With financial pressures putting their roles under threat, specialist nurses need to ensure they have evidence to prove they enhance services and are cost effective
In this article…
- Why the specialist role of nurses is at risk
- How specialist nurses can prove their worth
- Defining key performance indicators
- Developing a business case
Monica Fletcher is chief executive, Education for Health, and chair of the European Lung Foundation
Fletcher M (2011) Assessing the value of specialist nurses. Nursing Times; 107: 30/31, early online publication.
Despite an enormous growth in specialist nurse-led activity, specialist nursing posts are under threat. This article discusses why clinical specialist nursing roles are at risk. It also looks at what specialist nurses can do to prove their value and help protect their positions.
Keywords: Specialist nursing, Commissioning, NICE quality standards, Education, Care pathways
- This article has been double-blind peer reviewed
5 key points
- Since 2005-06, there has been a 465% increase in outpatient attendances at specialist nurse clinics – a rise of more 100,000 outpatients a year
- Patients appear to value specialist nurses’ services; these nurses are consistently more highly rated than other health professionals
- The role and function of specialist nurses, the services they provide and their effects should be described and measured accurately
- Specialist nurses need to ensure they have evidence their services are cost-effective and improve patient safety and outcomes
- The unique knowledge and experiences of specialist nurses mean they could play a vital role in commissioning services
In July 2011, the NHS Future Forum published its response to the NHS listening exercise and, as a result, prime minister David Cameron unveiled significant changes to the proposed reforms (Department of Health, 2011). Nurses’ roles and contributions in the future NHS were recognised when, under these changes, GP commissioning consortia became clinical commissioning groups and were instructed to have at least one nurse at the table. This marks a significant move forward for nurses.
Following the government’s decision to “pause, listen and reflect” on its recent health and social care bill, rather than occupying a seat in the upper circle of the NHS, nurses have the chance to take centre stage. Their unique knowledge, skills and experiences mean they could play a vital role in commissioning services. Now they have this opportunity, it will be interesting to see if they support the continuing commissioning of clinical specialist nurses.
Specialist role under threat
Since their inception, clinical specialist nursing roles have been under threat.
Earlier battles focused on professional issues, such as role demarcation and autonomous practice. These were fought and, in the main, won.
Medical colleagues’ confidence in the capabilities of nurse specialists has grown; in March this year, Nursing Times suggested that doctors were increasingly likely to refer patients to a nurse specialist (Santry, 2011). This report also indicated an enormous growth in specialist nurse-led activity, with a 465% increase in outpatient attendances at specialist nurse clinics since 2005-06, equivalent to a rise of more 100,000 outpatients a year.
The issues that threaten nurse specialist roles are complex. The main danger comes from a threat that is hard to fight, because it is both faceless and deadly – that of market forces.
How many times have we seen nurse specialist roles come under attack during times of financial austerity? When money needs to be saved relatively quickly, higher-grade nursing posts inevitably come under scrutiny as they can be seen as a quick way of cutting staff costs by either reducing their numbers or downgrading them.
The lack of a sound financial footing has made many posts vulnerable. Some rely on short-term funding while others have received pump-priming funds – partially or sometimes totally – from external sources such as disease-specific charities. Long-term funding from the local health economy has not always been available when this money has run out. Both commissioners and providers have immensely challenging financial issues to contend with to deliver the quality, innovation, productivity and prevention (QIPP) programme and cost improvement plans.
It is a given that all services should be reviewed regularly by both those providing them and those paying for them, to ensure they continue to meet specific needs and demonstrate cost-effectiveness.
With this in mind, it is important that specialist nurses are able to clearly demonstrate that they offer value for money, and this information is often unreliable. These nurses are not good at doing this proactively, so, whenever their services are under threat, they are often unable to provide robust data with which to fight their cause, relying on unsystematic data and anecdotal information.
If their posts survive, once the immediate threat has passed, they tend to keep a low profile until the next onslaught. According to the Royal College of Nursing (2010), during the previous NHS budget crisis in 2005-06, one in four specialist nurses was threatened by redundancy, half reported reductions in their services, 68% were asked to increase activity by seeing more patients, and 45% were asked to work outside their specialty in more generic roles.
Justifying any role needs careful forward planning and a long-term strategy. With the current financial constraints, the RCN, in conjunction with over 40 other organisations, has felt compelled to actively defend the role. Its report Specialist Nurses: Changing Lives, Saving Money highlights how worthwhile these roles and the services they provide are (RCN, 2010). However, nurses should not have to rely on others – such as unions or charities – to take up their defence.
Patients appear to value the services provided by specialist nurses greatly and they are consistently rated higher than other health professionals in terms of understanding patient needs, designing better personal care pathways, obtaining patient feedback and being transparent and honest (RCN/National Voices, 2009). Although policy documents have stated patients should be the central focus of all we do in the NHS and that their voices and views must be heard, positive patient feedback alone will not convince commissioners to continue funding a service. It is imperative those providing and commissioning services have quantifiable outcomes that clearly demonstrate the benefits offered by specialist nurses, such as those listed in Box 1.
Box 1. How specialist nurses add value to the NHS and social care
- Delivering services closer to home
- Developing innovative service delivery frameworks
- Promoting seamless care across sectors
- Developing and implementing care plans
- Delivering structured educational programmes for people with long-term conditions, which may lead to improved health outcomes (DH and Diabetes UK, 2005)
- Helping other staff to develop new skills by providing education and training
It is important that the role and function of specialist nurses, the services they provide and the impact they have can be accurately described and measured.
These roles, like many others, are being influenced by the changing NHS environment. Specialist nurses who have been prepared to adapt to change and have kept up to date with central policy and strategy are more likely to survive. NHS contracting currency is focused on meeting clearly defined targets; taking this approach will persuade others that specialist nurses are cost-efficient and worth continuing to fund.
The NHS white paper supports the shift of care from the acute sector into the community (DH, 2010). Many specialist nursing roles support the care of patients with long-term conditions. These nurses have had to adapt in terms of not only developing more complex clinical skills, but also managing cross-boundary relationships between the variety of health and social care providers.
Specialist nursing services in the community are often separate from others and so are more exposed than those in hospitals. As a result, many have already developed better systems for collecting management information based on clearly defined key performance indicators.
However, measuring activity alone will not necessarily convince commissioners to continue to purchase a service, and specialist nurses need to ensure they have evidence that their services are cost-effective, enhance patient safety and improve the quality of service delivery.
The evidence base that underpins the cost-effectiveness of specialist nurses is limited (RCN, 2010). Much of it is derived from evaluations of the many charitable bodies that have funded them. For example, the British Heart Foundation (Patterden, 2008) and Epilepsy Action (2010) have commissioned and produced their own compelling reports, demonstrating cost savings to the NHS in a multitude of ways.
While it is clear such charities have invested money, time and effort in producing these evaluations, they do not appear to be wholly persuasive. Sadly, there is little additional evidence in the literature to support the cost-effectiveness of specialist nurses. The charities may well have a vested interest in demonstrating to their charitable donors that their funds have been spent successfully but it is questionable whether such evaluations provide sufficiently robust evidence in themselves.
It seems inconceivable that these roles need justifying when there are so many ways in which specialist nurses, working independently or as part of multidisciplinary teams, can and already do contribute to meeting key performance indicators. If this is the case, these attributes need to be clearly written into service specifications and contracts.
Commissioners will set targets with acute trusts aimed at containing costs by reducing the number of follow-up appointments relative to the number of new outpatient referrals (this is known as “new to old ratios”). Specialist nurses may play an invaluable role in achieving these targets by providing services in the community that have traditionally been offered in hospital outpatient clinics. Earlier involvement of specialist nurses in hospitals could also help to reduce this ratio through improved liaison with the community team.
Meeting national and locally agreed care quality initiatives is in the interest of both commissioners and secondary care providers as these will form part of the contract between them.
Specialist nurses should ensure they play an integral part in their delivery. Tissue viability nurses, for example, should lead an acute trust’s strategy for meeting the care quality initiatives for pressure ulcer prevention. Without their specialist input, a hospital would struggle to meet this target and lose money, and patient care would not improve.
For several years, acute trusts have been experiencing an incremental rise in emergency admissions which, in the current financial climate, is not economically sustainable. By becoming the first point of contact for patients with long-term conditions such as chronic obstructive pulmonary disease, specialist nurses based in the community or working in an outreach service from the hospital can help reduce unnecessary admissions through reducing complications and improving self-care. This offers value for money and demonstrable efficiency savings from reduced hospital bed occupancy.
Sadly, the robust evidence base to support this is limited, so specialist nurses need to develop compelling locally based evidence to justify funding such schemes.
They may also help trusts with the recently introduced readmission targets, which penalise hospitals if patients are readmitted with the same problem within 30 days. These targets open up opportunities for specialist nurses to follow up patients who are discharged into the community and to support adherence to care pathways.
Education and self-management
If specialist nurses are involved with patients’ care at the time of admission or soon after, they can help them manage long-term conditions through better education and self-management. This can encourage earlier discharge and so reduce the length of stay in hospital. Reducing bed use and therefore hospital costs enables acute trusts to meet commissioning intentions, which are essentially designed to buy services for less money.
In the future, commissioners will be incorporating National Institute for Health and Clinical Excellence quality standards into their contracts. These will be aimed at improving and standardising quality of care based on evidence-based best practice. Components of these standards will undoubtedly need input from specialist nurses, so they should familiarise themselves with service-specific standards and ensure they are crucial to meeting these quality standards.
Lord Darzi, in his report High Quality Care for All, built a vision for clinicians as being central to service improvement and redesign, and specialist nurses are ideally placed to take on this leadership role (DH, 2008). They can, and clearly do, bring additional value in delivering services in the complex NHS and social care environment (Box 1).
Specialist nurses need to develop skills and competencies to justify and secure their future and it is vital for them to develop a level of business acumen that will put them in a stronger position to defend their services. They need to be able to write a strong business case that is grounded in current policy, national imperatives and the NHS outcomes framework. Some essential components of a business case are listed in Box 2.
Box 2. elements to consider in a developing a business case
What are you trying to achieve?
- How you will do it?
- Why should this service be considered a funding priority?
- Are there alternative ways of meeting the perceived needs? If so, state and cost these
Is the service:
- Meeting local and national targets?
- Increasing activity/throughput?
- Improving access to services?
- Improving the quality of the service?
- Improving patient satisfaction/patient safety?
Consider any “value-added” outcomes and nationally recognised best practice
Information on costs
- What are the recurrent and non-recurrent costs?
- What costs relate to staff and non-staff pay?
- How will the costs be covered?
- Is there any income generation from the new activity?
- Does the service save money elsewhere
- Well-defined, measurable targets
- Clarity about how each target will be measuredl
- Baseline measurement
- Ensure there is a performance and monitoring framework in place and that the data is retrievable
Source: Fletcher and Walmsley, 2009
If a business case already exists, it may well be out of date and it is likely the metrics and language that have been used in the past to describe the nurses’ role and function are no longer relevant.
Specialist nurses should revisit the thinking behind their services and ensure they are up-to-date, before someone else with a different agenda does it for them.
There is compelling reason to suggest that specialist nurses should be able to prove their worth, so they must gather the relevant evidence to ensure their value is recognised by service commissioners.
It will be interesting to speculate about what stance nurse members of local commissioning boards take when they have to be involved in decisions regarding the future of specialist nursing services.
Department of Health (2011) NHS Future Forum Recommendations to the Government.
Department of Health (2010) Equity and Excellence: Liberating the NHS. London: DH.
Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Department of Health and Diabetes UK (2005) Structured Patient Education in Diabetes. London: DH.
Epilepsy Action (2010) Best Care: the Value of Epilepsy Specialist Nurses. Leeds: Epilepsy Action.
Fletcher M, Walmsley S (2009) How to write a business case. British Journal of Primary Care; 3: 3.
Patterden J et al (2008) The Development and Impact of the British Heart Foundation and Big Lottery Fund Heart Failure Specialist Nurse Services in England. York: University of York.
Royal College of Nursing (2010) Specialist Nurses: Changing Lives, Saving Money. London: RCN.
Royal College of Nursing/National Voices (2009) Local Healthcare Commissioning: Grassroots Involvement? A National Survey of Health Advocacy Groups. London: RCN and National Voices.
Santry C (2011) “Powerful evidence” of growing role of specialist nurses revealed. Nursing Times; 107: 12, 2-3.