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NHS set to reduce the number and status of specialist nurses?

Marilyn Eveleigh
Consultant Editor

Life is tough if you are employed in the NHS at present, especially if you are in an acute hospital. Internal reviews of what departments will do and won't do, and visits from external "turnaround" teams that critically appraise the hospitals' overspend, make everybody nervous. The media reports the consequences regularly and the unthinkable has happened - doctors and nurses are being made redundant. And not so long ago we had a staffing crisis! How did it ever get to this?
For nursing it has been a particularly difficult time. We have regular warnings that more nurses will be made redundant, there is a moratorium against the use of agency and bank staff, overseas nurses are not having their contracts renewed, student nurses are not being given posts after qualification, and the "return to nursing" incentive for nurses to come back to work in the NHS has been axed - to name but a few.
The large nursing workforce has attracted significant attention into what value nursing has in a patient care episode. Attempting to contain the cost of nursing in the tariff price for procedures carried out in the acute hospital (known as "payment by results" - PbR) is particularly challenging. Nursing does a lot of "soft" activity that creates a safe and conducive environment of care, such as ensuring patients are fed or that patients and families are kept informed and have the opportunity to discuss progress and anxieties. But because it is so "soft", it's a tough one to price. Such nursing infrastructure and support is time-consuming and unpredictable, but inevitable and vitally important!
Colleagues across the country are indicating that hospital specialist nurses are having their roles closely scrutinised by their trust employers. We know who these nurses are: the diabetic specialist nurse who will give you advice over the phone, or the respiratory specialist nurse who will see your patient in outpatients, avoiding a hospital referral. They cover almost every specialty from epilepsy to cardiac care, from palliative care to dermatology. We have come to depend on them as hospital experts, willing and able to support us in the community. They have pioneered new approaches, many taking their services into primary care as an "outreach'' service.
Through formal and informal training of the clinical workforce, they support the secondary to primary care shift of services - as well as reduce hospital admissions and length of stay. There are reports that this training role is being curtailed by cash-strapped trusts to concentrate their time and skills within the hospital. Some PCT- and university-based training courses for primary care clinicians have been cancelled, or have had fees levied by the trust if specialist nurses are used. In the present climate, hospital managers only want to pay for what the tariff includes - and that's not for developing and supporting community services.
A narrow, knee-jerk reaction to reduce their numbers and influence is bad news for the status of these specialist nurses - and the profession. As "experts", they need to act and be accessed as such. I hope the detailed review of their roles justifies their existence. Ironically, it is the medically led, hospital-based care that the majority of specialist nurses give that may bring about their demise anyway. The future requires community-based care, developed and led by specialist nurses and their teams, which enhances the confidence of primary care clinicians, teaching them to manage patients better.
As clinicians, patients and taxpayers, we probably agree that there needs to be some control over escalating health costs and a better organised process for patients. Nursing directors in secondary and primary care need to work together NOW to ensure specialist nurses are not the short-term victims of a larger NHS overspend. Locating them in primary care would be an excellent start to secure their existence.