A continence clinical nurse specialist (CNS) is a valuable resource. With tailored education and training, a specialist should have the knowledge and accepted clinical credibility to receive and make referrals to others. That’s what being a specialist is all about.
Specials must be able to deal with advanced levels of treatment and management themselves. They are, in effect, independently operating practitioners. A continence specialist should know more about bladder and bowel dysfunction than the average GP, and this should mean patients are only referred to a secondary care consultant when all the primary care treatment and management options have been exhausted.
The cost of consultant referrals far outweighs the cost of referral to the CNS, and for the vast majority of patients consultant referral is unnecessary. Care pathways provide clear guidelines that dictate what should be done and at what points we decide to make the referrals.
The benefit of clinical nurse specialists undertaking referrals of patients to secondary care is evident when you consider who actually benefits from such referrals (patients and the public purse).
When a patient with bladder and bowel dysfunction is referred to secondary care, this is usually to a surgeon, and continence nurse specialists know that surgery only benefits a select few. It is therefore important that specialists only refer those select few after careful assessment, examinations and treatments including physiotherapy and occupational therapy.
When the consultant receives the referral he or she will be able to make judgements more or less straight away about whether they can help. The work of the specialist means only the most complex of additional tests and examinations are needed at this stage and neither consultants' or patients’ time is wasted.
There are a number of tests, for example urodynamics, that could be considered in primary care if referral routes were not closed to most community CNSs. If we had integrated continence services, as suggested in 2000 in the Department of Health document Good practice in continence services, this anomaly should not exist and patients would have timely and appropriate investigations when needed.
The problem is that the ‘N’ in CNS carries the risk of spoiling everything. After all, you are only a nurse and for some consultants, that just doesn’t count.
How can a consultant accept a referral from a nurse? Well this is not difficult. Accept the CNS as a valid referral source. Accept and use the available care pathways, there are lots about or you can develop your own. Unless it's personal, there shouldn’t be a problem. The new and modern NHS is very different from what ‘modern’ was just 10 years ago, and each and every one of us must move on if we are to succeed.
Aren’t we glad that there are lots of consultants who are visionary and appreciate that nurses are more than capable of carrying out a specialist role? We see this in many secondary care services. This has the benefit that services to patients are enhanced, with patients getting access to what they need when they need it locally.
Not all care needs start and end in secondary care. There are some patients who need secondary care immediately but by far the majority of continence related care should be able to start and end in primary care. So come on commissioners, understand local needs and ensure funding is placed where it is most appropriate and offers best value for money.