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Community nurses: fight for your autonomy!

Cheryll Adams
D(Nurs) MSc BSc(Hons), RN RHV Dip Man
Independent Consultant
Health Visiting and Community Nursing Policy and Practice;
Honorary Visiting Senior Lecturer
City University

So often, when there is a need to make cuts in NHS expenditure, early victims are senior clinical posts and education and training. This mustn't happen again. What we need most at this difficult time are knowledgeable, effective clinical leaders and specialists. They have the opportunity and experience to articulate what needs to be in place to support all clinical staff to deliver cost-effective services. Moreover, as clinical specialists they are a critical resource for more junior staff, providing not only expert advice, but also training.

Over the years I have learnt a great deal from a variety of specialist nurses; those for incontinence, patient nutrition, immunisation and safeguarding children, for example. What has been so important to me about that learning is that it has been grounded in practice experience and research; and, as such, when I have applied the advice I have been given it has made a real difference to my clients.

I see nurse consultants and senior specialist nurses, the nurse practitioner in the GP surgery, the senior health visitor, the Parkinson's nurse and so on, as sitting at the peak of a pyramid of clinical knowledge. In terms of cost-effectiveness, I firmly believe that the benefits for patients from these specialists is of much greater order than their cost when compared to non-specialists. No one queries the need to have a raft of senior specialist doctors in hospital, so why are senior clinical nurses always so vulnerable? We must maintain these posts; indeed, I believe there is a strong case to increase their numbers.

Clarity of purpose
We can let the senior/specialist nurse post-holders demonstrate their value by monitoring and publishing their outcomes. Clarity of purpose is essential in any role but particularly for nurse leaders. The government may maintain some targets and provide helpful evidence-based policy, but the impetus is for service design to be agreed locally. Community nurses and health visitors must lead this process for their services, and insist on working directly with the new GP commissioners to plan strategies for delivering health improvement.

What has happened to services such as health visiting in recent years has become counterproductive to health gain. Rather than protecting the health and wellbeing of children, disinvestment by strategic health authorities and PCTs in many areas of England has led to health visitors finding themselves only able to be reactive to contacts from their clients, or to respond to the needs of conspicuously vulnerable families. As a result, that critical relationship formed with all families, which is the bedrock of good health-visiting practice, has become largely impossible to achieve. Without it how much postnatal depression and domestic violence, as well as safeguarding issues, go unrecognised? Health visitors will tell you they don't sleep at night worrying about this.

How often are interventions too late to prevent damage to children's emotional wellbeing; damage which we know may hamper their life chances as adults? Recent research by the London School of Economics demonstrated that a good-quality health-visiting service, which is able to intervene to support mothers with postnatal depression, can result in over £600m a year in improved earning capacity for the children of those mothers when they become adults. The study only considered this one outcome, but how much more would be saved from, for example, a reduced need to use mental health services? We don't yet know.

Positive health improvement
It is now more important than ever to restore professional autonomy to community nurses and health visitors, and alongside this protect and extend clinical leadership roles. In return, our professions must stand up and be counted! We must clearly articulate which resources we need to deliver positive health improvement, and be prepared to be accountable for these resources. We know morale among those working in the community is often low. This is, in part, related to excessive workloads, where numbers of senior nurses and health visitors have been reduced; but it is also related to a loss of clinical autonomy.

Community nursing professions and health visitors must clearly articulate to future GP commissioners the contribution they could make to health improvement if they were given the autonomy and leadership to deliver services. My advice is that you should take a little time out with colleagues to do this.