential competitors who may wish to lobby the CCG to base all services for people with MS in secondary care. If national and local policy initiatives on long-term care do
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not give appropriate prominence to neurological conditions, service commissioners will tend to direct their resources elsewhere. In an environment of reduced resources for the NHS as a whole, such policy directives may have the unintended consequence of reducing the attention received by people with MS.
Discussion Changes in the NHS as a result of the passing of the Health and Social Care Act 2012 demand that nurses plan and act in new ways. A market
TABLE 1 Results of GP experience questionnaire (total respondents = 15) Question
Yes
No
Not applicable
No response
1. Overall, were you satisfied with the service you recently received from the community multiple sclerosis (MS) nursing service?
13
0
0
2
2. Were you satisfied with the speed of the service offered to you?
13
0
2
0
3. Were you satisfied with the availability of the service?
13
0
1
1
4. Did you find this an improved service from previous care pathways you used for patients with MS?
12
0
3
0
5. By using the MS specialist nurses in this way, did it ease your workload in any way?
13
0
2
0
6. Would you use the community MS nursing service again?
14
0
0
1
7. Would you miss this service if it was withdrawn?
14
0
0
1
8. Do you feel that this care pathway improved the outcome for the patient?
12
0
2
1
9. Did use of the care pathway result in fewer appointments with you and your colleagues at the surgery?
7
2
6
0
10. Are you sending fewer people with MS to acute services as a result of the community MS nursing service?
9
1
5
0
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Art & science service development economy in healthcare provision requires nurses to adopt many of the commercial approaches associated with private sector organisations. Since the future continuation of all services now depends on the willingness of CCGs to purchase them, much thought should be given to developing strategies to demonstrate that the CCGs’ requirements are being met. This calls for the production of evidence about patient and GP satisfaction with the service, regular updating to achieve adherence to international best practice and demonstration of value-for-money in the context of reduced resources. It is too early to provide definitive guidance on how these goals may best be achieved by nurses, but the need to make progress towards achieving them is urgent. The community MS nursing service is collecting and analysing data highlighting the benefits of pro-active case management and collaboration in reducing avoidable hospital admissions, for presentation to the CCGs to support the case for the service. Preliminary results show a significant decrease in avoidable
admissions and much shorter hospital stays for people with MS. Continued collaboration with GPs and secondary care is vital to ensure people with MS are offered a service that is provided by the right person at the right time. At a national level, pre and post-registration nurse education needs to reflect the realities of the new NHS environment and to provide all nurses with the skills necessary to work effectively in it.
Conclusion The creation of a fully developed healthcare market in England with clear purchaser and provider divisions between NHS organisations seems set to be a feature of health policy for the foreseeable future. Specialist nursing services, such as those for people with MS, must adapt rapidly to the new arrangements if they are to survive. They must demonstrate to local CCGs that they can provide a service that is cost-effective, accords with local and national policy directives, and meets the needs of service users NS
References Burgess M (2011) Improving relapse management in multiple sclerosis: a nurse-led model. British Journal of Neuroscience Nursing. 7, 1, 441-444. Corby Clinical Commissioning Group (2014) Corby’s Health Needs. It’s All About Quality of Life. tinyurl. com/kn5tgu7 (Last accessed: April 22 2014). Corry M, McKenna M, Duggan M (2011) The role of the clinical nurse specialist in MS: a literature review. British Journal of Nursing. 20, 2, 86-93. Department of Health (2010) Equity and Excellence: Liberating the NHS. The Stationery Office, London. Department of Health (2013) Guide to the Healthcare System in England. The Stationery Office, London. Forbes A, While A, Taylor M (2007) What people with multiple sclerosis perceive to be important to meeting their needs. Journal of Advanced Nursing. 58, 1, 11-22. Howieson W (2013) Mission command: a leadership philosophy
for the Health and Social Care Act 2012. International Journal of Clinical Leadership. 17, 4, 217-225.
At Work with MS. tinyurl.com/ kegj8e7 (Last accessed: April 22 2014.)
Leech D, Matthews J (2008) Nurse leaders and competition – are the blind leading the blind to market? Journal of Nursing Management. 16, 8, 898-899.
Multiple Sclerosis Trust (2013a) Prevalence and Incidence of Multiple Sclerosis. www.mstrust.org.uk/ atoz/prevalence_incidence.jsp (Last accessed: April 22 2014.)
Leech D, Willis R, Jones C (2011) Competition in a shrinking NHS market. British Journal of Healthcare Management. 17, 5, 198-200.
Multiple Sclerosis Trust (2013b) MS Specialist Nurses. www. mstrust.org.uk/atoz/ms_nurse.jsp (Last accessed: April 22 2014.)
Maynard A (2005) Competition in health care: what does it mean for nurse managers? Journal of Nursing Management. 13, 5, 403-410.
National Institute for Health and Care Excellence (2003) Multiple Sclerosis: Management of Multiple Sclerosis in Primary and Secondary Care. Clinical Guideline No. 8. NICE, London.
McDonald D (2012) Who is the clinical nurse specialist? Canadian Nurse. 108, 6, 22-25. Multiple Sclerosis Society (2014a) About MS. tinyurl.com/dx3cgfk (Last accessed: April 22 2014.) Multiple Sclerosis Society (2014b) What we do. www.mssociety.org. uk/about-us/what-we-do (Last accessed: April 22 2014.). Multiple Sclerosis Trust (2012)
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Nene Clinical Commissioning Group (2013) Commissioning Intentions for Long Term Conditions. tinyurl. com/kn8zyza (Last accessed: April 22 2014). Northamptonshire Healthcare NHS Foundation Trust (2012) Corporate Objectives. tinyurl.com/mg76kbg (Last accessed: April 22 2014.) Northamptonshire Primary Care Trust (2010) Business Plan
2011/2012. Northamptonshire PCT, Northampton. Pattenden J, Ismail H (2012) Setting up clinical nurse specialist services: what does our research tell us? British Journal of Cardiac Nursing. 7, 4, 184-186. Quinn D (2011) A collaborative care pathway to reduce multiple sclerosis admissions to secondary care. British Journal of Neuroscience Nursing. 7, 2, 497-499. Somerset M, Campbell R, Sharp D, Peters T (2001) What do people with MS want and expect from health-care services? Health Expectations. 4, 1, 29-37. Timmins N (2012) Never Again? The Story of the Health and Social Care Act 2012. The King’s Fund, London. Whayman K, Stansfield C, Duncan J, O’Connor M (2012) Developing the role of the clinical nurse specialist in inflammatory bowel disease. Gastrointestinal Nursing. 10, 8, 22-27.
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Developing a community multiple sclerosis nursing service Quinn D, Adams J (2014) Developing a community multiple sclerosis nursing service. Nursing Standard. 28, 37, 46-50. Date of submission: September 10 2013; date of acceptance: October 31 2013.
Abstract Reforms to the NHS following the passing of the Health and Social Care Act 2012 have created new purchaser organisations with responsibility for planning the configuration of healthcare services in their geographic areas. If a community multiple sclerosis (MS) nursing service is to survive in this environment, it must demonstrate its ability to contribute to achieving the purchaser organisations’ objectives. Evaluation data, such as hospital admission avoidance and patient satisfaction, will be crucial in demonstrating the community MS nursing service’s clinical and economic effectiveness. A strengths, weaknesses, opportunities and threats (SWOT) analysis of the issues facing a community MS service in this environment is provided.
Authors Debbie Quinn, Queen’s Nurse Multiple sclerosis specialist nurse, Northamptonshire Healthcare NHS Foundation Trust, Wellingborough, and nurse adviser, Multiple Sclerosis Trust. John Adams Temporary lecturer, Anglia Ruskin University, Peterborough. Correspondence to: [email protected]
Keywords Community nursing, multiple sclerosis, multiple sclerosis nursing service, specialist nurse
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
MULTIPLE SCLEROSIS (MS) is a disease of the central nervous system in which white matter in the brain and spinal cord becomes inflamed and then scarred. The cause is unknown, but it is believed to involve interaction between genetic and environmental factors. MS usually presents in the early adult years and is more common in women than men (National Institute for Health and Care Excellence 2003). For most people with MS, the disease runs a relapsing and remitting course and around 15% of individuals are diagnosed with progressive MS (MS Trust 2013a). The prevalence of MS in England and Wales is approximately 100-140 cases per 100,000 people, with higher rates in Northern Ireland and Scotland (MS Trust 2013a). It is estimated that around 100,000 people with MS are living in the UK (MS Society 2014a). MS is an important issue in Northamptonshire because it is the most common disabling condition in young adults, and local GP caseloads are higher than the national average (Northamptonshire Primary Care Trust 2010). MS is an unpredictable and variable disease that affects each person differently. Common symptoms include visual disturbances, neuropathic pain, fatigue, spasms, depression and cognitive impairment. Many people with MS do not experience symptoms severe enough to stop them working, however studies have estimated that 80% of people with the disease are likely to be unemployed within 15 years of diagnosis (MS Trust 2012). Self-management of MS is crucial to enable individuals to cope with this lifelong condition.
Background Many nurses entered the nursing profession at a time when the NHS was a monolithic organisation in which service provision was determined centrally and in which services, and therefore employment opportunities, could be unchanged for long periods of time. There was little opportunity or incentive for nurse managers to respond to changing patient needs by creating services based on new nursing roles (Leech et al 2011). Therefore, the introduction
46 may 14 :: vol 28 no 37 :: 2014
© NURSING STANDARD / RCN PUBLISHING
Nursing Standard 2014.28:46-50. Downloaded from journals.rcni.com by University of British Columbia on 11/23/15. For personal use only.
of market-driven reforms that encouraged competition between ‘provider’ organisations represented a major cultural shift (Maynard 2005, Leech and Matthews 2008). ‘Purchaser’ organisations increasingly used their new power to demand service configurations, with an emphasis on patient-centred care in the community. Specialist nursing roles have been developing internationally since the 1960s, and this cultural change in the NHS provided the opportunity for their development in a wide range of specialties in the UK (McDonald 2012, Pattenden and Ismail 2012, Whayman et al 2012). It was recognised that specialist nursing support could have an important role in helping people with MS, and since 1999 the MS Society (2014b) has spent nearly £6 million on specialist nurses. There are an estimated 250 MS specialist nurses in the UK (MS Trust 2013b). Research has consistently shown that the service offered by MS specialist nurses has been regarded positively by patients (Somerset et al 2001, Forbes et al 2007). The high level of support afforded to patients with MS has had an effect on the purchasing decisions of primary care trusts (PCTs). The funding of MS specialist nurse posts is also attractive to purchasers because of the scope for avoiding unnecessary hospital admissions. GPs and emergency department staff may have limited knowledge of the optimum management of MS symptoms or relapses, and so admission to an acute hospital may be considered the most appropriate decision (Quinn 2011). While the rationale for establishing and continuing to fund MS specialist nurse posts may appear clear, the reality is more complex and demands an entrepreneurial approach to renegotiating service developments. The local PCT in Northamptonshire, Rockingham Forest Trust, made a successful bid to the joint Department of Health (DH) and MS Society scheme in 2004 to fund a community-based MS specialist nurse. When that funding ended in 2007, the PCT took over the funding because the service developed to include one MS specialist nurse (0.6 whole time equivalent (WTE)) and a support nurse (0.4 WTE). In September 2009, the MS nursing service in Northamptonshire established a pilot care pathway with the local district general hospital and the GP out-of-hours service. This pilot aimed to reduce unplanned admissions through the emergency department and GP out-of-hours service by using an MS care pathway to ensure that people with the disease could receive treatment at home with additional support from MS specialist nurses. This service reconfiguration received strong support from service users, including a local representative of the MS Society.
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Service user input was crucial in ensuring that patients’ voices were heard, and it was a constant feature of the development of the community MS service. The MS care pathway was negotiated and developed with the emergency department and the local GP Pathfinder site to assist clinicians with their care of people with MS. It involved purchasing an extra seven hours of Band 6 nursing time, as agreed with the PCT. At the end of the pilot, which was conducted between September 2009 and February 2010, eight admissions had been avoided at the district general hospital and 28 potential admissions had been avoided by liaising with GPs in the community. This amounted to an estimated financial saving of around £75,000 based on the cost of treatment in the community versus a hospital stay of three days (Quinn 2011). The MS pathway was continued through local internal funding, and by March 2013 it had prevented a further 144 admissions by GPs and ten emergency department admissions. This equated to an estimated financial saving of around £300,000 based on the cost of treatment in the community versus a hospital stay of three days (unpublished data). These savings convinced the PCT to continue funding the extra nursing hours. This successful arrangement looked set to continue, but the NHS in England had been transformed in 2010 with the publication of the white paper Equity and Excellence: Liberating the NHS (DH 2010). It became clear the survival of a community MS nursing service would depend on adapting to the new organisational arrangements.
Health and Social Care Act 2012 Equity and Excellence: Liberating the NHS (DH 2010) provoked consternation throughout the NHS (Timmins 2012). Central to the Secretary of State for Health Andrew Lansley’s vision for the NHS was the abolition of PCTs and their replacement by clinical commissioning groups (CCGs), which would purchase health services on behalf of all GP practices in their area. Publication of the white paper was followed by 14 months of political dispute before the Health and Social Care Act became law in 2012 (Timmins 2012, Howieson 2013). Under the new system, CCGs are required to appoint nurses, and secondary care and lay representatives to the commissioning board, but this does not alter the reality that GPs now have a major influence on local purchasing decisions. The services they commission include planned hospital care, urgent and emergency care, rehabilitative care, and most community health, maternity, may 14 :: vol 28 no 37 :: 2014 47
Nursing Standard 2014.28:46-50. Downloaded from journals.rcni.com by University of British Columbia on 11/23/15. For personal use only.
Art & science service development mental health and learning disability services. The Health and Social Care Act 2012 also seeks to overcome the long-standing divisions between health and social care by requiring CCGs and local authorities to agree on commissioning priorities to meet local needs. Services more appropriately commissioned at the national level have become the responsibility of a new body, NHS England. In addition, NHS England is responsible for ensuring that the whole system works effectively (DH 2013). CCG boards have the primary responsibility for monitoring the safety and quality of services they have commissioned, while the Care Quality Commission monitors all health and social care provision on a national basis. Another organisation, Monitor, regulates NHS Foundation trusts to ensure that ‘health care services are provided effectively, efficiently and economically, while the quality of services is maintained or improved’ (DH 2013). Although PCTs were not formally abolished until March 31 2013, CCGs began to take shape in the preceding year when their organisational structures were established, their priorities were reviewed and preliminary negotiations with service providers were commenced. When the new arrangements began to emerge, it became clear that Northamptonshire would be served by two healthcare commissioning organisations: Nene CCG (2013) and Corby CCG (2014).
Community multiple sclerosis nursing service Before the Health and Social Care Act 2012 had come into force, a study of NHS organisations in England had found evidence of the effects of increased competition (Leech et al 2011). Examples included the appointment of marketing managers and commercial directors; an increasing focus on external communication and engagement with the main commissioners and stakeholders, for example PCTs and service-user groups, that most influence them; the development of ‘market share’ analysis as routine board reports, and a greater focus on understanding what neighbouring organisations (competitors) were doing (Leech et al 2011). In Northamptonshire it was realised that if the local community MS nursing service was to survive in the new environment, it must be seen to connect with the market-oriented agenda for health. The first requirement was to ensure that the community MS nursing service was aligned with the Northamptonshire Healthcare NHS Foundation Trust’s objectives to embed the service within the new NHS, and assisting the trust to meet vital objectives enabled this to occur. The 48 may 14 :: vol 28 no 37 :: 2014
four relevant objectives were (Northamptonshire Healthcare NHS Foundation Trust 2012): To be a patient-oriented organisation that treats people with compassion, values diversity, prevents ill health and personalises care to the needs of patients and carers. The goal is to be in the top 20% of NHS providers in terms of patient ratings. To provide services that are safe, oriented around evidence-based practice, delivered by empowered clinicians and that offer continuously improving service standards. The goal is to be in the top 20% of NHS providers for clinical and quality outcomes and performance against national targets. To provide services in modern, safe and clean environments that are accessible to the communities and populations they serve, designed around patient needs and ecologically sustainable. The goal is for buildings and facilities to be in the top 20% of NHS providers for environmental sustainability and efficiency. To provide an increasingly comprehensive, complementary and integrated range of services within Northamptonshire and surrounding counties. This includes primary and community services, local hospital services and specialist tertiary services. Based on these objectives, the community MS nursing service needed to focus on meeting the needs of its main purchasers, and examination of relevant policy statements was essential. One example that was examined was the Commissioning Intentions for Long Term Conditions document produced by Nene CCG (2013), one of the local purchasing organisations. It stressed the need for organisations to work with the local population to improve services, and specified objectives for health care in the locality (Nene CCG 2013). A strengths, weaknesses, opportunities and threats (SWOT) analysis provides a readily adaptable framework to assist an organisation in meeting the challenges of developing a service.
Strengths
Nene CCG (2013) highlighted the development of evaluation tools to assess the performance of integrated care for patients with long-term conditions, with the aim of achieving a 20% reduction in emergency admissions. This is one of the strengths of the community MS nursing service because admission avoidance is one of its demonstrated outcomes. This needs to continue to be a focus, with data available to demonstrate effectiveness of the service. Another strength of the service is the high level of patient satisfaction demonstrated by patient evaluations. Local
© NURSING STANDARD / RCN PUBLISHING
Nursing Standard 2014.28:46-50. Downloaded from journals.rcni.com by University of British Columbia on 11/23/15. For personal use only.
evaluations confirmed the positive findings of national studies (Somerset et al 2001, Corry et al 2011). Since CCGs are required to commission services that meet the needs of patients and provide high quality care, the collection and publication of evaluation data must be regarded as important for the service. In addition, the important role that GPs now have in commissioning services means their feedback is crucial. An initial small-scale survey of local GPs, which is awaiting publication, indicated a positive response to the service (Table 1).
Weaknesses
In contemporary health care, groups representing patients with particular conditions need to use the resources of media and political campaigns to ensure that their concerns are heard and their needs are met. Priority setting has helped to focus effort in the NHS, but a concentration on some aspects of care removes the spotlight from others, because not every patient group can have equal priority. While targeting patients with long-term conditions such as coronary heart disease, stroke and diabetes has resulted in major improvements in care provision, the relative neglect of neurological conditions in national and local policy documents (Quinn 2011) may affect the priority they receive in the medium and long term. Another long-term issue is the need for organisational and educational support for the MS specialist nurse role. In the absence of succession planning, nurses will not be encouraged to make the care of people with MS their career focus.
Opportunities
Collaborative working with colleagues in secondary care should ensure that people with MS receive appropriate care tailored to their needs, so that those who could be managed in the community avoid unnecessary hospital admissions (Burgess 2011). In addition, there are potential opportunities to improve liaison with nursing colleagues in the local care home sector. Enhanced working with the two CCGs that serve Northamptonshire holds promise for extending the current community MS nursing service for the benefit of patient care.
Threats
If opportunities are not grasped, they could be transformed into threats to the existence of the community MS nursing service. Hospital-based neurology services are potential competitors who may wish to lobby the CCG to base all services for people with MS in secondary care. If national and local policy initiatives on long-term care do
© NURSING STANDARD / RCN PUBLISHING
not give appropriate prominence to neurological conditions, service commissioners will tend to direct their resources elsewhere. In an environment of reduced resources for the NHS as a whole, such policy directives may have the unintended consequence of reducing the attention received by people with MS.
Discussion Changes in the NHS as a result of the passing of the Health and Social Care Act 2012 demand that nurses plan and act in new ways. A market
TABLE 1 Results of GP experience questionnaire (total respondents = 15) Question
Yes
No
Not applicable
No response
1. Overall, were you satisfied with the service you recently received from the community multiple sclerosis (MS) nursing service?
13
0
0
2
2. Were you satisfied with the speed of the service offered to you?
13
0
2
0
3. Were you satisfied with the availability of the service?
13
0
1
1
4. Did you find this an improved service from previous care pathways you used for patients with MS?
12
0
3
0
5. By using the MS specialist nurses in this way, did it ease your workload in any way?
13
0
2
0
6. Would you use the community MS nursing service again?
14
0
0
1
7. Would you miss this service if it was withdrawn?
14
0
0
1
8. Do you feel that this care pathway improved the outcome for the patient?
12
0
2
1
9. Did use of the care pathway result in fewer appointments with you and your colleagues at the surgery?
7
2
6
0
10. Are you sending fewer people with MS to acute services as a result of the community MS nursing service?
9
1
5
0
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Art & science service development economy in healthcare provision requires nurses to adopt many of the commercial approaches associated with private sector organisations. Since the future continuation of all services now depends on the willingness of CCGs to purchase them, much thought should be given to developing strategies to demonstrate that the CCGs’ requirements are being met. This calls for the production of evidence about patient and GP satisfaction with the service, regular updating to achieve adherence to international best practice and demonstration of value-for-money in the context of reduced resources. It is too early to provide definitive guidance on how these goals may best be achieved by nurses, but the need to make progress towards achieving them is urgent. The community MS nursing service is collecting and analysing data highlighting the benefits of pro-active case management and collaboration in reducing avoidable hospital admissions, for presentation to the CCGs to support the case for the service. Preliminary results show a significant decrease in avoidable
admissions and much shorter hospital stays for people with MS. Continued collaboration with GPs and secondary care is vital to ensure people with MS are offered a service that is provided by the right person at the right time. At a national level, pre and post-registration nurse education needs to reflect the realities of the new NHS environment and to provide all nurses with the skills necessary to work effectively in it.
Conclusion The creation of a fully developed healthcare market in England with clear purchaser and provider divisions between NHS organisations seems set to be a feature of health policy for the foreseeable future. Specialist nursing services, such as those for people with MS, must adapt rapidly to the new arrangements if they are to survive. They must demonstrate to local CCGs that they can provide a service that is cost-effective, accords with local and national policy directives, and meets the needs of service users NS
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