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Blog: An open letter to Professor Steve Field

Although the new chief inspector of primary care has already highlighted the importance of community and primary care nurses, Heather Henry thinks independence and interconnectedness could be the key to improving healthcare

Thank you, Professor Field, chief inspector of Primary Care, for highlighting the importance of primary and community nursing, and the role that they could take in helping to manage demand and deal with long term conditions more effectively in the community.

Organisations like the NHS Alliance, RCN and Queen's Nursing Institute have been shouting about this for years. Might I, at this point, offer some thoughts to assist you as you look to the future of how on earth to handle the tidal wave of demand?

In my view, skill mixing, increasing nursing numbers and re-educating are just tinkering with the engine - although a focus on falling district nursing numbers does need urgent attention, just as health visitor numbers did before that. We need a new vehicle entirely which will not engender more dependency, thus fuelling demand. In terms of long term conditions, a review of community nurse education should have an evidence-based focus on wellbeing as much as illness. And a rebalance of independence and interconnectedness. Five ways to wellbeing is a start, but oh, we could do so much more, given the chance, to help our patients, families and communities feel in control, have a reason for living, feel connected and have the confidence to live the lives they want. Nurses of the future will understand that they don't always have to care for; they can enable communities to care for themselves. We wish we had Scots Chief Medical Officer Sir Harry Burns in England to trumpet a glass half full approach and the clinical evidence for what I just wrote. We wonder whether you, Professor, will be the English flag waver, because we are sadly falling behind the Scots, Welsh and Irish.

Common purpose

We urge you to consider that nurse education is beyond curriculum development. It also includes experiential learning from our own practice and from exposure to others. Since I was made compulsorily redundant from the NHS two years ago I have learnt a huge amount about public health from fire and rescue, housing, neighbourhood teams in councils and the police - things I'd never have learnt otherwise. But current culture mitigates against this. Heavy workloads, territorialism, competition, austerity, clashing priorities and geographical distance force us to cling to our organisations. We need to find ways, as you rightly say, to bring nursing and related disciplines together. We nurses do have a bit a reputation for 'eating our own' it is true. But I tell you this; it will not be improved by top down diktats. What we need, as my good friend Hazel Stuteley always says, are what we call 'serial connectors'. People who connect others together, with common purpose, to rally the nursing troops to the cause and to share common values- because at the bottom of it all, we all care for our patients deeply. Serial connectors need to be valued and given the freedom to do what they do best. 

Please don't condone artificial 'calls to action', which may or may not reflect local priorities, let us discover our own, by listening to our communities (not consulting them). Let us first look at joint strategic asset assessments and think through how nurses might engage with them, rather than constantly focus on JSNAs. Residents priorities rarely reflect them and they are wary and indeed fed up of being 'fixed'.

Clinicians alone will not solve the problem of managing long term conditions. Only when we embrace communities, carers and patients themselves as partners - not just as 'expert patients', people who tell us their ' experience' or (massively unsupported) carers but as assets with complementary gifts of their own. In a now-famous animated video, “The Parable of the Blobs and Squares”, Edgar Cahn describes organisations as “squares” whose measure-and-tick-box approach misses the point of what really happens in communities. Likewise the “blobs” in communities lack the know-how to change their own destinies. The point Cahn makes is that we can't change the blobs into squares as it changes their very strengths. I wonder how much we try to make patients and carers in our own image- 'expert patients' springs to mind here. I'm not knocking it, I'm saying we should enlarge that concept beyond pathogenesis to salutogenesis - how health is created. Tell NICE to shove issuing guidance on asset-based approaches to the top of the pile and connect them to the Health Foundation who is currently doing a meta-analysis. Ask Public Health England why they are not thinking about this, because DCLG certainly is, and the NHS is looking increasingly foolish.

And please, when you're briefing Health Education England and LETBs, can you ask them to put something in there about nurses helping patients to use their strengths, as well as correct their deficits. 

Also, when we 're-educate' community nurses, might we slip a little something extra in there about inequalities, as Sir Michael keeps reminding us that it's getting worse, not better and it's not just a social injustice to me, it's a crime. So we need those housing, police, education, council and fire people to connect with nurses. Nurses can co-produce not only with patients but with those that influence the social determinants of health too!

Breaking boundaries

Community nurses, like other primary care professionals, can be natural entrepreneurs. During snowy weather in Somerset , district nurse Michael Palmer ensured the delivery of milk and bread to vulnerable elderly people so that they did not risk falling by going out to shop. So please add a sprinkling of support for entrepreneurship into your thinking - big up and expand the Nurse First programme at the QNI and let nurses try new stuff and even fail, for it's the only way we will learn what works.

Hopefully you will also remember the nurse assets in the third sector, social enterprise and the independent sector in your thinking. I have huge admiration for occupational health nurses for instance and they could be better connected to GP practices, the community and secondary care so as to keep people with long term conditions in work. When mass redundancy strikes, it makes not only workers but whole communities ill and OH nurses could play a huge part in building community resilience if they were taught how, because nurses are still hugely respected and listened to by residents. We at the Alliance can tell you how to do these things. We need to break boundaries not reinforce them.

Part of me hopes we will reach crisis point in managing long term conditions, so assets such as patients, carers and community will be press-ganged to help, as they will have no choice but to look after themselves, as my great-grandmother did on the streets of Darwen, tending to neighbours and friends at the coming and going of life. But with the profile and influence you have, Professor, we at the Alliance hope that it won't come to that.

This article was originally published on the NHS Alliance website