Primary, Intermediate Care and Public Health - Article Example

Primary, Intermediate Care and Public Health The delivery of health services has been a sector analyzed thoroughly regarding both its theoretical andpractical aspects. The common element of all studies has been the conclusion that nurse has a significant role in the provision of effective and appropriate health care services to the public in general but also in schemes targeting the cover of particular personal needs. In this context, it has been stated that ‘research has increasingly compared nurse led care with usual care for aspects of health care previously delivered by doctors; however, nurse led care does not have one meaning; nurse led care can be usefully viewed as a continuum with, at one end, nurses undertaking highly protocol driven, focused tasks (cardioversion, smoking cessation) and, at the other end, responding to far more diverse challenges in terms of clinical decision making, such as first contact care and rehabilitation’ (BMJ, 2005, 1). The role of the nurse has been recognized also by the authorized governmental bodies and as a result it has been decided that the authorities given to nurses should be increased in order for them to act more effectively regarding the support of the public health. In 2001 the UK government proceeded to the installation of a National Service Framework for older people. The scheme which was designed in order to ensure that the older people would be offered higher quality services was based on the following plans: limitation of the age discrimination and support of the person – centred care through the introduction of a series of integrated services. Moreover ‘a new layer of intermediate care was being developed at home or in care settings, while general hospital care was planned to be delivered by the appropriate hospital staff; also, NHS was committed to take action on stroke prevention, in the promotion of health and active life and a reduction in the number of falls for older people’ (National Service Framework for older people, 2001). Another important element of the above scheme was that older people would be offered integrated health mental services. Among the general principles, the above Framework contains the provisions which regulate all issues regarding the single assessment process, the primary and the intermediate care and the communication between older people and the medical staff. Specifically, regarding the responsibilities of nurses, this Framework set a series of rules that should be applied by nurses when delivering care either at a primary or an intermediate level. More specifically, in the Standard number Two of the above Framework and in the third Chapter (Care Trusts) it is stated that NHS would have the responsibility for the quality of single assessment process while it is explained that ‘Delivering the single assessment process will mean putting in place a framework to ensure good assessment practice by the professionals involved and to assist information sharing between professions; It will also involve working to agreed principles about best practice on assessment and care management’ (2.28). On the other hand, it is made clear that the quality of the single assessment process delivered to the older people will have significant importance for the government which would like to ensure older people that the above process have designed in order to identify and cover all their needs. Indicatively, it is stated that ‘for the older person, it will also mean far less duplication and worry - the fuller assessment can be carried out by one front-line professional and where other professionals need to be involved to provide specialist assessment this will be arranged for the older person, to provide a seamless service’ (2.29). In the above context, the responsibilities of nurses have been increased. This assumption does not mean that the number of nurses should be increased. In fact it is highlighted in the section number 2.30 that the single assessment process should be ‘properly targetted’, i.e. there will be no need for extra support medical staff (nurses) but there will be need for an accurate single assessment process and delivery of care that will be appropriate regarding the needs of the older people involved. On the other hand, it is stated that all medical staff involved in the above process should be staff should be ‘skilled in assessment practice and in multi-disciplinary working as well as in caring for older people’ (2.43). Moreover, it was considered as necessary that all medical staff should try to ensure that older people would be invited for assessment. Regarding the issue of intermediate care, it is stated in the National Framework (Standard Three, Aims and Objectives) that the priority of the NHS should be ‘to provide integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living’. Specifically, regarding the role of the care staff at this stage, it is noticed that the responsibilities of medical staff should be based on the following key elements: Key elements will be:  ‘a) Locally agreed protocols and care pathways will determine the precise arrangements within a particular intermediate care service, and ensure that at any time the locus for medical responsibility is clear. In most cases, the hospital based consultant will be a specialist in old age medicine but other specialties such as rehabilitation medicine, diabetic medicine or chest medicine may be involved if this best meets the older persons needs; b) a named nurse will be responsible for co-ordinating nursing care and for ensuring the effective transition between hospital and community based services; c) intermediate care services will always include a programme of active rehabilitation involving the contribution of one or more of the following: occupational therapy, physiotherapy, and speech and language therapy; d) social work is an integral part of the intermediate care service and the team should include a nominated social worker to be fully involved in the development of the teams practice; e) a clinical team leader will be accountable for professional development and clinical governance issues; f) new or increased support from care assistants may be required while patients recover independence within a rehabilitation programme following an acute event or after hospital discharge’. Although the above rules apply to the medical support staff in general it is necessary that they are all mentioned because in most cases nurse has a series of roles including these of the social worker or the team leader. It has to be noticed that apart from the above duties a nurse may have to proceed to additional support towards older people like home safety checks (in case that there is no medical staff of other category, e.g. social worker, available at that moment to perform this task). It should be mentioned here that ‘intermediate care’ refers to ‘services intended to bridge the gap between hospital and home for people who require the type of support that blends medical and social contributions’ (British Geriatrics Society, 2001, 433). In the above context, the care offered by nurses should be evaluated in accordance with the standards referred to each particular case and there could be no action decided on the needs in general (as a ‘collective’ issue). Under the rules that have been planned in order to enhance the effectiveness of the above Framework, a new set of responsibilities is imposed on nurses. More specifically, in accordance with the recent version of this Framework (2006) the nurse will be given an advanced role in order to help older people to face their health problems successfully promoting at the same time their level of living. In the above context it is stated that the new provisions regarding the role of nurses in the application of the National Service Framework for older people have focused ‘on patients with the most complex needs and the role of the community matron, drawing on the experiences of those places already delivering services in new ways’ (Philp, 2006, 42). The need for reform regarding the role and the duties of medical staff has been regarded as necessary because of the changes that have taken place in society, changes that have imposed a differentiation to all governmental plans that refer to the personal needs of the citizens, especially the health. The above assumption is supported by the above researcher as follows: ‘The changing demographics of our society present us with a tremendous challenge – and a once-in-a-lifetime opportunity if we grasp it. By 2007 there will be more people over 65 than under 18. The over 85s are the fastest growing segment of the population, set to double in number by 2020’. (Philp, 2006, 1) The above framework has been extensively analyzed by the medical researchers. In this context, it has been stated that this model ‘requires there to be comprehensive assessment, active rehabilitation, and medical leadership involving both hospital specialists and general practitioners; It will also ensure the involvement of older people in patient forums, the local strategic partnerships, and the development of personal care plans that reflect individual needs, circumstances, and priorities’ (Philp, 2001, 323). From another point of view it has been noticed that ‘a return to the ethos of the workhouse wards (diagnostic failures, inadequate treatment and rehabilitation, long stays, complications), only recently removed from our NHS, seems quite probable but will clearly cost more than before’ (Ebrahim, 2001, 25). On the other hand, to a report published by NHS in it has been stated – with a reference specifically to the single assessment process – that ‘the Single Assessment process will ensure older people receive an appropriate, effective and timely response to their health and social care needs, both in terms of earlydetection of risk factors, and appropriate case management’. As for the intermediate care it has been supported that ‘Rehabilitation services in hospitals and in the community have been in decline over the past few years’ and that under these terms ‘Health, social care, and independent sector providers need to work together to develop imaginative and accessible models of intermediate care if older people are to have the opportunity to attain their maximum potential following a fall’ (NHS, 2002). Regarding the role of nurse in the intermediate care it has been stated by Wiles et al. (2003) that at a first level this role should be considered as extremely valuable. However, because the responsibilities ‘imposed’ on nurses in accordance with the relevant governmental rules, it is necessary that the plans related with the intermediate care are examined in order to be evaluated as of their applicability in real terms. At a first level it is accepted by Wiles et al. (2003, 1) that ‘intermediate care currently forms one of the UK Governments main initiatives for improving the quality of post-acute care’. Furthermore, the above researchers examine ‘patients’ and carers’ experiences of a nurse-led unit, which aims to provide intermediate care for people no longer acutely ill’. Their study which is based on ‘findings from qualitative interview data’ is led to the result that ‘patients viewed this model of care as acceptable but that they had markedly inconsistent experiences of care and reported considerable variation in their perceptions of the Units purpose’ (Wiles et al., 2003, 1). From another point of view a research made by the British Medical Journal in 2001 revealed that ‘transferring patients to a low technology unit, where nurses rather than doctors manage recuperation after acute illness, is a safe alternative to conventional care on a general medical ward’ (British Medical Journal, 2001, 1). In other words, in UK the governmental plans related with the provision of advanced intermediate care services by nurses had been proved as well structured but no effective at least to the point that their planners would have primarily thought. In order for the above plans to be effective, a series of changes has to take place involving not only to the responsibilities imposed on the medical staff but also to the support offered to this staff by the government. The provision for the personal needs of medical staff in general (including nurses) has to be a priority for the government. An issue that has been probably underestimated by the Department of Health is the number of nurses working in UK. At this point it should be noticed that the National Service Framework for older people as described above have in practice limited the need for nurses as it focus mainly on the quality and the accuracy of assessment provided and not so much on the number of cases in which a nurse participate on a daily basis. As a result of the above governmental regulation, the number of nurses in UK is relatively limited (if taking into account the targets set by the government when designing the above plan). More specifically, a research made in the healthcare industry of Britain revealed that ‘1,439,000 people aged 16 and over were employed in the healthcare sector out of the total workforce of 22,932,000 in England and Wales; of the 1,439,000 healthcare workforce 1,350,000 (94 per cent) were working in England and 90,000 (6 per cent) in Wales; the healthcare sector workforce for England and Wales included 110,000 doctors (8 per cent), 20,000 dentists (1 per cent), 356,000 nurses (25 per cent) and 24,000 midwives (2 per cent); these four occupations together made up more than a third (35 per cent) of the entire healthcare workforce’ (Office for National Statistics, Winter, 2006, 32). It should be noticed however that the number of nurses working in the healthcare industry should be evaluated primarily in accordance with the intervention required in each particular sector. In the area of the literature it has been found that ‘professional nurses experience increasing workplace demands from inside and outside the hospital while the internal pressures of patient care and a traditional organizational hierarchy are coupled with external factors such as medical reimbursement guidelines and competition from other healthcare providers’ (Arneson et al., 2003, 35). In the above context, Lego (1999, 12) referred to the study of Maloney (1971) who stated that ‘the nurse’s unique and independent function was the management and supervision of the patient’s environment’ but also to the research of Lewis (1957) who saw ‘the nurse’s unique faction as ward organizer, as well as norm bearer, interpreter of nursing care orders, treatment facilitator, initiator of group activities, mirror of reality, overseer and ward administrator’. To a similar theoretical basis, Norris (1963) predicted ‘that the nurse’s roles would include therapist, cotherapist, diagnostician, casefinder and consultant’ (Norris, 1963, in Lego, 1999, 12). However, in practice the demand for nurses is extremely high and for this reason the planners of the governmental schemes in this industry should offer an appropriate and effective support to nurses in all medical areas. The quality of health services provided to the public in UK is being examined by the Department of Health on a continuous basis. On a relevant report of this department published in 2006 ‘the vast majority of NHS patients receive safe and effective care, however in the modern, increasingly complex health service that treats 1 million patients every 36 hours, mistakes can and will inevitably happen; often it is systems that have failed, rather than any individual being at fault’. Moreover, in accordance with a statistical report published in Winter of 2006 it has revealed that ‘people living in more deprived areas have higher mortality rates than those living in less deprived areas; a fact that has been proved to be true for both sexes and for all the age ranges considered – all ages, 15-64 and 0-74; while the all age death rate for males living in the most deprived wards in England and Wales was 1.7 times higher than for males living in the least deprived wards; the female death rate was 1.5 times higher in the most deprived areas than in the least deprived’ (Health Statistics Quarterly, Winter 2006, 32). The above reports can be used in order to evaluate – among other issues – the effectiveness of the governmental plans regarding the role of nurse in the provision of health care services in general. According to the above results the plans related with the involvement of nurses in the delivery of health care services – at least as structured – have not achieved the required results. A more detailed approach of the whole issue is required in order for the role of nurse to be accurately identified and supported. References British Geriatrics Society (2001) Intermediate care: More than a ‘nursing thing’, available at http://ageing.oxfordjournals.org/cgi/reprint/30/6/433.pdf British Medical Journal, BMJ (2005) Nurse-led care, available at http://www.bmj.com/cgi/content/full/330/7493/682 British Medical Journal, BMJ (2001) Could Nurse-led care help to unblock NHS beds? available at http://www.eurekalert.org/pub_releases/2001-02/BMJ-Cnch-2202101.php Department of Health (2006) ‘Quicker, easier reporting of incidents and stronger local focus to help improve patient safety’, available at http://www.gnn.gov.uk Ebrahim, S. (2001) Proposals for intermediate care are reinventing workhouse wards British Medical Journal, 325-328 Heatlh Statistics Quarterly, 2006, 32, available at http://www.statistics..gov.uk Lego, S. (1999) The One-to-one Nurse patient relationship. Perspectives in Psychiatric Care, 35(4): 4-30 Lewis, E. W. (1957) Identifying some concepts nursing personnel need to understand in relation to the nature of therapeutic functions. National League for Nursing, 30-39 Maloney, E. M. (1971) The subjective and objective definition of crisis. Perspectives of Psychiatric Care, 9(6): 257-268 National Service Framework for older people (2001) Department of Health, available at http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4003066&chk=wg3bg0 NHS (2002) Implementing the National Service Framework for older people, available at http://www.beh.nhs.uk/enfieldpct/pdf/falls_report_intro.pdf Norris, C. (1957) The nurse and the crying patient. American Journal of Nursing, 57: 323-327 Office for National Statistics (2006), available at http://www.statistics.gov.uk Philp, I. (2001) New beginning for care for elderly people? British Medical Journal, 323-325 Wiles, R., Postle, K., Steiner, A., Walsh, B. (2003) Nurse-led intermediate care: patients’ perceptions, available at http://www.citebase.org/abstract?id=oai:eprints.soton.ac.uk:35120 Read More