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Setting priorities for local services

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Lesley Strong, MA, BSc (Hons), RN, DN, HV, Dip Unv London.

Director of Community Nursing, Mid-Sussex Primary Care Trust, Haywards Heath Hospital, Haywards Heath, West Sussex

The provision of health care is made in an ever-changing environment. Demographic changes mean that the population is ageing and chronic disease increasing. Patients' expectations are changing, and there is an increase in the information they can access. Patients want more control and choice and high-quality treatment. The advances in technology mean that more care can take place within a primary care setting. To meet these challenges significant changes need to take place in the way health care is delivered.

The provision of health care is made in an ever-changing environment. Demographic changes mean that the population is ageing and chronic disease increasing. Patients' expectations are changing, and there is an increase in the information they can access. Patients want more control and choice and high-quality treatment. The advances in technology mean that more care can take place within a primary care setting. To meet these challenges significant changes need to take place in the way health care is delivered.

National and local initiatives
There has been a wealth of initiatives on national priority setting over the past few years, starting with The NHS Plan (DoH, 2000). A range of National Service Frameworks (NSFs) has set further targets.

In addition to national initiatives, each local health area has drawn up its local priorities through a health improvement and modernisation plan (HIMP) (DoH, 2001a). This has been followed up by the priorities and planning framework for 2003 to 2006 (DoH, 2002a). This sets out what is expected of local NHS and social-care organisations over the next three years.

These disparate plans have now been drawn together into a single three-year local delivery plan, which will identify milestones for each primary care trust (PCT). To achieve these milestones each PCT needs to follow six steps (Box 1). These will need to be supported by a financial strategy. Priority areas need to be identified and each will encompass key targets. Local delivery plans consist of three main strands:

- The national targets, set out in the priorities and planning framework

- Identified local priorities

- Proposed NSF targets, such as the NSFs for children and renal services.

The local delivery plan is an evolving document, which is amended as appropriate.

Implications for nursing in the PCT
Mid-Sussex PCT covers a population of 144 000. It provides a range of community nursing services and has strong primary care services.

One of the key features of the priority setting for the PCT is to involve local staff in planning. Nurses should be at the forefront of change and be prepared to use the wide knowledge they have of their patients and the communities within which they work to set realistic and robust targets.

Since its formation this PCT has held a regular consultation process through its 'annual college' - an open space event offering participants, which include staff, other agencies, voluntary organisations and users, the chance to raise topics for discussion and to develop key actions on the basis of the debates. These actions are then fed into the local priority-setting agenda and are included in the business planning and HIMP formation.

At the last annual college held in November 2002 the issues raised have been included as key priorities in the development of the local delivery plan. This event has always been well attended by nurses who, alongside other health professionals, have actively contributed to the discussions.

One of the key actions identified at the forum was a need to set out clearly how community nurses could respond to the identified priorities.

It was suggested that this could be achieved by developing a robust nursing strategy. This would set out the nursing contribution to the national and local priorities.

Nursing strategy
The nursing strategy group was formed from a variety of clinicians who were highly motivated to develop a vision of nursing in the PCT. Their challenge was to ensure the nursing strategy represented priorities in the NHS both nationally and locally and also reflected the contents of pertinent documents such as Making a Difference (DoH, 1999) and Liberating the Talents (DoH, 2002b).

The nursing services must be able to respond to local expectation and needs and be able to work in new ways with new roles to respond to these. Key to success is the provision of integrated care working in partnership and empowering both practitioners and the community. Above all is the need to ensure provision of high-quality care.

The first task was to define a vision that would encompass all these elements. A series of workshops and open forum meetings were held to ensure all staff were able to offer their views. Interestingly, one of the greatest difficulties when agreeing the vision was the use of the word community. This was also a mark of the divisions between the different groups with health visitors preferring the use of the term clients, and district and practice nurses using patients. The final agreed definition of 'community' was seen as drawing all these elements together and as a way forward to working in a new way together.

Vision statement
The vision statement: 'We are committed to working together as professionals within the community, creating an environment where we are inspired to strive for innovation, excellence and empowerment' was eventually agreed upon.

The task then was to develop this vision into a set of five main aims to underpin objectives:

- Promote integration, reduce professional boundaries

- Focus on the individual's experience

- Establish information policies that support the empowerment of the individual

- Establish a management and leadership framework that supports and empowers staff

- Emphasise learning and growth to support innovation and inspiration.

Each aim has key objectives and is supported by an action plan as follows (see also Box 2):

- Implement the single assessment process

- Ensure every patient has an agreed care plan, which forms the basis of a contract between the patient and professional; and which is reviewed regularly

- Ensure informed consent is robustly pursued

- Establish patient education as fundamental to the care process - Ensure every patient is appropriately supported to make their own care choices

- Establish a culture that values patient choice and empowerment

- Ensure provision of high- quality, evidence-based care.

Future challenges
Development of the strategy was the first in a series of many challenges. The nurse strategy group must now implement the strategy. The progress of this will be monitored via the clinical governance subcommittee.

The next challenge is to ensure that all nurses are aware of the strategy and how they can contribute. Most of the group membership was drawn from senior staff and staff at all levels must now be engaged.

Although this is named as a nursing strategy we need to ensure a joined-up approach to patient care. The third challenge therefore is to engage other staff groups in the work. This was recognised at an early stage and the future groups will include allied health professionals and, in time, social-care staff.

Conclusion
The success of this approach to priority setting depends on having sufficient money in the system to meet the large number of targets. It is also crucial that nurses are not only aware of the targets but actively contribute to meeting them.

In Mid-Sussex this has been achieved through the PCT's annual open forum and the development of the nursing strategy, which has formalised the nursing response to the many different areas.

This has been a significant piece of work and raised the nursing potential and profile locally.

Department of Health. (1999)Making a Difference. London: The Stationery Office.

Department of Health. (2000)The NHS Plan. London: Department of Health.

Department of Health. (2001a)Health Improvement and Modernisation Plans Requirements for 2002. London: Department of Health.

Department of Health. (2001b)The Essence of Care. London: Department of Health.

Department of Health. (2002a)Improvement, Expansion and Reform: The next three years' priorities and planning framework 2003-2006. London: Department of Health.

Department of Health. (2002b)Liberating the Talents. London: The Stationery Office.

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