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Profile: Clinical commissioning group nurse

Playing a vital role in commissioning quality healthcare, Angela Dempsey also goes into the community to understand patient experience firsthand by 'walking the patient pathway'

As the registered nurse on the governing board for Enfield clinical commissioning group (CCG), Angela Dempsey plays a vital role in commissioning quality healthcare for the local community. 

 “When you're on the governing body, you're not there just about nursing issues; you're there about performance, finance, forward planning, QIPP [Quality Innovation Productivity and Prevention]. So although you're there in a nursing capacity, you're really there in terms of how the whole CCG is performing,” says Angela, mum of three who's currently in the final stages of doing an MBA.

Although all CCGs are required to have a registered nurse who sits on the governing body, some CCGs have a single chief nurse leader while for other CCGs, the responsibilities of the role are divided between, for example, the director of quality and performance, and the registered nurse.

The governing body is very much a driving force of the CCG with members deciding on whether healthcare initiatives are to be implemented or not.

Besides the regular monthly meetings where issues ranging from training, development work to finance are discussed, the public also get to have their say in a public governing body meeting, which takes place every two months.

“This is when members of the public sit in on the whole meeting and can either ask questions to be answered by the chair or write in with any questions,” says Angela.

Responsible for the quality and safety committee as well as the quality and risk subgroup, Angela's role feeds into all aspects of commissioning as she helps to assess the safety of outcomes involved in every business case that is presented.

“Our quality safety committee is responsible for making sure everything we commission is the best that it can be. So, when the governing body presents a business case about commissioning a particular service, they'll say 'we're thinking of commissioning a particular service in a particular way, what do you think?' You'd then take into account the quality, the outcome and think about the bigger picture,” says Angela.

Once a month, Angela also undertakes a quality and risk assessment of providers where she looks at information relating to risks, quality and patient experiences in the performance report provided by their commissioning support unit (CSU).

“So we'll know in terms of service incidents, we'll know about complaints. We know about their friends and family test, we know about if they've breached anything in terms of waiting times.”

This also involves looking at the Board Assurance Framework (BAF) and risk registers of provider foundation trusts, which contain a profile of strategic risks that have been identified and the controls in place to give assurance as to how controls are managed. The information from the various sources is then triangulated to ensure a robust and accurate assessment has been made. If there appear to be risks to the quality of services, Angela, who works part-time one day a week for the CCG, will escalate her concerns to the quality and safety committee, and if necessary, the governing body, at which point it will be recorded in the corporate risk register.

Angela's role also crosses over into service redesign, as monitoring quality is a key part of that. 

One of these initiatives, which is a key aspect of the Barnet, Enfield and Haringey clinical strategy, is the introduction of an older person's assessment unit (OPAU), enabling a step change in the quality of care for the local elderly residents in Barnet, Enfield and Haringey.

The assessment centre, which is resourced with a multi-disciplinary team of health and social care professionals, headed by a consultant geriatrician, as well a range of diagnostic procedures including x-rays, blood test and CT scans, allows those over 60 to be treated following a referral from their GP, community health carer or hospital clinician. There are also teleconference provisions for GPs and community matrons to discuss patients of concern.

With a large disparity in the health of people living in affluent and poorer areas in the borough of Enfield, minimising this gap is a major priority for the CCG.

“There are some areas with real health needs - for example, between affluent and poorer areas in north London such as Highlands ward and upper Edmonton ward, where there is a 13-year life expectancy difference for women,” says Angela.

A primary care strategy has been developed to improve health and wellbeing and reduce health inequalities among Enfield CCG's population, and one of the initiatives includes attracting more people to become practice nurses. 

The area currently has a maturing practice nurse population and Enfield CCG are working towards a succession plan for younger practice nurses to come forward.

The CCG has also recently received some public funding to increase the capacity of practice nurses in three areas of Edmonton to do more preventative care work.

“We're doing a project with a bit of specialist money from public health to tackle three practices in Edmonton that need to increase the quality of their practice nurses to improve the health of their population in terms of prevention—so stop people dying prematurely, ensuring that they know what the practice nurse role can do, keeping people out of hospital and making sure that patients have health checks as well as looking at safeguarding issues,” says Angela

Angela is also part of a national integration steering group led by NHS England, which seeks to join up care in the transition from leaving the hospital to receiving care at home.

“So you know you've got people that get out of hospital and then they go home? It's about how we make that seamless, so in terms of acute provision that we commission, and as they get into their own settings, is the care sufficient, will it do what it says it's supposed to do?” 

As well as being fully immersed in the strategic planning and quality administration of commissioning, Angela also goes into the community to understand patient experience, taking an active role in patient participation groups as well as witnessing the quality of patient care first hand by personally 'walking the patient pathway,' part of the CCGs planned programme of visits to commissioned services.

“I've got to walk the pathway where I'm going into our hospitals where the patients are and following the patients pathway - so from referral from the GP to reception to where they'd be cared for, discharged from - so very much following what the patients do.”

By walking the patient pathway, Angela is able to address any complaints that have been made by patients and their families about providers. Other CCGs who use the same providers will also be invited on the walk in an attempt to share intelligence and pool resources.

Angela's part-time role in helping to monitor quality at the CCG and understanding patient experience fits in very well with what she does the rest of the week, which includes taking on a lead role in patient experience with NHS England and serving as a clinical advisor role for Patient Opinion, a social enterprise group with a focus on patient experiences.

Although Angela, who qualified as a nurse in 1989 with a background in midwifery and has an MSc in interprofessional studies, seems very comfortable in her role and is confident in being able to contribute to the quality agenda, it is clear that the role is very demanding and comes with its own set of challenges.

“There was so much to learn - it was a new organisation forming, so everything that comes with that - the agenda is huge, and also we've got the Barnet, Enfield Haringey clinical strategy, so there are a lot of challenges under that. With everything that needs to be done in the time commitment, there's lots of background reading.”

Angela adds that with the background of nurses in governing bodies varying widely and clinical commissioning duties being quite demanding, involving expertise in a range of areas, it can be difficult for nurses to be fully confident about the decisions they make unless adequate support is provided.

“CCGs have only been established since April, so it's very early days, and a lot of nurses are saying, 'It's early days, how do we know if we're doing it right?' 

Although as a body, you would talk about everything, but sometimes to say 'No, I don't agree with this,' you really need to have to confidence to say no.”

In a survey conducted by the National Network of Commissioning Nurse Leaders (NNCNL) and shown exclusively to Nursing in Practice, although 91% of nurses felt fairly confident in their roles, many CNLs (24%) reported that a lack of clarity around their responsibilities was a core challenge with 19% attributing this challenge to time restraints.

 The NNCNL which has been developed by NHS England in collaboration with the Royal College of Nursing (RCN), was developed to support nurses in their new roles within CCGs.

 The network aims to link all directors of nursing in area teams, CCG governing body nurses as well as directors of nursing or their equivalent senior nurses in commissioning support units (CSU) to bring together the experience of nurses involved in commissioning.

Some of the resources of the network include national webinars where CCG issues are discussed as well as the production of various forms of communication, which helps to make sense of commissioning responsibilities, shortening the understanding process. According to NHS England, the network, “aims to support commissioning nurse leaders to fulfill their function within the commissioning system and embed Compassion in Practice.”