Health Policy and Professional Practice - Assignment Example

? A Critical Analysis of a Current National Health Policy Nurses are the backbone of any health care setting. Due to their proximity with the patients they are able to guide both the patient and the physician in the treatment aspects of the patient leading to improved clinical outcomes. In cancer management too, nurses, especially the Clinical Specialist Nurses play a major role in the care and management of patients suffering from cancer. The importance of Clinical Nurse Specialists has been emphasized in various surveys that were conducted to evaluate the implications of cancer reform strategies in England (NCCP, 2005). The purpose of this essay is to discuss and critically analyze the Cancer Reform Strategy implemented by the Department of health in 2007 with reference to Clinical Nurse Specialist. The main focus of this essay will be on the Cancer Reform Strategy of 2007 (DOH, 2007). Various historical events related to cancer care that have influenced the development of the cancer Reform Strategy will be discussed. The essay will also examine the role of Clinical Nurse Specialists that has evolved as various developments took place in cancer care in England. In the mean time, various proposals of the coalition government, their policies, the role of Clinical Nurse Specialists and the implications of these policies and services on the patients will be discussed and critically analyzed. The role of the Clinical Nurse Specialist. Cancer is one of the major public health challenges all over the world including England. According to DOH (2007), each year, about 230,000 individuals in England are likely to be diagnosed on cancer and more than half this number are likely to succumb to the disease. Thus, cancer is the leading cause of mortality under those 75 years of age. In 2005, 38 percent of premature deaths in population less than 75 years of age was because of cancer. 3 decades ago, the state of cancer therapy in England and other parts of UK were worst in the Western European region (DOH, 2000). Patients were referred late for treatment and those referred were diagnosed and treated late. There was no proper coordination between various health professionals and referrals were not made to the right place and in the right time. Also, there existed a wide gap and inequality in health care access. Those who were poor had poor access to health care facilities and were more likely to die once a diagnosis of cancer was established (DOH, 2000). Due to such and several other reasons, cancer patients in England has less survival prospects than those in other countries of Europe. For cancers like breast and bowel cancers, diagnosis was usually done in advanced stages due to lack of information for both the patient and general practitioner. Also, whatever services were available were patchy. The number of cancer specialists were less and the equipment for cancer detection, prevention, screening and management were outdated (Morries et al, 2007). The type of treatment delivered also was varied. While some received excellent care, others received neglected care in an insensitive manner. Long time periods of waiting and uncertainty of treatment outcomes harassed the patients. This was evident from the report by the Chief Medical Officers of England and Wales, popularly known as the Calman Hine report (1995), in which it was evident that the survival and services with reference to cancer had geographical inequalities. In this report, the authors suggested restructuring of cancer services in order to provide suitable access of cancer services to all communities, geographical areas and socioeconomic strata to high levels of expertise. They recommended improvements in cancer networks. In 1997, the government pledged that death rate due to cancer in those under 75 years of age will be reduced to by atleast 50 percent by 2010. It was then that the White paper for "Smoking Kills" was passed as a part of comprehensive tobacco control programme. The government also began to focus or energy and money for boosting up the quality of health care services (DOH, 2000). The first Cancer Plan Strategy published in 2000 was a "comprehensive national cancer programme" and had the following aims (DOH, 2000): "1. To save more lives 2. To ensure people with cancer get the right professional support and careas well as the best treatments 3. To tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals 4. To build for the future through investment in the cancer workforce,through strong research and through preparation for the genetics revolution, so that the NHS never falls behind in cancer care again." The NHS Cancer Plan was a 10 year plan led by Professor Mike Richards, the National Cancer Director in consultation with cancer patients and health professionals across the country. This plan was comprehensive, in the sense that screening for cancer, preventive measures, diagnosis, especially early diagnosis and various management strategies were brought under one single roof. In order to achieve such comprehensive cancer care, investment was made in adequate equipment, increased and improved staffing, medicines, treatments and also information systems (DOH, 2000). The plan was aimed to provide convenient but yet high quality and fast care, centered around the patient. According to the plan, cancer services are high priority with promises for continuous progress, research and development in the field of prevention of cancer and is treatment. In order to put the plan into action, an extra of ?570 million a year was allocated to fund the new approach cancer services. The target was to get 1000 new cancer specialists by 2006 and a further more of other specialists like cancer specialists nurses, radiographers, etc, as a part of action to cover the shortages which already existed. The Cancer Plan 2000 also aimed at increasing public awareness about cancer. Information pertaining to cancer was to be made more available and accessible so that signs and symptoms pertaining to cancer are easily recognized in early stages, when treatment strategies are more effective. For this, the government proposed to tie up with various voluntary organizations for education and information delivery. Under the extended cancer screening programme of the plan, it was estimated that by 2010, an extra of 400,000 women would be screened for breast cancer each year especially for those between 65- 70 years of age (DOH, 2000). The cervical screening programme and colorectal screening programme was to be upgraded and prostate-specific antigen testing for prostate cancer was planned to be made available along with information about the benefits and risks associated with the test so that men in the country would be empowered to make their own choices. At that time, trial for lung cancer screening and ovarian cancer screening also were underway. The plan also targeted to improve cancer services in the community. This is because; community nurses, general practitioners and family doctors have a major role to play in the early detection, screening and prevention of cancer and follow up management of patients with cancer (DOH, 2000). Palliative care also received lot of importance. The aim of palliative care is to relieve the patient of suffering, promote function of the patient, deliver help to meet the daily living needs of the patient, provide psychosocial support to the patient and also the family of the patient and clarify goals of care and associated treatments. The four cardinal principles of palliative care are non-malificence, beneficience, patient autonomy and justice. These principles need to be applied in the perspective of respect for life, acceptance of the fact that death is inevitable, provision of treatments which take care of the ongoing suffering, striving to preserve life only as long as life is not a burden and beyond that only asserting life, and also individual needs and that of the society (National Cancer Control Programme, 2005). The 2000 plan also included partnership between the National health Services and Macmillan Cancer relief for providing ?3 million every year for the purpose of supporting a lead clinician every year for directing cancer services within a PCT and also ?2 million every year for the purpose of training and support of various community and district nurses providing palliative and hospice care (DOH, 2000). Since the implementation of NHS Cancer Plan in 2000, the outcomes of cancer management have improved. Mortality related to cancer in under-75 age group dropped by 17 percent between 1996 and 2005 (DOH, 2007). This means that 60,000 lives were saved during this period due to cancer plan. Year after year, the survival rates for some difficult cancers like breast cancer and bowel cancer have been improving on par with other countries in Europe. Patients themselves have reported better care and management by health professionals. The anti-smoking measures taken by the Cancer Plan 2000 have led to better preventive measures and this is evident from drop in smoking rates from 28 percent in 1998 to 24 percent in 2005. This amounted to decrease in the number of smokers by 1.6 million. The plan also led to increased screening and increased early diagnosis of breast cancer. The bowel cancer screening programme for both men and women was launched. The plan led to faster and accurate diagnosis and quick initiation of treatment, thus decreasing wasting time. More than 99 percent of patients referred by general practitioner with a suspected diagnosis of cancer are seen in less than 2 weeks time and more than 99 percent of patients diagnosed with cancer are initiated with cancer treatment within one month of diagnosis. Access for cancer treatment also improved after implementation of the plan. There has been adequate purchase and installation of various equipment including MRI scanning machines, CT scanners and linear accelerators including development of new cancer centers. Also several new posts for clinical nurse specialists were established for improving support, information and care of patients suffering from cancer. Even support, development and expansion of various hospice and palliative care units occurred and more than 1500 multidisciplinary teams came up. Redesigning of services have occurred and complex surgical procedures are being done only by surgical specialists. There has also been an increase in the cancer network coordinate services across various levels of care for patients from different organizational boundaries. Establishment of National Cancer Research Institute has occurred which helped the collaboration between interested research funders and researchers. In 2007, the Cancer Reform Strategy was implemented. According to the Cancer Research UK (DOH, 2007), the following were the priorities set: "•Clinical outcomes data and evidence-based policy • Investment, workforce and capacity planning and efficiency • Supporting cancer research and improving access to clinical trials • Prioritizing cancer prevention • Tackling inequalities • Improving early presentation, detection and screening • Ensuring access to new treatments • Providing high quality, tailored information to patients • Developing the cancer networks • Reconfiguring cancer services to deliver improved outcomes" The role of Clinical Nurse Specialist is discussed under the 5th chapter of the Cancer Reform Strategy and in the same chapter various benefits of the role of these specialists with reference to the experiences of the patient are listed. In 20 percent of the multidisciplinary teams, involving gynaecology, lung, upper gastrointestinal tract and urology specialities, shortfalls in the role of Clinical Nurse Specialist was noted. Even variations in case load of these specialists was noted. Those working in gynaecology and breast tumor units had cases load of 78 per whole time equivalent and those working in urology and lung tumor groups had a case load of about 123- 132 patients per whole time equivalent. The vision of the Cancer Reform Strategy was to provide all patients with cancer with an access to Cancer Nurse Specialist. Such an access, according to the strategy would decrease the amount of money spent by the National Health Service on the patient, through coordination of patient care economically and appropriately and by reducing replication of patient care (DOH, 2007). The role of Cancer Nurse Specialist in the care of cancer patients is significant and the origin of the role of concept of such specialist care in cancer care. Infact, there has never been a structured framework for the introduction of such a role. According to the National Collaborating Center for Acute Care (2005), there exists no economic benefit to support the role of specialist care for lung cancer with regards to treatment or diagnosis. Despite no evidence for economic benefit in cancer care, the center recommends that all cancer centers need to possess more than one Cancer Nurse Specialist. As far as prostate cancer patient guidelines are concerned, there is no specific mention of Cancer Nurse Specialist, but the guidelines stress the importance of providing individualized information to all cancer patients. In various cancer related guidelines published by NICE (NICE accessed 8th July, 2011), the role of Cancer Nurse Specialist is emphasized. The role of these specialists emerged either to decrease the workload of the medical staff or to extend the role of existing nurses. The benefits of Cancer Nurse Specialists is documented. According to the Macmillan Cancer Support (2010), patients receiving care through Cancer Nurse Specialists has consulted doctors less, thus saving consultation time of the doctors and decreasing costs for the national health Service. The National Cancer Patient Experience Survey Programme (DOH, 2010) is a national report that mainly provides insight in to the experiences of patients with care with regard to the care provided at health service corners across England both as outpatient basis and in-patient basis. According to DOH (2010), the survey was designed to "monitor national progress on cancer care; and to provide information that could be used to drive local quality improvements; and to help gather vital information on the Transforming Inpatient Care Programme, the National Cancer Survivorship Initiative and the National Cancer Equality Initiatives." The survey was conducted during the first 3 months of 2010. In this survey, 158 trusts affiliated to NHS were identified as cancer service providing health care units and 67,713 patients chose to participate in the survey. This amounted to a response rate of 67 percent which indicates the willingness of patients to respond to surveys pertaining to their services so that improvement in the quality of services can be done. In this survey, patients with all types of cancers were involved. From the results of the study, it was evident that, most patients provided a positive report on the care provided to them by the health care services (DOH, 2010). More than 90 percent of the patients waited less than four weeks between the referral time and time of first hospital visit. 85 percent of the patients reported that the health professionals tried everything to control pain, 84 percent of the patients reported that they trusted and had confidence in the doctors who treated them and 82 percent of the patients reported that they were treated with respect and dignity which is very important for terminally ill patients with cancer. On the other hand, aspects which not reported positively were provision of information, especially of financial help, collaboration of work between hospital clinicians and community health professionals and adequacy of staff when admitted to hospital (DOH, 2010). From the Guy`s and St Thomas` NHS Foundation Trust, 1068 patients responded. The highest number of respondents were those from breast tumor group. 89 percent of the patients reported that they were given the name of the Clinical Nurse Specialist who were taking care of them. 68 percent mentioned that they found it easy to contact their nurse. 90 percent of the patients reported that the Clinical Nurse Specialist listened to them carefully and answered questions in an understandable manner (DOH, 2011). The most positive aspect that merits importance in this survey is the care delivered by Clinical Nurse Specialists. More than 90 percent of the patients reported that their Clinical Nurse Specialists listened to their woes and problems carefully and delivered answers and solutions in a manner understandable to the patients. Another important finding in this survey was that those who were taken care of by clinical nurse specialist reported in a much favorable manner when compared to those without such a nurse, in terms of delivery of information, patient care and choice (DOH, 2010). Thus, the survey indicates that when compared to the comprehensive survey in 2000, with regard to inpatient treatment and outpatient services, cancer patients are more satisfied and this appears to be mainly due to increase in the number of Clinical Nurse Specialists. According to the Independent Cancer Patient's Voice (2010), "Clinical Nurse Specialists for all tumour groups are essential and their role must be protected and enhanced. There needs to be provision for patients with less common cancers and for those with secondary disease." For many patients, Clinical Nurse Specialists have made a huge difference in cancer management and care and also outcome. For cancer patients, priority is to provide adequate clinical nurse specialists, because; "they are seen as the key-worker, pathway coordinator, family support and main source of readily available expertise, advice and support." It is very important to protect their role and fund them appropriately because; they save the money of National Health Service by preventing duplication, preventing unreasonable admission and readmission and also be reducing the need to attend clinics. They also decrease distress and anxiety (Independent Cancer Patient's Voice, 2010). According to the Independent Cancer Patient's Voice (2010), the role of clinical nurse specialists is to "enable earlier discharge from hospital, facilitate a quick response to problems, explain treatments and expected “pathway”, help to cope with difficult information/emotional feelings and psychosocial care of patient, signpost patients to more help, recognize the needs of carers, run rapid access & triage clinics, provide continuity of care and continuity in follow-up clinics." Clinical Nurse Specialists save money to the NHS by “enabling earlier discharge from hospital, facilitating a quick response to problems, explaining treatments and expected “pathway”, helping to cope with difficult information/emotional feelings and psychosocial care of patient, signpost patients to more help, recognizing the needs of carers, running rapid access & triage clinics and providing continuity of care and continuity in follow-up clinics.” They improve the experience of the patient by “ helping to cope with difficult information/emotional feelings, explaining clinical information in a clear and comprehensible way, providing psychosocial care of patient, signposting patients to more help, recognizing the needs of carers, running rapid access & triage clinics and providing continuity of care and continuity in follow-up clinics.” Clinical Nurse Specialists have a distinct role in palliative care which is an integral part of cancer care. Palliative care is “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (WHO, 2009). The nurses are specifically trained in pain management. The corner stone of palliative care in terminally ill cancer patient would be pain relief. The pain management in these patients must be guided by the cancer pain management protocols. The 'analgesic ladder' approach of pain management by the World Health Organization (WHO, 2009)is an useful guide to management pain. Since most of the times, pain in terminal illness patients is associated with many other psychoemotional symptoms, Clinical Nurse Specialists provide psychological interventions also keeping in view holistic perspective of chronic pain. The nurses deliver educational interventions aimed to help the patients understand assessment of pain so that barriers to the treatment of pain are overcome (Keefe, Abernethy and Campbell, 2005). Education and training will also be delivered to caregivers and family members to increase the psychological and social dysfunctioning of the patient (Keefe et al, 2005). Clinical Nurse Specialists are a part of palliative care team. Palliative care is a team driven care approach. Palliative care is possible only through integration of the physical, emotional, social, psychological and spiritual aspects of life. The main caregiver in a cancer patient is the nursing staff, especially the Clinical Nurse Specialist. The activities of the team are coordinated by the primary care physician. Other team members include hospice physician, nurses, home health aides, social workers, clergy, trained volunteers, and other therapists like speech, physical and occupational therapists. The team outlines individualized medical and support services which includes nursing care, personal care like bathing, dressing and taking to toilet; physician visits, social services and counseling (NHPCO, 2008). The team also decides on the tests and procedures to be done on the patient, the medicines and other treatments to be given and the required medical equipment that should be around the patient (NHPCO, 2008). The ultimate aim of the team is high-quality comfort care (NHPCO, 2008). The Clinical Nurse Specialists are trained to assess, anticipate, treat and prevent certain physical symptoms which are the root cause for distress and discomfort. According to Mok and Chiu (2004), "Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse–patient relationships in palliative care." Nurses stay with the patients through their journey of illness to death. Thus, it is easy for them to connect to patients and establish a relationship with them. Only by establishing such a relationship will the nurses be able to deliver the best possible care and meet the levels of satisfaction of the patient. According to Mok and Chiu (2004), "involvement represents encounters that emphasize the importance of being concerned, interested and giving." Actions of care, appropriate attitudes and trustworthiness not only establish a connectedness with patient, but also help in the improvement of physical and emotional state and help them go through the journey of death with peace. Dignity is another issue which needs to be addressed in cancer care and is done by Clinical Nurse Specialists. Due to heavy reliance of the patient on the nursing staff and other caregivers, the sense of dignity in the cancer patient can get eroded. Thus it is utmost important to maintain dignity in palliative care. There is no clear-cut definition for the concept of dignity. Though there have been many definitions for dignity, the main theme in all definitions from a nursing perspective has been 'respecting a person as a person' (Hall, Longhurst and Higginson, 2009). In one study, the researchers identified 3 main themes of dignity, namely, the unrecognizable body, fragility and dependence and inner strength and a sense of coherence. Dignity-oriented care provision can be applied by using many models, the most appropriate one for end-of-life being Chochinov's dignity-conserving model. This model was actually developed after analyzing the interviews with various cancer patients pertaining to what supports their dignity and what undermines it. Conservation of dignity is implied basically through addressing issues pertaining to illness, dignity conserving repertoire and also addressing various social aspects of the experience of the illness. Thus, it is clear and evident that Clinical Nurse Specialists have a major role to play in cancer care. Their role is emphasized in not only prevention, screening, early detection and treatment, but also in palliative care. References Cancer Research UK Policy Statement. (2007). Priorities for the Cancer Reform Strategy. Retrieved on 9th July, 2011 from www.cancercampaigns.org.uk/prod.../crukmig_1000ast-2665.pdf Calman–Hine Report . (1995). A Report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. A Policy Framework for Commissioning Cancer Services – The Calman–Hine Report. London: Department of Health. DOH. (2000). The NHS Cancer Plan. Retrieved from image.guardian.co.uk/sys-files/Society/documents/.../cancerplan.pdf DOH. (2007). Cancer Reform Strategy. Retrieved from www.dh.gov.uk › Home › Publications DOH. (2010). National Cancer Patient Experience Survey Programme. Retrieved on 9th July, 2011 from http://www.quality-health.co.uk/cancer-reports DOH. (2011). National Cancer Patient Experience Programme 2010 National Survey Guy`s and St Thomas` NHS Foundation Trust. Retrieved on 9th July, 2011 from www.guysandstthomas.nhs.uk/.../2010/.../ 20%20BOD%20Quality%20Safety%20Report%20Q1%202010.pdf Hall, S., Longhurst, S., and Higginson, I. (2009). Living and Dying with Dignity: A Qualitative Study of the Views of Older People in Nursing Homes. Medscape Today. Retrieved on 9th July, 2011 from http://www.medscape.com/viewarticle/710065 Independent Cancer Patients' Voice. (2010). Response to Professor Sir Mike Richards review of the Cancer Reform Strategy. Retrieved on 9th July, 2011 from www.independentcancerpatientsvoice.org.uk/.../CRS+review+Independent+ Cancer+Patients+Voice.pdf Keefe, F.J, Abernethy, A.P., Campbell, L.C. (2005). Psychological approaches to understanding and treating disease-related pain. Ann Rev Psychol., 56, 601 –630 Meier, D.E. (2002). When pain and suffering do not require a prognosis: Working toward meaningful hospital-hospice partnership. Innovations in End-of-Life Care, 4(1). Retrieved on 9th July, 2011 from www.edc.org/lastacts Mok, E. and Chiu, P.C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing ,48(5), 475–483 Menefee, L.A., and Monti, D.A. (2005). Nonpharmacologic and Complementary Approaches to Cancer Pain Management. Journal of American Osteopathic Association, 105(5), 15-20. Morris, E., Haward, R.A., Gilthorpe, M.S., et al. (2007). The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients. Annals of Oncology, 19(2), 284-291. National Cancer Institute. (2009). Pain. Retrieved on 9th July, 2011 from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/healthprofessional National Cancer Control Programme. (2005). Manual for Palliative Care. Retrieved on 9th July, 2011 from http://www.whoindia.org/LinkFiles/Cancer_resource_Manual_5_Palliative_Care.pdf National Hospice and Palliative Care Organisation (NHPCO). (2008). Caring Connections. Retrieved on 9th July, 2011 from http://www.caringinfo.org. Read More