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Millennium Nursing

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Nursing opportunities have grown in the 21st century. Adrian O’Dowd reports

The past 10 years of the NHS will probably be remembered by nurses as the decade of change, reorganisation and policy overload.

Policy after policy has been launched by the Labour government since it came to power in 1997 and, during that time, nursing has developed and taken many opportunities to grow in professionalism, leadership and skills.

A sign of just how much nursing had developed its autonomy was demonstrated by the creation of NHS Direct in 1998 (and other later versions such as NHS 24 in Scotland) – a 24-hour nurse-led advice line that made nurses the gatekeepers of health services before GPs for the first time.

Another community development was the creation of walk-in centres in 2000 – nurse-led drop-in centres for minor ailments. Around 90 now exist, providing a complementary service to traditional GP and A&E services.

Jane Naish, RCN policy adviser, says: ‘Walk-in centres have been massively important because they are staffed by nurses and, on the whole, doctors are not there. In the last decade, nursing has moved considerably with nurses leading and coordinating care, as well as providing it.’

Nurse leadership received a boost in 1999 with an announcement from Tony Blair that a new role of consultant nurse was to be created. The idea was that nurses who took up the post would spend half of their time on management issues and half on direct patient care. It caught the public’s attention and gave nurses another career option.

Matron made a comeback, with modern matrons announced in 2000. An initially sceptical profession warmed to the move.

One of the biggest developments of the decade came with the publication of The NHS Plan in 2000 – a 10-year blueprint to reform and improve the NHS, with specific targets on waiting times for appointments and treatment.

In terms of finance, the government approved unprecedented levels of investment for the NHS between 2002 and 2005 but the money was soon swallowed up and by 2005–2006, the health service as a whole was £547m in deficit.

This led to a harsh period of recruitment freezes, a clampdown on spending and job cuts to get back into surplus.

Staffing shortages were a major problem for the NHS towards the end of the 1990s and early 2000s, which prompted the government to look abroad and recruit tens of thousands of overseas nurses, many from the Philippines. By 2003 there were 42,000 overseas nurses working in the UK and a further 39,000 joined the register between 2004 and 2007.

James Buchan, professor in health sciences at Queen Margaret University in Edinburgh and workforce policy expert, says mass recruitment of overseas nurses was at unprecedented levels. ‘That has changed the profile of the nursing workforce and has brought in many well-skilled staff from other countries,’ he explains.

A landmark development for nursing during this decade was the advent of nurse prescribing, which began with the Nurse Prescribers’ Formulary in 1998, aimed at district nurses and health visitors.

The Nurse Prescribers’ Extended Formulary followed in 2002 and now there are nurse independent prescribers who are allowed to prescribe any licensed medicine for any medical condition within their competence, including some controlled drugs. There are also supplementary prescribers. These developments caused some unrest among the medical profession but nurses were not to be stopped acquiring such skills and there are now almost 50,000 nurses qualified to prescribe.

Ms Naish says the rollout of prescribing has made a huge difference, adding: ‘The numbers are going up and we need to get ward managers doing prescribing as well. It’s important because they spend a lot of their time chasing junior doctors for prescriptions.’

Pay dominated much of the decade’s debates and despite attempts to boost nurse recruitment – such as an inflation-busting 12.5% pay rise for newly qualified nurses in 1999 – something more fundamental was needed.

That came in the form of a completely new pay system known as Agenda for Change, which was implemented in 2004.

Based on a thorough job evaluation process, the new system replaced gradings with bandings and promised to be a more accurate reflection of what a nurse actually did.

Despite Agenda for Change, pay has remained a thorny issue and, last year, nursing unions came close to sanctioning industrial action due to the level of unrest among the profession.

Primary care underwent various reorganisations and nurses were given many opportunities to develop with the advent of personal medical services (PMS) practices – some of which were run by nurses who could employ GPs.

Nick Goodwin, senior fellow at health policy think tank the King’s Fund, believes PMS practices were a step forward for nurses. ‘I knew one of the pioneering sites in Nottingham and it was tremendously difficult for nurses to get these schemes off the ground when they were up against an established way of doing things and some opposition,’ he says.

Mr Goodwin adds that over the last 10 years there has been a ‘refocusing of the nursing profession’. He explains that today’s model of nursing is less about reacting to illness and more about preventative care, such as nurse-led screening programmes.

Across the board there has been a significant development of specialist nurse posts over the past 10 years, in areas such as palliative care, diabetes, asthma, stoma wound care, infection control and Aids.

These specialists took over functions that had previously been carried out by hospital junior doctors or GPs such as pre-admission clinics and minor injury services.

How nurses develop in their careers has been something of a matter of chance over the years, which led all four UK health departments to launch the Modernising Nursing Careers initiative in 2006.

MNC has many different strands of work that are ongoing to ‘set the direction’ for careers and has four main aims: to develop a competent, flexible nursing workforce; update career pathways; prepare nurses to lead in a changing healthcare system; and modernise the image of nursing.

The government’s appetite for more policy continued last year when it published its Our NHS Our Future interim report, setting out a 10-year plan to make the NHS a more personalised service for patients.

And the decade is ending with a full review of the NHS being carried out by junior health minister Lord Darzi, which probably means more change, reorganisation and policy is on the horizon.

Overall, the past decade has been one of opportunities for the nursing profession – albeit opportunities that have come at a price, according to Professor Buchan. ‘We’ve made some significant progress in terms of pay and career structure but nurses continue to be challenged and have heavy workloads.’

‘I am enjoying nursing – Every day is different and that’s what I like’

Jeannie Jones, who works on an acute medical ward at Mid Cheshire Hospitals NHS Foundation Trust, is pretty typical of today’s newly qualified nurse – slightly more mature, with children, realistic, hard-working and confident.

Jeannie, aged 35, qualified last September with a degree in nursing from the University of Cheshire.

‘I had always been interested in a career in healthcare of some kind, however it never materialised,’ says Jeannie, who has two children aged 12 and 10.

‘I ended up in the army at 17 and I was living abroad for a while with my husband, who is a serving soldier. I left the army in 1994 to look after my children.

‘It was really a series of fortunate coincidences that allowed me to go into nursing. My husband works away and my father was retiring, which allowed him to look after the children. Paying for professional childcare would have been horrendously expensive.’

Jeannie admits she was worried she would not be able to find a job on qualifying but says: ‘I was one of the very lucky few who did get a post on qualifying. It wasn’t an area I was considering going into – I wanted to do sexual health at the time – but being a realist, I went for it.

‘I am enjoying nursing. It’s a challenging and worthwhile profession. Every day is different and that’s what I like.’

Today’s nurses are hard to compare with those in 1948, Jeannie adds, saying: ‘It’s a whole different environment and different age of technology. Nursing has come into itself and nurses are standing up and saying we are a profession and should be recognised.’

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