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Quicker treatment, closer to home ...

Lynn Young
Primary Healthcare Adviser for the RCN

Yet another document on primary healthcare (PHC) has recently appeared. Entitled "Quicker treatment closer to home",(1) this report concentrates on the ability of PCTs to redesign services in the interest of patient care and on improving the capacity and capability of PHC so it can provide what the government is demanding.

Redesign is the flavour of the month and of modernisation: "Redesign helps to ensure that patients are treated by the most appropriate healthcare professional in the most appropriate location. This improves patient experience (eg, by reducing waiting times), helps to manage demand for acute care and introduces a greater range of providers, thus supporting patient choice."(2)

One major initiative aimed at the successful redesign of services is the development of practitioners (eg, GPs, nurses) with special interests (PwSIs). It may well be that within your very own PHC organisation great efforts are being made to put in place a variety of PwSIs who are leading on specific redesign projects. You could become quite enthused about this interesting role development and identify what you would be able to do to improve a certain service in your area.

There are several examples of fine practice that have brought wonderful benefits to patients and high job satisfaction to staff. Medway PCT has developed a community respiratory service that helps people with chronic lung disease to manage their condition at home, without the need for an ambulance. Physiotherapists, nurses and a part-time dietician make up the team who care for about 40 patients regularly, and urgent cases within 2 hours. Pulmonary rehabilitation courses are run that offer "practical advice on medication, stress management, exercise and techniques to clear the chest".(3)

And then there is dermatology, a common but horribly distressing health problem in which patients often have to wait an unacceptably long time for an appropriate referral. South and West Bristol PCT started a new dermatology clinic run by a nurse with a special interest. Two GPs with a special interest work with the nurse to provide services to children with eczema, including parental education. The nurse is qualified to prescribe and has undergone specific training on certain conditions making her highly skilled and able to provide care to a variety of patients. Managing conditions that cannot be cured is the bedrock of good chronic disease management and calls for the very best of nursing skills and knowledge.

Newham in the heart of east London has an extremely high incidence of diabetes. The PCT's response to this was to set up a multidisciplinary diabetes team. The specialist nurses work closely with practice nurses and GPs to provide home care and constant telephone communication. A representative of the Newham patient support group said: "Going to see a specialist nurse makes such a difference. They can answer all your questions and make you feel they've got all the time in the world for you."(4)

Finally, the business of redesign challenges traditional boundaries, power bases and hierarchies, so my concluding remark has to come from consultant urologist Dr Mike Flannigan of Bradford Royal Infirmary: "For  PwSI services to work, there has to be a lack of selfishness among consultants and we can't worry about losing control of the referral process. Consultants also need to be prepared to commit time and effort to the service - not only to ensure primary care practitioners get adequate training, but also to carry out regular audits to ensure services are running safely and smoothly."(5)

1&2. Audit Commission. Quicker treatment closer to home. London: Audit Commission; 2004.
3,4&5. Department of Health. Practitioners with special interests: bringing services closer to patients. London: Department of Health; 2003.