The case for specialist nurses
- Correspondence to: Dr Peter Carter OBE
Chief Executive & General Secretary, Royal College of Nursing, UK;
Along with the obvious challenges presented by the restructuring of the NHS1 and the £20 billion productivity gain (the Nicholson Challenge), the NHS also faces a number of other issues. Demographic changes towards an ageing population mean that people are living longer, and more people are living with long-term conditions. Social changes mean that families are more dispersed, resulting in older people being more isolated; more single people living farther away from home with less family support; high levels of per capita income and educational attainments have increased expectations, and people want more personalised, patient-centred care. Better diagnoses and treatments have improved the health of the nation, and will require further funding in the future.
The Royal College of Nursing (RCN) has long known that the key ingredients for facing these challenges are to invest wisely in frontline staff and to constantly review service provision, to ensure that the health service is responsive to and adapts to meet prevailing needs. I am aware that for many, the idea of redesigning services at a time of financial crisis will seem like a naive diversion. However, the only way the NHS will cope with the demands of tomorrow is by supporting positive changes to the way we do things today.
Specialist nursing, for instance, provides an essential service for millions of people living with a long-term condition. In a recently published commissioning support guide by THE PROGRESSIVE SUPRANUCLEAR PALSY (PSP) Association,2 access to a keyworker, it states: “...is likely to ensure co-ordination of care and prompt access to appropriate services as they are needed.” This role is very often a specialist nurse highly trained in Parkinson's or neurology care. In a report on Parkinson's nurses,3 recommendations were made last year that those with Parkinson's should be reviewed by a specialist every 6 months. A nurse specialist in this role can lead to an average saving of £43 812 in consultant appointments. Furthermore, research by the MS Trust and South Bank University has suggested that every MS specialist nurse saves the NHS over £64 000 every year due to fewer unexpected hospital admissions and bed days.4
It is estimated that 15% of all strokes are caused by atrial fibrillation (AF)5—that is 12 500 strokes/year in England are directly attributable to AF.6 Sixty per cent of strokes could, therefore, be prevented every year by utilising the new GRASP-AF7 detection tool used by specialist nurses and saving the NHS £96 million each year. These numbers are not just idealistic, they are substantial examples of where specialist services change the way care is delivered for the better, saving money, and dramatically improving patient experience.8
Nursing has a key role to play in driving up standards, ensuring that patients are at the heart of care, embracing specialist practice, adopting new ways of working, including the use of technology to support clinical practice and promoting self-care. Nursing has, for a long time, played a fundamental role in making sure that services improve and that change can happen in a positive way.
RCN member Marina Lupari introduced a Chronic Illness case management service (CICM) to support older people at home who have multiple chronic conditions.9 She systematically reviewed the evidence of the model that saw nurses given extra education and support to work with high-risk older people in their own homes to manage these conditions. Sixteen full-time nurses were recruited to deliver specialist care for patients with conditions such as serious respiratory problems, heart failure and diabetes.
Marina secured funding to conduct a controlled trial, in which nearly 600 people took part; half receiving usual care and the other half the CICM intervention. At four points over 12 months, Marina compared differences in outcomes for the number of hospital visits, length of stay, health-related quality of life and functionality. Bed days were reduced by 59%, and patients also reported feeling generally improved, saying support from the CICM enabled them to function better. The difference in average cost per patient was £1493 lower compared with those who received standard care, representing a total saving of more than £400 000 across the 9-month follow-up period.
These examples tell us that there are great opportunities for good nursing care to flourish. Nursing is at the heart of care and that is where it must remain. And this does not stop us from thinking about effectiveness and outcomes at least as much as efficiency. We have to accept, on the evidence that is presented to us, that specialist nurses providing complex interventions and supporting other members of the nursing team are better for patients and save the NHS money. Evidence-based practice should be fundamental to all care and be the catalyst for innovation in the management of long-term conditions.