Creating a new vision for primary care

1 February, 2004

North Bradford Primary Care Trust is an award-winning, three-star trust known for its innovation and go-ahead attitude. First impressions are impressive if the PCT headquarters are anything to go by - based in a converted mill in Saltaire, Yorkshire, a world heritage site and also home of a permanent exhibition of the work of the artist David Hockney, who grew up in Bradford.

Mary Kiddy, lead nurse, describes how it feels to work at the PCT: 'This is an interesting and challenging place to work. There is a strong think tank in the PCT producing a lot of vibrant ideas. Bradford has a reputation for being at the forefront of development in primary care and the PCT prides itself on having a 'can do' culture and is willing to try to develop things very quickly.'

The PCT includes 12 GP practices, 11 dental practices, 12 opticians, 19 pharmacists and two community hospitals for a population of around 95,000.

This is a very strong commissioning organisation. The commissioning department is the largest department in the organisation. It is good at managing patient data, and in 2003 won the Health Service Journal's 'Prime Minister's Award for Excellence in Healthcare Management' for strong performance management and tight target-setting.

All but one of the GPs were fundholders in the past, demonstrating their commitment to looking forward. 'Community nursing now has the opportunity to build on this strong framework and move forward,' says Mary Kiddy.

Choice is seen as a challenge: how to offer choice to patients and how to guide them through that process. 'We are in the middle of building a treatment centre, due to open in March. It will give patients a choice and give us much more capacity for diagnostics and treatment.

'The PCT is also very keen on practice-based commissioning. Practices have more control over what they buy, which is better for patients. On the other hand, you get economies of scale when you buy at PCT level.'

Work on the management of long-term conditions - drawing from the Kaiser model in the USA - is well under way. A strong tradition for nurse practitioners in the area gives the basis for case management and this is being tackled according to local needs.

District nursing and school nursing are particularly in focus, and the challenge of delivering the vision of the public health White Paper and the Children's NSF are in mind.

A lot of work has been done on reforming emergency care during 2004, placing nurses in a better position to respond to the needs of patients at home during the day and out of hours to avoid their being admitted to hospital.

'The emergency services need to be dealing with true emergencies. It's about getting the patient the right care at the right time with the right person, and that right person need not always be a 999 paramedic or a GP. Most people would not have automatic access to a district nurse, for example,' explains Steph Lawrence, who is a trainee nurse practitioner for the district nurse-based community intervention team. 'But that is changing', she says.

North Bradford PCT's vision for primary care, based on Pursuing Perfection, a US programme for excellence in health care
- No needless deaths or disease

- No unnecessary pain

- No waste

- No delays

- No inequality of delivery

- No feelings of helplessness or despair.

Source: www.ihi.org/ihi/programs

What performance indicators for nursing do you have?
'Part of my remit is to develop a set of performance indicators that measure the effectiveness of nursing interventions in primary care. We know community nurses are worth their weight in gold, but we don't actually know why,' says Mary Kiddy.

'I hope to have these in place for April. Most of the other work on indicators for nursing in the UK is in the acute setting, although our neighbours in South and West Bradford PCT are working on this as well.

'The areas we are looking at are breastfeeding, obesity, nutrition and older people, immunisation, tissue viability, smoking cessation and nurse prescribing. About a third of older people are malnourished when they enter our hospitals, so there is clearly a high level of poor nutrition across our community. We are aiming for zero pressure ulcer development in the community within two years because we think that is a realistic target.

'The current challenge is to work out systems so that data already being collected can be used, rather than having people filling out any extra forms.

'We are also putting together service specifications for, in the first instance, district nursing, health visiting and school nursing. Like a lot of PCTs we don't have broad aims or objectives for any of those services, they are just traditional and have always been provided. But what exactly are we providing and what is expected? This can sometimes lead to misunderstandings between PCT staff and practice staff about who does what, what they are supposed to be achieving. Having clear outcomes will be helpful.'

How are you developing nursing roles?
'We are concentrating very hard on making sure that we have nurses to deliver those functions described in Liberating the Talents for first-contact care: management of long-term conditions and public health,' says Mary Kiddy, lead nurse.

'To do that we need staff who can work much more effectively across a broad range of areas in primary care. I don't think that we actually give nurses a very fair chance to do this in the way that we educate them presently. We are talking to the local university to see how we can commission postgraduate education for nurses to help us to do that more effectively.

'My view is that, in the next few years, we will start to see the demise of specialist practitioner roles in primary care. Nurses who do a postgraduate course in asthma, diabetes, COPD or cardiac care, for example, come back with very specific skills and knowledge. But actually we need nurses who can manage the broad range of conditions that many of our patients suffer from. We need more generic skills at staff nurse level, so we need to be doing things differently.

'This is a very exciting time for nursing, and in particular hugely exciting for primary care nurses. There are massive challenges and opportunities. Governance issues, too, are immense at the moment, because of the development of extended roles and because we have to change the way we work significantly. This is particularly important in the light of the recent Shipman report.

'Nurses are taking on an awful lot more responsibility in managing patients, caseloads, referrals, nurse discharge and nurse admissions, for example. This means taking some risks but protecting and supporting staff in new roles and systems. For example, we have recently been discussing how to arrange for our nurse practitioners to refer for X-ray. To develop this we need to understand what the risks are and make the accountability clear.

'We have recently put in a new nursing structure and now have clinical nursing leads for health visiting and district nursing across four clusters of practice- based teams.

'It was felt that having a practice nurse lead wasn't going to work here, so our suggestion is that we develop a network of practice nurses across the PCT instead.

'We are aiming to integrate practice nursing much more effectively into community nursing and we acknowledge that practice nurses can feel isolated and excluded because they are not directly employed by the PCT. That has huge strengths but also can have disadvantages in terms of having equal opportunity for access to training and being freed up to attend meetings.

'The leads pull together 'cluster meetings', which include the practice nurses and representatives from all of our specialist nursing teams, including school nursing, cardiac, rehabilitation, the community intervention team, continence, palliative care.

'It is early days and we don't have all the clinical leads in place at the moment, but we have the beginnings of an integrated structure.

'Another big area is team health visiting, where health visitors work together rather than being single-handed practitioners. This has lots of benefits in terms of work, morale and governance.' WHAT WE'VE ACHIEVED - Mary Kiddy, Lead Nurse
'Nurses are taking on an awful lot more responsibility in managing patients, caseloads, referrals, nurse discharge and nurse admissions, for example. This means taking some risks but protecting and supporting staff in new roles and systems.'

Projects

'The main role of the community intervention team is to prevent unnecessary admission to hospital. In the future we hope to be able to avoid some medical input.' See page 20

'A new and large area for us is child and adolescent work with mental health and behavioural issues. One of our great successes in this area has been consultation with young people.' See page 20

'When I started to refer patients to the hospital consultants they would say: 'Who are you and why should I accept patients from you?'' See page 21

'We are developing the case- management approach and are looking at what the community matron role might mean for us.' See page 21

We are aiming to avoid unnecessary admission to hospital and help patients have an improved quality of life.' See page 21

Steph Lawrence, Trainee Nurse Practitioner, Community Intervention Team, North Bradford PCT
''I am a district nurse training on a three-year master's course to be a nurse practitioner working in people's homes. This is the first time the PCT has considered the role in a setting other than general practice and there is a definite need for it.

'Our main role is to prevent unnecessary admission to hospital, but at present only if the patient is medically stable. The increased skills of a nurse practitioner, particularly with my past background in A&E, should enable me to make a diagnosis and start treatment, say in the case of a urinary tract or chest infection, which we see often. So in the future we hope to be able to avoid some medical input.

'The Community Intervention Team is a fast-response 24-hour, seven-days-a-week district nursing team. The majority of our calls come from the day-time district nurses, GPs and social services and some patients self-refer.

'We can get calls on just about anything, such as an older person who has developed an infection and needs increased input for a few days. We also provide six days of home support on a pathway for patients with deep-vein thrombosis for the acute hospital.

'The other side to the team is our intermediate care remit. Our health-care support workers have had additional training so that they are able to look after people discharged from our community or acute hospitals who need increased support for up to six weeks. We use the term 'enablement', which basically describes intermediate care in the community rather than that provided in hospital.

'The support workers might help patients to wash and dress and go to the bathroom, assist them in making a cup of tea and to start to make their own meals again or to go shopping. They give patients a bit of confidence in the first few weeks to start doing things for themselves again.

'I think at times that we get in home care before patients need anything so permanent. It would be better to help them to be independent again.'

Penny Wild, Lead School Nurse, North Bradford PCT
''The school nursing team in north Bradford covers 32 schools in the area. We work with different agencies, including the special teams in education, supporting schools in many different ways, for example helping them to achieve the Healthy Schools Standard. From Christmas until Easter we immunise in all the upper schools, and this year have the additional MMR as well.

'The public health White Paper offers enormous challenges for the future, of course. To help with this we have just set up a public health training programme for the staff. We expect nurses to deliver public health, but in fact they will not really have the specific skills needed unless they have done the specialist practitioner course.

'We now employ two nursery nurses and a health-care assistant in the team. The nursery nurses have brought new ideas for ways of delivering health promotion to reach children and young people.

'A new and large area for us is the child and adolescent work with mental health and behavioural issues. This involves supporting children and families to work through issues or directing them to appropriate agencies. We had 96 referrals between April and September 2004. This has been a very steep learning curve for us, because we were not previously mental health trained. One of our initial children's centres will be a family centre based within a school with social services involvement, too.

'One of our great successes in this area has been consultation with young people. A group of eight to 11-year-olds helped interview new staff for the nursing team, with preparation training from the Children's Fund. They were very professional and perceptive. We have also worked closely with school councils, to see if the children have particular issues that they would like us to work on with their school.''

Tracy Thompson, Out-of-Hours Nursing and Unscheduled Care Lead, North Bradford PCT
''Recently, the government agendas have taken off like fireworks and created massive opportunities for nursing. We have the reforming emergency care agenda, which is having a major impact on service delivery, the new GMS contracts, and the intermediate care agenda, to name but a few. It sometimes feels as though we are making the road while we are running on it, but I am passionate about ensuring we establish joined-up care for patients where we can. We have now started developing the case-management approach and are looking at what the community matron role might mean for us.

'I manage our community intervention team, which we set up in April 2004. Instead of having a separate twilight service, night service and an intermediate care service, we have one responsive 24-hour, seven-days-a-week service. We are developing links with our community hospitals and practice-based teams, as our success depends on a whole-systems approach to care.

'We are refocusing our case management model, which has provided us with an opportunity to look at patient pathways through our services. We aim to provide the right care in the right place, at the right time, with the right skills.''

Anne Williams, Clinical Lead Nurse for Heart Failure, North Bradford PCT
''Heart failure affects 1-2% of the population, up to 10-20% of the elderly population and can be considered a public health problem, often with a poor prognosis. Prevalence will continue to get higher because we have an increasing elderly population and are keeping more people alive after myocardial infarction. My post was one of the first wave of 19 heart failure nurses across the country funded by the British Heart Foundation in 2001; there are three of us in the Bradford area working in post-discharge management. The BHF has recently evaluated the role, which showed it to be successful and, excitingly, it is now funding a further 75 nurses across the UK.

'Fifty per cent of what we do is medicines management, and the rest is looking at how we can help patients in other ways - their social circumstances, aids and adaptations, for example. We are aiming to avoid unnecessary admission to hospital and to help patients live longer, with improved quality of life. In effect we are case managing these patients, most of whom are elderly.

'The average age of the patients is currently 81 and the caseload has been increasing in size. We have just taken on someone to help me and I hope that in the future we will be able to establish discharge routes to the case management and district nursing teams.''

Ghislaine Young, Nurse Practitioner, Primary Care, North Bradford PCT
''I was the first trained nurse practitioner in general practice in north Bradford eight years ago and am now a partner in the practice. We have eight trained NPs in Bradford, with four more completing their training.

'Because there was little national support or experience for the role at first it was up to me to set up some strategies to make the role accepted here. When I started to refer patients to the hospital consultants they would say: 'Who are you and why should I accept patients from you?' I therefore developed a register so that they knew who we were and agreed that they would accept referrals from us. Now the support we have from them is fantastic.

'In fact, the Nursing and Midwifery Council has still not regulated the role - the deadline for the return of comments on a consultation document is the end of February this year. We have had nurse practitioners since the early 1990s, yet there is still huge misunderstanding about the role and the level of responsibility we have and I am absolutely astounded that the NMC has not acted on this until now.

'Through the Bradford Nurse Practitioner Collaborative we are trying to raise our profile. We are working with the radiologists, for example, so that we can refer for X-rays in the hospital. Despite this issue being one of the chief nursing officer's 10 key roles, it has taken a whole year of hard negotiation with the radiologists to get them to accept us. You've got to keep knocking on doors.

'We are also liaising much more with clinical nurse specialists in the acute sector. We have started to refer patients to each other and to use each others' expertise across primary and secondary care. Being able to pick up the phone and discuss a patient is absolutely fantastic.''