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The Darzi Review: what does it mean for primary care nurses?

Nurses working in general practice will have a central role to play in delivering the goals of Lord Ara Darzi's new vision for the NHS. Nursing in Practice takes a close look at his report …

Nursing in Practice special report

A year in the making, the Lord Darzi report High Quality Care For All and its accompanying workforce and primary and community care strategy, outline the new direction of travel for the NHS.(1-3) The suite of reports clearly signal that responsibility for reshaping and leading health services will lie with nurses and other healthcare professionals at a local level.
The last 10 years of NHS reforms have focused on building capacity. Now the buzzwords are quality, personalisation, patient choice, user empowerment, equity, integrated care, clinical leadership and more responsive services. Patients will be given more say, more choice and control in their own healthcare, and there will be a greater emphasis on health promotion and prevention.
"The staff who work in these services speak with passion about the potential for using their professional skills to transform services," says the Department of Health.(2)
The review focuses on personal and responsive healthcare - providing integrated care that is closer to home and based around the person, not just their individual symptoms or care needs.
There will be new incentives to expand health prevention services which will create new opportunities for nurses to set up and become involved in providing services for weight management, alcohol and drug use, smoking cessation and sexual health. A programme of vascular checks for 40-74-year-olds will be launched in 2009. The Quality and Outcomes Framework will be renegotiated to include more points for keeping patients healthy by providing preventive care.
Nurses will play a key role in helping people to self care and will be central to care planning, where patients and professionals are "true experts and partners in care", and as care coordinators where people need to access multiple services. This will include offering care plans for all people with long-term conditions, developing a "patients' prospectus" to support self-care, and piloting individual budgets for health and social care.

Nurse entrepreneurs
Lord Darzi sees practice-based commissioning (PBC) as the way to redesign services locally and to develop more integrated care models in the community. Until now PBC has been predominantly medically led and patchily implemented, but Darzi outlines a commitment to multidisciplinary participation in the process and this should give nurses the opportunity to have a say in and even lead the development of new services. 
Entrepreneurial nurses who want to set up new services will now have the right to establish not-for-profit social enterprise organisations. Previous barriers to initiatives such as these have been fears about job security and loss of the NHS pension. New social enterprises will be offered three-year contracts or more and employees will retain their pension rights. 

High-quality care
Lord Darzi also addresses the needs of staff, emphasising that high-quality care can only be delivered by a well-trained, motivated workforce.
He says that healthcare is delivered by a team and every member of the team is valuable and has an important contribution to make. There are measures to improve the quality of education and training and employers, including GPs, will be held to account for providing continuing professional development (CPD)  for their staff. 
The Royal College of Nursing (RCN) has welcomed the focus on locally-driven services and engagement with frontline staff. But they say that it is clear that it is a very complex undertaking. There are challenges, for example with improving public health and identifying disease at an early stage - something that is easy to say but very hard to achieve. 
The RCN points out that high-quality care closer to home can only be achieved if there is an adequate number of appropriately qualified and skilled nurses in all settings who are appropriately resourced and supported. Improved public health needs involvement from a number of disciplines, but without sufficient community midwives, school nurses, health visitors and general practice nurses, worthy aspirations will remain aspirations.
Dr Peter Carter, RCN Chief Executive and General Secretary, told the RCN Practice Nurse Association annual conference in Cardiff in July that the review was 95% welcome: "What has particularly pleased the RCN with this review is that we have been in there right from the word go. We met Darzi a year ago and have been involved in all the work streams, so the RCN is in a position of creating policy rather than responding. So there were no surprises when Darzi launched [his report] because we were very comfortable with what he had to say.
"New opportunities will be created on the back of Darzi and nurses need to get involved in those initiatives and embrace them."
RCN primary care adviser Lynn Young is very enthusiastic: "This is what we have been calling for for the last decade - it reinforces all the things we have been asking for as primary care nurses. It even calls for employers to give their staff time off for CPD - this is great news.
"The point is we have to call employers to account, although this could be harder for nurses in general practice than those employed by the NHS," she admits.

Practice nurses could lead the way in primary care
RCN long-term conditions adviser Sue Thomas, also speaking at the PNA conference, said the whole strand in the review on long-term conditions was going to be the template for the future: "Practice nurses will be managing, assessing and monitoring patients - doing annual health reviews and ensuring patients have the support and information they need to remain independent. Practice nurses will have the opportunity to improve care for previously neglected conditions such as rheumatoid arthritis, Parkinson's disease and multiple sclerosis.
"We have to upskill ourselves in order to be able to manage patients - there are a lot of great courses around."
In order to deliver the new integrated care agenda all members of the primary care team will need to come together in a clinical network with the patient at the centre. "Practice nurses could lead the way in primary care and pull this together and be part of the clinical network - you could be the one that directs where people go," said Ms Thomas.

Social enterprises
Queen's Nursing Institute Director Rosemary Cook describes the review as a "charter for innovation and enterprise" - "There is a great emphasis on finding new ways to deliver services, not just through social enterprises, but through new integrated care organisations. This is important, as different community nurses will want to work in different kinds of organisations, not all be forced into one model. I think they will welcome the recognition that social enterprises will work in some places, partnerships with local authorities will be right in others, and one-stop-shops will be better elsewhere," she says.
The public services union UNISON is concerned about the impact that social enterprise schemes will have on staff. Head of Health Karen Jennings says: "Social enterprises are likely to be fragile organisations and subject to predatory takeover by the private sector - and staff would then lose their pensions guarantee.
"UNISON is also concerned that there will be long-term wrangling around the awarding of contracts to social enterprises. The Cooperation and Competition Board is being set up to hear from private companies that feel they have not been treated fairly in the tendering process and this is the first step to opening the door to the private sector."
Ms Jennings is also worried about the consequences of introducing individual care budgets. She warns: "There is a real danger that these budgets will pave the way towards means-testing and undermine the very principle of care being free at the point of need. These may only be pilots but we have already seen the government pressing ahead with the rollout of personal budgets in social care, without waiting for the results or reports back of the individual budgets pilots. There is a real danger that these latest pilots will also be just a cursory step before rollout."
Dr Anna Dixon, The King's Fund's Director of Policy, also has concerns about personalised budgets. "Challenges include getting the initial payment level right and determining who would pay for care should the budget be exhausted. There is also the danger that converting NHS services into cash could allow the better off to enhance their allowance thereby creating a two-tier service, which undermines the founding principles of the NHS," she says.
Niall Dickson, The King's Fund's Chief Executive, points out two significant omissions - there are no estimates of how much the implementation of the review will cost and no indication of just how different the government expects the quality of health services to be in five or 10 years time.
The Department of Health, however, in a document explaining how the primary care strategy will impact on nurses, urges staff to read the reports and make their own minds up.(4)
They suggest that practice nurses should get involved by contacting their local PCTs, which will now be developing local primary care strategies that they promise will secure improved health and enhanced healthcare.

References

  1. Department of Health. Professor the Lord Darzi of Denham. High quality care for all: NHS Next Stage Review final report. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_085825
  2. Department of Health. A high quality workforce: NHS Next Stage Review. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_085840
  3. Department of Health. NHS Next Stage Review: our vision for primary and community care. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_085937
  4. Department of Health. NHS Next Stage Review. Our vision for primary and community care: what it means for nurses, midwives, health visitors and AHPs. DH: London; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...

Your comments: (Terms and conditions apply)

"Yes the vision is good news for patients. But what is there to support practice nurses who are employed by GPs. Those employed directly by a PCT get all the benefits nurses get in terms of professional development and pay. But those employed by GP/partners have to always negotiate wages and other
benefits; these terms are set at the discretion of the partners. Could the new vision also ensure that these areas are addressed." - Lucy Nomenyo, London