Community Health Care Development

Community Health Care Series

Series Editor: Professor David Sines

Deborah Hennessy (ed.)

Community Health Care Development
Carolyn Mason (ed.)
Achieving Quality in Community Health Care
John 0vretveit, Peter Mathias and Tony Thompson (eds)
Interprofessional Working for Health and Social Care

Community Health Care Series

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Community Health
Care Development

Edited by
DEBORAH HENNESSY

Foreword by Andrew Wall

MACMILLAN
Selection, editorial matter and Introduction © Deborah Hennessy 1997
Preface © David Sines 1996, 1997
Foreword © Andrew Wall 1997

Individual chapters (in order) © Deborah Hennessy and Geraldine

Swain; Lesley Armitage; Liz Haggard; Caroline Taylor and Geoff
Meads; Ainna Fawcett-Henesy; Rita Bell, Kath Johnson and Heather
Scott; Kieran Walshe; Neil Small, Audrey Ashworth, Douglas Coyle,
Sue Hennessy, Sue Jenkins-Clarke, Nigel Rice and Sam Ahmedzai;
Lucy Hadfield; Sandra Legg and Helena Ellerington; Deborah
Hennessy and Geraldine Swain 1997
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Dedicated with love to the Sisters of the Community of St John the
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Nursing Order have given compassionate care in the development of
community health since 1848
 CONTENTS

List of Figures ix
List of Tables x
Foreword by Andrew Wall Xl

Preface by Professor David Sines Xlll

Acknowledgements XV

List of Contributors XVI

Introduction 1
Deborah Hennessy
1. Developing community health care 3
Deborah Hennessy and Geraldine Swain
2. Identifying health needs 37
Lesley E. Armitage
3. Commissioning services to meet identified needs 62
Liz Haggard

4. The development of primary care 86

Caroline Taylor and Geoff Meads

5. Inner-city changes: health care services in Britain's

inner cities 106
Ainna Fawcett-Henesy
6. Interprofessional education and curriculum
development: 'A Model for the Future' 123
Rita Bell, Kath Johnson, Heather Scott

7. Clinical effectiveness: the challenge for community

nursing 159
Kieran Walshe

8. Palliative care in the community 178

Neil Small, Audrey Ashworth, Douglas Coyle,
Sue Hennessy, Sue Jenkins-Clarke, Nigel Rice and
Sam Ahmedzai

vii
 9. How to deliver effective community health care 198
Lucy Hadfield
10. The effect of changes in hospital care on community
health care 226
Sandra Legg and Helena Ellerington
11. Epilogue 253
Deborah Hennessy and Geraldine Swain

Index of Names 255

Index of Subjects 259

viii
 LIST OF FIGURES

2.1 Diagram showing the relationship between need,

supply and demand 43
2.2 Scoring grid to assist in the determination of
priorities 56
6.1 Taxonomy of primary health care: a framework for
interprofessional education 148
7.1 Definition of evidence-based health care 161
7.2 Publications indexed on CINAHL by year of
publication 168
9.1 NHS key stakeholders and their roles 203
10.1 Organisational change resulting from new
technologies 230
10.2 The political, economic and technical trends which
have influenced changes in acute care 231

IX
 LIST OF TABLES

1.1 The development of NHS reforms 17

4.1 Primary care development (a motivational matrix) 96
6.1 National occupational standards and associated
qualifications 132
6.2 Interprofessional initiatives by geographical
distribution and combination of professions 136
7.1 Effective Health Care bulletins 170
7.2 Interventions to promote change 172
8.1 Hospice services in the UK and Republic of Ireland 180
8.2 Death rates per million population from common
conditions in England 181
8.3 Place of death in 1991 of patients who were
identified as having a terminal or palliative period in
one health region 181
8.4 Socio-demographic characteristics of patients,
recruited from the community 185
8.5 Medical characteristics of recruited patients,
community 186
8.6 Profile of carers in the community 187
8.7 Number of patients receiving visits from GPs and
nurses in the week before completion of baseline
data 188

x
 FOREWORD

Care started in the community. In the most primitive societies there

were no alternatives to caring at home. But with the developing
sophistication of civilisations health care went beyond the home
and people other than the immediate family became involved. And
with this came problems which we are now beginning to recognise
and are attempting to alleviate.
As care became more institutionalised so the family became more
distanced. The normal responses based on day-to-day knowledge of
the sick person could no longer be relied upon and nurses and
others had to learn to become proxies for the family and learn to
understand their patient. In an institution this is difficult because
there is no prompting from the patient's own context. We now are
attempting to redress the situation both by treating the patient at
home for as long as possible and when they have to be admitted
encouraging the care staff to acknowledge the patient as a complete
individual, not just a set of symptoms.
This regard for the wholeness of the patient is one of the
differences between primary care and community care. Primary
care is about the time and place of treatment but community care
comprehends the person in their own setting. The simplistic divide
between primary (good) and secondary (bad) therefore fails to
recognise the uniqueness of each individual and how that unique-
ness needs to be understood at every point along the continuum of
care.
Given the intimate knowledge that all care workers need to have
of those they are looking after, values and standards arising from
those values need to be articulated. These values have sometimes
been politically motivated: community care was thought to be a
cheaper option. Or they can lead to dogmatism: community care is
always best. But both these views are flawed. Community care can
be very expensive - think about twenty-four-hour home care - and
treating people at home is beneficial only if their full clinical needs
can be met. So the values need to be centred much more on
appropriateness.
Community care can create other problems. One of the reasons
for preferring institutional settings for care has been to standardise
practice. This has of course been the keystone of professionalism.
But how can this work in the community? Will the patient be put to
unnecessary risk when care workers are relatively unsupervised?

Xl
 Community care is diffuse and therefore more difficult to
manage. This is a challenge to managers who, by their very nature,
are concerned with control. They may react unfavourably to what
they may see as a sentimental approach to patients which in fact
camouflages poor practice and inefficient use of resources.
Community care is at the heart of today's health care rhetoric.
What this book does so valuably is to explore the reality of
community care and re-establish that, fundamentally, community
care is about recognising the supremacy of the patient and the
obligations health care workers have to recognise the patient's
individuality in the most appropriate manner possible. It is not
easy, it is not cheap, but adherence to the highest standards never is!

ANDREW WALL
Health Services Management Centre
University of Birimingham

xii
 PREFACE

Successive governments have indicated their commitment to enhan-

cing the health of the nation and, in recent years, the focus of care
delivery has shifted with escalating speed into the community. In so
doing, it has become evident that community nurses and health
visitors provide the focus for the promotion of health gain, and for
the maintenance of positive health status for individuals, groups
and local communities. Community nurses and health visitors are
destined, therefore, to become leaders in the design, delivery and
evaluation of effective health care interventions, informed by aca-
demic discovery, and advanced practice skills and competencies.
The changes that confront the contemporary community nursing
practitioner are characterised by the diverse nature of the context
within which community care is transacted, with an increasing
emphasis on inter-sectoral co-operation, interprofessional colla-
boration, community action and development, and reduced reliance
on the acute sector and residential care provision for longer-stay
client groups.
The impact of change, pushed by a growing demand for flexible,
high-quality services provided within local communities, will inevi-
tably shape the NHS of the future. Resources. have already been
shifted to the community (although at a pace that is all too often
criticised as being grossly inadequate to meet client need). Commis-
sioners and providers are now required to demonstrate that the care
they purchase and deliver is effective and responsive to the needs of
local practice populations. To complement this, community nurses
will be required to ensure that their activities make a significant
impact on health gain for their practice population and, as such,
should become seriously involved in structuring the political agenda
that ultimately governs their practice environment.
In order for the community workforce to respond to these
challenges, it will be necessary to ensure that community workers
are equipped with the necessary skills and knowledge-base to be
able to function effectively in the 'new world of community health
practice'. Nurses will be required to develop and change, drawing
upon the very best of their past experience, and becoming increas-
ingly reliant upon the production of research evidence to inform
their future practice.
This series is aimed at practising community nurses and health
visitors, their students, managers, professional colleagues and

Xlll
commISSIOners. It has been designed to provide a broad-ranging
synthesis and analysis of the major areas of community activity,
and to challenge models of traditional practice. The texts have been
designed specifically to appeal to a range of professional and
academic disciplines. Each volume will integrate contemporary
research, recent literature and practice examples relating to the
effective delivery of health and social care in the community.
Community nurses and health visitors are encouraged towards
critical exploration and, if necessary, to change their own contribu-
tion to health care delivery ~ at the same time as extending the
scope and boundaries of their own practice.
Authors and contributors have been carefully selected. Whether
they are nurses or social scientists (or both), their commitment to
the further development and enrichment of health science (and
nursing as an academic discipline in particular) is unquestionable.
The authors all demonstrate knowledge, experience and excellence
in curriculum design, and share a commitment to excellence in
service delivery. The result is a distillation of a range of contem-
porary themes, practice examples and recommendations that aim to
extend the working environment for practising community nurses
and health visitors and, in so doing, improve the health status of
their local consumer.
Community Health Care Development, edited by Dr Deborah
Hennessy, has been written by a range of carefully chosen selected
authors. Between them, they provide a breadth of creative vision
informed by a range of commissioning and practice perspectives.
The book challenges community practitioners to replace conven-
tional methods of delivery with a community action/development
focus. The authors provide an excellent synopsis of health-needs
assessment within the context of the present-day health service and,
in so doing, examine the growing importance of clinical and cost-
effectiveness in health care. The text is based on a vision of an
integrated primary care service and is imbued with examples from
clinical practice. Readers will be challenged to adopt a proactive
approach to care delivery and to act as change agents in their area
of specialist practice.

DAVID SINES
University of Ulster
Belfast

xiv
==========ACKNOWLEDGEMENTS==========

I am indebted to Lucy Hadfield, Caroline Taylor and Kayvan Zahir

who, as fellow colleagues on the King's Fund Leadership 2000
programme (funded by the NHS Executive: Women's Unit), both
advised on the structure of the book and contributed to the
contents.
My thanks are also extended to all other contributors who
managed to meet deadlines despite very busy jobs.
Finally, both Kathryn Conchie and Joy Rule provided consider-
able administrative support in a charming and efficient manner.

DEBORAH HENNESSY

xv
 LIST OF CONTRIBUTORS

Sam Ahmedzai BSc, MBChB, FRCP is Director of Trent Palliative

Care Centre and Professor at the University of Sheffield. He was
Medical Director of the Leicestershire Hospice from 1985-94.

Lesley E Armitage MB CH is Honorary Research Fellow in Public

Health at the Health Services Management Centre, University of
Birmingham.

Audrey Ashworth BA was a Research Fellow at the Centre for

Health Care Economics, University of York. Her research interests
include health psychology and palliative care.

Rita Bell RGN, DN, RNT, DNT, Cert Ed is Principal Lecturer in

Primary Care at the Faculty of Health, Social Work and Education,
University of Northumbria.

Douglas Coyle MSc is Associate Investigator in the Clinical Epide-

miology Unit at the Ottawa Civic Hospital, and Lecturer in the
Department of Medicine of the University of Ottawa, Canada. His
has a particular interest in the cost-effectiveness of health care
provision.

Helena Ellerington RN, RM, Dip Management Studies is Profes-

sional Advisor at The United Kingdom Central Council for Nur-
sing, Midwifery and Health Visiting. As Hospital Manager/Senior
Nurse of Newbury District Hospital she led a team of multidisci-
plinary staff through the health reforms of the early 1990s, mana-
ging the business agenda and the contractual process.

Ainna Fawcett-Henesy RGN, RHV is Acting Regional Adviser:

Nursing and Midwifery at the World Health Organisation in
Copenhagen. At the time of writing this chapter she was a member
of the London Implementation Group.

Lucy Hadfield BA is Chief Executive of Wandsworth Community

Health Trust and has been since its inception in 1994. She has
worked in a wide variety of management posts in the NHS and has

xvi
also had experience as a Management Consultant. Lucy is a
member of the Institute of Health Services Management.

Liz Haggard MA is a Fellow at the Office for Public Management,

London. She has worked in the NHS for 14 years, most recently as
Chief Executive of Southern Derbyshire Community Trust.

Deborah Hennessy BA PhD RN RM RHV Dip Public Health

Nursing is Senior Lecturer at the Health Services Management
Centre, University of Birmingham. Her previous post was that of
Chief Nurse, South West Thames RHA.

Sue Hennessy BA, MA is Research Fellow at the Centre for Health

Economics at the University of York. Her current research interests
are palliative care, health education and addiction.

Sue Jenkins-Clarke BSc, RGN, RHV is Research Fellow at the

Centre for Health Economics at the University of York. She has
worked in health services research for about 16 years.

Kath Johnson, MA, BSc, RN, DN, RHV, CPT, RNT, HVT,
Cert Ed, Cert IT is Senior Lecturer Primary Health Care at the
Faculty of Health, Social Work and Education, University of
Northumbria.

Sandra Legg RN, RM, BA, BSc, ThL, Dip Clin Counselling,
FRCNNSW was appointed Director of Nursing at Cabrini Hospi-
tal. Melbourne, Australia in 1996. Prior to this, she was Chief Nurse
of St George's Healthcare NHS Trust where she led nursing
through the London Acute Services reforms.

Geoff Meads MA, MSc and MHSM is Professor of Health Services

Development at the City University. He was a regional director of
the NHSE: South and West Office from 1992-6, having been
previously a FHSA Chief Executive. A Probation Officer by train-
ing, he has extensive experience in both Health and Social Services.

Nigel Rice BSc, PhD is Research Fellow at the Centre for Health
Economics at the University of York. His main interest is in
qualitative methods applied to health data and to quality of life
measurement.

XVll
Heather Scott BA, Dip Applied Social Studies, Dip MHSW, MBA
DPhil is Principal Lecturer and Head of the Division of Primary
Health Care, Faculty of Health, Social Work and Education,
University of Northumbria.

Neil Small BSc (Econ), MSW, PhD is Senior Research Fellow at the
Trent Palliative Care Centre and the University of Sheffield. Until
September 1995 he was Principal Investigator (Palliative Care) in
the Centre for Health Care Economics, University of York.

Geraldine Swain BD, RN, RHV, RNT, Dip Health Services Manage-
ment, Dip Advanced Psychodynamic Counselling is in clinical prac-
tice as a psychodynamic· counsellor and a freelance facilitator in
NHS staff development.

Caroline Taylor BA (Hons) is deputy Chief Executive of Camden

and Islington Health Authority. She has worked in Camden and
Islington since 1992 when she was appointed as FHSA General
Manager. She has recently led a national project on the develop-
ment needs of primary care in the context of the primary care-led
NHS.

Kieran Walshe, BSc, Dip HSM, MHSM is Senior Research Fellow

at the Health Services Management Centre, University of Birming-
ham. He has been both an NHS manager and a researcher, and his
research, consultancy and education activities at HSMC reflect a
continuing interest in both arenas.

xviii
 Introduction

De borah Hennessy

The transformation of the Health Service has had a huge impact on

the development of community health care. The introduction of
commissioning authorities has led to an emphasis on the provision
of identified health needs of geographical and general practice
populations. This has been accompanied by shifts of long-term
patient care into the community in the recent past, a considerable
proportion of acute care in the present and more in the immediate
future. This shift has been accompanied by new medical and
information technology and the changing epidemiological status
of the population.
The health care that has been provided in the community in the
United Kingdom to date has been the envy of many parts of the
world. This includes the free availability of general practitioners,
extensive community nursing services and the links and collabora-
tion of other public sector services such as social services and
housing. The health care that develops in the community in
response to the NHS reforms must hold on to the key elements of
current practice, particularly for the benefit of long-term patients.
At the same time there must also be massive development of highly
innovative and creative responses. Eventually both strands will
merge, but until they do there will be practical problems. One of
these is that many of the people who have to do the thinking and the
changing have both considerable experience and were educated and
trained to carry out pre-reform work in community health care.
Ways of influencing others to change traditional organisations,
systems and practices will be considered. Practitioners will be
encouraged to keep their eye on what is happening in Europe,
internationally, the United Kingdom, the British public sector, the

1
National Health Service and health care. This will be so that
practitioners can be very flexible and able to recognise signs that
require the development of new skills, and also so that they have the
power to contribute fully to the changes in health and social
services.
The text of this book breaks new ground and provide a practical
framework within the wider context of other issues for community
health practitioners working with a range of clients, with specific
attention given to community nurses.
The text is primarily aimed at an undergraduate nursing market
and reflects the needs of the post-diploma level students in higher
education. Consequently, attention will be given to the integration
of theory with practice and to analyses and synthesis of subject
matter. Issues relating to critical debate and moral deliberation
form the foundation of the text.

2
 CHAPTER ONE

Developing Community Health Care

Deborah Hennessy and Geraldine Swain

INTRODUCTION

'Community is not only an entity or a structure like a monastery.

It is also a process that has to do with exchanging what is held in
common.'
Christopher Perry

The intention of this book is to provide a useful resource to assist

nurses in the community in their comprehension of the societal and
policy framework within which they work, and within which they
will have to develop their nursing models of clinical practice.
These are challenging, and interesting, often painful times for
nurses, and indeed for all clinicians working within the health
sectors. At the time of writing, a general election is not so far
distant and we cannot tell what changes may lie ahead. Whatever
the outcome, the constant factors will remain, that is, the challenge,
the interest and the pain. Constant factors too are the pleasure and
the privilege of contributing to a service, working with, alongside,
for and on behalf of women, men and families, groups and
communities, of which we ourselves are a part.
Before we engage in an exploration of the main terms, let us
remind ourselves of the fundamental values and beliefs that under-
pin the human services in which we participate and which we
promote as necessary for the common good.
In the past decade and a half there has been a gradual eroding of
the professional confidence of many of those who work in clinical

3
practice within the NHS, certainly, and especially, amongst nurses.
The values, too, which many espouse are felt to be disregarded and
considered by others to be old-fashioned. In the current political
climate, zeal for wealth not enthusiasm for health, would appear to
many to be paramount. Social policies do not reflect a desire to
meet, or even acknowledge, some of the clear and basic unmet needs
within society, increasingly demonstrated in the widening gaps of
inequality together with an increase in social deprivation with its
concomitant low health status. It is, we believe, worth re-stating the
values and why we engage in the work at all. In the existing climate
of pressure it is easy to lose sight of this.
First and foremost, there is the belief in the fundamental value of
the individual human person, as a being of worth and having
potential for creative individual development, enabling creative
constructive engagement with other persons - in partnership, m
families, in groups and in the community.

'In a modern world which every day becomes more a mass world,
with massive problems that seem to despair of any but mass
solutions, the hold of the individual system of rights and value
and concerns becomes every day more precious.'
(Ekstein and Wallerstein, 1972, p. xviii)

In our work we meet individual women and men on a daily basis.

We forget their 'unique system of rights and values and concerns' at
their developmental peril and our own, and certainly ultimately to
the peril of the 'community' in which each is a unique part.
Garner (1989) writes: 'Human service is the heart of our collective
attempt to build a decent, fair and humane society.' We would
endorse that, adding simply that a precursor for a human service,
and humane society, is the acknowledgement of the humanity of
each and everyone. Other values will include:

' ... an equitable, universal health care service, funded through

taxation and free at the point of delivery; a service which values
the individual and the community; a service which acknowledges
their right to health care to meet - within realistic resource levels
- their need for care; a service which respects their right to
humane, respectful care and attention, and to protection from
abuse and exploitation; the value of a trained body of profes-
sional nurses; the valuing of the individuals providing those
services through the provision of continuing professional

4
 education and development, and individual support to help them
cope with the demands of their work.'
(Swain, 1995, p. 8)

Despite the vicissitudes of professional working life, let us exhort

each other to hold on to these values. In so doing we value our own
humanity which is fundamental to valuing others, and their valuing
ours. Enshrined in this possibility is our hope for the world.
'Community health care development' quite clearly means differ-
ent things to different people, whether described as patients or
clients, or professionals from either the health or social services. The
term itself is comprised of words which themselves are given a
multiplicity of meanings. It will be helpful to give some clarification
of these together with the whole term itself as used in the context of
this resource book.

Community

In respect of planned resources a community is usually defined

geographically. Matters of culture, ethnicity and age, however,
define, sometimes tightly and sometimes not, other communities
which are within the geographical community. All of these have to
be taken into account in respect of a service which is delivered
sensitively, responsively and responsibly. Sometimes the words
community and society are used interchangeably. Margaret Thatch-
er, when Prime Minister, made infamous her dictum that there is no
society only individuals and families. While it is true that the family
is the first group of which a child discovers himself to be a member,
it is also true that families need other people from other families to
enable the bulk of their needs to be met, whether emotional or
social or in the form of service provision of every type. A dictionary
definition gives us: '[Community is] a collection of individuals
composing a community or living under the same organisation or
government', and 'the state or condition of living in association,
company or intercourse with others of the same species; the system
or mode of life adopted by a body of individuals for the purpose of
harmonious co-existence or for mutual benefit' (The Shorter Oxford
English Dictionary on Historical Principles).
'Society', therefore, we see in this context as the generic, larger
term, comprising all communities with all the complexities to be

5
found within each community - some of which may be very
different indeed.
Turton and Orr write:

'The word community poses problems of definition ... in nur-

sing we utilise the word in two main ways. Firstly we use it to
describe the location of activities, ego community nursing. Sec-
ondly, we use it to place value or worth on feelings and senti-
ments, ego we speak of community spirit to describe the feelings
shared by people within a particular region .... Firstly, you
identify the community, as a place and secondly, as a set of
relationships which are important to you, ego neighbours. In the
first we are referring to a defined geographical area; we need to
study those aspects of the environment which are its features. In
the second we are referring to the social relationships and net-
works which exist within the area and which contribute to the
lives of the residents . . . When we talk of assessing the commu-
nity therefore we are focussing on these two elements, both of
which are important.'
(Turton and Orr, 1993, p. 5)

For the nurse working in community health care development, the

understanding and knowledge of the community is important, not
least because of the absence, or existence or potentiality of support
networks/systems that are within it.

Health

There are many familiar descriptions of health, but here we will

regard a state of health as a state of balance or harmony, of
homeostasis between the emotional, mental, physical, social and
spiritual aspects of a person's individual life. Even at the best of
times this state of health may be somewhat precarious for each one
of us, to say the least, and it is most assuredly not easy to maintain
such balance for any significant length of time. Emotional life alone
can cause such inner chaos that a state of balance or harmony can
seem far distant.
However, there is no doubting the fact that for some individuals
and families and communities, factors so mitigate against them that
their health status is in considerable jeopardy. For large sections of
society as a whole and within certain communities especially, and
for some people in all communities, this state of affairs has become

6
exacerbated over the past decade and a half (see for example Quick
and Wilkinson, 1991; Benzeval, Judge and Whitehead, 1995). The
resultant inequalities in health are a major area to be addressed,
with utmost urgency.
Although this is referred to again in this chapter, it is perhaps
important to say at this point that health services alone cannot
enable people to achieve their optimum health status. Other na-
tional social policies need to be devised and directed which will
assist people to develop their self-confidence and self-respect, and
appropriate independence and autonomy. This will enable people to
move from the margins of society into a life of community in which
they can participate and to which they can contribute, in a state of
health.
The following from Benzeval, Judge and Whitehead is considered
to be so important that it is here quoted in its entirety:

'A crucial step in tackling inequalities in health is the need to

create opportunities for prosperous and fulfilling employment for
all citizens. The causal link that runs from deprivation to poor
schooling, unemployment, low earnings and poor health, must be
broken. We highlight four key policy initiatives that are required
to help both the next generation of workers and those who
currently find it more difficult to find opportunities in the world
of work.
'Pre-school education should be expanded, particularly for chil-
dren living in disadvantaged circumstances, to give them a better
start in life and to create greater equality of educational oppor-
tunity;
'Particular efforts are needed to increase resources for education
in disadvantaged areas and to support those working there.
'Long-term unemployment should be tackled by improving edu-
cation and training programmes, overhauling the tax and benefit
system, and stimulating new patterns of working and entrepre-
neurship.
The quality and quantity of childcare services in Britain need to
be improved. The lack of provision of childcare facilities is
thought to be a major cause of poverty, since it prevents women,
particularly lone mothers, from taking up paid employment.
' ... observed social inequalities in health are amenable to
purposeful policy interventions. The problem is well documented
and the solutions become clearer every day. What is needed is a

7
 detennined effort to mobilise the political will to create a fairer
society that embraces all sections of the community ... there
should be a genuine commitment by policy makers to promote
action which will improve the health prospects of those whose
lives are blighted and shortened by avoidable and unacceptable
disadvantage. '
(Benzeval, Judge and Whitehead, 1995, p. xxv)

The nurse engaged in community health care development cannot

afford to underestimate this. The interrelatedness of matters which
necessarily contribute to genuine health for people is quite clear.
In 1977, health visitors were exhorted to 'influence policies
affecting health care' (Council for Education and Training of
Health Visitors, 1977) as one of the four basic principles of health
visiting. Twenty years later this has to be re-emphasised. True social
justice and a true state of health as we have defined it here go hand
in hand.

Care

Care is about having a concern for another/others; an appropriate

regard; a preparedness to act; and, sometimes properly, not to act.
Care, too, has to do with the balance which assists in promoting
independence and appropriate protection of the vulnerable from
exploitation and abuse. Intelligent, compassionate care recognises
the stressors which lead to occasional vulnerabIlity to which we all
are prone, and recognises those who are pennanently vulnerable.
Care demands 'serious mental attention' to what is needful. Care
is not about false sentimentality. Care and concern for others has its
rightful place in the human condition, in the development of the
individual human psyche. The development of a 'capacity for
concern' has its roots in infancy and will depend on a 'facilitating
environment' for assisting towards its eventual maturation (Winni-
cott, 1990).
The ability to provide a facilitating environment in infancy,
usually provided by the mother and which is the mother at the
start, will be affected by the mother's and the family's health status.
Those engaged in organised care and concern for the development
and promotion of health have to understand this, and ensure the
organised care which assists in the facilitation of the mother's
provision of a facilitating environment for her developing young.

8
 Organised care, from the state, voluntary, or through social
networks, has its benefits for the health of the psyche. There is
evidence to suggest that an altruistic approach contributes to the
positive health status of all participants.

Development

Development has to do with 'a gradual unfolding; a fuller working

out of the details of anything' (The Shorter Oxford English Dic-
tionary on Historical Principles).
In the context of community health care 'being more fully worked
out in respect of the details', a prerequisite is an ongoing under-
standing and knowledge of what is happening within the commu-
nity; the present health status; what is it most people in the
community are saying, and thinking and asking for; and their views
on what is wanted or is needed.
Community health care development here, then, has to be con-
cerned with responding imaginatively and flexibly in collaboration
with others, both within the geographical community and those
other specific communities within it, who together will shape the
'fuller working out'. The responding developments should be such
as to contribute to the emotional, physical, social and mental well-
being of all those individuals and families and groups who make up
the community. To add to the interest of the nomenclature and of
the term community health care development, there are further
additional and familiar terms which are sometimes used inter-
changeably, for example community care, community health care,
primary health care or primary care. (Primary nursing refers to a
form of organised nursing care for the nursing process within the
acute health care sector. It predates the 'named nurse' which arose
from The Patient's Charter, DoH, 1991b.)
Primary health care - sometimes referred to as primary care - is
the first point of call for health service provision. It is provided by
the general practitioners and district nurses, health visitors, practice
nurses and other personnel who more often than not (but not
always) comprise a primary health care team. This could also
include the professional services of a social worker, a counsellor
and other specialist nurses who mayor may not define themselves
as being part of the primary health care team, but who will certainly
be contributing and offering primary health care.
Turton and Orr (1993) describe the aims of primary health
care as:

9
'1. The promotion of health in its widest sense through education,
support and the encouragement of self-care.
2. The prevention of ill-health by prophylaxis, early diagnosis,
education and advice on the value of early contact with the
primary health care services.
3. The care, treatment and rehabilitation of those who are acutely
or chronically ill.
4. The referral of patients to specialist services where necessary and
the provision of continuing care following specialist treatment.'
(Ibid., p. 18)

Community health care

Refers to all the health care provided in the community both by the
primary health care team and others besides: dentists, dieticians,
pharmacists, ophthalmic workers, continence advisers, stoma care
advisers, Macmillan nurses, the Marie Curie services, to name but a
few.
Community health care development includes all these concepts,
those implied in the NHS and Community Care Act 1990, those
services traditionally now supplied by community trusts, and the
development of related voluntary and private sector services.
Historically, the term 'community care' or 'care in the commu-
nity' has come to mean the de-institutionalisation of people who for
reasons of chronic sickness or physical frailty or emotional or
intellectual vulnerability, or profound physical disability or a con-
tinuation of all these factors, have found themselves in what we call
'long-stay institutions'. For many, and some complex, reasons such
environments are no longer regarded as appropriate places for
people to be living and receiving care or indeed in which staff
should be offering professional services (see for example Martin,
1984). Care in the community or community care also refers to
service provision for people already living in the community who,
by reason of increased frailty or vulnerability, require specific
services or attention or help to enable them to remain in their
own homes, which is something the majority of people desire. The
term also embraces provision in smaller residential accommodation
which is not the person's own home, but neither is it the same as the
traditional long-stay institution.
Thus, community care or care in the community is used in this
way specifically to distinguish it from primary health care, commu-
nity health care and social care (James, 1994). In social services,

10
community care means all the latter and more besides. For social
services it is a way of working with specific values and methods.
Health and social services therefore use the same language but with
different emphases and sometimes different meanings.
In Autumn 1994, the NHS Executive published an Executive
Letter, Developing NBS Purchasing and GP Fundholding: Towards
a Primary Care Led NBS (NHS Executive, 1994). This announced
changes confirming a central position for primary health care in
decision-making within the NHS. For many individuals, primary
health care and its development has its own significance and
different interpretations. There are also many different models
for primary health care provision. New World, New Opportunities
(NHSME, 1993) looks at developments in primary health care and
stresses the importance of primary health care services focusing on
the general-practice population, those people registered with each
practice. A number of people believe that the emphasis on a
primary health care-led NHS actually means a focus on a general
practitioner led NHS. In the UK, however, despite the emphasis
on primary health care, community health services, as already
intimated, are also provided by community and acute trusts, as
well as independent and voluntary agencies; this has been so for a
century.
For the purpose and framework of this book, community health
care is defined as all the health care that is taking place and
developing at the interface of hospitals and communities, and also
all health care provision outside hospitals in the United Kingdom.
Consequently, community health care development is defined as all
the developments that are and will take place in these places of care.
It is perhaps somewhat mischievous to introduce yet another
term. Nevertheless, it is significant for our purposes here and that is
'Community Development'. Benzeval et al. (1995) write: 'In its
purest form, community development is essentially about increasing
the ability of marginalised communities to work together to identify
and take action on priorities defined as important by the commu-
nities themselves.' For example, 'Community development has
traditionally been concerned with strengthening the way the social
dynamics work in a community' (ibid., p. 36), and 'Investment in
community development ... can reduce crime, fear of crime, stress
and mental illness' (ibid., p. 67).
Reference has already been made to inequalities in health, and will
be again. It has been stressed eloquently by others that health care
provision cannot alone redress the imbalance that unequivocally

11
exists in the health status within the population. It is axiomatic,
therefore, and particularly in certain areas, that community health
care development and community development are closely interre-
lated. All those involved in the work of such developments need to
be working with and alongside each other.

DEMOGRAPHIC FACTORS

Four demographic factors are affecting the changes occurring in

community health care thinking and provision: a declining fertility,
an ageing work-force, more women in paid employment outside
the home and growing numbers of elderly people. All these have
a profound effect on the care and provision required to meet the
need.
Nursing is being particularly affected by these demographic
changes. There is a very long and world-wide respected history of
nursing in the community, with a record of a very major contribu-
tion to the health and care of the population. As we move towards
the next century this unquestionable fact should be recognised and
provide further courage for the changes that are taking place.
Community health care services in the United Kingdom are
amongst the most advanced in the world. In 1993 about 50000
nurses were working in the community. Most of them were district
nurses, practice nurses, health visitors, school nurses and commu-
nity psychiatric nurses. The number of contacts that they make with
patients and clients, particularly in their own homes, runs into tens
of millions (NHSME, 1993). Their work includes the care and
treatment of people with acute and chronic illness, health promo-
tion and prevention of ill-health. Clearly, a comprehensive primary
and community health system is believed to prevent over-use of
hospital services which will both assist people to stay at home, thus
avoiding the trauma of hospital admission, as well as containing the
costs of the expensive acute health care sector.
A very significant and large part of the work of the community
nurse is that it takes place within the patient's/client's own home.
Liaschenko reminds us that:

' ... early in the development of nursing, people were cared for in
their own homes; hospitals developed, not as meccas of knowl-
edge, but as society'S response to the poor. With the rise of
technology and therapeutics, the medical professional hospital

12
 usurped the home as the pre-eminent place of sickness ... Once
again the geography of sickness is shifting as hospitals are losing
their spatial pre-eminence and the home, and other structures of
the community are becoming central to the sick.'
(Liaschenko, 1994, p. 18)

Since 1994, the Department of Health has emphasised a shift in

strategy towards a primary health care-led NHS. This is emphasised
in considerable documentation. The specific definition of a primary
health care led NHS is less clear. In October 1995 Stephen Dorrell,
Secretary of State for Health, sketched out a further development
for the primary health care led NHS (Wood, 1995). This strategy
encourages more work to be moved from highly-technological
hospitals to primary and community health care. This includes
minor injuries from accident and emergency departments. It is
important to realise that inevitably this has implications for patients
and their nursing care. Not all these will necessarily be positive.
Nurses who work in people's own homes at present (and the
profession has been doing so for the last century) have respected
and recognised the home as the domain of the patient. This is
precisely why there are specific differences in the education and
preparation of professional nurses for the community. A different
approach is required on the part of the nurse, something perhaps
only truly understood by those who know and have engaged in the
work. One of the most important aspects of the common core
foundation in Project 2000 (UKCC, 1986) was, and is, that it gives
student nurses an experience of working in the community and the
socialised context of the patient/client. The importance of"recognis-
ing the patient as a person first will also enable the development of
a more holistic approach to the delivery of acute health care
services.
Increasingly though, if health care is moved from the modern
technological hospitals into people's homes with computer links
and mobile support machines (and renal dialysis is not unknown at
home), 'the home, a separate domain from medicine, where the
inhabitant's agency has been primary, may find itself an extension
of hospitals, those awesome citadels of science where it is the agency
of dominant practitioners that is pre-eminent' (Liaschenko, 1994).
The challenge for the nursing profession and individual nurses is
to maintain a perspective of respect for the patient's/person's
dominance in their own home, and to act as a strong antidote
to an exclusive bio-medical and evidence-based clinical effective

13
model. The nurse's role of patient/client advocate will be vital here.
This is not to say that clinical effective care is unimportant, indeed it
may be unethical not to provide such care. Doubtless many ethical
discussions will and must ensue. What is being underlined here is
that nursing and nurses offer something which must not be lost, and
which transcends the bio-medical and the shifts in the locus and
status of primary and community care. Nurses stay alongside
patients in their pain, emotional and mental as well as physical
pain. They gather observations which are more than observed
physical changes. They need exquisite interpersonal skills to accom-
pany their theoretical knowledge. Other nursing skills are influenced
by the nurse's capacity to access, trust and use their own intuition.
While they can be the eyes and ears of the physician, they are also in
relationship with the patient; patient and professional nurse - two
people. 'The work of all nurses in the community, indeed of all
nurses wherever they work, centres on human relationships and
personal communication. The quality of this will determine the
effectiveness of the practitioner's practice' (Swain, 1995, p. 78).
The work of the nurse engaged in community health care devel-
opment both now and for the future, has to be set against the
background of recent, enormous and rapid change within the NHS.
The amount of change exceeds that of all previous years since the
NHS, based on the Beveridge Report of 1946, came into being in
1948.
The National Health Service and Community Care Act received
the Royal Assent in June 1990. The different interpretations of the
reforms are worth noting and nurses are encouraged to read both
Ham (1994) and Robinson and Le Grand (1994) amongst other
texts.
The following may be of interest; Ham writes:

' ... it is often argued that the reforms involve the introduction of
an internal market into the NHS. In fact it is more accurate to use
the phrase "managed market". One reason for preferring this
terminology is that competition is not confined to the NHS but
also involves providers outside the NHS. Even more important is
the fact that it has never been the government's intention to
introduce a free market. Rather, the aim has been to graft some
of the incentives that are often found in markets on to the
structure of the NHS and to regulate or manage the operation
of these incentives to avoid the problem of market failure.'
(Ham, 1993, p. 10)

14
which may be compared to:

'The reforms embodied in the 1990 NHS and Community Care

Act and introduced on 1 April 1991 represent the greatest change
in the organisation and management of the NHS since it was
established. In essence an internal market has been created within
the NHS in which the responsibility for purchasing or commis-
sioning services has been separated from the responsibility for
providing them.'
(Robinson and Le Grand, 1994, p. 2)

and again:

'In shorthand language, the internal market in the NHS was the
product of a political environment that valued wealth above
welfare, markets above bureaucracies and competition above
patronage; and it was the steady application of these preferences
to the NHS throughout the 1980s that made possible the intro-
duction of the internal market in the 1990s.'
(Butler in Robinson and Le Grand, p. 14)

Nurses will be familiar with encountering these somewhat different

interpretations as well as the possibility of accompanying passion or
otherwise within the ethos of their working environment. Inevita-
bly, those who see and experience the effects of such reforms on
services per se and on individual patients/clients, for good or ill, will
form their own views.
The word 'reform' itself is interesting. It is thrice presented in The
Shorter Oxford English Dictionary definition:

'To convert into another and better form; to free from previous
faults or imperfections. To amend or improve by removal of faults
or abuses. To put a stop or end to (an abuse, disorder, malpractice,
etc) by enforcing or introducing a better procedure or conduct. '
'Re-form, reform.'
'To form a second time, form over again.'

As to whether what are called NHS reforms constitute 'another and

better form' of NHS, or the 'introduction of better procedures'
within the NHS, or the 'ending of abuse and malpractice' within the

15
NHS, or a newly-created form of NHS, or something intermediate
between these each practitioner will decide.
The development of the NHS reforms is shown in Table 1.1. Ham
cites the most significant elements of the reforms as:

• separation of purchaser and provider roles;

• the creation of self-governing NHS trusts;
• the transformation of district health authorities into purchasers
of services;
• the introduction of GP fund holding;
• the use of contracts or service agreements to provide links
between purchasers and providers.

and adds that, 'Taken together, the reforms involve a transition

from an integrated system of health services financing and delivery
to a contract system. . . They have proceeded in parallel with
reforms of community care' (Ham, 1994, p. 10).
Sir Roy Griffiths, whose name is linked with the introduction of
General Management into the NHS, also undertook the task of
looking at service provision for those who were particularly vulner-
able. His work and recommendations emphasised the responsibility
of local authorities in service provision. Initially a very unpopular
response for the then Governmental leadership, it was acknowl-
edged in the White Paper Caring for People (DoH, 1989b) whose
recommendations have subsequently been incorporated in the NHS
and Community Care Act.

'The Act gave local authorities the lead responsibility for com-
munity care, and their role was that of enablers rather than direct
service providers. Local authorities were required to prepare
community care plans in association with health authorities and
other agencies. They were also given additional resources to
enable them to discharge their responsibilities. Most of these
resources involved the transfer of funds from the social security
budget. The Government made it clear that it expected these
funds to be used primarily to buy services from providers in the
independent sector rather than to fund direct provision by local
authorities. This meant that a community care market began to
grow alongside the NHS market, based on a separation of
purchaser and provider roles, the use of contracts, and the
emergence of a mixed economy of care.'
(Ham, 1994, p. 29)

16
 Table 1.1 The development of NHS reforms

1988 January Margaret Thatcher announces Ministerial Review of the

NHS.
July Department of Health created following the splitting up of the
Department of Health and Social Security. Kenneth Clarke
appointed as Secretary of State for Health.
1989 January Working for Patients published.
November NHS and Community Care Bill published.
1990 June NHS and Community Care Bill receives Royal Assent.
November William Waldegrave replaces Kenneth Clarke as Secretary of
State for Health.
1991 April NHS reforms come into operation. The first wave of 57 NHS
trusts and 306 GP fundholders is established in England.
June The government agrees guidelines with the medical profession
to avoid queue-jumping by GP fundholders.
A green paper on The Health of the Nation is published.
1992 April The Conservative Party is re-elected. Virginia Bottomley
replaces William Waldegrave as Secretary of State for Health.
The second wave of 99 NHS trusts and 288 GP fundholders is
established in England.
July A white paper on The Health of the Nation is published.
October The report of the Tomlinson Inquiry into health services in
London is published.
1993 February The government publishes its response to the Tomlinson
Inquiry, 'Making London Better'.
A review of functions and manpower in the NHS is
announced.
April The third wave of 136 NHS trusts and over 600 GP
fundholders is established in England.
July The functions and manpower review reports to ministers.
October The government publishes its response to the functions and
manpower review, Managing the New NHS. This includes the
proposed abolition of regional health authorities, the merger
of district health authorities and family health services
authorities, and a streamlining of the NHS management
executive.
1994 April The fourth wave of 140 NHS trusts and 800 GP fundholders is
established in England.
The Government set up pilot scheme of Total Purchasing GP
Fundholding.
1995 August The Health Authorities Act was passed. Virginia Bottomley
replaced by Stephen Dorrell as Secretary of State for Health.
1996 April The Health Authorities Act came into effect and RHAs were
abolished, District Health Authorities and Family Health
Service Authorities merged to make New Health Authorities
and GP Fundholding was extended.

Source: Adapted from Ham (1994).

17
These changes alone require sufficient adjustment and understand-
ing on the part of the nurse - on the part of anyone, indeed, engaged
in health service work. Most aspects (not all) of the NHS have
certainly been affected and some changed utterly by the reforms.
But this is not all. They are further accompanied by changes and
developments in respect of technology in general, health technology
and information technology in particular. Furthermore there have
been, and continue to be, changes in nurse education, post-registra-
tion education and statutory requirements for the profession, and
other professional issues of concern, and not only for nurses.
Finally, this is all taking place in an economic climate and
national prevailing ethos in which the economic and health status
of individuals, families and communities is demonstrating great
inequality and division. Taken as a whole, this is the Sturm und
Drang in which community nurses are required to work sensitively
and effectively with their clients and patients together with their
colleagues.
The epidemiological factors and needs are reflected throughout
this chapter. Quite clearly, the work of the nurse engaged in
community health care development will be influenced by the
causation, distribution and frequency of disease and other biologi-
calor social phenomena. The disease may be infectious or non-
infectious, influenced by factors in the environment both physical
and social. The epidemiology of accidents, smoking, poor nutrition,
teenage pregnancies and mental illness and the poor low-health
status arising from poverty will emphasise the areas of work into
which energies must be directed. The Health of the Nation (DoH,
1991 b) strategy concentrates on a number of specific areas but by no
means all of them, and one area that we tirelessly and unapologe-
tically repeat here, is the lack of energetic social policies, particularly
concerned with housing, influences the epidemiological trends.
During the Thatcher years, budgetary constraint and the growth
of demand by the public led to attempts to achieve greater outputs
from public services within existing resources leading, as we have
seen, to greater competition and a search for resources beyond
them, thus encouraging competition (see Taylor-Gooby and Law-
son, 1993).
The consequent health care market (managed or not) has intro-
duced fragmentation and pluralism, characterised by a blurring of
boundaries between providers, purchasers, professionals and man-
agers and between professionals themselves. There is also a diffu-
sion of power as private and voluntary services increase their role

18
and importance as providers. Important new public-private health
care provision partnerships have emerged. The outcomes of the
future political elections, however, could influence the role of the
private sector in the health service. Although there is a perception
that the private sector provides better care than the NHS, this has
not been proven, especially for direct 'basic' care. Private health
care may provide some better facilities but may lack the skills
required for complex, chronic and continuing care. There is also a
debate about who it is that actually benefits from private health
care. Is it the affluent, or financially less-fortunate members of the
public, the owners of the private institutions such as nursing homes,
or some of the clinicians who may be working for more than one
employer, possibly at the same time? (Yates, 1995).
The private sector is largely funded by health insurance. Increas-
ing selectivity and restrictions on cover are emerging and such
insurance may not provide value for money for patients. What is
important is that patients and their carers are aware of the cover
provided. This is the direction of Health Maintenance Organisa-
tions and State Benefit funds in the United States. In the United
Kingdom, insurance companies are moving away from funding
mental health care and chronic care. A person is excluded from
joining an insurance system if they have clinical needs. Insurance
premiums are cheaper if there is no cover for relapsing illnesses.
Insurance cover is more expensive for out-patient activity than in-
patient care, leading to difficulty in following up chronic illness. It
would seem, therefore, that many insurance-paid health systems
lead to a consumer-doctor conspiracy, with patients demanding
more and being encouraged by clinicians and insurance cover to ask
for expensive and sometimes unnecessary health care.

POVERTY AND HEALTH INEQUALITIES

Although there is an increase in the health status of the population

in the UK in general, there is a widening gap between the rich and
the poor which may well increase the web of demand for health and
social care, such as for those needing continuing care, and not least
in areas such as mental health needs. Many environmental situa-
tions increase the incidence of mental illness, including the demands
of the work-place and changes in work and current labour market
patterns. The correlation between unemployment and mental illness

19
is well-known; and the precarious nature of employment situations
adds to stress.
The President of the Royal College of Psychiatrists stressed that
there was enormous alienation and disengagement from society
when individuals, no matter what their age, were not able to achieve
their full potential (Hennessy, Ham and Tremblay, 1995). The
breakdown in society, especially in family life and community
values of corporacy, is reflected and expressed in ill-health. This
was pointed out also in 1985 research when discussing the health
visitor's role in caring for post-partum mothers and the demands
placed on the health care system by post natal depression, which
seemed at that time to have a clear link with changes in society such
as mobile, nuclear or broken families and the huge societal demands
placed on the new mother (Hennessy, 1985).
Citing the work of Benzeval et al. (1995) earlier in the chapter, it
was stressed that the health inequalities caused by economic in-
equalities could not be resolved by health care services and person-
nel alone. The observation has been made, too, by others that there
has long been a societal belief that medicine has always been the
healer of society's difficulties. Health care professionals are, in fact,
seen as licensed patient-touchers and healers for whatever causes
discomfort, pain and disease, be it physiological, emotional, mental,
social or environmental. It may be of course that doctors and nurses
have - albeit unwittingly sometimes - colluded with this to the
detriment of all concerned. Benzeval et al. have made quite clear
whence further impetus is required in terms of social policy and
action as we have already shown.

TECHNOLOGICAL INFLUENCES

Developments in health technology are having an exciting impact

on health care. This subject includes new drugs for psychotic
disorders, improvements in surgical techniques such as keyhole
surgery, and nerve transplants for multiple-sclerosis sufferers. De-
velopments in genetics are opening up horizons and challenging the
traditional view that we have control over our own health, as well as
raising many ethical questions.
This is of course one aspect of the general major technological
shift leading to a massive acceleration in the pace of change in
society. The industrial age has been replaced by the information
age, with a society intent on producing knowledge. Manufacturing

20
employment has been replaced by jobs connected with information.
The technology associated with information permits considerable
decentralisation of decision-making without loss of administrative
control. This therefore leads to a flattening of hierarchies because
the middle management communication systems can be replaced by
computers. Information technology in particular is growing very
rapidly in the health service, and there is increasing potential for the
integration of information systems between organisations to im-
prove co-ordination of patient and client care across primary,
secondary and other community agency settings. For nursing in
the community, inevitably, there will be an increase in momentum
for relaying information between nurses and the clinical work and
smaller decentralised administrative offices (Ranade, 1994).
It is important, therefore, that nurses in the community (and
indeed everywhere) are familiar and confident in using computers
for accessing information. For those still reluctant to acknowledge
their importance and to develop skills in their usage, it needs to be
remembered that knowledge/information is power. A refusal to
make the necessary adjustment means a loss both of personal and
professional control. The most important aspect of the use of this
technology, for both the reluctant nurse and equally for the zealous
user, is that these are tools to be used in the service of the work. As
Patrick Casement (1994) describes the use of theory, the same words
can be applied to this use of technology. It is as servant to the work,
not master, and the findings can be used or, if inappropriate, set
aside. In the context of Community Health Care Development,
information technology is to be used in the service and interest of
the client/patient, for epidemiological information, and to assist the
practitioner in making an effective contribution to the health of the
community. Nurses will already appreciate that information is to be
used ethically.

PRIMARY HEALTH CARE AND HEALTH PROMOTION

The development of primary health care, based on general-practice

patient registers, has had much attention for more than two
decades. This was prompted by concerns that primary health care
had open-ended public expenditure and there was no way of
imposing cash limits on the amount spent on prescribing, nor the
number of people referred by general practitioners to hospitals. The
focus of the attention has been to curb expenditure, raise standards

21
and give greater emphasis to health promotion and prevention of
illness (Ranade, 1994).
These points were outlined in a number of consultative docu-
ments starting with Primary Health Care (DHSS, 1986) Neighbour-
hood Nursing (DHSS, 1986a). These were followed by a White
Paper, Promoting Better Health (DHSS, 1987). These proposals are
thought to have been the starting point for the subsequent reforms
(see for example Ranade, 1994) and Working for Patients (DHSS,
1989). Many of the proposals in the White Paper were introduced
into the new GP Contract in April 1990. The way for challenging
general practice opened, introducing business plans and contracts
and the efficient use of all resources. The contract facilitates
scrutiny of the procedures, the use of resources and the commitment
to health promotion in general practice.
Ham, quoted earlier, saw the introduction of GP fundholding as
one of the most significant elements in the reforms; as GP fund-
holding is seen by some as 'the real cutting edge of the reforms or
alternatively a major source of disruption and inequity' ('Wild Card
or Winning Hand', in Robinson and Le Grand, 1994, pp. 105-6).
He argued that:
'fundholding is probably one of the few parts of the reforms that
is having the competitive efficiency effects on the hospital system
that the reformers hoped for. On the other hand, it only applies
to a minority of patients and is therefore open to criticism for its
equity effects. There are also long-term worries about cream
skimming or risk selection.'
(Ibid., pp. 105-6)
In their summary, Benzeval et al. (1995) stress 'a fairer system of
allocating resources to GP fundholders needs to be established'
(p. xxiii), and later, 'it is not at all clear that adequate data and
methodologies are available to allocate resources to fundholders in
ways that fully reflect the health care needs of their patients. This
could exacerbate the phenomenon of "cream skimming"; incentives
will be created for fundholders to limit care on the grounds of cost
rather than appropriateness or even to exclude some patients
altogether' (Benzeval et aI., 1995, p. 101).
Whatever the view held concerning GP fund holding, the atten-
tion given to primary health care services has increased. It has
always taken second place to the hitherto high profile acute sector
which has always been allocated and consumed higher funding.
Prior to the reforms following the NHS and Community Care Act,

22
 very many community units will have known the bitterness of
funding being reallocated from their own areas of service provision
to overspent acute hospital budgets, whose initial allocation anyway
was far in excess of that of the community unit.
This can no longer happen, which perhaps is why the financial
plight of so much of the acute sector is more clearly exposed. The
spotlight now is much more focused on community health care in
general, and primary health care in particular. This has the effect of
raising the profile of the work of nurses in the community. There is
now much more interest and awareness of the contribution of this
massive group of professional clinical staff to community health
care development. Such policy changes together with others in
nursing per se, are providing nurses with numerous opportunities
to expand their skills in direct client and patient care, health needs
assessment, health promotion, patient protocols, care management
and the provision of a greater range of rehabilitative aid specialist
services (NHSME, 1993).
Health promotion strategies were devised for the four countries
of the UK. Benzeval et al. regard the Welsh strategy, as the most
advanced, as it takes into account the inequalities in health as well
as moves to reduce them. They regard the Northern Ireland strategy
as in second place. The English and Scottish documents, although
they signal a welcome move towards wider health promotion, have
yet to make a commitment and formulate associated policy. Never-
theless, one recent development holds promise for the future: in
May 1994 a sub-group of the Chief Medical Officer's Health of the
Nation Working Group was established to examine variations in
health. They reported in 1995 (DoH, 1995a) and this could be the
beginning of more positive moves to tackle inequalities in health in
England. This is only to be welcomed. The initial discussion
document, The Health of the Nation (DoH, 1991b), identified five
key areas for attention including the prevention of coronary heart
disease and stroke, accident prevention, cancers, mental health and
sexual health.
Particular action by professionals and managers for achieving
targets in the five key areas was suggested in The Health of the
Nation - First Steps for the NHS (NHSME, 1992). This document
was followed by another addressing, especially, the contribution of
nurses, midwives and health visitors (DoH, 1993b). In terms of
illness prevention and health promotion, clearly the community
nurse has a part to play, but at a glance these targets cannot be met
by the practitioner alone.

23
 This was further emphasised by the WHO (1986) in Nursing and
the 38 Targets for Health for All by the year 2000 in Europe. The
focus, 38 targets in all, included the following areas: health for all;
lifestyles conducive to health for all; producing healthy environ-
ments; providing appropriate care; and support for health develop-
ment. Within the section dealing with lifestyles, two of the targets
were developing healthy public policies and developing social
support systems. Within the provision of appropriate care was
included the target of a health care system based on primary health
care. This demonstrates the primacy given to health care in Europe
and the acknowledgement that other appropriate policies are
required to contribute to an increase in positive health status within
communities. Nurses engaged in community health care develop-
ment in the UK need to be aware of these European targets and
how their own work is part of European community health care
development as a whole.

'WHO says that community nurses acting as advocates for the

community should help in the essential task of involving people
in making decisions about health care and speaking for people's
interests. '
(WHO,1986)

CLIENT/PATIENT INVOLVEMENT IN HEALTH CARE

A major aspect of primary and community health care is the

encouragement of more active involvement of individuals, families
and groups in contributing to their own care. Some of the country's
opinion leaders of health care interviewed early in 1995 believed
that there was a shift in the public values and attitudes towards
health and well-being (Hennessy, Ham and Tremblay, 1995). This
means that the public may take more responsibility for their own
health and rely less on medical and organised public health services.
It is suggested by some that the public are less concerned with the
effectiveness of health care than they are with being involved about
the decisions that are taken when the treatment is unpleasant. They
also wish to be heard and listened to in respect of when they want
health care, and from whom they wish to receive it. For instance,
great concern was expressed about the diminution, without public
discussion, of long-term caring services for those who are very
elderly. There was a feeling that it was immoral considering the

24
public expectation of 50 years of care from the cradle to the grave
and their lifetime contribution to the health services through
taxation and National Insurance.
The role of pressure, self-help and other consumer groups, and
the role of the Community Health Councils created in 1974 are
important, but their effectiveness is queried. 'One widespread
criticism of consumer groups and Community Health Councils
has been the extent to which they truly represent health service
users (Bates, 1983; Richardson and Bray, 1987; Pollock, 1992). The
consumerism of the 1990s, however, goes further than questioning
the representatives of collective bodies by questioning the belief that
consumers can exert an influence through such bodies at all. The
collectivist approach to consumerism, traditionally associated with
the NHS, has been replaced by an individualistic approach that
attempts to achieve responsiveness to users through the introduc-
tion of a market ethos into the management and structure of the
NHS' (Robinson and Le Grand, 1994, p. 109). Regional Health
Authorities ceased in April 1996, replaced by an organisation that is
part of the civil service. Whether this will have any impact on
Community Health Councils, for good or ill, remains to be seen!
The facilitation of active involvement to enable true participation
on the part of the community is, again, a focal part of the work of
those engaged in community development and Community Health
Care Development. These are also the principles of health visiting:
the searching for health needs; stimulating awareness of health
needs; influencing policies affecting health care; and facilitating
health enhancement activities (Council for Education and Training
of Health Visitors, 1977).

POLICIES AND THE PEOPLE

Margaret Whitehead's review of international interventions (1995),

'suggests that policy initiatives that can influence inequalities in
health exist at four different levels:

• strengthening individuals
• strengthening communities
• improving access to essential facilities and services
• encouraging macro economic and cultural change',

and that,

25
 ' ... policies that attempt to strengthen individuals aim to change
people's behaviour or coping skills through personal education
and for empowerment. General health education messages have
had a limited impact on people from disadvantaged environments
because the pressure of their lives constrain the scope for
behavioural change. However, more sensitive interventions that
continue education and support can have a positive effect on the
health of people in disadvantaged circumstances if they are
carefully related to their needs and combined with action at other
policy levels.'
'Policies that aim to strengthen communities have either focused
on strengthening their social networks or they have adopted a
broader strategy that develops the physical, economic and social
structure of an area. Such initiatives can, through involving the
community itself in the determination of priorities, change the
local environment, services and support systems in ways that
promote equity in health.'
(Margaret Whitehead in Benzeval et al., p. xviii)

The writer goes on to say that this alone does not reduce inequalities
in health significantly - it requires work at other levels of policy.
The stated principles of health visiting interweave with all of them.
People's involvement will be affected by their own self confidence.
Empowering individuals, and strengthening communities is an area
in which the community nurse must engage.
The use of professional clinical counselling services too, within
primary health, can assist in the individual strengthening and
empowerment of individuals. Counselling can help people to dis-
cover some of their inner resources which may be mobilised with
others, in the face of unemployment, emotional crisis and to prevent
more serious mental illness, which so often can accompany social
and economic deprivation. It is, though, a service provided to assist
people in difficulty, and should never seek to deny the reality of
deprivation or health inequality. Most assuredly it is not to be used
as a sop to prevent the need for policy changes.
When the Health of the Nation discussion document (DoH,
1991 b) was published, public involvement was invited in respect
of comment. Advertisements in the national press gave individuals
as well as communities and their representatives, together with
health professionals and allied bodies, an opportunity to make a
contribution to the debate.

26
 Four years after the launching of The Patient's Charter, Raising
the Standard (DoH, 1991a), came the 1995 publication The Patient's
Charter and You: A Charter for England (DoH, 1995a). It referred to
the rights 'which all patients will receive all the time', and 'expecta-
tions - these are the standards of service which the NHS is aiming to
achieve. Exceptional circumstances may sometimes prevent these
standards being met.' Amongst other services it referred to GP and
community services, including the community nursing services. It
referred to .the new standards for community care services in which
the NHS works together with local authorities.
Ham described both The Citizen's Charter and The Patient's
Charter as 'an attempt to distinguish Majorism from Thatcherism,
and served to highlight those aspects of the NHS reforms concerned
to improve the quality of services from the patient's perspective'
(Ham, 1994, p. 36). Part of the work of the nurse engaged in
community health care development is to ensure that whatever
the politics, the patient's and client's perspective should always be
on the agenda in the purchasing and provision of health care.

PREPARING NURSES FOR THE FUTURE

A Strategy for Nursing (DoH, 1989a), Vision for the Future (DoH,
1993a), The Scope of Professional Practice (UKCC, 1992a), and
New World, New Opportunities (NHSME, 1993) are a few of the
recent policy documents that herald fundamental change for the
work of nurses in the community up to and well into the twenty-
first century. Ranade (1994) provided an interesting and logical
summary of the educational change in nurses' pre-registration
education. Ranade suggested that this educational model will
prepare nurses to work in hospitals and the community, and for
the changes and demands of twenty-first century health care.
Increasingly, nurses and their teams will work in decentralised work
patterns in different settings in the community.
The Heathrow Debate (DoH, 1994) discusses the possible future
implications for nursing practice in the next century, influenced as it
will be by all the changes which are and will be taking place:

'To advance confidently nurses need to consider what they are

and what they want to be. An important debate must begin at all
levels and across the whole spectrum. It must be moulded by the
most senior members within the profession, but involve even the

27
 newest recruits ... Nurses believe that their own insight should
be available at all levels - for the patient, for the local community
and where commissioning and policy decisions are taken.'
(DoH, 1994, p. 23)

Project 2000 (UKCC, 1986) received government approval in

1986. This provided an eighteen-month common core foundation
with a strong emphasis on the whole person, community and health.
The subsequent eighteen months leading to registratiIJn concen-
trates on one of four specialities: adult, child, mental health and
mental handicap/learning disabilities. Importantly, the student
nurses were to be supernumerary. Community nurses would still
be required to have a post-registration specialty training in district
nursing, health visiting and school nursing, together with commu-
nity psychiatric or learning disability training for specialist nurses.
The Project 2000 nurse, after registration, is able to work as a
first-level nurse in the community, directed by a specialist commu-
nity health nurse.

HEALTH CARE SUPPORT STAFF

The inevitable shortfall of actual direct-care staff exacerbated by

supernumerary students was to be met in some degree by the
creation of the health care assistant (HCA). It is hoped that many
will be given the opportunity to acquire National Vocational
Qualifications (NVQs) in health care. 'HCAs are likely to be in
widespread use in the NHS by the mid or late 1990s working in
support of and in some situations instead of clinical professionals in
nursing and the therapy professions' (Robinson and Le Grand,
1994, p. 185).
Whatever the profession may think of this further dilution of
direct hands-on professional care, it is something which is happen-
ing, will accelerate, and must be used as an opportunity. Further-
more, without such staff in all aspects of the National Health
Service, the service would come to a halt overnight. Sometimes
the work such supporting staff do is described as menial or basic,
and the word 'task' is usually added. This usually refers to care of an
intimate, direct and personal nature, which requires skill, sensitivity,
respect, courtesy and compassion. The staff who are doing the work
require preparation, guidance, supervision and support which is also
sensitive, respectful, courteous and compassionate.

28
 In the community, professional nurses and supporting staff often
work unseen, alone with a client, in a client's own home. There is a
constant need to continue, maintain and increase/improve stan-
dards of care, and the community nurse is required to be mindful of
The Scope of Professional Practice (UKCC, 1992a) as well of course
as The Code of Professional Conduct (UKCC, 1992b). The former
sets out the boundaries for safe practice and those educational
requirements for areas regarded as 'extended nursing practice'. The
DoH withdrew its guidance on the extended role of the nurse
following the publication.
Concerning HCAs it is unequivocal:

'The Council's position in relation to support roles is as follows:

23.1 Health care assistants to registered nurses, midwives and

health visitors must work under the direction and super-
vision of those registered practitioners;
23.2 Registered nurses, midwives and health visitors must re-
main accountable for assessment, planning and standard
of care and for determining the activity of their support
staff;
23.3 Health care assistants must not be allowed to work beyond
their level of competence;
23.4 Continuity of care and appropriate skill/staff mix is im-
portant, so health care assistants should be integral mem-
bers of the caring team;
23.5 Standards of care must be safeguarded and the need for
patients and clients, across the spectrum of health care, to
receive skilled professional nursing, midwifery and health
visiting assessment and care must be recognised as of
primary importance;
23.6 Health care assistants with the desire and ability to pro-
gress to professional education should be encouraged to
obtain vocational qualifications, some of which may be
approved by the Council as acceptable entry criteria into
programmes of professional education; and
23.7 Registered nurses, midwives and health visitors should be
involved in these developments so that the support role can
be designed to ensure that professional skills are used most
appropriately for the benefit of patients and clients.'
(UKCC, 1992a)

29
 As previously mentioned, there is and will be an increase of
health care assistants working in the community. Alongside the
work in community health care development, the community nurse
must remain stringently aware of her responsibilities in respect of
both the Code and Scope and to further engage the HCA or support
worker in an understanding of community health care development
and how the support worker contributes towards such goals.

CLINICAL SUPERVISION

Another significant development is that of clinical supervlSlon.

Long overdue, it is a most necessary professional provision for
nursing staff, to enable them to reflect on their practice regularly
and increase its effectiveness. At the time of writing this is a very
recent development and not yet as well understood as it needs to be.

'Supervision is a dynamic, inter-personally focused experience

which promotes the development of therapeutic proficiency. One
of the primary reasons for all supervision is to ensure that the
quality of all therapeutic work with the client is of a consistently
high standard in relation to the client's needs. Consequently,
supervision must be acknowledged as a cornerstone of clinical
practice.'
(Hill, 1989, pp. 9-15)

And:

'Our experience is that supervision can be an important part of

taking care of oneself, staying open to new learning, and an
indispensable part of the helper's on-going self-development, self-
awareness and commitment to learning.'
(Hawkins and Shohet, 1989, p. 5)

The hitherto autocratic and hierarchical organisation of nursing

inevitably leads to suspicion concerning the introduction of some-
thing which contains the word 'supervision'. Professional clinical
supervision has long been established in psychoanalysis, psy-
chotherapy and professional counselling practice, and is regarded
as one of the sine qua non of such work. It is firmly on the nursing
agenda and we can welcome it wholeheartedly.

30
 The provision of a facilitating environment as in clinical super-
vision 'offers the opportunity for vision to be widened; for the
practitioner to take a broader view of professional practice and to
apply her own skills and knowledge gained from experience to a
given situation' (Swain, 1995, p. 23).
Community health care development requires a vision. Nurses
working alongside individuals, families, groups, communities, and
so often sharing the pain as well as the pleasure, must be given the
opportunity to reflect on their work with a professional other
(ibid.).

ONGOING RESEARCH

Post-Registration, Education and Practice (PREP, UKCC, 1994),

implemented from I April 1995, also seeks to ensure that practi-
tioners are in receipt of regular updating, and that they will be able
to show evidence of their fitness to practise by virtue of on-going
study and personal and professional development in the form of a
personal professional profile. All of this is concerned with the
raising and maintaining of standards, and the protection of the
public and inevitably the practitioner. Community health care
development increasingly requires continuing education which de-
velops skills and competencies of practitioners to Masters degree
level. These skills are used in research and development, which are
very important in identifying the efficiency as well as the cost-
effectiveness of using various interventions with limited resources.
Community health care development, along with community devel-
opment, are so crucial that the community nurse should be encour-
aged to participate in research into these areas. This will lead to an
increasing influence on how health interventions are applied, to
whom and when.

MATTERS OF ETHICS

Inevitably some ethical issues are raised. An example could be

whether it is reasonable to remove a cancerous colon, given the
emotional and physical cost to the patient/person, particularly if
very old, as well as the financial cost to the State. Such a procedure
might enable an elderly person to return to independence in the

31
community, even for a short period of time. On the other hand,
should such an invasive procedure be done. Is it unethical not to do
so, leaving instead a very frail and unwell person in the community,
dependent on family, the community, and the health and social
services? Added to these considerations is the increasing role of
clinical audit which attempts to ensure that clinicians are practising
evidence-based care, even though the latter may not be appropriate
in the eyes of the patient (Hopkins, 1993).
The subject of ethics mentioned more than once in this chapter,
will be returned to throughout this book since health care reforms
has led to many questions about its role.
Brody (1994), in discussing the health reform debate in the
United States, pointed out that Clinton's health reform speech to
Congress in 1993 carefully identified the most important moral
values which justified his reform proposals. Brody stressed that it
was important to consider ethics as the:

' ... optimistic voter tends to assume that health reform is about
the policies and economics of health care; the pessimistic voter
tends to assume that the debate is a smoke screen behind which
the powerful interest groups will assure that no change in health
care cuts too deeply into their profits or privileges ... The moral
values at stake - universal access, reasonable equality of benefits,
fairness of burdens, quality and efficiency of care - are readily
grasped by most people and form the basis for a serious com-
munity discussion of what sort of system best suits the nation and
what sort of trade-offs ought to be made in implementing it.'
(Brody, 1994, p. 7)

These points are highly relevant in the NHS, which on numerous

occasions has mirrored the Oregon Health Decisions Project quoted
in Brody's article. Many citizens and communities are becoming
involved in health debates, and the officials in charge of the
distribution of resources are having to answer to the public as well
as the clinicians for the rationale behind their distribution of health
care resources.
The opportunities for such debates are taking different forms -
on the radio, the television, in general-practitioner surgery partici-
pation groups and focus groups and health authority-patient focus
groups. Although it is difficult to get adequate involvement of the
public they are beginning to say they are not consulted enough (see
for example NHS Executive, 1994). Here then is yet another

32
challenge for the community nurse m community health care
development.
Whether, individually, community nurses would describe them-
selves as 'optimistic or pessimistic voters' only each person knows.
What we do know is that general elections are regularly held with
subsequent ramifications for the National Health Service.

END PIECE

Our values were stated at the beginning of this chapter. Wherever

changes may lie ahead, and change as we know is inevitable, the
values that we hold at the core of our work which are essential to
community health care development do not change; they form the
backbone of our work, together with a commitment to social justice
in the community.
It is eminently sensible to try to link major societal and conse-
quent health policy changes with the reality of their impact on the
work of community nurses. Opportunities should be sought by
nurses to continue developing compassionate and knowledgeable
care.
In this regard the chapter authors in this book have been
deliberately chosen to provide a balance of health care personnel.
There are a number of nurses, and others who are not nurses, and
who may not personally hold or fully understand the eternal values
of nursing. It suffices that nurses do. In this state of confidence,
then, there is the opportunity to learn from and listen to other
colleagues and from other disciplines concerning their approach to
community health care development, in which the community
health nurse has, and will continue to have, an integral contribution
to make.

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Ham, C. (1994) Management and Competition in the New NHS.
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36
 CHAPTER TWO

Identifying Health Needs

Lesley E. Armitage

INTRODUCTION

What is health? What are health needs? Who decides who has what
needs? Why do these decisions have to be made? What is this to do
with community nurses? How are health needs identified?
The covert rationing of health services by the use of waiting lists
should be past history, and now the challenge to every health
professional in the NHS is to ensure that its resources are prioritised
according to need and health outcome. Furthermore, purchasing
and commissioning are now at the heart of health service planning
and provision. These two factors give health professionals, includ-
ing community nurses, a dual responsibility:

1. to prioritise the resources available to them according to need

and health outcome; and
2. to provide input into purchasing and commissioning which is
based on soundly researched fact.

This chapter will discuss how much more far-ranging ill-health and
its determinants are than the familiar medical model, how commu-
nity nurses are ideally placed to observe the effects of these
determinants, why and how health needs are determined, and the
role of community nurses in identifying health needs and informing
the purchasing or commissioning of health care.

37
HEALTH

What is health? A minimaIistic medical model would be 'the

absence of disease'. However, health is generally considered to be
a much wider concept than this, and the most quoted definition is
probably that of the World Health Organisation: 'Health is a state
of complete physical, mental and social well-being and not merely
the absence of disease or infirmity'. A criticism of this could be that
it is so rarely achieved as to invalidate it on practical grounds, but
should this disqualify a definition which provides a goal to aim for?
Perhaps a slightly more realistic definition is that of mainstream
biological thought: 'Health is a satisfactory adaptation of the
individual to his total environment - physical, psychological, and
socio-cultural. The optimum use of human powers through this
adaptation leads to a sense of well-being' (Royal College of General
Practitioners, 1972). The important factor in the second and third
definitions is that health is considered to have three dimensions,
that it is not just associated with the absence or presence of disease
but also results from a successful interaction of the individual with
his or her physical and social environment.

ILL HEALTH AND SOME OF ITS DETERMINANTS

It is only necessary to think through an imaginary 24 hours in the

lives of a range of people to begin to have some idea of how many
factors impact on health, and how relatively small, although
important, is the part played by conventional health services. People
spend their lives at home, at work, at school, in looking for
employment, in aimlessly waiting for the day to pass, in leisure
activities, in carrying out chores, in travelling on foot or by vehicle,
in social isolation, and so on. Through these they are in contact with
a range of environments which influence their health by exposing
them to pollution, major and minor accidents, stress, unhealthy
lifestyles, and so forth. The deleterious effects of these are com-
pounded by unemployment and poverty, be it absolute or relative,
and there is now an abundance of evidence to show that poverty is
associated with higher morbidity and mortality rates when com-
pared with those for people of higher socio-economic classes. The
Black Report was a seminal document on the effects of poverty on
health, and 15 years later, in 1995, The King's Fund and The

38
Department of Health both produced reports on socio-economic
deprivation and health, which serves to show the continuing
importance of this topic, despite almost 50 years of health service
provision free at the point of delivery (see for example Black et al.,
1992; Benzeval, Judge and Whitehead, 1995; and Department of
Health, 1995).
The NHS seeks to promote health; to prevent disease - for
example, measles and rubella by immunisation, and lung cancer
and chronic obstructive airways disease by anti-smoking initiatives;
to detect other diseases early so that treatment will be of maximum
benefit - for example hypertension, non-insulin-dependent diabetes
and breast cancer; to treat trauma and acute illnesses effectively so
that patients return to their previous state of health, or one in which
impairment, disability or handicap are minimised; and to manage
chronic diseases so that their progression and their effect on the
sufferers' quality of life are kept to a minimum. However, none of
this can happen unless there is contact between the public and the
providers of health care, and unless that contact is effective. In the
face of illness, people's behaviour varies and is often socially
determined. People from lower social classes, when compared with
those from higher social classes, tend to seek medical advice more
often for relatively minor acute illnesses, and less often for their
serious illnesses, and to make less use of preventative services (see
for example Black et al., 1992; Forster, 1976; and Pill et al., 1988).
This difference has been shown to extend to the quality of the GP
consultation, when middle-class patients have longer consultations
and discuss more problems than working-class patients (Cartwright
and O'Brien, 1976; and Buchan and Richardson, 1973).
There are people whose housing or working conditions expose
them to health risks or increased danger from accidents, while the
continuing employment and income of others can be jeopardised by
time off work due to ill-health or regular appointments with their
doctor, and this is especially so for people in low-paid or piece-
work, or the black economy, who are often not protected by
employment law. For these or other reasons they may delay going
to their GP until their condition has become so bad that treatment
cannot be avoided, and may then require more time off work than if
they had gone earlier. Some people suffer from a physical disability,
but their environment then turns that condition into a handicap; for
example someone who is wheelchair-bound is unable to take up a
job because of lack of transport facilities, or the office is inaccessible
to a wheelchair user (WHO, 1980).

39
 The Public Health Alliance's Charter for Public Health lists the
factors that it considers to be 'the essential basis of every citizen's
right to good health'. These factors are not only useful in illustrat-
ing how wide-ranging are the social determinants of health, but they
also serve as a list of topics requiring responses from health
professionals and others (Public Health Alliance, 1993).

WHY IT IS NECESSARY TO IDENTIFY HEALTH NEEDS

There never was, and there is never going to be, enough money for
the NHS to meet all the health needs and demands of the public.
The increases in available treatments, in patient throughput, in
technological development, and in patient expectations mean ever-
increasing costs for health care which need to be funded. The
Department of Health has to compete with other government
departments for its financial allocation, and the amount it receives
reflects political and financial expediency as well as health need. For
all of these reasons health service provision throughout the NHS
will always be constrained by the resources available to it, and this
is why health needs must be identified, priorities determined
according to clinical need, and resources used to gain the best
health outcome.

Who assesses health need?

Until the advent in the 1980s of the changes recommended by the

Griffiths Report (DHSS, 1983), the NHS was administered rather
than managed; consultants effectively made the decisions which
determined the use of the majority of its resources; and there was
little or no management of those resources to ensure that they were
used according to the greatest patient need and health outcome, and
that the service was provided efficiently and effectively. With the
advent of 'the new NHS' in the 1990s came management and the
purchaser-provider split. This gave health authorities and GP
fundholders (GPFHs) the power to decide which services they were
going to purchase for their patient populations; the opportunity to
base their decisions on health need and health gain; and the chance
to demand better value for money and improvements in the quality
of the services provided. Although these two bodies have the direct
power to place service contracts with the providers of their choice,

40
district health authorities (DHAs) are often in a better position to
make their decisions if they receive input from the health profes-
sionals in daily contact with patients. Many DHAs therefore work
with non-fundholding GPs, who form commissioning groups and
advise their DHAs of the services they would like purchased on
behalf of their patients, and from which Trust they would like them
purchased. Community nurses are employed by GPs and commu-
nity trusts, and are in an ideal position to provide advice on the
need for services.

Tensions in the assessment process

Unfortunately it has not always been possible to base purchasing

decisions on health need and health gain for a variety of reasons.
Ideally, departments of public health should assess the health needs
of their authority's population and use it to drive that health
authority's agenda, but they may have difficulty in achieving this
because of the tension between the dual roles of such departments;
that is, the tension between being independent advocates on behalf
of the public's health, and the need to respond to the demands of
their health authority. The situation with GPFHs is variable, as
they are in the potentially awkward situation of being responsible
for rationing the health care they provide for their patients, while
having personal contact with their patients and their patients'
demands. As a result there is a greater chance that they may find
it difficult to refuse the loud voice of consumerism in favour of what
may be the almost silent voice of need. Already there are criticisms
that some GPFHs are purchasing services from the limited 'pool'
available in their district, so that their patients receive the services at
a low threshold of need, and this reduces the health outcome and
the services available for the rest of the authority's population, who
therefore do not gain access to them until they reach a higher
threshold of need.

Meeting incessant needs

The changing working structure for community nurses is from a

rigid nursing hierarchy towards a loose framework consisting of
community nurses and other health professionals. This gives excit-
ing opportunities to community nurses for controlling and promot-
ing their own work and for innovative ideas, including the effective
management of their caseloads. The hazard of the loose framework

41
is its lack of controls. For instance, if a nurse is providing a poor
quality service to her clients because of health or social problems,
burnout, or increasing disinterest, there is a greater potential for
this problem to go undetected. It is therefore important to recognise
the greater professional responsibility required if community nurses
are to work in the more challenging and exciting environment of
modern nursing practice, and it is especially important to have
sensitive and constructive systems in place which will enable nurses
in difficulties to have access to the support they need, and their
clients to regain access to professional care of a standard that they
have a right to expect.

Matching resources to need

All health professionals have at least one commodity at their

disposal, and that is the hours that they are employed to work.
Some may also be responsible for how equipment, operating
theatres, and so on are used, while others are gatekeepers to further
services, for example, GPs to consultant outpatient clinics, com-
munity nurses to, perhaps, bathing attendants, speech therapists or
chiropodists. The decision for the individual health professional to
make is how to allocate their time, their resources or access to
another service, to those patients with the greatest need.
It is important to recognise that when time, equipment and
services are used on one patient they are then no longer available
for another patient. In an environment of scarce resources econo-
mists describe this concept as 'opportunity cost', which is the cost of
not doing the next best thing because the resource has been used on
the first choice. This 'cost' can be measured in many ways, for
example health outcome, years of life lost, the consequences of not
being able to provide, say, hospice care because the resources have
been used on increasing the district nursing service, carrying out
home visits to mothers of young children, and so on. The key point
is, was the first choice the best choice, and if so, for what reasons,
and what was its opportunity cost? By thinking this through when
reviewing one's own decisions on matching resources to need, it
becomes possible to consider the criteria that were used in the
decision-making process, to reconsider their relative importance,
and to decide whether alterations to those criteria need to be made.
It is, therefore, important to keep the concept of opportunity cost in
mind when making decisions on resource use, including profes-
sional time.

42
MATCHING DEMAND AND NEED

The definition of health need favoured by the NHS Executive is 'the

ability to benefit from a health intervention' and is distinct from
both demand and supply, although there is a relationship between
the three concepts, as illustrated below in Figure 2.l (Stevens, 1991).
Incumbent in this definition of need are three factors:

1. there is a health problem;

2. there is available an effective treatment or intervention for that
health problem; and
3. people with that health problem believe that the resultant health
gain is worth their input of time, effort and/or money to receive
that treatment.

It is important to distinguish between the need for health care and

the need for health. The need for health care indicates the potential
to benefit from an intervention, and therefore requires a relevant
intervention and a corresponding improvement in health. The need
for health is a more general term for which it is often not possible to
determine an effective health intervention; for example the health
consequences of social deprivation.
The services currently provided by the NHS are controlled by the
three factors shown in Figure 2.1, demand, need and supply. The
ideal is for anyone service to be needed, demanded and supplied
(sector 7 of Figure 2.1), but this is by no means always the case, and

Figure 2.1 Diagram showing the relationship between need, supply and
demand

1 2
4
Supply Need
\7J
6 5

Demand
3

Source: Stevens (1991)

43
services can reflect anyone of the seven situations illustrated by
Figure 2.1:

1. supplied and not needed or demanded;

2. needed and not demanded or supplied;
3. demanded and not supplied or needed;
4. needed and supplied and not demanded;
5. demanded and needed and not supplied;
6. demanded and supplied and not needed;
7. needed, demanded and supplied.

Childhood immunisation is an example of a service that is needed,

demanded and supplied (Figure 2.1, sector 7). However, although
always needed, measles. immunisation is an example of a service that
used not to be in great demand (Figure 2.1, sector 4). Before the
introduction of the measles/mumps/rubella (MMR) immunisation
in 1988, the uptake of the measles immunisation was low in some
districts. Measles is an unpleasant childhood illness, which used to
be common, and from which most sufferers made a full recovery. It
caused the death of some children, however, and left others
permanently disabled, was unpleasant for the sufferers and carers
alike, and for some of the latter caused difficulties with their
employers. One of the factors that contributed to the low immuni-
sation uptake was the relative insignificance given to such a
common complaint by both parents and health professionals. In
the meantime, the danger to the unborn child of maternal rubella
infection during early pregnancy was a well-known and feared
hazard. The addition of rubella to the measles immunisation
resulted in an increase in its uptake due to the demand for MMR
from both parents and health professionals (Figure 2.1, sector 7);
(Miller et ai., 1991).
Screening for osteoporosis in post-menopausal women is a service
for which there are repeated demands. However, the current state of
knowledge of osteoporosis and its treatment, and the lack of an
effective screening test, mean that the criteria for population screen-
ing cannot be fulfilled, and the hoped-for health gain in this
population is not yet possible (see for example School of Public
Health, 1992). Therefore, although there is a demand, there is no
need for health care, and no service provision (supply) for screening
this population for osteoporosis (Figure 2.1, sector 3).
In most situations there is some demand and some need. In the
past, the relationship between the two was often ill-balanced, but it

44
is improving continuously since the introduction of management
and the purchaser-provider split in the NHS. The professional
demand for, and supply of, dilatation and curettage as a gynaeco-
logical investigation in women under 40 years of age is being
reduced by the introduction of guidelines which limit its use to
situations in which it has proved to be effective in this age group
(that is, proved to meet a need). Many school nurses, health visitors
and school doctors have spent a great deal of time in the routine
examination of children, for example school entry medicals which
were historically determined and whose usefulness or need was not
questioned. The Hall Report (Hall, 1991) reviewed the effectiveness
of this type of routine examination and found much of it to be
unnecessary, ineffective and a waste of resources, as it was not
meeting a health need but reflecting what had become a cultural
norm, or demand, of community health professionals and parents
(Figure 2.1, sector 6). The opportunity cost of this must have been
considerable. As a result, in many health districts the school health
service was completely restructured in order to meet more effect-
ively the health care needs of school pupils.
As indicated above, the ability to benefit from a health inter-
vention probably requires services designed so that potential
recipients can access them without difficulty (Figure 2.1, sector 5).
Such access is often socially determined, and can be increased by
altering services in such a way as to reduce the effort or cost
required to take them up. For example, clinics or appointments
timed so that mothers can still take their children to and from
school; peripatetic services such as childhood immunisations, chir-
opody, family planning, and diabetic care for those people who
cannot, or will not, go to a health centre or clinic. There are
situations in which sympathetic staff attitudes and increasing public
awareness can help to increase demand such that it reflects need. In
recent years continence services have been introduced in many
health districts because of a recognition of the need for them, but
the size of the demand can be affected by the embarrassment of the
sufferers in making known their need for the service (Figure 2.1,
sector 4). The need for services as wide-ranging as travel health
advice and cervical screening is not always recognised by the
public, or such services avoided by them because of fear, for
example of injections or embarrassment (Figure 2.1, sector 4).
Sympathetic understanding from health professionals and recep-
tionists is one way of helping to increase demand for these
important services (Figure 2.1, sector 7).

45
CONSUMERISM

How does consumerism link into needs assessment in the NHS? One
dictionary definition of consumerism is 'the protection or promo-
tion of consumers' interests in relation to the producer'. The key
word in this definition in respect to the health service-patient
relationship is 'interests'. Who decides what those interests are?
The difficulty with introducing a word from the commercial world
into the NHS is the differing nature of their contexts, the implica-
tions of this, and the misunderstandings that can arise from it. In
both commercial and health service contexts the consumer (patient)
makes a transaction (demand) with the supplier (for example nurse)
for the provision of an item (service). Implicit in this is that the
consumer is demanding something that he/she wants and perhaps
needs. In both the commercial and NHS contexts this provision
may be the result of the supplier being determined to provide this
item for his or her own interests while 'selling' it as being in the
consumer's interest, or believing it to be in the consumer's best
interests or what the consumer is seeking. However, the main
difference between the contexts is the direct relationship between
demand and supply in the commercial world, compared with the
NHS's more complex responsibility for establishing whether the
demand is also a need, and then determining the relative priorities
of that need among the many needs competing for resources, and
this can only be done when there are adequate data and information
to inform the debate and decision-making process.
Sometimes in the past, and it may still be true in some cases, the
patient (consumer) was treated as though their presence was for the
convenience of the NHS (producer), instead of the NHS being there
to serve the patient. For example, it was not in patients' interests to
wait many months, and sometimes years, for out-patient appoint-
ments or in-patient treatment; nor was it in their interests to give six
patients the same appointment time; all common practices in the
recent past. It was to protect patients, to promote consumerism,
and possibly to help develop a culture in the NHS that was more
sympathetic towards patients as people, that The Patient's Charter
was introduced in 1991/92 and gave patients certain rights (DoH,
1991). However, consumerism is a two-edged sword, and what the
Charter failed to do was to require responsibilities from patients in
response to those rights, for example to cancel their appointments
when they know in advance that they will not be able to keep them
or no longer need them, or to notify their GP when they change

46
address. Every community nurse knows the frustration of abortive
visits, especially when set against the tension of trying to meet the
responsibilities of service requirements and the needs of a case load.
A recent example of the debate and difficulties surrounding
consumerism and need is the new drug for use in the treatment of
multiple sclerosis (MS), beta-interferon. Following early publicity,
the expectation of the drug by MS sufferers resulted in very strong
demands for District Health Authorities to make it available. The
expected cost per course of treatment was very high, causing debate
about whether the opportunity cost was unacceptable (Figure 2.1,
sector 5). This was a situation where it would be possible to match
demand and need by service provision, but the cost of that service
would be so high that its priority over other competing service needs
had to be determined (Collier, 1996). Another example is the
Oregon experiment, which failed, but was a brave attempt to
prioritise the health needs to be included in that state's health care
programme by involving the public in the prioritising process
(Kitzhaber, 1993; and Kitzhaber and Kenny, 1995).
It is important to recognise that consumerism can make a very
positive contribution to identification of health need and quality of
health care delivery, especially as it is difficult for health profes-
sionals and managers to appreciate the less-obvious needs of
patients within the NHS without seeking their views. Some common
examples are notices written up in writing too small for patients
with imperfect eyesight to realise their presence; low chairs without
arms, which are difficult for many elderly people and for those with
joint problems to get into and out of; the lack of toys or books to
entertain children when they accompany their parents or grand-
parents; and instructions on bottles of tablets too faint to be read
easily. There are also larger issues such as the lack of services,
timing and siting of clinics, lack of interpreters, and health profes-
sionals giving explanations that are not understood by the service-
users.
Consumers are a valuable resource in helping any aspect of the
NHS to improve the quality of its services, and should be encour-
aged to report on their experiences as users of these services so that
this information can be judged, and, if appropriate, acted upon. At
present much of this role is taken on by the Community Health
Council, but many organisations within the voluntary sector have a
wealth of information built up from the experiences of their
members, which are a useful resource in terms of assessing health
needs. However, it must be remembered that these voluntary sector

47
organisations are, first and foremost, consumer groups set up to
meet their own ends, and it is the responsibility of health profes-
sionals to set such information in the wider context of the needs of
the whole population for whom they are responsible.

WHO DETERMINES HEALTH NEEDS?

There are numerous people who can, and do, decide that someone
has a health need and then take some sort of action, for example
their family, their GP, a community nurse, a social worker, a head
teacher, a consultant, a town councillor, and so on. These decisions
can range from a grandmother advising her daughter that the
grandchild needs to see a doctor, to a social worker recognising
non-accidental injury, or a community nurse believing that one of
her clients may be clinically depressed due to social isolation, or a
local authority councillor recommending that one of their consti-
tuents is rehoused on health grounds. There are many families that
are in touch with a multitude of medical, educational and social
work professionals, all of whom are trying very hard to provide the
professional care they believe one or more members of the family
need, and many of whom are unknowingly opposing other profes-
sionals by their actions. This can be very well demonstrated by
using a case history to build up a 'statue' of all the people involved
in caring for, or supporting, a family, and then getting all the people
forming the statue to pull in the direction they believe their efforts
lie on behalf of that family. It can be a very telling lesson.
An example of this would be to imagine an unmarried mother
with a partner who has a history of alcohol and violence. She has
two children, a nursery-aged child (A) who is failing to thrive, and a
child (B) at infant school who is having behavioural problems,
largely due to the home situation. The health visitor, consultant
paediatrician, GP, nursery school staff and social worker are all
involved in supporting child A and its mother. Another group of
professionals, consisting of the school nurse, educational psychol-
ogist, teacher, head teacher and GP, is concerned with supporting
child B, and this support may be extended to its mother. Mean-
while, the heavy drinking, violent partner is jealous of the mother's
involvement with her children, and has a probation officer, his own
GP, and the local drug dependency unit staff supporting him. The
mother is depressed, and receiving her own support from the family
GP and a community psychiatric nurse. It sounds confusing be-

48
cause it is confusing. Each professional believes he/she is working in
his client's best interests. The problem is that no one is looking at
the family as a whole, and as a result each group is working against
the needs of the other groups, and the members within each group
are in danger of competing with each other unless they have
ensured, through effective communication, that they are working
together within an agreed structure which is truly in the interests of
their client. This sort of problem is not uncommon, in part because
the independence of action that many professionals have can make
them poor team workers.
On some occasions confused communication can lead to well-
meaning but inappropriate efforts on behalf of someone's health
needs. For example, take a family in council accommodation whose
application for medical points for rehousing was turned down on
the basis of insufficient medical need. A subsequent traumatic
occurrence in their block of flats set in motion a series of caring
professionals who, probably due to enthusiasm and confused
information, gave advice which culminated in the tenants being
advised to approach their MP, and he, of course, took up their
cause and made a complaint about a decision that turned out to
have been made long before the upsetting incident had occurred.
This series of confused, but well-meaning, actions resulted in a great
deal of unnecessary time, effort and stress being expended, and
considerable delay in gaining the necessary help, when one tele-
phone call would have elicited the required response.

COMMUNITY NURSES AND ASSESSING HEALTH NEED

Community nurses are in an ideal position to determine health

needs. They are all required to prepare a community health care
profile, which will give them an overview of the social and health
background of the population they will be serving, and assist them
in planning their activities according to the theoretical needs of their
clients or patients. That profile is a valuable starting point, but how
many nurses find the time to reappraise the profile in order to check
whether they need to modify their activities, or add further infor-
mation to the profile in the light of their practical experience?
If community nurses are to be effective, not only in determining
the health needs of their clients but also in bringing about change to
meet them, they need to work to their own professional strengths
and to have a clear understanding of the resources that they can

49
mobilise, both within the primary health care team (PHCT) and
among other carers in the network, whether those carers are
informal, such as family, friends and support groups, or formal,
such as health and social workers. It is, therefore, important for
each nurse to have a clear understanding of their own role and its
boundaries, as well as of the roles of the other members of their
PHCT. There can still be considerable ignorance within PHCTs of
the roles of its members, and in particular of the subtle differences
arising from the increased independence of nurses from the medical
profession. The temptation to behave as social worker, parent, as
well as nurse, can be considerable. This does not mean that
community nurses should only be concerned with the medical
model of health needs, as their patients' health exists within the
context of their homes, families, neighbours, neighbourhood, em-
ployment, and so forth. A holistic approach is therefore important,
but, by attempting to take on the role of other professionals, nurses
reduce the time available to them to assess health needs, and are
likely to be less effective in an area of work that is not their own.
They are also, without realising it, perhaps encouraging dependence
and reducing empowerment. The key is to know when to involve
another professional.
At present there are many types of community nurse, for example
midwife, practice nurse, community psychiatric nurse and health
visitor, which can mean that one household may receive visits from
several nurses for the care of its members. This is inefficient service
delivery, and, with the gradual demographic changes, will not be
able to meet the needs of the client groups in future. It might be
feasible to maintain the current system if the threshold at which
clients qualify for community nursing services is raised, and less
nursing care per client is provided, but most health professionals
would reject this solution. However, there is a further problem
which may arise from a multiplicity of health professionals provid-
ing support for one or more members of a family, and that is that
each professional focuses on the item of need in their field of
expertise, instead of making an overall assessment of their client's
health needs. The limitations of this was illustrated by the example
of a 'statue' given above. An alternative approach is to train generic
nurses who can meet most of the health care needs which arise in the
community. Project 2000 training was begun with this in mind, and
is viewed as a very threatening development by some more tradi-
tional nurses (UKCC, 1987). However, it provides the challenge
and greater satisfaction of being able to provide nursing care for

50
whole families, just as general practitioners prefer to provide
medical care for whole families.
Community nurses have access to a range of formal data con-
cerning their patient population and the wider population and
environment in which they live, and also to a wealth of informal
knowledge gained from seeing many of their clients and patients in
their own homes, and from the items of personal information
shared with them as a result of their professional relationship with
their clients or patients. Such information may be on social isola-
tion, problems with housing and health, lack of health service
uptake due to language difficulties, bullying at the local school,
fears of pregnancy, to name but a few. Its value is that it raises ideas
for further investigation and action by community nurses on behalf
of their clients' needs.

DATA AND INFORMATION

Data are the facts from which information is derived.

In recent years there has been concern expressed, particularly
among purchasers, about the value of some of the services provided
by community nurses. The current vogue, for understandable
reasons, is for evidence-based medicine and randomised controlled
trials, which require 'hard' and accurate data obtained by strictly-
standardised methodology. The difficulty about this is that not all
health care work lends itself to such rigidity, and that health care
provision which does not meet these tight criteria can be devalued
or may not be purchased. However, information derived from data
lends weight to any discussion or proposal, and lack of information
weakens it. It is important, therefore, to remember that while 'hard'
data are the most valued, information is better than no information,
and hard information is better than soft information. Good,
objective information is certainly a prerequisite if community nurses
are to put forward a cogent argument on behalf of their patients'
needs, and if their voices are to be heard in the purchasing and
commISSIOnIng processes.
One of the great advantages community nurses have is the
records they keep on their clients or patients; records which contain
a gold-mine of information which in many cases has not yet been
tapped. Until recent years the NHS had a long history of collecting
data which were then almost inaccessible for further use, and
although in general this has now changed, it may be fair to suggest

51
that community nursing has been somewhat slow to recognise the
value of its own data and to make effective use of it. Its records can
be a source of morbidity data; of evaluating wound-management by
reviewing the duration of treatment and outcome of different types
of wound dressings; of domestic violence; of the prevalence of
diabetes by age and ethnic group; of accidents in young children
and the appropriate preventive measures required; to give just a few
examples. This information source is of considerable help when
determining health needs, and it can also be used to monitor the
effect of community-nurse interventions, and whether trends are
upwards or downwards.

IDENTIFYING HEALTH NEEDS AND ACTION

The heading for this section has been retained as 'health needs' to
encourage the idea that health needs are broader than the classic
NHS medical model of health care. Health is so multi-faceted, and
affected by so many factors, that health needs can range from the
need for health promotion, financial resources, companionship,
empowerment and problem-sharing, to uptake of screening, and
diagnosis and treatment. It must still be emphasised, however, that
whether the need is physical, psychological, social or any combina-
tion of these, there is no point in using scarce resources to make a
response unless there is the potential for benefit.

Informing commissioners

The identification of health needs, as a dynamic process with a

practical and beneficial outcome, requires an exploration of the
relationship between the health problems in a community and the
resources available to address those problems. What form this will
take will depend on the individual responsibilities of each commu-
nity nurse. If community nurses are to make a contribution to
purchasing and commissioning at health district level, or to com-
missioning groups which represent large populations, for example
multifunds, it is unrealistic to expect that this process will be able to
respond to a multitude of individual issues, each covering the
relatively tiny population of a community nurse's caseload, even
if they are well-argued and supported by reliable data. However,
community nurses working with fundholding practices, or in a total
purchasing scheme with GP fundholders (GPFHs), are working

52
much closer to the purchasing process. They are therefore well-
placed to have a good understanding of the resources available to
meet the health problems of that community, and can more readily
combine their efforts to collate and analyse data, determine prio-
rities, and present their case to the GPFHs for purchasing or
commissioning services on behalf of their clients. Whatever pur-
chasing environment the community nurse works in, teamwork will
be vital. The team could be a nurse's own PHCT, it could be all the
community nurses in a health district, all those supporting a
commissioning group, or a locality, and so on. The advantage for
generic nurses looking after whole families is that they will have an
overview of the health needs of all age groups, and the difficulties of
sorting out the competing views of different specialist nurse groups
are therefore avoided.

Other action

There is no reason why any community nurse should not make an

individual response to a need by using the resources for which she
has responsibility, including her time. For example, there may be a
type of council house peculiar to her geographical patch which has a
design fault which makes access to the stairs dangerous, especially
to the very young and the elderly. Data can be collated on this and
used in representations to the housing authority. Many accident
and emergency departments (A&E) have a system of notifying
health visitors of children being brought to their department. An
appraisal of these may show trends, such as a problem with the local
playground. The nurse can then ascertain whether her colleagues
have similar problems with other playgrounds, and they can
combine to put a case to the relevant authority.
There are still pockets of low childhood immunisation uptake,
which may be geographical or relate to a particular GP practice. In
many districts community nurses immunise children, and action can
therefore be taken by them to meet this need. Every year many
children of Asian families return to India or Pakistan to visit their
families. Not all these children have received their childhood
immunisations, and there have been occasional cases of diphtheria,
one fatal, and paralytic poliomyelitis (Efstratiou, George and
Healing, 1995; and Hamilton, Healing and Newman, 1994). Com-
munity nurses are well-placed to determine this health need in their
locality and to meet this deficit. How many pharmacies or practices
issue bottles of tablets with labels too faint to read, and what can be

53
done about it? There are numerous ways in which community
nurses, by themselves or by sharing their information with their
nursing colleagues, can take action to meet the health needs of their
clients.
In a similar way, data can be collated on the number of people
expected to need services, and a case made for the purchase of
further services (see for example Stevens and Raftery, 1994, or any
major medical textbook). How many people have continence
problems, and does the true prevalence reflect service provision?
Another example is for diabetes nurse practitioners to compare with
the expected prevalence, the prevalence of diabetes by age, sex and
ethnic group in the population for which they are responsible. If
there is a discrepancy between the two, how is this accounted for? It
may be that maturity-onset diabetes is going unrecognised, and the
nurses' data can be used to argue for res(')urces for improved
diabetes detection, treatment and management.
Many people suffer from chronic diseases, such as Alzheimer's,
stroke, visual handicap, and arthritis, as well as the less-common
congenital handicapping conditions such as cystic fibrosis and
cerebral palsy. There is a wealth of information, support and
companionship available through self-help groups, and community
nurses can help put such people in touch with these groups. Even
now, in the 1990s, there are men and women and sometimes children
who have been struggling alone, sometimes for many years, with
severely handicapped partners, children or parents because they did
not know that it was possible to get help. Community nurses are a
valuable resource in hearing about, and doing something for, such
families. It may be that their own nursing skills are inadequate, but
they can help put the family in touch with one of the very many self-
help groups, social services, or occupational therapists, so that
others can provide the support that is appropriate.
Having just touched on a few of the vast number of ways that
community nurses can help to meet the health needs of their
populations, how should they set about it? All community nurses
are trained in how to carry out a community health care profile, so
there is no point in reiterating it here. However, there are a few
comments that should be made, and there is also the key issue of how
to prioritise health needs which are competing for limited resources.
Determining health needs is not a once-and-for-all operation, and
it is important in one's daily work always to keep questioning
whether there may be other people having the same health difficul-
ties, and whether there is an effective intervention from which they

54
might benefit. There are all sorts of information available to
community nurses, and it is important that full use of these
resources is made when determining health needs - for example
GP computer data (if access is allowed); data on social deprivation;
child health data on immunisation and paediatric surveillance;
disease prevalence data; local physical handicap registers; census
data on factors such as lone parents, lone pensioners, overcrowded
households, and ethnic group; screening uptake rates; death and
birth data published annually; A&E notifications; and Health of the
Nation data, which are also published annually.
Equally important is an awareness of the services available to that
community, and these go well beyond the traditional doctor-patient
services, and include day centres, nurseries, schools, mother and
toddler groups, youth clubs, women's groups, family planning and
youth health clinics, drop in clubs, self-help groups, religious groups
or leaders, and so on (see for example Picken and St Leger, 1993). In
order to increase their effectiveness, community nurses should keep
an up-to-date file of all such facilities and key contact people within
them, and should also liaise and network with these people so that
when they need their assistance they do not meet as strangers.
Being fair in responding to, and assessing, health needs is not
easy, as it is human nature to want to respond to pleasant and
cooperative clients or patients, and to dread dealing with the most
querulous or difficult ones. In order to ensure that bias is not
introduced by these very human responses, it is important to
develop some objective scale of need so that, if challenged, the
decisions made can be defended by facts.
The outcomes of health interventions need to be reviewed and
evaluated against objective criteria, so that if they prove not to be
beneficial, it is possible to use this information to decide whether to
withdraw the intervention. Such criteria will vary with the topic, but
it is not necessary to have highly complicated criteria. They can be
as simple as whether or not mothers thought a mother and toddler
group was definitely beneficial both to them and their toddlers, or
how long it took wounds to reach a defined stage in healing when
they were randomly allocated to different treatment regimens.

HOW TO PRIORITISE

This should be done objectively, and is probably most easily carried

out using a simple scoring grid (Figure 2.2).

55
 Figure 2.2 Scoring grid to assist in the determination of priorities

CRITERIA TOPIC
Smoking Carers' Immunisation Lonely Diabetes
support mothers
Prevalence/incidence
Severity of problem
Effective intervention
Acceptability/feasibility
Community involvement
Cost and resources
TOTAL SCORE

Source: By kind permission of Dr C. A. Birt, Health Services Management

Centre, University of Birmingham

A score of 0 to 4 is allocated to each topic for each criterion (Figure

2.2). A score of 0 is for very low priority, and 4 is for very high
priority.
It is important to consider the potential for a positive outcome
for each item when allocating scores. An item may be a significant
problem, but if resources are already in place to deal with it, so that
little additional benefit can be envisaged from the input of further
resources, then it should be allocated a low priority.

Prevalence/incidence

I nCl'dence rate -_ Number bof new .cases

k .
in period
. d
Num er at ns III peno
Number of persons with the
disease at a point in time
Point prevalence rate = - - - = - - : : - - - - : - - - - : - - - - -
Total population

Severity of problem
Severity can be measured in terms of morbidity and mortality. The
former includes the effect on quality of life and whether it is a major
drain on resources, either medically or socially.

56
Effective intervention
There is no point in allocating resources to a health problem if
there is no effective intervention; in such a case the score would be
low.

Acceptability/feasibility
Is the intervention feasible: for example is it too large, likely to be
successful, are there time and skills available for it, and is it
culturally acceptable?

Community involvement
Community involvement can be an asset, not only as a resource to
be tapped, but as a means of empowerment and confidence-raising.

Cost and resources

What are the resource implications in terms of staff time, skills,
equipment, training and so forth?

Once such a grid has been completed, it gives an indication of

priorities set in the context of feasibility and resources, and it can
then be used to aid the decision-making process.

ADVOCACY AND EMPOWERMENT

Whether health professionals like it or not, their relationship with

patients or clients is generally disempowering. This is partly deter-
mined by four factors:

1. the patient or client is seeking help for a health problem;

2. the health professional is the provider of help, either directly or
indirectly;
3. the health professional encourages the patient or client to seek
help, for example screening programmes and immunisation;
4. overtly or subliminally health professionals encourage depen-
dency, and rarely seek to build up their patient's or client's
confidence in their own ability to cope with, or take control of,
their own health.

57
Another subtle means of disempowering people is to act as their
advocates. There are times when it is essential that health profes-
sionals act as advocates for those who are incapable, for one reason
or another, of taking on this role for themselves, or because the
status bestowed on them by their professional role also bestows the
power and influence to gain the desired outcome. But, how often
are patients involved in the decision-making processes for health
service provision, such as assessing and prioritising health need?
Whilst reading this chapter, how often have you, the reader,
thought, 'I would ask the client', or, 'If I brought X along with
me to that meeting, they could contribute by presenting the
patient's viewpoint'?

PURCHASING AND COMMISSIONING

Many things can be done without extra resources, as suggested in

this chapter. Many health professionals have had ideas or plans to
meet health needs but have not taken them forward. It is not
enough to produce proposals, however well-researched, and expect
them to be accepted and implemented, especially in a climate of
limited resources. To be effective it is important to have a full
understanding of the local purchasing and commissioning proce-
dures, and how to bring proposals to them.
In the first instance find out how purchasing and commissioning
operates in your locality. If you work with GPFHs it is they who
will be purchasing services on behalf of their patient population. If
the GPs you work with are not fundholders, then they may be
aligned in commissioning groups which advise the DHA on the
services they wish to have purchased for their patients. In some
cases it is the Director of Public Health who takes the lead role in
advising the DHA on such matters, or the director of a community
trust.
The larger the health need is perceived to be by the purchasers or
commissioners, and the greater the potential outcome, the more
likely it is that action will be taken to meet it. Therefore see if
collaboration with other community nurses or voluntary groups
will provide a greater weight of data to support your case.
The next stage is to know who will be presenting your case, and
to whom. It may be yourself, especially in a fundholding practice, or
it may be a nurse manager if purchasing occurs through the DHA

58
or a community unit. In either case it is probably helpful to prepare
the ground in advance. This can be done by raising awareness of the
issues with GPFHs, nurse managers, or whoever else you feel may
be in a position to support your ideas. It can be done in casual
conversation, in practice meetings, in sector meetings, and so on. It
is necessary to know who are the key players within these proce-
dures, and the people most likely to oppose your ideas and why they
would want to do so, so that you can prepare counter-arguments.
If you are the one to present your own case, find out how it will
be done, for example a formal oral presentation using an overhead
projector, or a written presentation, and then make sure your visual
aids, written report or verbal presentation skills are of high quality.
If a nurse manager is to promote your ideas, ensure she/he has the
necessary information to gain a clear understanding of your case so
that it is easy for her/him to put it over with conviction. If you think
that alliances with other professionals, community or voluntary
groups will help your cause, find out how, or if, they can become
involved in presenting your case to the relevant purchasers. The
local purchasing process may allow them to make an oral or written
report supporting the need for the provision of a service.
After all your efforts, the competing needs within the NHS may
still mean that your attempts to ensure that a health need is met do
not succeed. Do not be daunted by this, but use the experience to
help make yourself more effective next time.
Determining health needs, and being involved in the challenging
process of meeting them, can be very stimulating and satisfying.
Enjoy it.

References

Benzeval, M., Judge, K. and Whitehead, M. (eds) (1995) Tackling

Inequalities in Health: An Agenda for Action. London: King's
Fund.
Black, D., Morris, J. N., Smith, C. and Townsend, P. (1992) The
Black Report. In P. Townsend and N. Davidson (eds), Inequal-
ities in Health. London: Penguin.
Buchan, I. C., Richardson, I. M. (1973) Time Study of Consultations
in General Practice. Scottish Health Service Study No. 27.
Edinburgh: Scottish Home and Health Department.
Cartwright, A. and O'Brien, M. (1976) Social class variations in
health care and in the nature of general practitioner consulta-
tions. In M. Stacey (ed.), The Sociology of the National Health

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 Service, Sociological Review Monograph No. 22, pp. 77~98,
University of Keele.
Collier, J. (ed.) (1996) Interferon Beta ~ IB ~ hope or hype? Drug
and Therapeutics Bulletin, 34(2), pp. 9~ 11.
Department of Health (1991) The Patient's Charter. London:
HMSO.
Department of Health (1995) Variations in Health; What can the
Department of Health and the NHS Do? (Health of the Nation).
London: DoH.
Department of Health and Social Security (1983) NHS Manage-
ment Inquiry Report. London: HMSO.
Efstratiou, A., George, R. and Healing, T. (1995) Quarterly com-
municable disease review: July to September 1994. Journal of
Public Health Medicine, 17(1), pp. 110-15.
Forster, D. P. (1976) Social class differences in sickness and general
practitioner consultations. Health Trends, 8, pp. 29~32.
Hall, D. M. B (ed.) (1991) Healthfor All Children: A Programme for
Child Health Surveillance. Oxford: Oxford University Press.
Hamilton, G., Healing, T. and Newman, C. (1994) Quarterly
communicable disease review: October to December 1993.
Journal of Public Health Medicine, 16(2), pp. 235-41.
Kitzhaber, J. A. (1993) Prioritising health services in an era of
limits: the Oregon experience. British Medical Journal, 307
(6900), pp. 373~7.
Kitzhaber, J. and Kenny, A. M. (1995) On the Oregon trail. British
Medical Bulletin, 51(4), pp. 808~18.
Miller, E., Waight, P. A., Vurdien, J. E., White, J. M., Jones, G.,
Miller, B. H. R., Tookey, P. A. and Peckham, C. S. (1991)
Rubella surveillance to December 1990: a joint report from
the PHLS and National Congenital Rubella Surveillance
Programme. CDR Review, 1, (4), R 33~7.
Picken, C. and St Leger, S. (1993) Assessing Health Need Using
the Life Cycle Framework. Buckingham, Philadelphia: Open
University Press.
Pill, R., French, J., Harding, K. and Stott, N. (1988) Invitation to
attend a health check in a general practice setting: comparison
of attenders and non-attenders. Journal of the Royal College of
General Practitioners, February, pp. 53~6.
Public Health Alliance (1993) The PHA Charter for Public Health.
Birmingham: The Public Health Alliance.
Royal College of General Practitioners (1972) The Future Practi-
tioner: Learning and Teaching. London: British Medical Journal.

60
School of Public Health, University of Leeds, Centre for Health
Economics, University of York, Royal College of Physicians
(1992) Effective Health Care: Screening for Osteoporosis to
Prevent Fractures. Leeds: The University of Leeds.
Stevens, A. (1991) Assessing Health Care Needs. A DHA project
discussion paper. London: NHS Management Executive.
Stevens, A. and Raftery, J. (eds) (1994) Health Care Needs Assess-
ment: The Epidemiologically Based Needs Assessment Review.
Oxford & New York: Radcliffe Medical Press.
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) (1987) Project 2000: The Final Propo-
sals. Project Paper 9. London: UKCC.
World Health Organisation (1980) International Classification of
Impairments, Disabilities and Handicaps. Geneva: WHO.

61
============CHAPTERTHREE,============

Commissioning Services to Meet

Identified Needs

Liz Haggard

COMMISSIONING AND COMPETITION

The introduction of commissioning purchasing and services as an

activity which is organisationally separated from the provision of
services is the mechanism which brings a form of competition into
the National Health Service. The belief is that once the purchaser/
commissioner organisation has established which services are
needed for a population, they can then use competition between
providers as the lever to ensure best value for money for the
available resources. The commissioning/purchasing lever operates
at health authority level seeking best value from health service
provider trusts, and also at general practice level where fundholders
and general practice total purchasers use their buying power to get
best value.
There are a number of different stages in the health authority
commissioning/providing cycle, and in theory community health
nurses could be involved at all levels.

The commissioning cycle

• Assessing health needs in the local population;

• Deciding which health needs are most important;
• Deciding the most effective ways of meeting the health needs
identified as most important;
• Commissioning (stating for which health needs service provision
will be made, given the resources available);

62
• Specifying for each service to be provided details about the
volume, quality and style of service required;
• Inviting potential providers to reply to the specification with their
plans for service provision to give best value for money, outcomes
and satisfaction;
• Evaluation provider proposals received;
• Contracting (working with the selected providers to agree cost,
volume and quality standards for providing services);
• Monitoring the contract once awarded;
• Reviewing the whole process to improve the next cycle.

In practice, there is a small nursing team at health authority

commissioning level and it may be that only one member of the
team will have a community or primary care background. Com-
munity health nurses in provider trusts have therefore often been
involved in helping commissioning health authorities to work up a
specification for community health services. Most Family Health
Services Authorities (FHSAs) have some staff from a community
nursing background, often employed initially as primary care
facilitators. As health authorities and FHSAs became one organisa-
tion in April 1996, health authority awareness of community
nursing issues may have increased.
Identifying health needs can be thought of as a survey of all the
known health problems in a given population; it will include
information about age at death, causes of death, incidence of
different health problems, hospitalisation rates and will use a wide
range of information. Commissioning is the process of deciding
which ways of intervening where there is ill-health, reducing the
amount of ill-health and improving well-being for that population
will be most effective. Services to deliver the commissioners' chosen
pattern of service will then be purchased to give best value for
money. If there is good understanding of community health nursing
issues at commissioning and purchasing levels it is more likely that
local providers will feel that the decisions are fair.
In the previous chapter we have seen that there are many ways in
which need can be identified. The result of any survey of need is
likely to be open to a number of interpretations, debate about the
value of particular interventions in their own right, the comparative
value of interventions and in particular which should be given
priority.
From this survey of possible ways of intervening and knowledge
of the health finance available, the decision about which services to

63
provide begins to highlight choices based on value judgements,
imperfect evidence, local feelings, past patterns of expenditure and
service provision, professional and political preferences and a whole
range of other factors.
Commissioning services was the key role of the District Health
Authorities, now merged with the FHSAs. With this merger com-
missioning decisions about how to spend health money have brought
the secondary, primary and community health services together for
the first time. Some commentators outside Britain (see for example
Thomasson, 1995) see this as a unique opportunity to develop care
services where they provide best value for patients and pounds.
Although many of the boundaries which have made it difficult to
shift services in the past will still exist, the bringing together of
secondary, primary and community health care will sharpen the
question: 'If we wish to commission this service for our local
population, where is it best provided and by whom?' Community
and primary care services may hope that more services will be
provided out of the acute sector, although so far resource shifts
have been small (Thomasson, 1995) and take-up of schemes like
hospital-at-home has been slow (Iliffe and Gould, 1995).

Evidence-based commissioning

However, what is a good solution for one part of the system may
have dis benefits for another part of the system. For example,
patients may prefer treatment in their own homes, but the oppor-
tunity cost of home treatment for one person when clinic treatment
could be offered to four patients for the same time-cost, may not be
a good commissioning decision for the majority of patients.
In many cases we do not have enough high-quality evidence to
justify major shifts in care. The increasing emphasis on evidence-
based commissioning has revealed how difficult it is to find evidence
which gives a clear enough answer to justify major change. The
York Centre for Reviews and Dissemination is responsible for
'systematic reviews' on issues felt to be of major importance to
commissioners; the term 'systematic review' describes a process of
careful evaluation of the type and quality of research on which
current knowledge is based. By bringing together studies which
have been done, evaluating them and summarising the conclusions
in which we can have confidence, the York Centre has been able to
give guidance to commissioners on a range of important issues (see
for example Chapter 7 in this book).

64
 In time it may be possible to look to systematic reviews to give
answers to community health care issues, but good research design
in community settings is difficult given the influence of complex
social factors. Research results may also question the value of
community care. We all prefer to believe evidence which supports
our current practice and point of view. With the increasing focus on
primary and community health services, the effectiveness and value
for money of community health services will be under scrutiny and
community health professionals need to be prepared to change or
abandon ways of practising when there is convincing evidence that
these are not effective.
Recent examples of effectiveness studies which have affected
community health services include the Hall Report (1996) on child
health screening, which showed that some traditional screening
activities were not reliable or valid enough to be retained. A number
of studies have focused on the appropriate skill level for different
community health activities; where it is not possible to prove that
the use of higher-grade nurses is necessary, it is likely that commis-
sioners will choose providers who use the lowest grade shown to be
necessary for effective care. Managers of community health services
have a particular responsibility to be aware of new research which
questions current practice and to work with staff to re-shape
services.

Comparative information and pressure for change

Commissioning will rely increasingly on research-based evidence. It

will also have increasing access to comparative information to
enable providers of community health services in similar geogra-
phical areas to be compared. This approach is used for example by
the Audit Commission in its reports, and it is increasingly likely that
at national, regional and local commissioner level such approaches
will expose variation between community health services providers.
The development of Read codes (a standardised set of terms for
nursing use in computerised patient records) will enable patient care
to be compared more easily. Some degree of variation is, of course,
necessary and expected - service provision will vary where popula-
tion and geographical characteristics vary. However, when similar
services delivered to similar populations in similar geographical
areas are found to have wide variation this will increasingly be seen
as unacceptable (Harley, 1995). Community health professionals
will need increasingly to make sure that they have access to

65
comparative information, so that they are alerted if their perfor-
mance is out of line and therefore likely to be the target of
commissioner pressure.

GPs as commissioners

Community health services will not only be under increasing

pressure from health authority commissioners, but also from GP
fundholders and GP fundholders in total purchasing schemes.
Health authorities have often found community health services
hard to understand, but GPs are more familiar with the realities
of work in the community and feel better placed to require changes
either in direct negotiations with community health services provi-
ders, or through influencing health authorities as commissioners.
The current intention is to move towards a primary care led NHS
(NHS Executive, 1994) where GPs will have an increasing influence
on what services will be commissioned and where and how they will
be provided. It will be increasingly important for community health
service providers to predict the likely requirements of general
practitioners and meet them. The move stimulated by the Cumber-
lege Report (DHSS, 1986) to establish neighbourhood nursing
teams lost considerable goodwill with general practitioners where
it led to community health staff working in neighbourhood teams
rather than attached to general practice. Most community health
providers have now moved to general practice attachment, but
strong feelings can remain based on historic difficulties which
GPs felt they had in accessing community health services. Some-
times GPs' apparent over-reaction to a current proposal can be
traced back to memorieii like these.
In some ways the achievement of establishing community health
district nursing, health visiting and psychiatric nursing as branches
of the profession with their own qualification routes may make it
harder for community services to recognise the need to work with,
and for, general practice. During the establishment of professional
disciplines and training for community nursing, it was seen as
important to establish independence from doctors. The establish-
ment of community trusts as separate organisations may also
initially have led community nurses to focus on their own profes-
sional and organisational issues and encouraged a 'stand-alone'
position.
With the rapid doubling of the numbers of practice nurses made
possible by the new GP contract, there were fears that nurses who

66
worked directly for general practitioners would in some way be
'handmaidens' and less likely to have their professional judgement
respected. Recent results show that while there may have been some
justification for such fears, practice nurses now feel generally
satisfied with their role and their relationship with general practi-
tioners (Atkin and Lunt, 1995). Although there is as yet no
nationally-accepted practice nurse qualification, there are now a
number of training opportunities. Studies of practices working with
attached district nurses, health visitors, community psychiatric
nurses (CPNs) and midwives show a high rate of satisfaction for
staff, GP and patient; given that attachment is usually made to
'better' practices this is understandable, but it also indicates that it
will become the preferred delivery pattern as standards in general
practice rise.
Because the general practice serves patients, not populations,
there are real problems for both commissioners and providers in
organising services focused on general practice (Gordon, 1995). The
Cumberlege Report felt that the balance of advantage lay with
serving a population rather that attaching staff to GP patients. The
balance of advantage is now seen to be with attachment to GPs.
There are inherent dis benefits in GP attachment, but in many places
these are over-ridden by the advantage of the GP as the most easily
accessible first point of contact with health services. However, in
areas where it is acknowledged that current general practice is not at
an acceptable level (particularly in deprived sectors of large cities),
there will continue to be a role for some form of geographically-
organised community health service acting as a safety net and
substitute for local general practice. It is likely that current changes
in the general practice contract, and developments enabling salaried
GPs to work in inner city areas will reduce the number and
proportion of inadequate general practices. This means that most
community health services will see their role change from that of
independent organisation to something more like that of an agency
providing appropriately skilled staff to work with and for general
practitioners, health authorities and others.

The pressure to be 'business-like'

There is no doubt that the health service of the future will be

required to be business-like. Although there is now a swing away
from applying commercial business principles to the health service
without acknowledging key differences, nevertheless the require-

67
ment that services be managed in a cost-effective, consumer-focused
and well-organised way will remain. This means that staff may have
to accept limitations to their preferred practice. Commissioner
decisions may be based on cost and patient satisfaction measures
rather than clinically preferred measures, and a continuing pressure
to demonstrate value for money will include collecting non-clinical
information on a regular basis.
Although at one level staff accept the need to be business-like, at
another level they resist the invasion of the professional practice
area by finance and performance measures. Patient preferences may
appear to focus on cosmetic or Patient's Charter elements whose
value is not given priority by community health staff. Professional
staff and managers working in community health services need to
be able to point out the consequences of making changes purely for
'business' reasons, without appearing defensive. They also need to
accept that as fundholders and innovative community trusts else-
where show that changes can be made, it will be harder to defend
local custom and practice.

MARKETING COMMUNITY HEALTH SERVICES

A marketing orientation is a key part of commercial business

practice. Developing an appropriate marketing approach is increas-
ingly important in the health service and community health services.
The purchaser-provider split on which commissioning is based
means that the commissioner seeks to have a choice of providers;
a good provider who fails to demonstrate that their services are
good may not be chosen; a provider who may be less good but who
has paid more attention to 'marketing' may well be chosen.
It is easy to dismiss marketing as commercially-driven, with glitzy
advertising and unnecessary expense. Community health profes-
sionals who take this view are avoiding the real issue. Marketing is
generally defined as the process whereby a business finds out what
people want to purchase, provides goods or services tailored along
those lines, and thereby develops services which will sell and satisfy
customers. Using this definition of marketing, community health
services which fail to have a marketing orientation will not meet
customer needs and will not be successful.
In providing health services there is no single customer - the
patient is one customer, the GP who has the responsibility for the
primary health care of the patient is another customer, the fund-

68
holder and total purchasing GP who can choose from whom to
purchase community health services is another customer, and the
health authorities as commissioners are customers; the media
locally and nationally, and politicians locally and nationally, can
influence all these customers.
In the current climate the general practitioner is emerging as the
key customer for community health services, either as direct pur-
chaser through fund holding and total purchasing, or as a key
influencer of the health authority through involvement in locality
commissioning work. GPs increasingly wish to be involved in the
appointment of community health staff to their practices, and are
unwilling to work with staff whom they perceive as not working as
part of their primary health care team.
The market orientation in health has also to take into account the
values of those who deliver community and other health services.
There are some services which health professionals are not willing to
deliver even though a number of customers may wish them to be
provided, and it will remain important to have routes which staff
can safely use to alert commissioners to unsafe practice, misuse of
funds and unmet need.
If community health professionals work increasingly as autono-
mous professionals selling their services to general practices, they
will need the ability to market themselves as individual profes-
sionals worth employing and able to work in a team, with a range of
specialist skills. Each community health service professional has to
understand what marketing in their context means and, increas-
ingly, the subtle and complex skills which are appropriate to
marketing of this kind will be the hallmark of the successful
community health professional. Community trusts will need to
market the added value of employing staff who work in the trust,
emphasising quality, training, support and access to other services.
In so far as they are successful and learn these skills, community
health services will be seen as successful and effective ways of using
health resources.

From universal to personalised service

The health service when it was founded in 1948 prided itself on not
treating people differently. A key value of the National Health
Service was that everyone would receive treatment, without distinc-
tion based on ability to pay, social background or cost of their
treatment. For many years the uniformity of services was regarded

69
as a sign that the NHS was achieving this objective. Rows of beds
with identical bed covers, and rows of identically uncomfortable
seats in out-patient departments reflected one interpretation of
equity. In the early years of the NHS the public valued and accepted
this uniformity.
However, economic, social and technological changes increas-
ingly meant that in other aspects of their life people came to expect
a much wider range of choice and a personalised service. The
impersonality of the NHS and its uniformity began to contrast
unfavourably with the way other services were provided. Other
political and social trends encouraged people to think of themselves
as individuals with rights, rather than as citizens sharing commonly-
provided services. The development of The Citizen's Charter and
The Patient's Charter (DoH, 1991 a, 1991 b) reflect this trend.
Patients prefer to feel services are personalised and their personal
needs have been understood. The right of patients and carers to
know when a district nurse will call are an example of this trend; ten
years ago it was thought acceptable that the nurse could call at any
time which she decided - this clearly valued the district nurse's time
and assumed that time was of no importance to the patient and
carer, who would be happy to have their ongoing activity disrupted
to suit the district nurse. We no longer think that this is acceptable.
Community health professionals need to project these changes
forward to imagine what further changes will be needed as currently
acceptable practice moves into the realm of the unacceptable.
So far we have looked at how the commissioning process, which
centrally involves decisions, choices and priorities, is going to be
increasingly influenced by services appearing to be 'business-like',
marketing themselves so that they are perceived as good value for
money, showing that they are meeting general-practice customer
needs, and delivering an increasingly personalised service.

Commissioning, specification and service delivery

The post-commissioning stage of specifying in more detail the

services which the commissioners have decided to purchase also
has an impact on community health service professionals. The
specification will cover a range of aspects under the general head-
ings of volume and quality; some specifications run to many pages
and are very detailed. At the moment we have probably not got
the balance right in specifications. Too much time and resources can
go into attempting to write detailed, water-tight specifications

70
which are then not followed up and monitored in any comparable
detail.
In the past, services were delivered within broad parameters
based on a combination of professional decisions balanced by
administrative and financial requirements. There has been a move
away from these broad agreements based on trusting professionals
to do their best. However, specification of complex services deliv-
ered in multiple settings, such as community health services, are
unlikely to be successful if they hope to pin down the complexity in
point-by-point specifications. Probably the middle road will turn
out to be a broad description of the services which should be
provided, with a small number of measurable standards specified
and more closely monitored. The proposed contract of minimum
data set for community health services may meet this need.
At a local level it is becoming increasingly vital for each com-
munity health professional to understand the specification for the
services he/she is paid to deliver. For example, if the specification
requires that a given percentage of new patients be seen, every
community health professional involved in that contract needs to be
aware of this requirement so that they encourage self-help and
discharge as soon as possible for existing patients, and achieve the
required percentage of new patients. Similarly, if the specification is
based on the majority of treatments being carried out in the clinic
and community health professionals instead choose to carry out
treatment in the patient's own home, the clinic-based target will not
be met and costs will be higher than contracted for. Staff also need
information on specifications about quality standards and purcha-
sers will increasingly wish them to be monitored.

Costing issues

How services are specified and costed is therefore key information

without which it is not possible to practise effectively. If you were
running a small community health business yourself and you failed
to include the costs of dressings, travel time, annual leave cover and
sickness cover when you set prices to charge to customers, you
would very soon be a bankrupt small business. Although no health
professional wishes to see cost as their first consideration in decid-
ing what treatment to give, no health professional who is a citizen
would want public services to be provided without any awareness
of cost.

71
 The decision about which services to purchase from amongst a
range of providers who all claim to be able to meet the specification
will be based on cost and value for money. It is legitimate for
purchasers to seek the lowest-cost services, provided quality stan-
dards are met, because the more successful purchasers are, in
achieving services at less cost than before, the more money will be
released for other services and to meet unmet need. Community
health professionals in their personal purchasing seek value for
money, and it is acceptable that their purchasers should do so too.
It is not always possible for purchasers to find a range of
providers to compete, and the term 'contestability' is used to
describe a situation where the purchaser has not been able to
choose between competing providers, but retains the right to
market test services if there is any doubt about the value being
offered by the current provider. Some community trusts have begun
to market their services to authorities and fundholders well beyond
their own headquarters base, and this is a legitimate means of
market-testing local services. If there is a growing trend to contract
for locally-provided community health services with a distant
provider, it will make it difficult for local community trusts to
continue to claim that they have a role based on providing services
for their local community. It is also likely to make communication
and integration with other local services less effective.

Costing community care: complex care packages

The introduction of community care has meant that district nurses

and other health professionals working in the community also have
to understand costing issues in relation to individual patients.
The community care legislation transferred the funding being
spent on social security support to people in private and voluntary
sector nursing and residential homes to social services; the aim was
to provide an incentive for packages of care to be offered as an
alternative to entering a nursing or residential home place. The pre-
community care system was not cash-limited: anyone who qualified
for social security support and had a place in nursing or residential
home care received funding. The new system is cash-limited and
therefore offers on the one hand the incentive and possibility of
devising imaginative personal care packages in the community, and
on the other makes those devising the packages keenly aware of
limited resources and costs.

72
 Social services are the lead authority for community care, and the
majority of people for whom services are provided are older people,
although the system also covers younger people with a disability,
and people with mental health and learning disability needs. In
some cases health service staff have been given delegated responsi-
bility to be the care manager for individuals, putting together an
appropriate mix of health and social care from a range of providers;
this role clearly involves making decisions which balance client
needs and resources available, and finding ways of meeting needs
within resources which offer good value for money and client
satisfaction. However, it also makes the health professional aware
of the impact on other and future clients of a decision on a current
client; if a high-cost care package is put together for a current client,
this in a sense makes less care available for future clients, and this
impact is particularly important where the current care package
may last for some years. This type of decision has always to some
degree been a part of the workload management of staff working in
the community, but community care makes it explicit. GPs are also
now more directly involved through fundholding and total purchas-
ing, and they have a direct interest in how community health
resources are used.
Co-ordinating complex packages of care has high overheads in
managing contacts with other agencies and professionals involved,
in co-ordinating the contributions of a number of different mem-
bers of staff, and in overseeing care delivery and reviewing client
needs to respond to change. The greater the number of such time-
absorbing complex packages in which staff are involved, the less-
efficient are services likely to seem if they are measured using
current performance indicators which record face-to-face contacts
with patients as the main indicator.
It is often difficult and inefficient to separate health from social
care, and where care is delivered in the patient's home there are high
overheads in separating care - if a nursing assistant and a home
help both visit to carry out 'health' and 'social care' tasks, the costs
of travel and travel time, communication and liaison and employ-
ment overheads are doubled. It is likely that there will be an
increasing use of generic staff in community care where such staff
will be trained to deliver a mix of care needs including elements of
care previously seen as requiring qualified health professionals: the
private sector may take the lead in offering this kind of care if
statutory services are unable to agree ways of providing it. Total

73
purchasing GPs are also more likely to develop care packages using
generic staff, co-ordinated by a lead nurse from the practice.
The fact that national health service care is free to clients whereas
they can be asked to pay for local authority care on a means-tested
basis complicates the picture. The current attempt to agree local
eligibility criteria for continuing NHS care is an attempt to ensure
that people do not remain in NHS free care if their needs do not
require it.
It seems likely for many reasons that more people with greater
needs will be cared for in the community in the future. Resources
will continue to be limited and staff delivering services will have to
be increasingly aware of costs. As care becomes more complex the
costs of co-ordination rise and services can appear more costly and
less efficient.

Contract monitoring

Contract monitoring in the NHS is still in its infancy. It takes

considerable time to build up an understanding of the variation
which is inevitable in any service delivery business. In the first years
of contracting, variations were sometimes regarded as serious and
requiring remedial action when they are now seen to be part of an
expected rise and fall which is predictable from past trends.
Awareness of what the contract expects, in terms of numbers of
patient contacts, length of treatment, case-mix and the like is
essential; the contract monitoring process gives feedback on how
far the agreed contract is being met, and is an important part of
achieving reasonable performance.
The acute sector has found working to contract difficult, and
'over-performing' (carrying out more activity than the contract
allows for) is an annual cause for concern. For a number of reasons
it may be easier to perform to contract levels in community services,
but it may be harder to assess whether the contract is achieving the
goal of improving health. There have been repeated criticisms about
using number of contacts as the contract currency in community
health services, and alternatives such as programmes of care and
outcome-based measures have been suggested. However, as infor-
mation systems improve it is possible to get more detail about the
nature of each contact, and more community trusts are now able to
show they are targeting services on particular age-groups or patients
with more severe conditions.

74
Measurement of professional health care

In many ways the emphasis on competition, proving that services

are value for money, delivering services within an agreed contract,
and making value for money of central importance is felt to be a
threat by the health professions. Attempts at measurement by
people who do not have the daily task of delivering health care
and cannot 'understand' what is involved are resented. There is also
resentment of assumptions that health professionals are not work-
ing as hard as possible, and need to be monitored when most people
who work in the health service feel they are highly-motivated and
work hard.
Changes in social expectations mean that increasingly the public
are willing to ask professionals questions and accept that profes-
sionals' work should be monitored in some way - in the past the
assumption of superior knowledge held by the professional meant
that professional opinions and judgements were less likely to be
challenged by the public. Politically and financially, professional
knowledge is now also more open to challenge. The fact that
professional opinion supports a particular course of action is no
longer enough to override objections on the grounds of cost and
lack of proven effectiveness. This change in the respect accorded to
professional opinion has affected all the professions, including the
health professions. The professions are now more aware of the need
to explain their actions and justify them in layman's terms, although
most people still have trust in health service professional~, and
doctors retain their place as senior trusted professionals.

RE-DESIGNING SERVICE DELIVERY

The pressures of competition and value for money have also led to a
number of management-led investigations which question current
methods of delivering health care. In business and acute hospital
services the term 're-engineering' has been used to describe rethink-
ing the way in which the service is delivered to reduce duplication,
unproductive time and unnecessary delays (see for example Leice-
ster Royal Infirmary, 1995). The same approach is now an im-
portant part of managing and working in community health
services. The decision to allow nurse-prescribing is in a sense an
example of a re-engineering approach; nurses explained that they

75
often had to repeat a visit to a patient merely because they had been
unable to prescribe and use a dressing without returning to the
surgery to get the GP's prescription - this process has been re-
engineered so that the nurse can herself prescribe and apply the
treatment while she is in the patient's home, with clear advantages
for the patient who receives immediate treatment, the nurse who
saves a time-consuming and non-productive journey, and for the
GP who no longer has to write a prescription which does not
require his particular level of expertise.
Rethinking the need to have the district nurse visit patients for
suture removal is another form of re-engineering; many community
health services now use systems which encourage patients to attend
their general practice surgery for suture removal if the patient is
able to do so. The re-engineering approach focuses on the impor-
tant outcome - in this example safe and timely suture removal by a
health professional who can answer questions and check progress -
and then looks for the most effective way of achieving the desired
outcome. Typically, improvement results from eliminating a num-
ber of steps in the process which on examination are agreed to be
unnecessary. For instance, it is unnecessary for the hospital dis-
charge procedure to request a district nurse to make a home visit to
remove sutures if it is clear that the patient is able to visit the
surgery, and ring up and make their own appointment to do so at a
time convenient to them and the surgery.
Purchasers will increasingly be looking for more cost-effective
ways Qf achieving a good outcome for patients. With the increasing
ability to compare performance, purchasers will be asking their
community health services to match what can be achieved elsewhere.
Community health professionals need to understand and respect this
approach and adopt a re-engineering way of thinking about their
own work. This does not mean abandoning high standards of care
or professional judgement. It does mean recognising that many of
the ways in which we work have grown up historically for reasons
that no longer apply, and that common sense requires historically-
based behaviour to be regularly evaluated.

Community nurse managers

Community nurse management and community nurse managers

have had to reassess their role in response to changes in general
practice and the increase in nursing staff employed directly by GPs.

76
In the past the role of community nurse manager was not generally
valued by general practice. There are some reasons why this is
inevitable - community nurse managers had a clear responsibility to
the general population which was often in conflict with an indivi-
dual GP's wishes to improve their share of the community nursing
resource. It may have seemed legitimate to a community nurse
manager to move a staff member from one practice to another to
cover for maternity leave, sickness or vacancy, but it is not surpris-
ing that GPs losing 'their' nurse were not pleased. Community nurse
managers were often seen by GPs to be unnecessarily restrictive and
unwilling to give nurses permission to carry out a range of tasks
such as venepuncture or immunisation on the grounds that this was
an 'extended role' procedure. Even if nurses were attached to GPs,
they were often based in buildings some distance from the practice.
For these and many other reasons even the ablest of community
nurse managers found that once GPs had an element of choice
through their ability to employ more practice nurses, and the
leverage they gained when community health services became part
of the fundholding scheme, the inherited hostility many GPs felt
meant community nurse managers had to rethink their role. GPs
often saw nurse managers as a barrier between them and the
nursing services they felt they should have, and they also resented
the cost of that barrier.
In business terms, management overheads have to be accepted by
customers as adding value; if two firms are in competition and the
products seem equally good, the firm whose products are more
costly because they have more layers of management which do not
seem to add value will be less successful. The influence of the
market together with the UKCC Code of Professional Conduct
(UKCC, 1992) which makes nurses accountable for their own
professional practice, the expansion in the range of work which
GP-employed practice nurses have undertaken, and the pressure on
cost-overheads and the move away from neighbourhood models to
GP-focused models of primary and community care, mean that the
community nurse manager role has already changed and will
continue to change.
GP fundholding means that the day-to-day management of
community services staff is largely within the general practice.
Although functions like recruitment, personnel and payroll may
continue to be carried out by the community health services trust,
many of the other J"oles which used to be part of community nurse
management have gone. In the future there will be fewer nurse

77
manager posts linked to community trusts, but an increasing
number of opportunities to be the lead nurse within larger primary
and community care nursing groups attached to a general practice.
Community nurse managers have to convince GPs that they add
value. One of their roles may be training.
Clinical nurse grading introduced a new rigour into post-regis-
tration training; unless qualifications and training were relevant to
current work they were no longer rewarded. There have been
significant changes in arrangements for training within the NHS
as a result, and training costs have to offer value for money in terms
of safer or improved practice. New routes to more focused and
effective training are developing with National Vocational Qualifi-
cations (NVQs) and distance learning. GPs want short, effective,
relevant training for their practice nurses, delivered close to the
practice with a content which clearly benefits patient care and
enhances the practice.

Specialist nurses

The role of the specialist nurse is also likely to change and expand.
As care becomes more focused on the general practice there will be
a need for specialist services which recognise that even a large
practice will not contain enough cases of less-common conditions to
give staff attached to the practice the necessary experience to offer
good services. New arrangements will be required to provide
specialist services; a specialist practitioner could meet the needs of
a group of practices or offer training and advice to staff in the
practices. In some cases this specialist service will be provided by
national charities (epilepsy for example), or by drug companies with
an interest in special conditions.
Acute services are increasingly interested in the specialist out-
reach nurse as a way of taking acute services out to primary and
community care settings. Most community trusts already employ
some specialist nurses - diabetic, stoma and palliative care for
example. It is likely that there will be a greater number of specialist
nurses in the future, working from a number of different organisa-
tions. Knowing how to work effectively with specialists, keeping up
to date with what specialist nursing services are available and
ensuring that referrals are appropriate will be important skills for
primary and community nurses in the future, and may require a
change in current attitudes (Fawcett-Henesy, 1995; and Hennessy,

78
1995). For the community nursing manager, trainer or specialist
nurse working in a primary care led NHS, the challenge will be to
enable nurses to provide services which are flexible enough to meet
the needs of individual general practices and primary care teams, of
a high enough standard to add value convincingly with minimum
management costs, and innovative enough to offer new services and
styles of service at short notice without losing the reliability and
continuity which are also required.

Technology and community nursing

Advances in technology will also affect the work of community

nurses. Communication technology in particular will mean that
nurses are contactable when out of surgery. Advances in pharma-
cology mean that many medicines are safer in use and can be
administered in individually-prepared packs which no longer re-
quire a qualified nurse to administer them. Other advances in
technology have enabled tasks which previously required a high
level of skill to be systematised or computerised so that they can be
carried out in the home, or by someone with a lower level of skill
and appropriate training. If outcomes are shown to be equally
good, the use of the higher level of skill is no longer justified.
The acceptance of change is clearly important, and will be a
permanent part of the working landscape. Change will, of course,
be accepted much more readily if there are understandings that staff
will be retrained where new skills are indicated, moved to new work
rather than find themselves unemployed, and where the need for the
change has been convincingly demonstrated.

Health and social care

The boundary between health and social care will remain an issue
for the lifetime of anyone reading this book. For nurses, this
boundary has implications which are at the heart of the value of
nursing and nursing values. Many nurses argue that it is in the
process of caring for patients in the broadest sense that the value of
nursing as a relationship between nurse and patient is expressed.
Others claim that by being involved in work with patients which is
not strictly clinical nursing, nurses have a wide range of opportu-
nities to develop patient self-esteem, promote patient health and

79
observe clinical signs. However, it seems likely that there will be
increasing challenges to the claim that 'only nurses can do this
task' as non-nurses are shown to be able to carry out the tasks,
and patients and carers take on increasingly complex tasks pre-
viously done by nurses. There will also be increasing challenges
of 'dumping' and cost-shifting as nurses move out of social care
tasks. The arguments about medical and social bathing are well-
known examples.

The nurses of the future: supply-demand issues

Many of these issues will be linked to the future supply of trained

nurses. There are already known difficulties in recruiting nurses for
acute-sector specialties such as paediatrics and intensive care. It is
becoming harder to be confident about the national training picture
as nurse training is also affected by a range of far-reaching changes,
and at a time when a new style of basic nurse training, Project 2000
(UKCC, 1987), is still in its early stages. If an increasing amount of
work previously done through the NHS is done by the private
sector, it will also make the assessment of the requirements for
current and future trained nursing staff more complex.
The availability of other staff will also affect the future role of
nurses; the need to organise the hours of junior doctors to meet new
restrictions on their working week, the shortage of doctors in some
grades, specialties and geographical areas, and the demonstration
that some tasks currently undertaken by doctors can be safely
delegated to nurses will tend to increase the number of specialist
and practitioner nurses.
The title 'nurse practitioner' is used to describe a nurse who
chooses to work relatively independently, and who in particular
accepts patients directly rather than through a referral process
managed by a doctor or a health organisation. There are examples
of nurse practitioners offering minor-illness and casualty services to
the homeless, clinics in the community, self-referral nurse practi-
tioner clinics within general practice, and nurse practitioners oper-
ating within general practice providing agreed services which have
been delegated by general practitioners. For some nurses this option
will be attractive, offering greater autonomy. Studies show that the
service is appreciated by those patients who use it, but that nurse
practitioner services do not necessarily represent cost savings
(Fawcett-Henesy, 1995).

80
More opportunities, less freedom?

In some ways community and primary care nurses in the future will
therefore have more autonomy, but in other ways they may have
less. We have seen that the commissioning role and the purchaser-
provider split means that the choices which have always had to be
made in deciding which health services to provide are now more
explicit. Choices are also more explicit now for community health
nurses.
Increasingly nurses will be working within agreed protocols,
guidelines or programmes of care where their choice of treatment,
length of treatment and follow-up will be made within agreed
parameters. Protocols are often developed at a local or individual
practice level, although many of them follow similar models so that
transferring from one practice protocol to another is unlikely to be
difficult. As the use of protocols and guidelines increases, more
community health nurses will find themselves moving to posts
where they are required to work within a protocol or guideline
which they have not been involved in developing.
In this sense nurses will be less autonomous and will have to be
able to account for any departures from agreed protocols and
guidelines. It is likely that the increased use of protocols to ensure
standards of care, threat of litigation favouring adherence to
protocols, and the increased use of information technology to
prompt agreed protocol use, will lead to less individuality in
practice. From the point of the view of the patient this may be an
advantage; many patients report that conflicting advice from pro-
fessionals causes confusion.
There may also be less autonomy in deciding priorities between
patients. Health professionals have always been expected to prior-
itise their own workload, and it is one aspect of working as a
professional to be equipped with the knowledge and experience to
enable presenting patients and problems to be ranked in terms of
their urgency and relative priority. The new issue now facing health
professionals is that priorities may also have been decided in
contracting terms. In most cases contract priorities will mirror
professional judgements, put in cases where they do not there can
be real conflict for health professionals. These conflicts may be
particularly acute in primary and community care where the patient
may well be living in unsupported home conditions such that if the
nurse, for example, stops visiting, the patient will not be receiving
care from any other source. Community nurses and their managers

81
need to act as advocates for patients who may not be on the
contract priority list, but whose health and social circumstances
in all their complexity require them to be treated.
One advantage for community nurses of working closely within
primary care is that the interaction of health and social circum-
stances are more likely to be understood by general practitioners.
Early signs are that as fundholding extends into total purchasing
and GPs are responsible for the whole continuum of care, they
acknowledge that health care without social care is not enough. A
number of GP fundholders have succeeded in arguing for practice-
attached social services staff, and total purchasing is likely to
increase this trend as long as savings from acute care allow.

FUTURE TRENDS

As the population ages, more and more health and social care will
be delivered to the very old, who will increasingly be living alone
without close family support. Although some advances in technol-
ogy, such as alarm and monitoring systems, improved home equip-
ment and automatic drug dispensing and recording systems, may
make maintaining frail elderly people alone at home more feasible,
it is unlikely that there will be a significant reduction in the high cost
of supporting vulnerable people in their own homes. In some ways
nursing care in the patient's own home is likely to become relatively
more expensive: cost reductions are less possible in areas of work
where the major input is staff time, and there are limited ways of
automating staff input and reducing costs.
Although the introduction of the purchaser-provider system has
opened up opportunities for private home-care agencies to compete
with the statutory sector, it appears that in order to be cost-
competitive many private home-care agencies have to offer terms
and conditions of service to non-nursing staff which are too low to
attract a stable workforce able to give continuity of care. A low
wage and serial short-term contract workforce, nearly all women,
will itself be unable to build up adequate pension entitlement, and
will thus create an increasing number of future elderly. people
unable to provide for their own old age.
It is likely that more community staff will become directly
employed by GPs. If the government's wish to see providers develop

82
is realised, many more community staff will work in new organisa-
tions, including voluntary and not-for-profit providers. Some staff
will set up provider organisations themselves; the example of the
independent midwives is likely to be repeated. A large number of
nurses already work in the private nursing home sector, often on a
part-time basis, and it is likely that part-time private nursing home
and agency nursing in the patient's home will increase. For many
nurses the possibility of part-time working to enable them to
manage family responsibilities is a key requirement.
This style of working may offer flexibility to community health
professionals with other responsibilities, but it will raise issues of
access to training, team-working and familiarity with protocols and
work-place regulations. The requirement for nurses to demonstrate
that they have received relevant training is now a condition of
registration, whether employed by the health service, general prac-
tice, a private nursing home, an agency or working as a freelance.
We are likely to see an increase in the range and types of training on
offer. As the role of training expands, issues of quality and
comparability of training will become problems too.
The general picture is of a profession whose members are more
likely to work outside the current trust-based large organisations
with their restrictions, protections, opportunities and regulations.
Individual practitioners will increasingly have to prove their values,
learn how to work so that their professional contribution is valued,
recognise that lifetime employment with one public sector employer
is decreasingly likely, and work in a way which expects change to be
ongoing. Accountability and responsibility for standards of prac-
tice, training, career-management, pensions and insurance are more
likely to be issues for each individual nurse.
As community health nurses move away from employment in
large community trust-type organisations to working as members of
small teams in general practice or as sessional nurses, there will be a
wider range of ways in which to work as a community health nurse.
Some of the restrictions and problems which are a part of member-
ship of large organisations working within a centralised nationally-
directed service will be gladly left behind. Some of the security and
protection it offered for staff and patients may be regretted.
There has never been so much national determination to ensure
that primary and community care services should be developed.
Community health service nurses have the relevant experience and
knowledge, and if they are able to understand the reasons for

83
change and adapt their nursing and managing skills appropriately
they will also develop. Managers in community health trusts have a
responsibility to help staff adapt to the new styles of work required
by the changes in health care and the focus on primary care.

References

Atkin, K. and Lunt, N. (1995) Nurses in practice: the role of the

practice nurse in primary health care. York: University of York
Social Policy Research Unit.
Department of Health (l991a) The Patient's Charter. London:
HMSO.
Department of Health (1991b) The Citizen's Charter. London:
HMSO.
Department of Health and Social Security (1986) Neighbourhood
Nursing: A Focus for Care. Chair: Julia Cumberlege. London:
HMSO.
Fawcett-Henesey, A. (1995) Nurse practitioners: the South Thames
RHA experience. Nursing Times, 22 March, 91(12), pp. 40-1.
Gordon, P. (1995) Core values in general practice. Health Service
Journal, 23 March, pp. 24-5.
Hall, D. (1996) Health for All Children. Oxford: Oxford University
Press. 3rd edn.
Harley, M. (1995) Contact points: has increased hospital activity
pushed up demand for community nursing? Health Service
Journal, 105(5469), p. 29.
Hennessy, D. (1995) 'A changing health service requires a changing
workforce'. In J. Littlewood (ed.), Current [sues in Community
Nursing. London: Churchill Livingstone.
Iliffe, S. and Gould, M. M. (1995) Hospital at home: a substitution
technology that nobody wants? British Journal of Healthcare
Management, 1(13), pp. 663-5.
Leicester Royal Infirmary (1995) Whole hospital re-engineering.
Health Service Journal, 105 (5449), p. 11.
NHS Executive (1994) Towards a Primary Care Led NHS: An
Accountability Framework for GP Fundholding [EL (94) 92].
London: HMSO.
Thomasson, G. (1995) Monitoring and evaluating the shift of health
care services and resources from secondary to primary and
community sectors. York Health Economics Consortium, Uni-
versity of York.

84
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) (1987) Project 2000: The Final Propo-
sals. London: UKCC.
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) (1992) The Code of Professional Con-
duct. London: UKCC.

85
=============CHAPTERFOUR=============

The Development of Primary Care

Caroline Taylor and Geoff Meads

A BRIEF HISTORY

Primary care has occupied a pivotal role in the NHS since 1948 with
GPs acting as the first contact for over 90 per cent of users of NHS
services, and acting as gate-keepers to the majority of other services.
At the same time primary care has arguably been at the margin of
the organisation, through a combination of the zealously preserved
independent contractor status of GPs and the management of
community health services by local authorities until 1974. Even
after the integration of community health services into the NHS in
1974, family health services remained quite separately managed,
although from 1974 until 1982 family practitioner committees
(FPCs) were formally committees of the Area Health Authorities.
From 1982 until 1990, family practitioner committees reported
directly to the Department of Health (DoH).
The Charter for General Practice, produced in 1966, succeeded in
raising the status and perceived value of general practice within the
NHS. Nonetheless, in 1981 Acheson was still identifying significant
problems with the quality and resourcing of general practice in
inner London, and the picture which he painted could equally well
be applied to other urban areas (Acheson, 1981).
From 1990 onwards, however, primary care has undergone
substantial change. The NHS and Community Care Act 1990
(DoH, 1990), through the purchaser-provider split and the estab-
lishment of GP fundholding, began to change the balance of power
between hospitals and primary care, particularly GPs. Family
Health Services Authorities (FHSAs) were created to replace FPCs

86
with an expectation that they would take responsibility for the
planning and development of family health services to meet the
needs of their populations, rather than being merely administrative
bodies to support the practitioners. District Health Authorities
(DHAs) also had a population focus without the previous tensions
of having to reconcile the interests of the local population and the
management of provider units, part of whose role was frequently to
serve a different population. GP fundholders began to contract for
services for their practice population and to manage a cash-limited
budget comprising a mixture of hospital services plus their own
prescribing and practice staff. The fund holding scheme was rapidly
expanded to include community health services as well.
The Act also reaffirmed the development of community care
services as a priority and gave local authorities the formal lead in
planning such services. In 1993, local authorities were required to
commission social care to meet the needs of the priority client
groups, defined as elderly people, people with a mental illness,
people with learning difficulties, and people with physical disabil-
ities, and to secure such services for individuals requiring them
through the process of care-management. The requirement for
individual assessment, followed by the establishment of an appro-
priate package of care managed by a single person, was designed to
produce an appropriate response to individual needs in a histori-
cally unco-ordinated area of service provision. The developing role
of local authorities as commissioners, albeit in a less defined form
than health authorities, and the health authorities' new focus on
their populations combined to encourage a variety of approaches to
jointly delivering or jointly commissioning services for the commu-
nity care client groups; while the care-management approach led in
a number of areas to increased working across health and social
care boundaries in respect of individual clients.
Other changes in emphasis within the NHS were occurring in
parallel in the early to mid -1990s.
The Health of the Nation (DoH, 1992) formally established a
commitment to health promotion and the prevention of ill-health,
as well as the more traditional role of the NHS in its response to ill-
health. This development had also been signalled in the GP Con-
tract of 1990 which, through its requirement for health checks at
regular intervals and reward for health promotion activities,
marked a significant change from the previously recognised role
of the GP focused mainly on the treatment of illness, although in
practice many GPs were already moving in that direction. Similar

87
shifts occurred in oral health and dental services with the publica-
tion in 1994 of the Green Paper Improving NHS Dentistry (DoH,
1994b) and the Oral Health Strategy (DoH, 1994a). Both sought to
move away from the general dental services tradition of remedial
treatment, towards an emphasis on prevention.
This was a period, too, of increasing emphasis on the rights and
responsibilities of the individual, partly reflected in policy state-
ments such as the Health of the Nation but most strongly the
Citizen's Charter initiative (DoH, 1991a) which within the NHS
became the Patient's Charter (DoH, 1991 b). The Children Act 1989
(DoH, 1989a) similarly made clear the paramountcy of the interests
of the child in all work with children.
The NHS also began to address the issue of effectiveness in health
care. The promotion of medical then clinical audit through desig-
nated funding from 1991, and the publication in 1994 of a Research
and Development Strategy (DoH, 1993b) for the service and
subsequently in 1994 the Culyer Report (DoH, 1994c) on research
and development, signalled a recognition of the interrelationship
between services and research and the need to focus on the effec-
tiveness of interventions to make the most effective use of resources,
while recognising the legitimate role of the NHS in supporting
relevant research.
The Tomlinson Report in 1992 (Tomlinson, 1992) followed by
the Secretary of State's response Making London Better (DoH,
1993), recognised the need to develop primary care in London as
complementary to the requirement to rationalise hospital provision
to meet changing needs. Similar analyses were undertaken on a
local basis in other cities such as Birmingham and Newcastle. These
strategies complemented the developing impact of fundholding,
which increasingly made primary care the focus of the health
service, with secondary care acquiring the role of specialist support.
This contrasted with the previous organisational model in which the
hospital arguably formed the hub, with community services the
spokes and general practice at the rim.
Integration of primary and secondary care began to be reflected
at health authority level, with DHAs and FHSAs increasingly
working in partnership and often integrating their management
organisations to form 'agencies' or 'health commissions'. The over-
all influences during this period were the need to control public
expenditure, the development of a management market approach in
health care, deregulation, and the simultaneous promotion both of
consumerism and of a population-based approach to health care.

88
 The Health Authorities Act 1995 (DoH, 1995) which abolished
Regional Health Authorities and established a single health author-
ity for each area, replacing both DHAs and FHSAs, marked the
first formal integration of primary and secondary care structures.
Perhaps more significantly, management guidance which accompa-
nied it, from EL(94) 79 Developing NHS Purchasing and GP
Fundholding, established a framework for a primary care-led NHS
(NHS Executive, 1994).
Arrangements for GP engagement through fundholding are being
extended with the introduction of 51 total purchasing projects from
1 April 1995 on a pilot basis, in which groups of GPs purchase the
full range of health care for their practice population; from 1 April
1996 general practitioners with lists as small as 3000 will be engaged
through community fundholding (covering community health ser-
vices, the GP's own prescribing, and practice staff), and the mini-
mum list size for standard fundholding will be reduced to 5000
patients.
The new health authorities have as their main functions the
development locally of strategies to meet the health needs of the
local population; the commissioning of health care; support to
primary care; particularly GPs, in commissioning health care, and
monitoring. This takes the involvement of primary care in the
overall commissioning of health services a significant step forward,
with the strategic intention being that primary care will take the lead
with the health authority undertaking a co-ordinating, supporting
and regulatory role, but no longer directly responsible for contract-
ing for services. This is undoubtedly a long-term agenda and requires
substantial development of primary care in many areas, both in its
role as a provider of services and in its capacity to commission. It
also assumes that as commissioners GPs will function as part of the
corporate NHS, accountable ultimately to parliament for the use of
public funds and the delivery of national policies. This is a significant
qualitative change in the relationship of GPs with the rest of the
NHS; the price of power is the loss of some independence.

PRIMARY CARE - THE TROJAN HORSE

One of the main aims of the reforms described above was to

liberate both thinking and practice in the NHS. Prior to 1991,
the NHS rivalled the prison service in its preoccupation with
institutions. Given that most appointments were drawn from the

89
ranks of ex-hospital administrators the advent of general manage-
ment following the first Griffiths Report (DHSS, 1983) had actu-
ally done little to challenge this insularity of the NHS, particularly
as new top-down management techniques, such as the Efficiency
Index (which is a tool used by the Treasury to assess NHS
productivity), were largely directed towards the secondary care
sector. By 1991 the need to break up this closed mind-set had
become not only intellectually desirable but a functional impera-
tive. The overall performance of the reformed NHS, with its new
responsibilities for health as well as health care, depended upon its
capacity to operate effectively both with other public sector en-
terprises, such as housing and transportation, where market prin-
ciples had already been introduced in the 1980s, and within a policy
framework that was more and more defined externally through
such forces as European Community legislation and international
developments in managed health care.
The fundamental shift of attention from the hospital to the
primary care setting in the 1990s has been a critical factor in this
process of freeing up the NHS. The positioning of the general
practice as the pivotal role in purchasing as well as the first stop for
NHS provider investment has itself compelled a new relationship
between the NHS and the private sector, given the continuing
independent-contractor status of the former's lead professionals.
The rapid expansion of general practice fundholding is spawning a
range of organisational alternatives with which health authorities
can now contract, from limited companies to legal partnerships,
from consortia to charitable trusts. On the back of primary care
development the modern NHS has become a mixed economy. As
such, both its potential risks and resources - in terms of capital,
personnel and finance - have been substantially expanded. And as
with all mixed economies the most taxing questions for the new
Primary Care Led NHS (NHS Executive, 1994) revolve around
accountability: how and when to intervene, if at all?
So, GP-led primary care has been the government's Trojan horse.
An appreciation of its impact on the NHS cannot be gained simply
by understanding the 1990 General Medical Services Contract
(DoH, 1989b) or even the constantly changing fundholding regula-
tions. For community nurses and other professionals affected by
what often feels, in some cases, like a relentless shift to not just GP-
led but GP-dominated primary care, it is important to understand
what dividends this shift brings, other than the levels of enhanced
patient care that may be far easier to assert than to demonstrate.

90
Primary care planning is, of course, always a highly participative
process, and at least six contributions can be identified in the matrix
of motivating forces behind its current development. By looking
now at what these are and how they impinge on contemporary
models of general practice, a much better understanding may be
gained by primary care teams of how their future identities will be
formed.

PRIMARY CARE DEVELOPMENT - THE MOTIVATIONAL

MATRIX

The small business

The first factor is that of the general practice as a competitive small

business. Demand-driven, privately-owned and part-funded, with
intrinsically low management overheads as a result of its profes-
sional partnership status, the promotion of general practice falls
right in the middle of late twentieth-century macro-economic
change. As traditional industries have declined and Eastern suppli-
ers have dominated new technology developments, the growth of
Western economies has relied heavily on the expansion of small
businesses, often into sectors previously taboo for private sector
entrepreneurialism. The attachment of the individual to his or her
GP, of course, helps legitimise the movement to public service
businesses as an integral part of the national health care system.
Parallel developments can be observed in, for example, Holland,
where the tradition of publicly-funded independent-sector care has
been much stronger. The overriding ethic of the Dutch system is
solidarity, and one of the challenges facing the UK in the years
ahead is the extent to which the normative consensus on which the
NHS has relied for its sense of purpose - as a comprehensive, free
and equal public service - can be effectively supplemented by the
essentially remunerative incentives that come as a result of a new
commercial overlay expressed in terms of increased choice, differing
quality standards and, above all, competition.
NHS trusts were devised with close reference to their hospital
counterparts in Holland. These are used to operating within Ee
competitive tendering regulations. In UK primary care these too are
now beginning to apply. 1995 witnessed, for example, the first
entries in the European Journal from an English health authority
(Dorset) wishing to place up to ten contracts (at a value of over

91
£1.5m) with a general practice in Lyme Regis for a range of facilities
from chiropody to hospital-at-home that, in financial terms, at least
matched the income from the national General Medical Services
Contract.

Consumerism

Small businesses have customers and trade in a market-place.

Markets are inherently dynamic responding inter alia to changing
public fashions and preferences. General practice-based primary
care has accordingly been an important vehicle for bringing the
forces of consumerism into the wider NHS. Practice brochures,
local information directories and patient satisfactory surveys are the
most obvious and readily acceptable signs of this new trend.
But the new consumerism of the NHS has its harder edges as well.
In an environment of demand outstripping limited financial re-
sources, virtually all national health care systems have looked to
deploy their resources to legitimise priority-setting in terms of
overall investment and the rationing of individual care. This has
taken different forms: from the (refundable) entry fee to see a
doctor in Sweden, to the merger of private insurance companies
with public Sickness Funds in Holland, and the marketing of
different health-care assurance packages to employers in the United
States. The public, as individuals, has to select and the primary care
business is the first to respond and adjust its services. This means
automatically that the consumer must be better informed, and in
the UK with the general practice as the gate-keeper to all NHS
facilities it is here that the whole fusillade of opinion-forming data,
from self-help health promotion booklets to waiting-list league
tables, is now being targeted.
The new consumerism is both an antidote to traditional demo-
cratic control of public services and a supplement. At its crudest in
the UK it creates a new system of checks and balances between local
councillors and GPs. The latter's position as the consumer's ad-
vocate now has to be taken into account by elected representatives,
particularly as local authorities witness both their own roles in
direct provision and electoral turnouts dwindle.

Subsidiarity

General practices can only, of course, be agents of a central

government's determination to counter fluctuations in local author-

92
ity positions if they have real and significant resources at their direct
disposal. It is here that the NHS's 'new consumerism' and the EC
principle of subsidiarity go hand in hand. General practice fund-
holding (GPFH) is the classic statement of local decision-making
with budgetary control.
Although indebted in part to such earlier associated develop-
ments in the UK, including the growth of housing associations and
the local management of schools, GPFH has far outstripped all
other public service initiatives designed to transfer resource alloca-
tions and differential funding policy issues from the national to the
local level. Its perceived success, in parallel with its counterpart in
the New Zealand Independent Primary Care Provider Association,
has attracted enormous international interest.
This is not simply because of the opportunities for financial
control of prescribing and secondary care that fundholding appears
to offer. Recurrent 3 per cent underspends and less-expensive skill-
mixes are certainly impressive, but essentially only as by-products of
a primary care-led NHS which allows government to move from
(escalating) activity-driven to (controlled) population-based health
care funding. A future government may begin to contemplate, as
the acute sector downsizes and reconfigures, whether public sector
capital investment in NHS providers will even be necessary or
appropriate in the future.
In short, a primary care led NHS starts to look like a best buy.

Value for money

The value for money (VFM) banner has been raised since 1980 as a
series of professional monopolies have been challenged. Consul-
tants, lawyers, teachers and social workers have each seen their
exclusive claims to determine services reduced as the focus has
moved to the individual and his or her needs. The principle of
individual needs assessment is at the heart, of course, of the
conventional general practice consultation. Since the 1990 legisla-
tion introduced care management, it is now similarly located for
community care. Operational convergence may well only be a
matter of time, and with GPs and care managers increasingly
occupying the same primary care setting the prospect of combined
health and social care organisations superseding conventional GP
partnerships becomes a tenable proposition. Local authorities such
as Wiltshire and Somerset are already directly funding staff in

93
primary care teams, which in turn are having to sign up to the local
authority's service level agreements or contracts.

Anti-bureaucracy

The outcome of such joint commissioning is a set of contractual

relationships which converts the individual GP from independent
contractor status. He or she becomes another part of a service unit,
the extended primary care team, in the independent sector. The
continuous shift of service-delivery responsibilities from being pub-
licly-accountable and directly-managed bureaucracies to the inde-
pendent sector is the fifth underlying factor in contemporary
primary care development. This is the anti-bureaucracy dimension
to the motivational matrix.
In the simplest terms, with the post-1991 division of functions,
purchasing is seen as a direct public responsibility whilst, increas-
ingly, providing is not. Released from most of their obligations for
the latter, health and local authorities have been able to develop a
new range of service specifications reflected in a wide range of
contracts of differing lengths and scope, each with their own
incentives and penalties. For social services departments the attrac-
tion of primary care as its independent sector is increasingly
irresistible given central injunctions to direct 80 per cent of its
community care investments in this direction, and the paucity of
alternatives. Whilst the UK independent sector can embrace private
and commercial enterprises as well as voluntary and not-for-profit
organisations, in reality all forms of independent sector care provi-
sion have been underdeveloped. Agencies such as Mind, Mencap
and the National Schizophrenia Fellowship, to name but three,
have their histories as representative bodies, not providers. With
commercial banks having their fingers burnt in the early 1990s, the
estate agency fiasco, residential benefits cash-limited for the first
time, and the property market remaining flat, major private com-
panies have yet to make a major entrance on to the provider stage.
Expanding general practices is an altogether better bet, especially as
the scarcely visible transfer of management-overhead costs is usual-
ly only part-funded and always justifiable in terms of reducing
public bureaucracy.
Primary care development has become, as a result, a convenient
home for difficult causes. In the last analysis it offers, through GPs,
an acceptable face for decisions on priorities, or in other words the
rationing of care.

94
The principle of diversity

In parallel with the anti-bureaucratic tendency, over the past ten

years throughout the public services the restrictive practices of
professional monopolies have been addressed by central govern-
ment. The introduction of the national curriculum in teaching is the
classic example, but medical consultants and lawyers would equally
feel that their hegemonies have been eroded.
This trend has also applied to general practice. At the heart of
fundholding is the direct attachment of financial control to clinical
responsibilities, and the change in the role of authorities described
above increasingly challenges the self-regulating status of general
practitioners, as the latter move away from a single national
General Medical Services Contract to arrangements which involve
the former increasingly as the regulators and performance monitors
of primary care.
In the NHS these trends are driven by the growing legitimacy
given to the principle of diversity. Presented as the other side of the
coin to consumer choice, this can be identified as the sixth main
driver behind primary care development. Primary care led purchas-
ing itself is creating a new diversity of organisations and organisa-
tional status in primary care: multifunds, preferred providers,
community care centres, charitable trusts, limited companies, total
fundholders and so on. With diversity comes competition as the
illusion of a standardised NHS collapses and the latter transmutes
into a complex of health care markets operating within an increas-
ingly diminishing national framework of strategic priorities - the
first of which in 1996/97 is primary care development.
In the following section we offer examples of four different
practices which illustrate this increased diversity. Table 4.1 illus-
trates how the six dimensions of the motivational matrix behind
primary care development, described in this section, impact differ-
ently on these four practices. There are no universal truths in
today's NHS; different histories, geography and cultures can now
much more easily mould development. Staff and patients may have
to be much more discerning as a result.

PRACTICE A: STANDARD INNER CITY

A three-partner practice working from a converted house in an area

predominantly residential with some light industry and near to a

95
 Table 4.1 Primary care development (a motivational matrix)

Factors A Standard B Street team CRural D Suburban

inner city market town managed care

Small Business Determines Not Comes Driving force

economic currently an naturally; at behind
survival: issue, but heart of local expansionist
conflicts with may be culture tendencies
local service important in
ethos future
Consumerism Increasingly Expressed as Legitimises Harnesses
responsive, protective extra local public
but on its paternalism payments for support to
own terms services counter
central
accountability
Subsidiarity Reluctant to Driving Consolidates Maximises
have to take force; resent position as market
on decisions any external leader of potential
priorities controls local public
service
Value for Fulfil Justified by Assumed as Key indicator
money requirements need more natural versus health
but object in than quality authorities
principle outcomes and trusts
Anti- Opposed to Releases Basis for Important at
bureaucracy bureaucracy local local start-up, but
in principle, freedoms alliances with at risk of
dependent in patients becoming the
practice new
bureaucracy
Diversity Unaware of At leading At leading Survival
wider edge, and edge, and depends on
developments proud of it proud of it this

local shopping centre. The list size is 6300, with moderate to high
levels of social deprivation, 20 per cent mobility within the practice
population, approximately 300 refugees on the list, a similar
number of homeless people, a total of some 1600 patients from
ethnic minority groups including the refugees, and some 20 regis-
tered drug addicts. The GPs earn approximately £40000 each
before personal tax Gust below the current national average for
GPs of £43 000).

96
 The practice team comprises three doctors, a manager, a practice
nurse and receptionist. A counsellor attends for two sessions a
week. Health visiting and district nursing teams are attached to the
practice despite significant initial resistance from the local commu-
nity trust. Community mental health services and midwifery are
practice linked. The practice has a dietician attending for one
session a week and is developing links with a local community
pharmacist who is working with the partners to provide prescribing
advice and develop a practice formulary.
The practice would like to see linked or attached social workers
and physiotherapists, and is contemplating the employment of a
nurse practitioner. The practice is not fundholding but wants to
have better control of the services it uses, particularly community
health services. It has begun a community-orientated primary care
project with the intention of strengthening the working of the
primary care team and developing a better understanding of the
needs of its local population for mental health services. It is also
working with the health authority on developing practice-based
needs assessment and, in conjunction with other practices in the
area, to pilot an intensive home nursing service.
The nursing members of the team enjoy being part of a practice
team and appreciate the continuity of service which they are able to
offer to individuals and to communities. They share the team's
general philosophy of providing a holistic approach. There remain
some issues of role definition to be resolved in the team, particularly
between the practice nurse and the district nurses and health
visitors, and there is some ambivalence among the existing team
about the employment of a nurse practitioner who might deprive
them of some of their more interesting work and perhaps lead to a
skill-mix review, although in principle they support the idea of an
extended role for the profession. The nurses and health visitors
generally would wish to see more focus on promotion of health and
prevention of ill-health. They have some feelings that the medical
model is too treatment-focused.

PRACTICE B: PRIMARY CARE STREET TEAM

One part-time principal salaried by the Department of Health plus

doctors working on sessional basis from local practices. Three nurse
practitioners or clinical nurse specialists, two 'E' grade and two 'B'
grade nurses recently recruited. Community health services and

97
social services provide sessional input. The team is based in an
inner-city district and works from a number of sites including drop-
in centres and the premises of a range of organisations, many of
them voluntary, working with their client group. It provides both a
direct service to unregistered street people (defined as homeless
people, prostitutes and marginalised groups, often with HIV and/or
drug-related health care needs) and support to other professionals
in working with these groups. It has some long-term clients, but
with many changing, either as they move away from the area or,
more positively, as they register with local practices.
The team is committed to integrating services for street people
with mainstream services rather than developing a ghetto or
marginalised service, but team members at present are ambivalent
about the desire or capacity of mainstream services to provide
appropriate responses. There are increasingly links with specialist
services particularly in relation to TB, HIV and drug use. The style
of the team is co-operative, although the most senior nurse has
recently been appointed as team manager following the first yearly
review, which indicated that the team lacked coherent direction and
that there were serious tensions between the different professionals,
particularly the doctors and nurses. The team has enjoyed its
relative autonomy and is ambivalent about the development of a
more hierarchical approach with the appointment of the manager
and the lower-grade nurses, although most team members would
acknowledge privately that the previous arrangement was ineffi-
cient, requiring very frequent team meetings to resolve relatively
minor issues and highly-graded nurses undertaking work of a basic
nature which did not make use of their skills.
The team is currently directly managed by the health authority,
although there is a recognition by both parties that this should be
an interim arrangement. The team is resistant to being managed by
the local community trust and would prefer to be recognised as a
local practice in contract with the health authority.
Other options include joint commissioning by the health author-
ity, and the local authority or the commissioning of services by GP
fundholders and other devolved purchasers. The team recognises
the need to respond to changing circumstances and to target its
services at otherwise unmet needs, but there is some frustration at
what are perceived to be increasing external controls and the loss of
previous freedom to set the agenda. The staff worry that others will
not fully value their client group or their own work, but they also
acknowledge that their present arrangements may leave them

98
marginalised. They want to contribute to developing a model of
primary care led services which include those who have previously
been poorly served by conventional general practice.

PRACTICE C: RURAL MARKET TOWN

A six-partner practice based in the new and spacious premises of a

large medical centre, partly funded through the FHSA-administered
cost-rent scheme and partly through the capital investment of a
major retail pharmacy. The latter has a community pharmacy on
the premises. The overall list size is 11 500 and includes patients
from surrounding villages. The town itself has an 18000 population
and there are two other small practices which combine with practice
C on the out-of-hours rota.
Although there are no deprivation areas in Jarman terms, rural
unemployment is a growing issue and the lack of public transport
services is one of the most persistent complaints. Having initially
opposed the scheme, the practice is a community fund holder and
the district nurses and health visitors operate as part of one team
with the practice nurses. A combined patient's record is used by all
professionals, supported by a single information technology net-
work in the practice.
The senior partner is the lead fundholding partner. His father was
also a local GP and in the past he has served on the district council.
Two of the other partners are on the board of a local charity, the
fundraising from which helps support the range of services provided
at practice C. These include both homeopathy and a number of
alternative therapies. Practice-based physiotherapy, chiropody and
counselling are long-established. Fifteen per cent of Practice C's
patients make use of private medicine. Despite this, both secondary-
care referrals and prescribing costs are a little above the district
averages.
The practice is keen to preserve its good local name for medical
and paramedical services. It wants the district general hospital in
the next town five miles away to be retained despite growing doubts
about its critical mass in terms of both clinical expertise and
population catchment area. The practice is closely involved in
discussions about the future of the A&E department and has
reluctantly agreed to consider becoming the town's primary-care
emergency centre supported by all GPs.

99
 Working relations with the divisional social services department
are functional but relatively distant, following a long series of
changes in social worker personnel. Most contact is around referrals
for residential care. The practice has considered taking proprietor-
ship of the large local nursing home since the community care
reforms developments (DoH, 1990).

PRACTICE D: SUBURBAN MANAGED CARE

ORGANISATION

A seven-partner training practice with two assistants and a regis-

tered list of 17000 including 2000 college students. Operates from a
1970s health centre bought from the community trust with FHSA
support, and recently extended through DHA capital investment to
allow for the provision of day-surgery and X-ray facilities. The
practice population covers a wide social mixture including both
significant commuter and council-estate elements.
The centre is served now by a limited company, of which the full-
time partners are the board members. The company has eight
service contracts with the health authority which include dermatol-
ogy, hospital-at-home, audiology and respite care services. The
community nurses are employed direct by the company, having
previously been part of the local NHS trust. They are now respon-
sible for the social services department's local care-management
allocation which has been delegated to the practice. The latter terms
itself a 'community care centre' and its significant public informa-
tion service includes welfare rights and benefits advice.
One of the partners is a member of the local health commission,
which is encouraging the practice to become a total fundholding
pilot. The partners are, however, divided on this subject with some
reluctant to become part of the General Practice Fundholding
(GPFH) accountability arrangements. One partner writes in the
professional press on the potential benefits of an insurance-based
NHS with a patient-voucher subscriber system.
The strategic vision of the practice (not published) is ultimately to
take on employment responsibility for several of the clinical func-
tions now provided at the town's hospital. It believes the latter has a
limited life expectancy, under pressure from a major teaching
hospital 12 miles away. It is in negotiation with the Rowntree and
Nuffield Foundations on joint ventures designed to extend its range
of service outlets.

100
WHERE NEXT?

The developing model of a primary care-led NHS has a number of

inherent tensions. Most obviously there is the need to deliver
national policies and strategies across the country, but a potentially
conflicting expectation that health authorities will respond specifi-
cally to differing local needs and to the wishes of their own
communities. This tension is replicated at local level with health
authorities held accountable for the development of local strategies
and the co-ordination of their implementation, but with a strong
emphasis on the value of primary care-led commissioning reflecting
the ability of practices to respond to the differing needs of their
populations.
Diversity is therefore an increasing theme, but within a national
framework. The very nature of local health-care markets varies
considerably. Some, particularly in city areas, can be highly com-
petitive with commissioners having easy access to a range of
providers, both NHS and independent, and a degree of spare
capacity allowing the movement of work, although traditional
loyalties to particular institutions, the complexities of obtaining a
consensus for major change, and the policy decision to maintain a
degree of management in the market have so far mitigated the
extreme consequences of a purely competitive approach. In signifi-
cant parts of the country there effectively remain monopoly or near
monopoly supplies for most services, the imperative of geographical
access preventing competition from any distance, and the cost of
entering the market, combined perhaps with conservative behaviour
by commissioners, leading to relatively few alternative providers
developing.
Within each local market there is significant diversity in the
provision of primary care, linked to the independent nature of
GPs as contractors and as individuals providing personal services to
a particular group of patients, the needs of different populations
within a particular area, and historical and cultural factors affecting
the baseline from which primary care is developing and the influ-
ences on practices and individual practitioners. Thus, for example, a
large inner-city practice meeting the needs of a highly-deprived and
mobile population, with GPs paid less than the national average but
with consultation rates higher, may have very different motivations
and work within very different networks from a similarly-sized
practice located in a reasonably affluent market town and serving a
relatively stable and homogeneous population.

101
 Historically, general practices have been very small organisations,
at one extreme a single GP with little or no support staff. The
complexity of managing and developing primary care in the late
twentieth century, together with the costs of investing in premises
and other support, has generally led to an increase in practice size
and the development of sometimes very extensive primary health
care teams. But even a large practice is unlikely to have a total
personnel complement of more than 30. The trend nationally
towards larger practices and a decline in single-handed practitioners
is hard to discern in many cities, and the increasing tendency of
FHSAs or health authorities not to replace retiring single-handers is
frequently offset by splits of larger practices.
New vocationally-trained GPs tend to have trained in larger
practices and to have an expectation of working in a medium to
large practice in order to develop a range of services which they
believe appropriate, and to avoid too onerous a burden of out-of-
hours cover. But there is evidence that many patients prefer the
personal services of smaller practices, and the general need for good
geographical access to primary care means that in many parts of the
country the maximum size of a practice is constrained by the
dispersed nature of the population it serves. In addition, the nature
of the GP partnership and the individualistic nature of many
practitioners, together with the need to maintain a personal service,
are drivers towards small to medium-sized practices.
As GP fundholding develops, both in population coverage and
range of services commissioned, there is increasing evidence of
collaboration amongst purchasers to achieve greater leverage with
providers and thereby to secure change. It would, however, be
simplistic to forecast the early development of managed care
organisations along the lines of the American health maintenance
organisations (HMOs). HMOs assume a defined population and
effectively a single organisation in which all the players have an
interest in containing health care requirements within available
resources, and meeting those requirements within the organisation.
The nature of primary care in Britain is likely to preclude such an
approach on a number of counts. The right of every individual to
register with a GP and the promulgation of choice between practi-
tioners, combined with the independence of such practitioners, is
enshrined in the current regulatory framework. Furthermore, one of
the motivations for many GPs to enter fundholding has been to
exercise greater control over what happens to their patients across

102
the full range of health services, and particularly to maintain their
right of freedom of referral to a hospital of their choice.
Multifunds may be relatively large purchasing organisations but
practices within them, as within fundholding consortia or locality
projects, tend to maintain quite strongly their independence within
the larger organisation. In the cities, particularly, single-handed and
double-handed practices remain common, often the result of a split
in larger practices, and arrangements of consortia, locality projects
and other collaborative but non-collective arrangements prevail.
As has already been indicated, primary care is by its nature highly
diverse in terms of the population served by a practice, the personal
nature of the relationship between the practice and its patients and
the personal services offered, the smallness of individual practices
and their independence from direct managerial control, and the
highly individualistic nature of many doctors who choose to enter
primary care. This diversity can be both a strength and a weakness.
It offers patient choice and the possibility of a personal service
closely aligned with the patients' own aspirations. Its weaknesses lie
in the risk of too wide a range of quality as well as of services, the
lack of controls on performance, and the historical pattern of
marginalising some groups such as homeless people and ethnic
minorities.
It is arguable that the primary care agenda has until recently been
led by the counties, and that the model of the primary care-led NHS
may feel more comfortable in a county town with a relatively
homogeneous population and general practices as a key part of
the local infrastructure. But as this chapter has illustrated there are a
range of developments now in the cities addressing the needs of a far
more diverse, mobile and geographically-concentrated population,
which may signal some of the future directions for primary care and
a primary care-led NHS. Tackling the inclusion of historically-
marginalised groups, for example, or developing consensus on
change in an environment with many diverse providers of secondary
as well as primary care will offer some interesting lessons, as will the
need to develop the networks of primary care with social care,
housing, and other contributors to health in the broadest sense.
Organisationally the NHS has moved visibly from a monolithic
hierarchy to a network of much smaller, flatter and highly-varied
organisations, although secondary and tertiary-care providers still
offer examples of large institutional management. This means that
conventional career pathways up a very visible management ladder

103
no longer exist. Accompanying the diversity of organisations is
clearly a diversity of roles whether clinical, managerial or both. The
significant determinants of roles may lie in geography, history and
the culture of particular organisations. Organisational values and
philosophy may become the most significant links in career pro-
gression. Diversity at its worst may lead to fragmentation and offer
too great an opportunity for the exercise of personal power. More
positively it may offer an enormous range of opportunities and the
potential for the development of personal leadership which the
imperative to improve services requires.

References

Department of Health (1989a) Children Act. London: HMSO.

Department of Health (1989b) General Practice in the National
Health Service The 1990 Contract: The Government's pro-
gramme for changes to GPs' terms of service and remuneration
system. London: HMSO.
Department of Health (1990) The National Health Service and
Community Care Act 1990. London: HMSO.
Department of Health (199la) The Citizen's Charter. London:
HMSO.
Department of Health (199lb) The Patient's Charter. London:
HMSO.
Department of Health (1992) Health of the Nation: A Strategy for
Health in England. London: HMSO.
Department of Health (1993a) Making London Better. London:
HMSO.
Department of Health (1993b) Research for Health. London: DoH.
Department of Health (1994a) An Oral Health Strategy for England.
(Green Paper) DoH.
Department of Health (1994b) Improving NHS Dentistry. London:
HMSO.
Department of Health (1994c) Supporting Research Development in
the NHS: a report by a Research and Development Task Force
(Chair, A. Culyer). London: HMSO.
Department of Health (1995) Health Authorities Act 1995. London:
HMSO.
Department of Health and Social Security (1983) Report of National
Health Service Management Enquiry. (Chair, R. Griffiths)
London: DHSS.

104
Department of Health and Social Security (1988) Community Care:
agenda for action. A report to the Secretary of State for Social
Services Chair, R. Griffiths. London: HMSO.
London Health Planning Consortium, Primary Health Care Study
Group (1981) Primary Health Care in Inner London (Chair,
D. Acheson). London: LPHC.
NHS Executive (1994) EL(94)79 Developing NHS Purchasing and
General Practitioner Fundholding. London: DoH.
Tomlinson, Sir Bernard (1992) Report of the Inquiry into London's
Health Service, Medical Education and Research. London:
HMSO.

105
 CHAPTER FIVE

Inner-City Changes: Health Care

Services in Britain's Inner Cities

Ainna Fawcett-Henesy

INTRODUCTION

The ideal of health care provision based on prior assessment of

health needs has long been aspired to by health planners. The
Acheson Report (London Health Planning Consortium, 1981) laid
the foundation for a radical approach to public health, and in 1989
the government set out the basis for a greatly altered national health
service in which the clear identification of the population's health
care needs and the channelling of resources to meet those needs
emerged as complex and challenging tasks.
Target 27 of the WHO programmes Health for all by the year
2000 (WHO, 1988) is concerned with the provision of health care
according to need, and of adequate access for all persons. Though
the systematic and objective assessment of needs is considered to be
the logical point to break into the purchasing cycle and, by
extension, the basis for setting priorities (in a resource-limited
NHS), there are a number of differing perspectives on these issues
which have to be reconciled before it is possible to arrive at rational
judgements relevant to the targeting of resources and the provision
of health care according to need. Needs assessment as Cunningham
(1990) reminds us may not be new. What is emerging, however, is
the requirement for a coherent and more explicit approach to this
task at a very local level.

106
 Much of the literature on health-needs assessment and resource
allocation relates back to a wider debate about the causes of health
inequality. A model of needs assessment based on the concept of
deficiency reflected in the writings of nineteenth-century social
reformers and writers like Engels, Dickens and Rowntree, is robust
and persistent. The Black Report (DHSS, 1980) drew attention to
the relationship between disadvantage and poor health, summaris-
ing the differentials in the health experiences of different groups
according to social class, housing tenure, region and ethnicity.
Subsequent research during the 1980s has demonstrated that, far
from exaggerating, the Black Report may have actually under-
estimated the strength of the relationship between poor health and
various indicators of social and material deprivation in a country
still caught in the grips of a severe economic recession. Studies
based on small area variations make a convincing case for the
existence of multiple deprivation which impacts on the health of
local communities (Smith, Bartley and Blance, 1990; Judge and
Benzeval, 1990). In what are, in common parlance, termed 'inner
city' areas, the effects of poor social and material conditions on
health are seen at their worst.
The Royal Commission on the NHS (1979) stated, quite unequi-
vocally, that improving the quality of care in inner city areas was
the most urgent problem which the National He,alth Service had to
address. Other studies have voiced similar concerns (Bolden, 1981;
Carstairs, 1981; Wood, 1983).
Adding a further dimension to the debate, the Archbishop of
Canterbury set up a Commission in 1983 to examine social and
economic conditions in urban areas. The Commission's report
entitled 'Faith in the City, A Case for Action by Church and
Nation' (Archbishop of Canterbury's Commission, 1985) was in-
fluential in focusing public attention on the plight of the inner cities.
In graphic detail it set out the structure of inequality within cities,
the economic and physical decline and social disintegration experi-
enced in the outer housing estates as well as in the central urban
areas.
The key messages from this report suggest first, that a growing
number of people are excluded from sharing in the common life of
the nation, because of poverty and powerlessness, and second, that
a considerable number of the nation's population are forced to live
on the margins of society and below an acceptable standard of
living. The report challenges the nation and questions whether there
is any serious political will to change the present situation.

107
The recommendations emerging from the study were in tune
with the spirit of the Black Report, with radical proposals for
concerted action on poverty, unemployment, housing conditions,
homelessness, community care, public safety and national policies
on health.
Big city changes continue to be a key issue of concern to the
National Health Service management and health care professionals.
The Tomlinson Inquiry into London's health service, medical
education and research, drew attention to particular sub-groups
in the capital's population whose characteristics and access to
health services have for long caused concern to policy-makers and
social and political activists. The Inquiry concluded that:

'Londoners are no less healthy than people elsewhere. However,

it is quite clear from the available reports and statistical material,
and from the visits and discussions we have had ... that the
population of inner London presents a range of need unparalleled
in the rest of England.'
(Tomlinson, 1992, p. 6)

When it reported in 1992, it would appear that the Tomlinson

Inquiry had taken the cold calculation of the market as well as the
conclusions of other researchers to recommend the most radical
shake-up of London's health service for more than 100 years.
Other cities in Britain are facing similar challenges and perceive a
need to effect radical improvements in the health of their most
deprived populations. Almost every large city has had, or is carry-
ing out, a review of services and all reviews implicitly see a role for
planning with the market mechanisms and the need for rationalisa-
tion of services in order for the internal market to function more
effectively.
While other contributors to this book consider in detail the
implications of commissioning, the effects of changes in hospital
care on the community, the development of primary care and
continuing care/primary care interface issues, this chapter will focus
on the challenge of meeting the health needs of multiple deprived
populations in Britain's major cities in ways which achieve equality
of access and which also compensate for social or economic factors
which severely restrict individuals' abilities to choose a healthy
lifestyle and prevent illness. However, before considering how needs
and services can best be brought into strategic balance, it is

108
necessary to conceptualise more clearly the nature and extent of
inner city deprivation.

BRITAIN'S INNER CITIES: SOCIO-ECONOMIC AND

DEMOGRAPHIC CHARACTERISTICS

Inner city areas share a number of characteristics. The concentra-

tion of these characteristics in anyone area is reflected in the need
for most types of health services, particularly those which are able
to deal with the health problems most strongly associated with
poverty.
The 1991 Census suggests that populations in all major conurba-
tions in England, show a pronounced polarisation between young
and old. The large number of children below the age of five is more
than counter-balanced, at the opposite end of the age gradient, by
the increase in the population aged 65 or over. As a group, the
elderly living in inner city areas are not wealthy. Many of the
difficulties of economic vulnerability and social isolation are en-
hanced in the elderly. For most, the greater part of their income
comes from state benefits; many live on or below the poverty line.
Fewer older people in all the major urban areas of Britain are owner
occupiers. The majority live in rented accommodation, usually of a
poor quality.
The 1991 Census indicates a higher rate of over-75s living alone,
both in inner London and other conurbations, than England as a
whole. Dependants are more likely to live without a carer or in a
lone-carer household in inner London and other inner city areas
than in England as a whole. Importantly and un surprisingly, older
people use the health service more often than other groups living in
inner cities and record great levels of chronic illness. Data from the
General Household Survey (OPCS, 1993) suggest that over half of
those above the age of 75 report some form of long-standing
limiting illness, with higher levels amongst the poorest groups.
A survey of very old people in Hackney, an Inner London
borough, undertaken in 1991 with a sample aged over 85 showed
a substantial shift taking place in the attitudes of elderly people to
preferred sources of support. The vast majority (88 per cent) of
those surveyed wanted more help with tasks they found difficult and
preferred this help to come from formal services. Only 6 per cent
wanted more help from relatives and friends (Bowling, Farquhar
and Grundy, 1991).

109
 Inner cities households tend, on the whole, to have much higher
rates of overcrowding. Inner London has more households which
lack basic amenities than the rest of the country.
Unemployment rates in the inner city areas of all major metro-
politan centres are higher than the national average. A higher than
average rate of gross national product per head is contributed
overall by Londoners to the UK economy. Paradoxically, the
unemployment rate in some of the capital's inner city census
enumeration districts is also well above the national average.
Inner London's resident population numbers approximately 2.5
million people. They are joined every weekday by about 1.3 million
commuters who come to work in the city and, during the course of
the year, by around 8 million tourists. Population turnover is also
high. As a result of migration from city centres, all the major cities
in England are significantly weighted capitation-losers under their
respective regional formulae.
London has a markedly higher proportion of individuals from
minority ethnic groups than other cities in Britain. Inner London
has over four times the national proportion. People from ethnic
minority communities account for 18 per cent of Birmingham's
population, and areas in Small Heath and Handsworth where they
are heavily concentrated are among the most deprived in the
country. Non-English-speaking minority ethnic groups have special
needs and experience major difficulties in accessing appropriate
health care and advice.
London also has a high number of refugees from all over the
world. Their patterns of settlement indicate that new arrivals tend,
by and large, to gravitate to the inner London boroughs where there
are longer established, more settled minority ethnic and refugee
communities.
Despite inadequacies in the system of collecting and collating
information, figures from the Department of the Environment
indicate a steep increase, since 1986/87 in the size of the official
homeless population in Britain (DoE, 1985). The decline, nation-
ally, of private sector renting, the steep increase in rents which have
put such accommodation above the reach of people with low
incomes, the decline in public sector rented accommodation due
to the sale of local authority-owned properties, the cutbacks in state
investment in public sector housing, negative equity, and the
dramatic increase in the numbers of repossessions by banks and
mortgage lending companies, have contributed to the growing
problems of homelessness.

110
 However, the scale of the problem is far greater in big cities, with
London heading the league tables in this respect largely because the
capital has traditionally acted as a magnet for homeless people from
across the country. In some inner London boroughs, as many as
one in twenty people are homeless and the numbers are steadily
increasing.

HEALTH NEEDS OF PEOPLE LIVING IN INNER CITY

AREAS

The relative health needs of the residents of deprived areas can be

established most clearly by mortality statistics contained in the
Department of Health's Public Health Common Dataset (DoH,
1992). These confirm that regional differences in mortality range
from high in the north and west to low in the south and east for
both males and females. Inner London, however, is a major
exception with above average mortality.
Two useful summary measures of mortality are avoidable and
premature deaths. The former was developed as an indicator of the
quality of medical treatment; the latter based on an assumption that
normal human life expectancy is 75 years. The overall health status
of people living in inner city areas as represented by these two
measures is poor when compared to the rest of the country. Under
the age of 65, premature mortality is much higher in inner London
and other conurbations compared to the national average, although
over the age of 65, the Standard Mortality Rate (SMR) is lower in
inner London than elsewhere. Over the age of 75, it is lower than
the ratio for England as a whole.
Infant and neonatal mortality are as high in inner London as in
other conurbations, as is the number of years of potential life lost,
an alternative mortality indicator. The Office of Population Census
Statistics (OPCS) identified three parts of the country - Tyneside
and Teesside, greater Manchester and Merseyside, and inner Lon-
don, as having the worst overall mortality experience.
Levels of morbidity are high with a particular concentration of
stress and morbidity in some inner city areas. Inner London, for
instance, has a poorer health experience than England as a whole,
although as the Tomlinson Inquiry concluded, the health status of
Londoners overall is similar to that experienced in the country as
a whole.

111
 In all urban areas, certain groups are more likely than others to
be adversely affected by higher morbidity and have higher than
average consultation rates. A local survey in Ladywood, Birming-
ham, showed that single mothers have an incidence rate for episodes
of new illness which is 63 per cent above the national average.
Unemployed people in all areas are more likely to consult their
family doctors, as do people from minority ethnic groups living in
inner urban areas.
In an attempt to disentangle the influence of socio-economic and
environmental factors on geographic variation in mortality, Britton
et al. (1990) identified inner city council estates as areas which have
the highest SMRs for both males and females, typically in excess of
120 (1 per 10 000). The environment on some estates, characterised
by higher than average crime rates, overcrowding, overpowering
greyness and dog litter, also provides the setting for higher than
average morbidity levels.
There have been several attempts to combine a number of
presumed indicators of need or relative deprivation into a single
score or composite index. These scores are then computed for the
population at either district or electoral-ward level to be used as a
guide to where additional health or social resources need to be
targeted. Townsend's Overall Deprivation Index and Overall
Health Index (Townsend et ai., 1988) combines the score on four
census variables (the percentage unemployed; in overcrowded
households; in households without a car; and in households not
owner-occupied). Each variable is given equal weighting and regres-
sion analysis is used to relate the variation in the level of health, to
variation in the level of material deprivation.
The Department of the Environment's Inner Cities Directorate
has produced a measure of urban deprivation by combining six
indicators. Equal weights are given to each indicator, except for
unemployment which has a double weighting (DoE, 1985).
The Jarman index (Jarman et ai., 1991) was designed to measure
the workload effects of providing services for groups of people 'at
risk' of deprivation. Given the high proportion of elderly people
living alone, of households suffering overcrowding, single-parent
households, the higher proportion of ethnic minorities and highly
mobile people, all inner London districts score higher in terms of
the Jarman under-privileged area (UPA) score, compared to an
England average of zero.
Recent qualitative community-based needs assessment in several
inner urban areas have identified crime, noise and traffic pollution,

112
poor local facilities for shopping, sport and recreation, inadequate
public transport and travel connections to the other areas of the
city, as important concerns in the general health environment of the
resident population. In all areas where there is severe social and
economic deprivation, the needs of young people, lonely older
people, the mentally ill and the homeless tend to be more acute.
Within the inner city, however, deprivation levels are not necessarily
uniform. In London and Birmingham and other cities, for instance,
socio-economic conditions vary dramatically within small geogra-
phical zones. Often pockets of severe deprivation exist adjacent to
very affluent areas (DHSS, 1986).
The operation of Tudor Hart's inverse care law (Hart, 1971) is
clearly manifested in inner cities where need has tended to impact
most where there is greater pressure on services. The main features
of health care provision in inner cities are described next.

HEALTH CARE SERVICES IN INNER CITY AREAS

Health services in all big cities in Britain have been dominated by

acute hospital provision. Almost all have big teaching hospitals
which have traditionally attracted patients into the city from the
surrounding area. During the early period of the NHS's existence,
both revenue and capital funding were determined by the historical
pattern of hospital provision. Cities like London, which were well-
endowed with hospitals, also gained in terms of the funding
allocated to keep services running. The consequence has been more
hospital beds per 1000 of the population, and duplicated specialist
services.
The Tomlinson Inquiry (1992) noted that London had 43 major
acute hospitals with over 250 beds each, far more than any other
major city, and inner London had 3.3 acute hospital beds (excluding
Special Health Authorities) for every 1000 people as against the
national average of 2.3 (1992/93). London also had an over-
abundance of specialist services: 14 cardiac centres; 13 cancer; 13
neuro sciences; 11 renal; and 9 plastic surgery. The average length of
stay in London's teaching hospitals was 15 per cent above that for
provincial teaching hospitals (in 1991/92) and the average cost per
case (1992/93) in inner London teaching hospitals was 46 per cent
higher than provincial teaching hospitals.
Medical manpower in relation to resident population has also
tended to be in relatively abundant supply in major cities,

113
particularly in teaching districts. A Department of Health and
Social Security paper (DHSS, 1988) noted that 'hospitalisation
rates increase with the number of junior doctors in relation to the
number of consultants, after allowing for social and health factors
and bed availability'.
With the introduction of market forces, big city teaching hospi-
tals have come under pressure as the funding they used to receive
from their host health authority now has to be won in contracts
from health authorities further afield who may wish to use their
own local hospitals. Medical advances increasingly enable proce-
dures which used to require a stay in hospital to be dealt with on a
day-case basis or in a primary or community-based setting. Bed
numbers have been declining all over the country, but the process
has been noticeably sharp in London, particularly since it has been
compressed into a relatively short timescale, without the back-up of
well-developed primary and community health services.
Primary health care provision in most big cities has tended to be
patchy. Issues highlighted in 1981 by the Acheson review of primary
health care services in inner London were reiterated by the Tom-
linson Inquiry and indeed by recent reviews of health services in
other big cities. Generally speaking, in areas with major social
problems, the primary care services are less well able to cope,
mainly because of the large numbers of single-handed practitioners
and the higher incidence of large lists. London has three times the
national average of GPs over the age of 65, and inner cities in
general are characterised by an older age profile for GPs still
practising as compared with other parts of the country.
The problems of accessibility and availability of GPs in inner city
areas has long been noted. Certain groups, like the homeless, have
traditionally experienced difficulties in being accepted on general
practitioners' lists, and the non-availability of GP services outside
normal hours has resulted in inappropriate attendance at accident
and emergency departments.
The quality of practice premises in big cities is variable. Up to 50
per cent of GP premises in inner London were found to be below
standard by the Tomlinson Inquiry. Elsewhere, too, the greater
proportion of low-income practices situated in inner city areas led
Bosanquet and Leese (1988) to conclude that general practice was
becoming increasingly polarised between high-income, high-cost
practices and those with low incomes and few resources.
Practices with few resources naturally face greater disincentives to
investment. Lack of adequate premises has prevented many inner

114
city practices from taking on partners or support staff and from
developing primary health-care teams. Lack of space has also
prevented many of these practices expanding into the full range of
primary health-care services, including health promotion, screening,
minor surgery and hospital outreach clinics. Bosanquet and Leese
(1988) noted that fewer general practitioners responded to profes-
sional and economic incentives in deprived areas than in more
affluent areas, and observed that practices in deprived areas had a
smaller margin for developing services.
By adopting the World Health Organisation's target of 90 per
cent immunization and 80 per cent cytology uptake, the government
effectively excluded many inner city practices from payment.
Although the subsequent agreement to introduce a lower stage
payment at the 70 per cent and 50 per cent levels respectively was
a more realistic target, even these proved difficult to achieve in areas
of severe deprivation. A significant proportion of the street home-
less and of occupants of hostels and other forms of temporary
accommodation in large cities are vulnerable people with mental
illness, drug addiction problems, alcoholism and multiple social
problems. Although such individuals have the same rights of access
to good medical care and social support, mental health care
provision in many large cities has not met demand. Many inner
London areas lack fully-resourced community mental health teams
and the number of easy access, drop-in facilities for the homeless
and socially deprived has been falling. A marked lack of non-NHS
continuing-care facilities in inner London and other comparable
areas has resulted in patients staying in hospital longer than
necessary, adding to the high cost of providing health care.
Emergency admission to hospital is one extreme of a continuum
of forms of support and care for people facing potential medical
crisis. At the other end lies the care provided by members of the
family or household. In between lies the support provided by GPs
and social and community health services.
Given the social characteristics of inner city populations, the high
proportion of people living alone, particularly the number of people
aged 75 and over living alone and the higher incidence of single-
parent families, it is hardly surprising that the level of support and
care which can be provided from within the household is negligible.
All forms of social care are also known to be under pressure in areas
with high levels of social and material deprivation.
In order to demonstrate how the health services have responded
to the problems of social deprivation and health in inner cities,

115
I shall draw extensively, although not exclusively, upon post-
Tomlinson developments in London.

DELIVERING EFFECTIVE HEALTH SERVICES IN INNER

CITIES

Most diagnoses of inner London's health care problems have

pointed to the over-supply of acute hospital beds and the impact
of the internal market on the major hospitals, compounded by
expensive, but inadequate community health and primary care
services. As a result, inner London residents have tended to rely
on hospital services more than people elsewhere.
The reports produced by the King's Fund London Commission
(Benzeval, Judge and Solomon, 1992; Royle and Smaje, 1993) set
out in detail many of these issues. The Tomlinson Inquiry reached a
similar set of conclusions, and recommended substantial investment
in and improvement of primary care as the way forward.
The government's response, Making London Better (Department
of Health, 1993) incorporated the Tomlinson recommendations as
well as many of the King's Fund London Commission's views in its
strategy for future developments. Along with acute-sector rationa-
lisation, the development of specialist services and the merging of
medical schools into multi-faculty colleges affiliated to London
University, the substantial development of primary care services
was seen as essential to resolving the crisis facing London's health
care.
Making London Better recognised that changes in London's
health service on the scale envisaged required careful management.
The London Implementation Group was established for an initial
period of three years to co-ordinate implementation of Ministers'
decisions on a cost-effective hospital service and improved primary
care in London. Furthermore, the London Initiative Zone (LIZ),
covering part or the whole of 12 inner London health districts was
created for fast-track health developments in primary care - the
focus for new investment, new approaches and new ideas. LIZ has a
five-year time-frame and the range and speed of development
planned within its boundary was substantial.
It was clear from the very outset that the scale and scope of the
development programme needed to go beyond simple investments
in bricks and mortar, conventional methods of professional devel-
opment, or the traditional means of spreading good practice within

116
the NHS. The depth of London's problems and their persistence
required specialist treatment and the first priority was to get the
basics right, that is to improve premises and to attract and maintain
high quality staff in London.
Given the diversity and the high level of need among the inner
city population, particularly that of margin ali sed groups such as
homeless families and individuals, refugees and minority ethnic
groups, people with mental health problems and substance misu-
sers, close collaboration between health, social and voluntary-sector
agencies was envisaged as well as with a range of health care
professionals, including nurse practitioners, salaried GPs and com-
munity nursing services. Other key players who had to be engaged
with included Regional Health Authorities, Family Health Services
Authorities (FHSAs), District Health Authorities (DHAs), Com-
munity Trusts, professionals, local authorities as well as the Treas-
ury, NHS Executive and Ministers.
The pace of change as well as the detailed way forward for
primary care services in London had to be synchronised with the
rationalisation of the acute sector. As hospitals merged or closed, it
was essential that the primary care sector, as well as community
health and social services, were capable of handling the increased
demands made as a direct consequence. If things were to change in
London, and the problems of social deprivation and health were to
be addressed, the piecemeal experimentation of the past had to give
way to a sustained programme of planned development.
Never before has primary care occupied the pre-eminent position
that it does today. Work undertaken by the London Implementa-
tion Group in the mid-1990s demonstrated that the management of
primary care is full of complexities and that greater clarity is needed
about the expected overall impact of changes, both in the mode and
location of services as well as the interface between primary and
secondary care (Fawcett-Henesy, 1994).
A recent report from the National Association for Health Autho-
rities and Trusts (NAHAT, 1995) suggests that health authorities
throughout the country are, for the first time, explicitly addressing
the question of how resources are to be distributed socially as well
as geographically. Sixty per cent of the strategy plans give equality
of access to services as their guiding principle, and 42 per cent cite
what they call 'equitable services'.
The primary care strategy for South East London Health
Authority, for instance, stresses that health and social care needs
must be assessed and primary care services planned very locally to

117
cope with variations in levels of deprivation and the need for health
care services (Lambeth, Southwark, Lewisham Health Commission,
1995). Locality commissioning is seen as an important way for a
community and its interest groups to give their views and to become
involved in the purchasing of health and social care. However,
consumer groups warn that if there is a real desire to involve people
in the changes happening to health services, it is essential that they
are given high-quality information, not fed propaganda, that there
is less use of jargon and that there is genuine dialogue and
consultation with the public (Joule, 1994).
The increased demand for out-of-hours services in many inner
city areas reflects increasing consumer expectation and some
specific difficulties in accessing services during normal working
hours. Several research studies have shown that between a quarter
and a third of out-of-hours calls relate to children under five. Social
deprivation and lack of support networks also lead to high contact
rates. If health services are to be made more accessible to inner-city
residents then a number of key issues, including the personal
safety of service providers, communication between users and
service-providers and referral processes between GPs and members
of primary health care teams and other agencies, have to be
clarified.
Preliminary findings from a four-year project in Lambeth, South-
wark and Lewisham (an area characterised by marked deprivation
in south-east London) to tackle these issues in the inner city indicate
that there is great potential for improving the quality of out-of-
hours medical and other services through inter-agency working,
local rotas and a unified telephone answering and advice service to
simplify access for patients. Better liaison at the non-statutory /
statutory interface to enable local agencies and community groups
to work together more effectively and to develop more culturally
sensitive services has been stressed (Department of General Prac-
tice, King's College, 1995).
The theme of inter-agency collaboration reverberates throughout
other radical approaches to improve the health of inner city
populations. As part of their Inner Cities Initiative, 14 mental
health trusts plan to provide a 'guarantee of care comprising a
package of services to severely mentally ill people. This would
include the entire range of services, from clinical care through to
employment schemes and housing support, and a wide group of
providers such as housing associations and carer groups would be
involved (Fawcett-Henesy, 1995a).

118
 Making London Better saw the voluntary sector playing an
integral role in the development of primary care services across
London. £7.5 million was made available over three years to fund
40 projects (selected through a competitive tendering process) aimed
at facilitating early discharge from hospital and preventing inap-
propriate admission in the first place. While a number of innovative
and imaginative schemes have taken off with the injection of extra
funding, and a range of client groups have been offered greater
choices of services in more appropriate locations, consumer watch-
dog groups warn that competitive bidding for resources tends, by its
very nature, to favour larger more-established voluntary groups at
the expense of those sections of the community that are most
disadvantaged, for example black and minority ethnic people,
people with disabilities and other historically underfunded groups
(Levenson, 1995).
Socially deprived populations have complex health needs which
call for a radical shift in the philosophy of care and the re-config-
uration of professional roles and responsibilities. The shift of
services and resources across the acute primary care interface is also
a priority. The substitution debate, however, is not simply about
shifting 'resources' or for providing a more cost-effective service. It is
also about enhancing patients' choice for a more holistic range of
care options nearer to their own home environments and the
provision of services which are appropriate as well as cost-effective.
Effective substitution policies not only redistribute the delivery of
services or identify the need for currently unprovided services. In
some cases they may, in fact, demonstrate that a medical model of
'cure' is not appropriate and that other forms of 'care', support and
health education are a more effective substitute. Substitution po-
licies may also reveal large areas of unmet need.
Substitution has the potential to reconfigure a wide range of
professional roles and responsibilities. The emerging evidence sug-
gests that nurse practitioners will be among the professionals at the
leading edge of new models of health care.
A recent evaluation of 20 nurse practitioners working in a range
of primary care settings - single-handed and group general prac-
tices, specialist and generalist accident and emergency departments
and in the community in pharmacies, fixed and mobile clinics and a
centre for homeless people - has shown that nurses could play a
much more prominent role in primary care by providing a directly
accessible service in their own right (Fawcett-Henesy, 1995b). The
study reaffirmed the importance of general practice as the focal

119
point for most health care services and concluded that nurse
practitioners could not only effectively manage a comprehensive
case-load jointly with general practitioners, but that they also have
a key role in meeting a 'care gap' in primary care. This gap might
constitute the lack of a service altogether such as where deprived
populations are involved, or the difficulties of providing time for
patients to discuss ambiguous, trivial or non-specific problems.
Filling these gaps might appear to be uncovering a problem best
left alone. However, by addressing the poor health of disadvantaged
and marginalised people, it is likely that more serious problems
could be avoided in the future.

CONCLUSION

Britain is a signatory to the WHO Health for all by the Year 2000
declaration (WHO, 1988) and as we approach the end of the
millennium it is appropriate to pause and take stock of the progress
made towards achieving this target. The problems faced by people
living in deprived urban areas are complex and by no means
uniform, but the Health Service response, in the past, has been
one of unco-ordinated action.
Following recent reviews, there is a general intention to invest in
primary care, as a way of providing equitable, accessible and
appropriate health care in the cities. However, the shift of activity
or funding from acute to primary care is unlikely to proceed
smoothly. The strategic direction for tackling inner city health
problems can be set by answers to the question 'what is the best
way of providing health care services to these populations', rather
than examining whether primary care and community services can
complement or substitute for hospital-based care. Users of health
services and potential client groups also need to be convinced that
effective health services can be developed within a reasonable time-
frame and the benefits of such developments need to be commu-
nicated clearly.

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Benzeval, M., Judge, K. and Solomon, M. (1992) The Health Status
of Londoners: A Comparative Perspective. London: King's Fund
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Bolden, K. J. (1981) Inner Cities. Occasional paper 19, London:
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Bosanquet, N. and Leese, B. (1988) Family doctors and innovation
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Bowling, A., Farquhar, M. and Grundy, E. (1991) Report of the
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Britton, B. (ed.) (1990 ) Mortality and Geography: A review in the
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Carstairs, V. (1981) Multiple deprivation and health state. Commu-
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Cunningham, D. (1990) Needs assessment. In E. J. Beck and S. A.
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Fawcett-Henesy, A. (1995b) Nurse Practitioners for General Prac-
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Hart, J. T. (1971) The inverse care law. Lancet, 1, pp. 405-12.
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London Health Planning Consortium, Primary Health Care Study
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Quantifying the challenge. London: King's Fund Commission.
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122
 CHAPTER SIX

Interprofessional Education
and Curriculum Development:
'A Model for the Future'

Rita Bell, Kath Johnson

and Heather Scott

A climate of political change and reform is having a profound effect

upon the provision of community health care in the United King-
dom, particularly in relation to the professional skills and compe-
tencies necessary to support quality community care (Fletcher,
1994; Bowman, 1995; Clifton, 1995).
According to Clark (1995), the resulting stress and turbulence in
the health care system and in society as a whole is placing heavy
demands on all health care professionals involved in the delivery of
health and social care in the community. It is suggested that the new
market-orientated culture of the NHS challenges traditional values
and requires new approaches to professional practice in the com-
munity. In addition, James (1994) draws attention to an important
dimension in this climate of change which must be given careful
consideration by health and social care educationalists. It is the
change in the social structure of the environment which includes a
number of trends including a current population with an increase in
higher formal qualifications which it is suggested may influence
their expectations and understanding of health care issues.
In practice, these challenges highlight the importance of enhanced
collaboration and partnerships in the delivery of care. This in turn
has major implications for educationalists striving to offer innova-
tive programmes and 'fitness for purpose' curriculum models

123
designed to meet the actual competency requirements of the rapidly
changing work-place. Moreover, the recent interest in National and
Vocational Qualifications (NVQs), occupational standards, compe-
tency levels and the promotion of transferable skills has emphasised
the importance of teamwork at all levels. (Fletcher, 1994; NHS
Executive Letters, EL (95)27, EL (95)84). Bahrami (1995) goes
further and highlights the importance of continuing education for
professional development and suggests the use of personal educa-
tion plans (PEPs) for professionals as a positive approach to rapid
change and developments in the NHS.
This chapter proposes that effective teamwork in the community
rests heavily upon common understanding of the principles under-
pinning the complexity of the working environment of primary
health care as a means of fostering a collaborative and flexible
approach to community care delivery. Therefore, the authors
recommend an innovative but uncomplicated approach to planning
and developing interprofessional education for all involved in the
delivery of primary health care as the way forward. This raises the
question:

What are the key principles inherenT in primary health and com-
munity care which need to be taken into account by course planners
and those involved in professional development for a range of
practitioners?

According to the World Health Organisation (1979, 1988), the key

elements of any primary health care system are defined as
accessibility, availability, cost-effectiveness and client acceptability
if we are to secure client-sensitive care provision (Fry and Hasler,
1986).
Education has an essential part to play in service development,
and the NHS Executive stated in August 1995, that 'it is essential
that the National Health Service must secure an adequate number
of appropriately qualified and prepared health care professionals if
it is to achieve its purpose and objectives' (NHS Executive, 1995c).
Subsequently, this chapter proposes that the development of
interprofessional education to support the community working
environment should reflect the basic principles of primary health
care. In practical terms, this suggests that those involved in educa-
tion should use the key elements of a recognised definition of
primary health care as a flexible and realistic framework to guide
curriculum development. This would ensure a mechanism capable

124
of establishing relevant continuing education which could be ap-
plied to professional development for disciplines involved in the
delivery of primary health care. It is argued that in the current
climate this requires an emphasis on health promotion and subse-
quently relies upon a fundamental shift from individualistic ap-
proaches which have been the cornerstone of medicine, to a model
which includes promotative/preventative/curative and rehabilitative
elements (O'Keefe et at., 1992).
This change of stance has subsequently given urgency to making
a reality of multidisciplinary teamwork to support primary health
care. This presents an unenviable challenge to professionals to
rethink their occupational purpose and reconsider the value of
education in achieving change and growth (Horder, 1995). Support
for interprofessional education is growing and considerable oppor-
tunities to work together abound to share ideas and approaches
(Barr, 1995). On reflection, growth appears to have been 'patchy'
which indicates that although teamwork and collaboration have
been the focus of attention in practice for 20 years, the concept has
failed to materialise beyond isolated experiences in reality (Nocan,
1994). A recent project funded by the Social Services Inspectorate of
the Department of Health raises some crucial issues worthy of
consideration when examining the potential of collaborative educa-
tion, particularly in relation to:

• Why collaboration works well in some areas and not others?

• Why despite knowing how to run good joint training is it still so
difficult and rare for social workers and general practitioners to
work effectively together? (Vanclay and Hingston, 1995)

Nevertheless, this chapter recognises the importance of learning

from past experiences and supports the view of James (1994), who
states that the challenge is to take that learning with us. Therefore,
this chapter intends to use World Health Organisation criteria
designed to clarify the meaning of primary health care (WHO,
1979, 1988) to address the following questions:

• How can professional education/training for community health

care ensure the development of professionals who have the ability
to work effectively in partnership across professional and agency
boundaries?
• What would an educational framework designed to encourage
collaboration and change in service delivery look like?

125
The chapter will firstly identify current forces for change from the
perspectives of community nursing and social work in terms of the
context of care delivery, before expanding upon the World Health
Organisation criteria as a framework to promote advances in
interprofessional education and training for all care professionals
engaged in the delivery of primary health care.

THE CHANGING FACE OF PRIMARY HEALTH CARE

The current climate of service delivery presents community practi-

tioners with a complex working environment which will stretch their
management abilities and evaluation skills if they are to influence
the health status of the community population. This is particularly
important in these times of inequalities of health, the introduction
of competition within a quasi-market economy, and the importance
of consumer participation to name but a few. This level of complex-
ity demands community practitioners who have a high level of
competence to cope with the heavy demands of practice in non-
institutional settings and to support the delivery of care to clients in
their own homes. Undoubtedly, the caring community agencies are
at present faced with the challenge of how best to manage innova-
tion and change and expand their ability to work in partnerships
with others.
Evidence suggests that primary health care is not about the
contribution of anyone professional but relies upon a collaborative
approach to care. Furthermore, good quality primary health care is
not simply based upon the clinical skills of general practitioners, but
relies upon effective relationships between all members of the
primary health care team (Talbot, 1995).
Partnerships are, therefore, crucial in this day and age, and
interprofessional collaboration is seen as central to the success of
government health and social care reforms. In addition, the chal-
lenge of the 1990s is one of recognising the importance of transfer-
able skills in the health and social care sectors (NHS Executive,
1995b). In reality, however, the complexity and sophistication of
modern health care means that most clients will be assessed by a
number of different professionals who will need to work as a team
(Cain 1995).
Overall, the need for change in the 1990s is underpinned by a
range of crucial issues which should influence interprofessional

126
education and be taken into account when planning professional
development. This is summarised as follows:

'Firstly, evidence predicts a potential health crisis over the next

decade, and, secondly a range of barriers and hazards in primary
health care are facing practitioners which could impede service
delivery. These pressures are emerging from the acute and
independent sectors and include moves towards deprofessionali-
sation and the return to informal care, difficulties in collabora-
tion and limited structured interprofess-ional education for
primary health care. Furthermore, many would argue that inter-
professional education is fragmented and not service led.'
(Talbot, 1995, p. 16)

FORCES FOR CHANGE IN COMMUNITY HEALTH CARE

The reality of the working environment in primary health care is

posing a series of problems for professionals responsible for care
delivery, including pressures on resources and escalating health care
costs, but it is clear that attempts to improve service needs must be
supported by changes in training and education (Mackay et al.
1995). It is essential, therefore, that the first step in the process must
be to grasp an appreciation of the contextual position when
considering interprofessional education for primary health care.
In the first instance this can be related to the global environment
and presents an intimidating picture as follows.

Health crisis by the year 2000

According to O'Keefe et at. (1992) there is a potential health crisis

in the next decade which must be taken seriously by professionals in
primary health care. This is deemed to be 'no idle threat' and is
underpinned by clear evidence in relation to:

• a 'demographic timebomb';
• widening gaps between demand and supply;
• environmental pollution;
• user dissatisfaction;
• an 'iceberg of sickness';
• an 'epidemiological transition' from childhood illnesses to
chronic and degenerative disorders;
• a shift in emphasis to prevention.

127
Many people also predict that the community care changes will
result in some confusion which could place vulnerable and frail
people at greater risk (RCN, 1995).
In Britain, this crisis is exacerbated by poor levels of health care
in comparison to other western countries, particularly when varia-
tions in health by class, race and region, and aspects of quality and
quantity are considered (George and Miller, 1994).
Positive action relies upon teamwork and a pooling of knowledge
and skills in order to respond to this crisis, but evidence suggests
that partnerships and effective collaboration are still presenting
problems in the United Kingdom particularly in relation to profes-
sional ideologies, power struggles, organisational structures and
poor communication (Howkins, 1995).
The way forward must be through more effective means of
education which, in turn, call for an immediate strategy to promote
effective interprofessional education. It is abundantly clear, how-
ever, that any strategy of this nature must be supported by a
realistic and acceptable curriculum designed to address all parties
in the 'framework' or work setting. It is essential that education for
primary health care is built upon a co-ordinated approach to
curriculum development which takes full account of the urgency
of the current situation and ensures flexible, appropriate pro-
grammes which are designed to ensure collaboration in practice.

Barriers and hazards to progress

It is also essential to analyse the hindrances and challenges which

exist and which may inhibit progress in the immediate and diverse
working environment. In relation to primary health care and
community care, it is possible to categorise two important dimen-
sions which should be given careful attention when considering
future education and training.

Challenges from the 'centre'

A range of challenges imposed by the current socio-political climate
of health and social care delivery has serious implications for the
nature and pace of change, and consequently educational initiatives.
Francombe and Marks (1996) go further and propose that the
introduction of a market culture in the NHS and the notion of
competition interferes with the whole public service ethos. Undoubt-
edly, the impact of NHS reforms and the Community Care Act

128
 1990, with the subsequent shift to primary health care, has resulted
in review and role development of health care professionals to match
the complexity of the working environment (Hugman, 1995).
This has required a profound and painful ideological shift for
many professionals working in the community, and requires them to
expand and develop their range of managerial and political skills. In
reality, many tensions exist as a result of the increased emphasis
upon partnerships and collaboration which are proving difficult to
handle (Titterton, 1994). These dilemmas are caused by the policy-
makers on the one hand, and the implications of GP fundholding
for multidisciplinary teamwork on the other (Department of Health,
1989; Glennester, 1992). In addition, the current legislative thinking
promotes employer involvement in education and training as an
impetus to the development of service-led programmes of study.
According to Glynn and Perkins (1995), 'In the view of the
government and National Health Service Executive, it should be
the employer who should determine patterns of training that are
required.' (pp. 104 and 249). Furthermore, the notion of consumer-
ism which is central to current government thinking (Department of
Health, 1989) is placing heavy demands on professionals in the
community; not only do they have to respond to Charter initiatives,
but they are expected to advocate on behalf of the most vulnerable
members of society in their care.
Undoubtedly, practitioners are functioning in a changing climate
in the community which requires both collaborative approaches and
a rethinking of their role. This reflects the importance of relevant
professional development and the need for more effective interpro-
fessional education in this field (Department of Health, 1993; NHS
Executive, 1995d). Reorientation and innovation is a necessary
phenomenon in the current climate and policy-makers are explicit
about the way forward, believing that targets for progress must
include taking account of advances in technology, shifting patterns
of care and changes in the expectations of the public (NHS
Executive, 1995f).
Inevitably, this will create dilemmas and tensions for the profes-
sionals with diverse professional backgrounds. O'Keefe et al. (1992)
note the complexity of professional practice and draw attention to
the implications of the 'powerful actors in the game'. This is a
crucial dimension which should be given particular attention by
those wishing to reduce the barriers and encourage interprofessional
growth in primary health care. Tribalism has a longstanding
reputation in the National Health Service which many would argue

129
has hampered progress. However, according to Beattie (1995),
traditional boundaries appear to be under attack as never before.

InterproJessional collaboration
According to Howkins (1995), it is a generally held belief that
collaborative working is a good thing both for clients and profes-
sionals, but the evidence suggests the process can be fraught with
difficulties (Nocan, 1994). Furthermore, it is widely recognised that
joint working of all kinds has been an area of disappointment in the
recent history of community care (Mackay et al., 1995). This raises
the crucial questions of,

• why is it such a struggle? and,

• to what extent does this reflect on patterns of professional
education and inappropriate curriculum development?

There appears, however, to be support for collaboration as a means

of securing quality service provision. According to Howkins (1995),
the main message from both clients and professionals is that
working together has real benefits for everyone.
Specifically, it is argued that there are three main strengths in
support of collaboration which should be acknowledged:

1. Users are not concerned with professional demarcations but

simple efficiency and effectiveness;
2. The 'contract culture' of the 1990s emphasises outcomes rather
than assigning responsibility for quality to specific profes-
sionals;
3. Reduction of overlap and duplication with subsequent financial
savings.

Cumberlege (1990), however, recognises the complexities of work-

ing together and argues that structural changes are not enough.
Progress also requires a change of attitude, noting that there are
fundamental issues around collaboration which require careful
consideration, for example power, gender differences, professional
ideologies and indeed tribalism (Howkins, 1995).

The NVQ revolution and occupational standards movement

Over the last few years, there has been a steady shift towards a
changing work-force in health and social care which demands a

130
flexible and innovative approach to education and training. This
work-force has introduced skill-mix into situations in the commu-
nity which have been traditionally supported by health care profes-
sionals carrying recognised and statutory qualifications (Hennessy,
1995). Indeed, it is suggested that care in the 1990s has highlighted a
skill-mix gap which is particularly significant in primary health care.
This will require a radical change to secure a flexible and adaptable
work-force to accommodate the complex range of care packages
required in the community at this time (James, 1994).
Furthermore, the development of National Vocational Qualifica-
tions (NVQs) and the introduction of General National Vocational
Qualifications (GNVQs) in schools and colleges are considered to
be key components in achieving a learning society which can be
competitive in the global marketplace. This is a consideration which
can readily be applied to the health and social care field, and it has
become a development which requires diligent thought when plan-
ning education and training for the health care professions. It is
essential for educationalists to recognise that the revolution in
vocational qualifications in Britain is now gathering pace (OUin
and Tucker, 1994).
Moreover, according to Fletcher (1994), these changes have
major implications for both providers and users of vocational
qualifications. For example, in the community, the introduction
of care or support workers has led to a rethink in terms of
professional education and training for primary health careparti-
cularly in relation to methods and modes of training, work-based
learning, revision of curriculum, and credit accumulation initiatives.

'For employers, the potential is enormous for flexibility of

training and development provision, increased co-operation
and involvement with providers, better targeted training and
performance assessment, improved recruitment, selection and
manpower planning and ultimately, improved economic perfor-
mance.'
(Fletcher, 1994, p. 36)

However, the question remains, what does this mean in terms of

health and social care?
According to the NHS Executive (1995b), NVQs made up of
occupational standards, are a key aspect of government policy,
which suggests that they must be given careful consideration by
those designing education in this arena. In this context, occupational

131
standards are defined as agreed benchmarks specifying performance
outcomes expected in employment for specific occupational areas.
Functional analysis is used to identify key roles which in turn are
broken down into units, elements, performance criteria and range
statements (NHS Executive, 1995b). This framework of NVQs based
upon occupational standards is intended to improve the work-force
competence and develop staff with transferable skills. Furthermore,
it is viewed as staff development in some instances as it is pointed out
that many NHS staff have not had access to qualifications, and it is
suggested that staff obtaining NVQs may find they provide a useful
entry point to some professional programmes. In addition, it is
proposed that some professionals may find NVQs useful as a means
of professional development or 'ladders of opportunity', particularly
in areas such as management and information technology.
How this fits with the Occupational Standards Council's propo-
sals for health and social care is indicated in Table 6.1.
What do these developments mean in the field of primary health
and community care and interprofessional education initiatives?
What do they mean in 'real terms' in a climate of financial restraint?
In spite of assurances that these developments will not promote
the emergence of alternatives to current programmes of training
leading to registration with statutory bodies, do they signal an
erosion of the role of professional bodies in standard-setting for
entry to education and training in primary health care? How can the
new concept of occupational standards be translated effectively in
community health care?

Table 6.1 National occupational standards and associated qualifications

National occupational standards NVQs/SVQs

Residential, domiciliary, day-care Level 2 Level 3

Health care support workers Level I Level 2 Level 3
Integrated care awards, Care awards Level 2 Level 3
Child care and education Level 2 Level 3
Operating department practice Level 2 Level 3
Physiological measurement Level 3
Criminal justice Level 3/4
Ambulance not accredited yet as NVQs/
SVQs but currently being
implemented as basis of the
revised NHS ambulance awards.

Source: NHS Executive (1995b), EL(95)84.

132
 Furthermore, what does the concept of competence mean in the
context of primary health care? Hyland notes the complexity of the
competency debate and urges caution, stressing the importance of
more research:

' ... it is time to inspect more closely the alleged flaws, weak-
nesses and inconsistencies in competence based education and
NVQs in the areas of learning, assessment and knowledge before
looking at the impact upon vocational education, adult, further
and higher education and professional courses.'
(Hyland, 1994, p. 18)

Fletcher notes that new occupational standards are based on a

concept of competence which has emerged through long debate. In
reality, however, there appear to be many ambiguities surrounding
the concept of competence which should be given careful considera-
tion by educationalists at this point in time. This highlights the
importance of dialogue between all parties involved to ensure
conceptual understanding of terms and to avoid disagreement
about definitions and differing views on role performance.

'Competence and competence talk may have powerful persuasive

powers at slogan level but it is conceptually imprecise, logically
equivocal and systematically ambiguous.'
(Hyland, 1994, p. 31)

These criticisms and concerns have major implications for those

responsible for education and training for the caring professions.
Hennessy and Hicks (1996) discuss the importance of a systematic
and rational approach to identifying and prioritising training and
updating needs, as well as the organisational developments to
support this. The latter process is essential for the strategic manage-
ment of cost-effective education.
How can quality of community service be assured? How does this
development fit in relation to professional accountability for health
and social care in the community setting where there is limited
direct monitoring or scrutiny of standards of care?
In conclusion, the impact of the volume, pace and complexity of
policy directives and legislation is presenting practitioners in the
work-place with unprecedented challenges to their adaptability and
their repertoire of skills. According to Health Care 2000,

133
 'Professionals are likely to work for increasingly autonomous
providers who are more accountable to purchasers and patients
in the future. The pattern of general and specialist skills will
change and there will be a demand for more highly skilled
specialists and more multi-skilled teams. It is likely that tasks
and skills will be increasingly shared by professions and special-
ties.'
(Health Care 2000, 1995, p. 8)

Mackay et al. (1995) state that there has been a surge of interest
in interprofessional working in recent years which in turn has led to
a number of initiatives designed to promote shared learning to
enhance closer working relationships. There is a common-sense
attractiveness to the view that enhanced service delivery will result if
those who work together learn together (Funnell, 1995). However,
according to Horder (1995) we have no accurate knowledge of the
present state of interprofessional education for primary and com-
munity care. What this means in relation to the education and
training of community nurses and social workers will be discussed
in the following sections.

THE CONTEXT OF PROFESSIONAL EDUCATION FOR

PRIMARY HEALTH AND COMMUNITY CARE

Primary health care delivery is a complex and challenging activity,

depending upon a team approach to care. However, it is clear that
interprofessional working is a goal that is not easy to achieve. The
current working environment and professional influences present a
tremendous challenge to educationalists, and this challenge is the
centre of a great deal of debate particularly in relation to inter-
professional education opportunities and initiatives. This is a
perplexing situation for educationalists who are charged with the
task of presenting innovative programmes which match the require-
ments of clients, professionals and service providers, as well as the
requirements of higher education.
According to National Health Service Training and Develop-
ment, 'Not only are they obliged to deliver a curriculum that
prepares students to respond to these changes, but they must do
so while equipping students with an education that is solid in the

134
provision of the specialist knowledge, skills and principles which
define their professional identities' (NHSTD, 1995, p. 2000). The
current environment is indicating a radical shift in professional
education in order to meet the challenges of the 19908.
It must be appreciated that the new community care policies
represent a challenge to the health and social care professions to
develop fresh ways of defining their skills around the tasks of
purchasing and providing, rather than formal professional identi-
ties. It is suggested that the overlap between health and social care
professions is such that what is required is a new professional mix,
and the possibility of new professions emerging (Hugman, 1995).
Howkins (1995) reminds us that the difficulties of working
together are substantial and the whole issue is far more complex
and more deeply embedded in professional ideologies than origin-
ally envisaged. Nevertheless, if collaborative work is an essential
development for health and social care, it is imperative to promote
the way forward through education based upon shared learning.
Examples of integrated and interdisciplinary training pro-
grammes exist nationally and across the professions as shown in
Table 6.2. However, there is a danger that joint endeavours will
only be developed in the less-problematic areas of practice, leaving
areas of conflict between different professional groups unqamined
and unresolved. There are indications (NHSTD, 1995) not only that
experiments in shared learning are sometimes limited to peripheral
concerns, but also that leading-edge practice responds more quickly
and is more advanced in more problematic areas than education
programmes.
The need to develop a core curriculum is, therefore, urgent and it
would appear essential that everyone involved in growth and
development in the field of interprofessional education shares a
common goal to make progress. This raises the crucial question:
what is the meaning of interprofessional education? According to
one definition:

'Interprofessional education is an approach to teaching and

learning that develops professional expertise, encourages colla-
boration between health and social care, integrates opportunities
for shared learning and development opportunities in partnership
with service providers and users and carers of the primary health
care.'
(Horder, 1995, p. 11)

135
Table 6.2 Interprofessional initiatives by geographical distribution and
combination of professions

Geographical by NHS region

Location of activity by NHS region Number of initiatives

Northern 39 ( 6%)
Yorkshire 35 ( 5%)
Trent 46 ( 7%)
East Anglia 19 ( 3%)
North West Thames 59 ( 8%)
North East Thames 43 ( 6%)
South East Thames 37 ( 5%)
South West Thames 21 ( 3%)
Wessex 39 ( 6%)
Oxford 31 ( 5%)
South Western 73 (11 %)
West Midlands 52 ( 8%)
Mersey 28 ( 4%)
North Western 67 (10%)
Wales 59 ( 9%)
Scotland 40 ( 6%)
More than one region 7 ( 1%)

Combination of professions
Combination of professions Percentage of initiatives

DN and HV 20
DN, HVand MW 11
DN, HVand SW 11
HVand SW 8
DN, HVand GP 7
DN, HV, SW and GP 7
DN, HV, MW, SW and GP 6
HVand MW 6

Note: DN = district nurses, GP = general practitioners, HV = health

visitors, MW = community midwives, SW = social workers.
Source: Horder (1995).

CHANGES IN COMMUNITY NURSE EDUCATION

Howkins (1995) states that 'the world of community nursing is one

of constant change and changes that will continue and magnify'.
Inevitably this has shaped the way in which nurses are educated and
has had a major impact on post-registration programmes for the
community.

136
 In the 1990s, community nurse education has necessarily changed
in response to major developments in pre-registration nurse educa-
tion in the form of Project 2000 (UKCC, 1987). Although this new
programme was introduced in 1986, its impact has only just started
to take effect in the community setting, particularly in terms of the
recruitment of staff nurses with diploma level qualifications and a
limited level of community experience. Inevitably this has had
major implications for the future of specialist practitioners such
as health visitors and district nurses who currently undergo profes-
sionally recognised post-registration education to work in the
primary health care setting. The introduction of first level nurses
directly into the community as a result of Project 2000 is having a
profound effect upon skill-mix initiatives in the community, and
undoubtedly calls for role development of specialist practitioners
particularly in relation to leadership qualities, clinical competencies
and managerial skills.
This challenge has been recently addressed to some extent by the
United Kingdom Central Council for Nurses, Midwives and Health
Visitors (UKCC) who recommend major changes in community
nurse education (UKCC, 1994). In other words, the profession
recognises the critical contribution specialist community nurses are
capable of making to the health and well-being of the community in
the 1990s and beyond. There is, however, little doubt that a radical
rethink of skills is necessary to address effectively the changing health
needs of the community in the closing years of the twentieth century
and subsequently lead community nurses into the next millennium
(Trnobranski, 1994; Carey, 1994; Department of Health, 1993).
Education will play a crucial part in these developments, and
appropriate study programmes are imperative to ensure safe and
autonomous nursing practice in the community (Department of
Health, 1995). In recent years, common core initiatives have become
the norm for community nurse education in relation to the nursing
disciplines, but the development of shared learning with other
disciplines in primary health care has been less frequent, particu-
larly in relation to shared learning initiatives with general practi-
tioners undergoing vocational training.
In the United Kingdom, historically, it has been necessary to
create a number of health care professionals to address the health
needs of the community. In turn problems of role overlap, mis-
understanding and stress in the work-place have been created which
above all has resulted in gaps in service. These historical problems
have supported the need to rethink the way in which community

137
nurses are prepared at post-registration level (UKCC, 1994). The
introduction of the new regulations for post-registration education
and training for community specialist practitioners will ensure
further development of common-core programmes for all commu-
nity nurses including school nurses, occupational health nurses,
community psychiatric nurses, community learning disability and
general practice nurses. This is viewed as a positive means of
developing teamwork and understanding of roles in primary health
care in the final years of the decade, and could be a valiant attempt
by the professional body, the UKCC, to address the nursing
requirements of the community into the next millennium. The
current literature, however, appears to be suggesting that 'general-
ism' should go further and incorporate other professional groups to
consider the introduction of a 'generalist' community worker. This
is stimulating great debate (Hugman, 1995).
The future is still uncertain, and many would argue that the way
forward should include the development of the concept of a
generalist community health care professional who is capable of
responding to the initial and immediate health and social care needs
of the community in a more practical and comprehensive way,
taking responsibility for decision-making and referring on to gen-
eral practitioners and colleagues involved in secondary levels of care
where necessary.
What is clear, is that community nurse education must develop
practitioners capable of becoming autonomous professionals,
skilled in high-level decision-making, with the ability to take risks
and take full responsibility for all their work activities (Howkins,
1995).

CHANGES IN SOCIAL WORK AND EDUCATION

The shift from institutional care and the increased emphasis on care
in the community has in some ways meant fewer changes for social
workers. Social services departments have the lead responsibility for
implementing care in the community, and social workers have long
been primarily community-based, with a greater degree of autono-
my and responsibility for decision-making than many of their
colleagues in nursing and other professions supplementary to
medicine.
In other ways, however, the changes are particularly challenging.
They have required social workers to develop closer and more

138
formal working relationships with health professionals. Many social
workers value highly their hard-won independence from the per-
ceived domination of doctors and the medical model. Furthermore,
the ideological shift required by community care legislation, parti-
cularly the requirement on local authorities to purchase a high
proportion of provision from the independent sector, has for many
been great. There is also widespread concern about the diminished
opportunities for a direct therapeutic role under the care manage-
ment system (Payne, 1995).
The changes are taking place in a climate in which government
and the media have long been hostile to social work: in addition to
critical comment, particularly in relation to issues around child
protection and mental illness, there was antagonism towards social
workers in general and their statutory training body, the Council
for Education and Training of Social Workers, in particular. This
antagonism persisted throughout the 1980s over social work's
commitment to challenging policies and structures which were
perceived as oppressive. This has had direct consequences for
social work education and training. In 1989, the government
rejected proposals to increase the length of social work qualifying
training from two to three years, and currently plans to drop
the requirement for probation officers to have a social work
qualification.
These issues have affected both the structure and content of
training. In common with other professions there has been a shift
towards competence-based training and assessment. However, a
number of established features of social work training mean that it
is relatively well placed to respond to the need to produce profes-
sionals with the required diversity of skills. These include:

1. The requirement that training programmes are developed and

managed by a partnership of the educational institution(s) and
employing agencies, both statutory and independent
(CCETSW, 1992a, Paper 30).
2. The development of the range and quality of practice-learning
opportunities. The education-employer partnerships have
played a key role here. Training programmes at post-qualifying
level for practice teachers are well-established and can provide a
model for other professions: in our own university, a joint
programme for training clinical supervisors in five professions
building on the existing programmes for practice teachers has
recently come into operation.

139
3. The creation of an integrated framework of training and
qualifications encompassing pre-qualifying, qualifying and
post-qualifying levels (CCETSW, 1992b, Paper 31).

CHANGES IN THE PLANNING AND COMMISSIONING OF

EDUCATION AND TRAINING IN HEALTH AND SOCIAL
CARE

This discussion would not be complete without specific reference to

the current impact of changes in the way education and training for
health and social care services is purchased. In 1994, the impact of
the publication of the government document Managing the New
NHS: Functions and Responsibilities in the New NHS had a pro-
found effect on educationalists in the higher education sector. This
review of education and training has presented a number of
challenges to those with responsibility for the professional education
of community nursing and social work (NHS Executive, 1995c). For
example, the introduction of local consortia with budget-holding
powers who are charged with the responsibility for robust work-
force planning and cost-effective education and training measures
has challenged educationalists to articulate effectively the rationales
underpinning professional courses in a number of ways.
They will be required to introduce credit accumulation systems
and expand work-based teaching and learning strategies as part of
the norm. In addition, the consortia will seek evidence that the
outcome competencies of programmes will support service delivery
and developments. Furthermore, according to the NHS Executive:

'Consortia will increasingly commission education direct from

education providers. For this purpose they will need to be
operational budgetholders. This will enable them to influence
not only numbers but also quality, admission policies and "fitness
for purpose".'
(NHS Executive, 1995a, para. 9)

The power base of consortia and the implications of education

commissioning on educational developments for primary health
care including interprofessional initiatives must not be underesti-
mated. According to Jarrold, the NHS Executive (l995a) is com-
mitted to an employer-led process to ensure that plans take
sufficient account of the local labour market and secure the best

140
value for money and achieve the best return for investment in
education and training (NHS Executive, 1995c).
The current government strategy however, appears to encourage
positive links between professional, academic and vocational edu-
cation. This is evident by the introduction of the commissioning
process which highlights collaboration and partnerships as a prior-
ity, in their planning guidelines published in August 1995, as a
means of supporting the implementation of education-commission-
ing in non-medical education and training (NHS Executive, 1995c).
Furthermore, these guidelines could offer strong support for
innovative interprofessional projects including primary health care
if full account is taken of priority 5, which is documented as follows:

' ... to influence the development of multidisciplinary education

and training'.

Specific reference is made to the promotion of multidisciplinary

practice, the importance of co-operation and collaboration between
agencies and institutions, and the need to capitalise upon shared
learning opportunities which to some extent have already been
developed in the form of common core developments for commu-
nity nurses in recent years.
It is stressed that this priority does not imply a threat to existing
professional courses or to independent professional self-regulation.
This may be viewed with some scepticism in community profes-
sional areas. Nevertheless, it is proposed that this development will
benefit subsequent professional practice and assist cost-effective
joint education and training which could offer some interesting
opportunities for innovative curricula. This has great potential in
the community setting but raises some crucial issues such as practice
teaching of clinical competence in the community and fragmenta-
tion of programmes.
What is abundantly clear is that educationalists must take up the
challenge presented in the new planning and commissioning guide-
lines laid down by the centre for education and training in health
and social care. Review of the current climate of change sends a
crucial signal to those educationalists preparing programmes for the
next century which have distinct implications for primary health
and community care. It appears essential to support the develop-
ment of a hierarchy of qualifications providing links and ladders of
opportunity leading to a continuum of qualifications designed to
meet the needs of individual localities in the community.

141
THE FUTURE OF PRIMARY HEALTH CARE EDUCATION: A
MODEL FOR CHANGE

The issue of a common core curriculum for community health care

professionals has generated much debate and provided the focus for
innovative developments in higher education. According to Vanclay
(1995), the challenge that remains is how to tackle implementation
difficulties and develop processes, relationships and systems that
will really help to create and sustain increased understanding and
coUaboration between users, practitioners, educators, managers,
purchasers and policy-makers. This debate is now extended to
include the hypotheses of an 'NVQ revolution' and 'occupational
standards movement' in the education commissioning process.
In spite of many uncertainties and challenges, Health Care 2000
(1995) has recently drawn attention to some clearly-identified trends
which are likely to challenge educators over the coming decade. In
particular, the shift towards the community is raising key questions
about the way in which health and social care professionals are
educated to practise in the community setting. The document
identifies key areas which should be given careful consideration
by planners and policy makers in the immediate future. These areas
are as follows:

• Exploring the merits of a common core curriculum, such as

understanding the ethics of health care and quality assurances,
for all health care professions .
• Facilitating greater flexibility between professions in the acquisi-
tion of new skills and performance of tasks (Health Care 2000,
1995).

Skillbeck (1982) argued that:

' ... core learnings are basic and essential, in that they are
intended to provide a foundation or base upon which subsequent
and related learnings may be built and this should provide
learners with conceptual and methodological tools to continue
their own learning.'
(Skillbeck, 1982, cited in Gilling, 1989, p. 82)

Hugman (1995) also recognises the potential of shared learning in

community health care, and notes that it is possible to define the
core of both professions in the field of child protection in similar

142
 terms. Examples include assessment skills, especially in relation to
risk factors, knowledge of child development and family dynamics,
skills in intervention in families, anti-discriminatory values and
legal knowledge.
It would therefore appear from the literature that there is the
potential in the immediate future to introduce innovative and
exciting programmes of study to facilitate the preparation of profes-
sionals fully competent to work in the primary health care setting
and able to cope efficiently with the diversity of community needs
• into the next century (Department of Health, 1993; SNMAC, 1995).
This complexity and diversity presents a major challenge to
educationalists whose key aim is to provide flexible and innovative
study programmes designed to assist practitioners to cope with
change in day-to-day practice (NHS Executive, 1995c).
It is clear that many would argue that the way forward should be
determined through common core approaches to education and
training as a means of capitalising on the perceived advantages of
shared learning. Furthermore, if it is agreed that, as proposed by
Howkins (1995), professional ideology relates to particular sets of
values and moral attitudes which are generally acquired through
training and induction processes, it is essential to progress with
interprofessional education for primary health care. This poses the
question:

• Why is it so difficult to provide interprofessional education?

With two additional questions raised by Horder (1995):

• What is needed to advance interprofessional education?

• What are the factors that should be taken into account to ensure
a curriculum for collaboration?

Experience of joint preparation programmes suggests that consider-

able planning is required from the onset (Bell, 1988). Credence must
be paid to the long-established histories of some aspects of com-
munity education involving strong professional interests. Hyde
(1989) reminded us that a definition of curriculum encompasses
an attempt to communicate essential features of an educational
programme in such a form that it is open to scrutiny and yet is
capable of translation into practice. It involves both content and
method in its widest senses taking account of problems of imple-
mentation in higher education establishments. The corollary of

143
this is that careful planning should be applied to curriculum
development.

• What does this mean for interprofessional education for primary

health care?

INTERPROFESSIONAL EDUCATION FOR COMMUNITY

CARE: THE CONCEPT OF PLANNING

Over the years, many attempts have been made to clarify the
meaning of planning. Lee and Mills (1982), described planning as
the process of deciding how the future should be different from the
present, what changes are necessary and how should they be
implemented. In theory it is a detailed, rational and corporate
attempt to handle broad societal problems (Lee and Mills, 1982).
Furthermore, Hoare et al. (1984) point out that the practice of
planning is a process whereby choices and alternatives are consid-
ered and evaluated according to the likelihood that this will result in
the achievement of the desired objectives. Whilst concurring with
the previous points, it is proposed that the definition fails to take
into account:

• Different actors/participants and interest groups;

• Mechanisms that exist for them to negotiate and thereby identify
objectives and resolve conflict;
• The context in which the planning takes place in terms of political
economic and technical structures;
• Problems of implementing plans;
• The degree to which planning constitutes a separate discipline
from other methods of decision-making and thought processes.

Nevertheless, there are number of planning theories which could

assist curriculum planning involved in community care education.
According to the literature there appear to be two polar extremes:

1. A rational comprehensive model which assumes that the plan-

ner is able to identify objectives and systematically evaluate all
the options.
2. An incrementalist model, the other extreme, emphasising the
practical difficulties of the rational approach and focusing on

144
 marginal or incremental steps, often referred to as 'muddling
through' (Hoare et at., 1984)

However, there is a third approach which could be effectively

applied to curriculum development of interprofessional education
for community health and social care professionals: the process of
'mixed scanning'. This model views the planning process as a
continuum and confines itself to the use of key areas of the
decision-making process. Lee and Mills (1982) quotes Etzioni, who
coined the term 'mixed scanning' indicating that such a strategy
would employ two 'cameras', one wide-angled camera that would
cover all parts of the landscape but not in detail, and a second which
would zoom in on all those areas indicated by the first as worthy of
more detailed examination. In relation to education for community
health care, the first would involve a review of the totality of the
working environment including the diversity of health care profes-
sionals involved in care delivery, with the second zooming in on all
those key areas indicated by the first process which reflect common
factors and which warrant consideration in order to move forward.
Using a 'mixed scanning' approach to review community health
education it is possible to utilise the aims of primary health care
identified by WHO (1978) as a rational framework for curriculum
development. This definition implies that primary health care is
about accessibility, availability, cost-effectiveness and acceptability.
Educationalists in the field of health care delivery should use
these key elements as a focus to develop a framework incorporating
the essential features which must be taken into account when
developing a curriculum to secure interprofessional education and
shared learning for collaborative community health care.
Justification for this proposal is as follows: firstly, change is
essential. Changes are already taking place in education and radical
approaches are required which encourage the sharing of skills
and effective collaboration in health care (Health Care 2000, 1995;
NHS Executive, 1995c). An acceptable framework to encourage
the development of common core programmes which support the
development of a continuum of qualifications appears essential as
we approach the next century.
Secondly, the main objective of education and training is to
promote standards of care and to motivate people to provide
optimum service, while securing maximum cost-effectiveness in
times of financial constraints (Talbot, 1995; Mackay and Webb,
1995; NHS Executive, 1995c).

145
 This rests heavily on producing education and trammg that
reflects the service environment and takes full account of work-
force planning projections. In this context both community nurses
and social workers are subject to many influences in common and
therefore the aims of primary health care as defined by the World
Health Organisation (1978) are relevant to both. Using the key
elements of the definition of primary health care, it is possible to
categorise crucial issues which must be taken into account when
attempting to develop appropriate interprofessional education for
primary health and community care' workers. This will ensure that
planners reflect upon pertinent issues which reflect the overall aims
of primary health care. Essentially, this should also encourage all
participants in primary health care to generate care delivery based
upon globally-accepted aims in accordance with policy-makers'
directives.
We propose that planning offers a simple yet effective approach
to curriculum development and design in support of interprofes-
sional education for primary health and community care. It recog-
nises that interprofessional education offers a means of 'bridging
the gap' between services and promoting collaboration, but also
that it is essential to make programmes contextually meaningful to
encourage true understanding and collaborative growth (Nocan,
1994). Moreover, this proposal acknowledges the importance of
educationalists endeavouring to assist organisations to analyse
locality needs and to identify gaps in learning-needs of a range of
health care professionals (NHS Executive, 1995c).
In addition, we recommend that curriculum planners should base
their curriculum design around a model reflecting the crucial
elements of primary health care as illustrated in the universally
accepted definition of primary health care which is promoted by the
World Health Organisation. It is argued that this model will give an
easily-recognised sense of direction to interprofessional educational
strategies for this important working environment, and offer a
framework by which to measure the effectiveness of programmes
of study and indeed interprofessional education per se .

• What will this mean in terms of practical developments in

interprofessional education?

The main purpose of this approach is to ensure a sound and

relevant 'bedrock' for interprofessional education which maximises

146
the potential for shared learning and takes on board the importance
of robust work-force-planning in the health and social care sectors
(NHS Executive, 1995c). According to Funnell (1995), shared
learning is more likely to generate value when all participants are
united by a common and commonly-perceived task with clear end
products. The fulfilment of the WHO aims appears to be mean-
ingful to groups from diverse professional backgrounds. It is
suggested that use of this model by curriculum planners will
produce a contextual environment and encourage modes oflearning
that are perceived as relevant. The recent CAIPE project (Vanclay,
1995) proposed the following reasons for shared learning which give
an insight into the benefits of developments in this field:

• The desire to increase trust and communication;

• Economy of scale;
• Responding to education changes;
• Updating knowledge together;
• Breaking down the professional boundaries (Vanclay, 1995).

Building upon the 'mixed scanning' approach to curriculum

development, and scanning the broad arena of primary health care
and current education, suggests that, in reality, primary health care
is about a cluster of activities which can be viewed as a taxonomy of
primary health care, as shown in Figure 6.1. These clusters of
activities centre around accessibility, availability, cost-effectiveness
and acceptability. Each cluster could be used to identify many
complex aspects and factors inherent in, and relevant to, planning
of interprofessional education for primary health care. The compo-
nents of the taxonomy can act as catalysts for curriculum develop-
ment and encourage the development of interprofessional education
which is meaningful and relevant to the range of health care
professionals engaged in the delivery of care.
The following text gives examples of, and insight into, the
application of the taxonomy and is presented as a model for debate.
It is intended to simply reflect the breadth and complexity of the
issues which face those involved in primary health and community
education in today's climate, and gives a flavour to the kinds of
issues which require consideration. It should be noted that this
framework is not exhaustive but should be viewed as a starting
point for collaborative ventures in this field.

147
Accessibility

Curriculum planners must pay strict attention to the complexity of

accessibility issues and recognise that education must be practice or
service-based where possible (Horder, 1995). In addition, this model
addresses the necessity to provide 'ladders of opportunity' across the
continuum of qualifications at all levels (NHS Executive, 1995b).
In relation to curriculum planning, this will involve taking full
account of preferences in relation to, for example, modes of
delivery: recognising that the range of alternatives is wide, including
full-time/part-time/modular programmes; accredited workshops
and distance/work-based learning; entry profiles and selection
criteria; equal opportunities issues; information technology ad-
vances and Internet systems; learning packages and interactive
teaching methods; timing of programmes and units of learning;
institutional policies and regulations.
See for example Barr (1995), Horder (1995), Funnell (1995),
CETSW Paper 31 (1992), NHS Executive (1995c).

Figure 6.1 Taxonomy of primary health care: a framework for

interprofessional education

VE W
R ATI O RKI
LL ABO NG
CO
AIMS OF
_~lMS OF
y

co
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ef

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iv
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av

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ai

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RE

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PA Y HEALTH
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148
Availability

According to the literature, evaluation of interprofessional educa-

tion in the UK indicates that shared learning can improve attitudes
and perceptions between professionals (Barr and Shaw, 1995) in a
way which rests heavily upon the appropriateness of the curricu-
lum. Focusing on the issue of availability would provide the
opportunity to examine the central concept of competency as
perceived by all groups in greater detail, thus ensuring levels of
dialogue that complement the complexity of the debate (Hyland,
1994).
This component of the taxonomy could facilitate review of the
curriculum and the professional requirements of the different
professional groups in order to devise a relevant programme of
study. This could include:

• Models of care and professional competencies;

• Generic and core skills;
• Reflective practice and quality assurance;
• User-centred philosophies;
• Academic studies to encourage understanding of communication
and management skills, as well as socio-economic and political
aspects of care delivery, for example child protection;
• Epidemiology, health needs analysis and collaborative inquiry;
• Multidisciplinary outcomes;
• Professional requirements and regulatory mechanisms;
• Legal aspects of primary health and social care;
• Health economics;
• Health ethics and values;
• Profession-specific studies.

See for example Barr (1995), Howkins (1995), Cain et al. (1995),
SNMAC (1995), Department of Health (1994), Hyland (1994),
Thornton (1995), Home Office, Department of Health, Department
of Education and Science and Welsh Office (1991), NHS Executive
(1994).

Cost-effectiveness

According to Soothill, Mackay and Webb (1995) exploring the

reality of current professional working is complex for there are

149
many sites and situations where one could focus on the effectiveness
or otherwise of interprofessional relationships. However, it is clear
that in all professions cost-effectiveness is high on the agenda, both
in terms of actual and 'hidden' costs of service delivery. It is
abundantly clear that, in the future, education-commissioning will
focus upon cost-effectiveness as a crucial consideration (NHS
Executive, 1995b).
This component of the taxonomy will provide the opportunity for
curriculum planners to address crucial issues which influence the
current patterns of education provision for primary health care.
These issues should involve:

• Value for money;

• Work-force planning and human resource strategies,;
• Labour replacement costs;
• Rationalisation issues;
• Credit accumulation and transfer systems;
• Skill-mix bundles and professional development;
• Purchaser consortia.

See for example NHS Executive (1995d), UKCC (1992), Soothill et

af. (1995), Hugman (1995), NHS Executive (l995e), NHS Executive
(1995f).

Acceptability

The National Consumer Council in 1995 reminded us that we must

listen to the views of the users, and yet it could be argued that lay
representation on professional committees is token. It is essential
that education for primary health and community care involves the
community it serves; therefore, opportunities must be made avail-
able for users to influence educational developments. This element
of the model should ensure that the user's voice is given a high
priority in the planning process.
According to Elliott (1995), separate education of different
professionals and their distinctive philosophies makes for difficul-
ties in working relationships which can present serious difficulties
when planning interprofessional education. This requires careful
handling from the outset and it is proposed that this final compo-
nent of the taxonomy will provide a forum to discuss contentious
issues surrounding profession ideologies, not least to encourage the

150
use of a common language to support the understanding of roles
and responsibilities (NHS Executive, 1995c). This aspect of the
model should also encourage consideration of flexibility and the
redefining of roles, if appropriate drawing attention to professional
monitoring mechanisms already in place. Ultimately, this element
recognises quite clearly, that it is possible to develop strategies for
primary health care which are available, accessible and cost-effec-
tive, but are totally unacceptable to the professionals and service-
providers involved. Consideration of this final component of the
taxonomy will ensure that in-depth consideration is given to
'acceptability' issues including:

• Quality assurance and standards;

• Competencies and professional guidelines;
• The constitution of planning teams;
• The concept of patients/clients as partners;
• The status of user/service involvement;
• Professional representation;
• Continuing education and professional development agendas;
• Profiles of teachers;
• Research questions and opportunities.

See for example DoH (1991), Hennessy (1994), Hyland (1994),

Bloomfield (1996), Berlin (1995).

CONCLUSIONS: CHALLENGES AND PRIORITIES

Firstly, the notion of an impending health crisis must be used

positively in that there is an increased willingness to work together
to promote health in the primary health and community setting
(Vanc1ay, 1995). Interprofessional education rests heavily upon the
willingness of all involved, so present trends (Hennessy and Tom-
linson, 1994) indicate that the current environment should prove
extremely supportive in developing 'education for collaboration.
This must be capitalised upon!
In addition everyone will need to work together in a spirit of
goodwill so that service users and carers can gain access to the ideal
of 'seamless packages' of community care, which are designed to
ensure that each individual receives sensible, caring treatment
regardless of the status of the provider (Spurgeon, 1991).

151
 Finally, the challenges facing professionals must be recognised
and responded to:

'Change may be slow but professions must adapt to changing

trends and needs ... the distinctions in status will have to be less
and more varied bundles of skills accommodated.'
(Normand, 1993, p. 244)

The proposed taxonomy of Primary Health Care as a curriculum

framework for interprofessional education is flexible and will take
account of the diversity of professional interests in primary health
and community care and encourage security and commitment to the
development of broad-based primary health care. It acknowledges
that learning takes place in a range of settings and recognises the
importance of competence-based professional development for all
members of the primary health care team. According to Berlin
(1995), competence is common educational currency in all disci-
plines, particularly health, and must feature highly in all interpro-
fessional developments. Interprofessional education must be
practice or service-based focusing on the real tasks of service
delivery for improved patient/client care (Horder, 1995).
In addition, this model will prove a useful tool with which to
measure the outcomes of interprofessional programmes, and eva-
luation skills will play an essential part in moving forward in this
crucial field.
According to Darvill (1995), perhaps the greatest challenge of all
now is to involve users and carers as co-learners in order to achieve
'real feedback'. This is essential if education is to develop quality
service delivery.
In addition, evaluation of interprofessional learning is crucial ~
the proposed taxonomy does not preclude the importance of
evaluation of interprofessional initiatives in education ~ it is im-
perative that we gain more evidence about the value of interprofes-
sional education as a way of improving collaboration. Horder
(1995) reminds us that further studies are needed to demonstrate
what shared learning can and cannot achieve. We need more
evidence to prove its capacity to change behaviour as well as
attitudes. In addition, the introduction of NVQs and occupational
standards has heightened the competency debate. This is of crucial
importance particularly in the field of primary health and commu-
nity care if we are to take seriously the concept of quality service
delivery.

152
 This poses the questions:

• What do people need to learn about?

• Do they need to learn together?
fD Is it possible to provide the level of flexibility demanded in the

current market-place as well as safeguarding the interests of those

entrusted to our care?

The challenges are great - primary health and community care,

traditionally the Cinderella area of services, is at the start of a phase
of great development in which interprofessional education and
training will playa major part (Burton, 1995).

EDUCATIONALISTS MUST GRASP THE NETTLE NOW!

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158
=============CHAPTERSEVEN=============

Clinical Effectiveness: The Challenge for

Community Nursing

Kieran Walshe

If this chapter were solely to report, concisely but fairly, the

available evidence for the clinical effectiveness of community nur-
sing services, it might be very short indeed. It is often said that there
is little or no scientific evidence to support many health care
interventions, but this evidentiary vacuum is more marked in some
professions and care settings than in others. It seems to an outside
observer that those working in community nursing services, such as
district nursing, health visiting, practice nursing and school nursing,
have remarkably little formal evidence with which to justify their
patterns of clinical practice, or even in some cases their continued
employment. There is a growing pressure on health care profes-
sionals in all disciplines and specialties, not just in the UK but
internationally, to demonstrate the value of the services they pro-
vide. For community nurses in the NHS this challenge is particularly
serious, because many of the services they deliver are already
threatened by continuing changes resulting from the NHS reforms
of 1989. In the 1990s, health care professions and organisations will
increasingly have to demonstrate not only that they provide good
quality care, at a low cost, but that their care is clinically and cost
effective. Those who cannot or do not prove the effectiveness of
what they do may not be doing it for much longer.
This chapter is structured into four main parts. It begins by
examining the growing importance of clinical and cost-effectiveness
in health care, and the development of what is becoming called
the evidence-based health care movement. It then sets out some of
the limited available evidence on the effectiveness of community

159
nursing, and argues that the need for a more evidence-based
community nursing service is almost self-evident. With that aim in
mind, it then explores the quality and usefulness of research into
community nursing, the arrangements for disseminating and com-
municating the findings of that research, and the challenges of
changing clinical practice. Finally, some conclusions are presented
on the implications of clinical effectiveness and evidence-based
health care for community nurses.

THE DEVELOPMENT OF EVIDENCE-BASED HEALTH

CARE

It is a truism that more or less all health care professionals would

wish to provide the most effective care they can to the patients
they serve. But what does 'effective' really mean in this context?
Cochrane, an epidemiologist who was one of the founders of the
science of evaluating health care interventions, suggested that
effectiveness should be measured in terms of 'the benefit and the
cost to the population of a particular type of activity' (Cochrane,
1972). Put another way, a health care intervention might be said to
be effective if it can be demonstrated that it produces benefits (such
as improved health status, reduced morbidity and mortality, or
greater life satisfaction) for patients which justify its costs. It seems
eminently reasonable that we should expect there to be evidence of
the effectiveness of all health care interventions in regular use, but
there is not. In practice, we seem a long way away from having a
health care system which is 'evidence-based'.
Evidence-based health care is a relatively new term - at least in
regular use - and there is no single and agreed definition of what it
means. One of the leading advocates of the evidence-based health
care movement, Canadian general physician David Sackett, argues
that the term is shorthand for five linked ideas (Sackett, 1995).
Firstly, clinical decision-making should be based on the best avail-
able information about effectiveness, from individual patients and
from epidemiological, research and laboratory sources. Secondly,
the clinical situation facing the professional should determine the
nature and source of evidence used to make decisions, rather than
habits, precedent or tradition. Thirdly, clinicians should be more
willing to use epidemiological and statistical ways of thinking, and
more able to integrate such evidence with their own personal
experience. Fourthly, the evidence must be translated into actions

160
which improve the effectiveness and quality of care for patients.
Fifthly, clinicians should continually evaluate their own perfor-
mance against these ideas. Sackett argues that practising evidence-
based health care requires clinicians both to learn to find and use
evidence of clinical effectiveness for themselves, and to make use of
tools like guide-lines and protocols which others have produced and
based on the best available information on the effectiveness of
interventions.
Appleby, Walshe and Ham (1995) offer a simpler and more direct
definition of evidence-based health care - that it involves research-
ing the clinical and cost-effectiveness of health care interventions
rigorously; disseminating the findings of that research proactively
to clinicians and others with an interest in them; and applying those
findings to change the patterns of clinical practice. These three
stages are illustrated in Figure 7.1. Of course, the process is not as
simple nor as linear as this diagram suggests, but it provides a useful
model. Appleby et al. (1995) argue that traditionally, the NHS has
been poor at each of these three stages. They suggest that research,
not just in nursing but in all clinical disciplines, has been badly
planned and inadequately resourced, and has failed to target the key
research questions of importance to the health service. They assert
that the dissemination of research findings has relied largely on
publication in academic journals, despite plentiful evidence that
such publications are a very poor way of getting information to
clinicians who lack the time, skills or inclination to read them.
Finally, they argue that the application of research findings to
clinical practice has been almost wholly left up to the individual
clinician, with the result that some have adopted new practices and
kept up to date while many others have not.
The assertion at the start of this chapter, that there is little or
no scientific evidence to support many common health care

Figure 7.1 Definition of evidence-based health care

Primary research
Review, Application of
into clinical and
management and research findings
cost effectiveness
dissemination of to change clinical
of healthcare
research findings practice
interventions

161
interventions, is rarely challenged but it deserves to be. Leaving
aside for the moment the question of what constitutes evidence
(which is discussed later on), the US Office of Technology Assess-
ment (1983) estimated that only about 10-20 per cent of medical
practice was supported by experimental evidence from randomised
controlled trials. In another study, Williamson, Goldschmidt and
Jullson (1979) suggested that fewer than 10 per cent of common
medical procedures were based on such research, while Dubinsky
and Ferguson (1990) reported that only 21 per cent of a sample of
126 therapeutic and diagnostic technologies were firmly based on
research evidence. All these available estimates relate to acute
medical care, but it seems likely that, if anything, the figures for
nursing, physiotherapy and community-based services would be
lower still. Ellis and colleagues (1995) demonstrated that it does not
have to be thus. They found that in a general medical team which
was making strenuous efforts to practice evidence-based medicine,
82 per cent of treatments used had strong research evidence to
support them. In other words, where the will to seek out and use
evidence exists, the balance between interventions with research
evidence to support them and those without can be dramatically
reversed.
If the absence of research evidence to support many health care
interventions does not convince health care professionals of the
need for more evidence-based practice, then some examples of
ineffective care which at best waste resources and at worst result
in avoidable death and injury to patients should be considered.
Such instances can generally be divided into three types. Firstly,
there are health care interventions which are known to be effective,
but which are not being used sufficiently or appropriately. It has
been known for many years now that thrombolytic therapy given as
soon as possible to people who have a myocardial infarction
reduces the likelihood of further infarcts, and saves lives. However,
there is plenty of evidence that some patients never get the throm-
bolytic drugs they need, and a proportion suffer and die as a result
(Ketley and Woods, 1993). Another example is the use of steroids
for women in pre-term labour. Giving steroids helps to prevent
respiratory distress in the neonate, but although the research
evidence is clear, many women do not get this therapy and the
inevitable result is that some babies suffer avoidable morbidity or
even mortality (Donaldson, 1992).
Secondly, there are health care interventions which are known to
be ineffective, but which nevertheless continue to be used inappro-

162
priately. There is now good research evidence to suggest that
dilatation and curettage is of no diagnostic or therapeutic benefit
to women under 40 (Lewis, 1993), yet it continues to be the fourth
commonest operation performed in the NHS (Yates, 1995). The
insertion of grommets to treat glue ear in children, one of the
commonest operations that ENT surgeons perform, has been much
criticised as providing only temporary and limited improvements in
hearing for many children, in whom the condition often sponta-
neously resolves anyway (Lancet, 1992). Surgical intervention to
treat benign prostatic hyperplasia (BPH) is increasingly recognised
as being inappropriate in men with mild or moderate symptoms
because the procedure often does not improve things and can have
serious adverse effects, yet many men in this category are still being
advised to have a transurethral resection of prostate (TURP)
(Donovan et at., 1994).
Thirdly, there are many health care interventions of unknown or
doubtful effectiveness, whose usage varies so much, from area to
area or practitioner to practitioner, that they must be being used
inappropriately in many cases. There is relatively little evidence for
the effectiveness of different forms of stroke care and rehabilitation
services, and tremendous variation around the UK in the propor-
tion of patients with strokes who are admitted to hospital, the
investigations used to confirm the diagnosis (such as CT scans,
lumbar punctures and angiography), the treatments used to avoid
further strokes (oral aspirin, oral anticoagulation, and carotid
endarterectomy), and the treatments used in rehabilitation (such
as speech therapy and physiotherapy) (Wade, 1994).
Of course there is some overlap between these categories, espe-
cially between the third category and the first or second. Even when
the evidence seems relatively clear-cut, it is still possible for health
care professionals to interpret it quite differently, which tends to
move interventions from the first and second categories into the
third.

THE EFFECTIVENESS OF COMMUNITY NURSING

Of course, many interventions by community nurses are effective,

and there is research to demonstrate their effectiveness (Deal, 1994),
but many others are of doubtful or unproven value. While the
examples of ineffective clinical practice cited above are largely
medical, similar instances can be sought and found in most

163
disciplines, including community nursing. For example, compres-
sion bandaging for venous leg ulceration is an effective health care
intervention which is still grossly under-used by district nurses
(Moffat and O'Hare, 1995). Patients whose leg ulcers are being
subjected to a wide range of other therapies are being denied the
benefit of effective therapy, and their continuing treatment repre-
sents an avoidable and wasteful deployment of nursing resources.
There are also some ineffective health care interventions, which
should probably be used less often than they are at present. Some
nurses persist in undertaking frequent bladder washouts on patients
with indwelling catheters with the intention of preventing blockages
and infections, despite evidence that the untargetted use of this
procedure is probably unnecessary and ineffective, and might even
be harmful (Pomfret, 1995). Health visitors continue to make eight-
month hearing checks on all babies, despite evidence that this is an
ineffective way to identify children with significant hearing loss
(Mott and Emond, 1994).
In community nursing it is the unexplained and unexplainable
variations in practice in areas where there is little or no evidence
that are most striking. Nurses working from the same office, let
alone those from different parts of the country, often have quite
difference approaches to dealing with similar referrals, and will
devote very different numbers of visits to patients with the same
condition. For example, Harley (1995) reported that the average
episode of care by district nurses (from referral to eventual dis-
charge) varied from four visits in one health authority to 63 visits in
another, a massive difference which cannot be explained by differ-
ences in case-mix. The first-contact rate for patients over the age of
75 ranged from under 100 to over 800 contacts per thousand
population per annum, and there was no relationship with measures
of deprivation or need. In the face of this evidence, one has to
conclude that some community nurses must be providing ineffective
and inappropriate care.
Patients might be understandably confused and concerned if they
realised how much of what health care professionals do is not based
on strong scientific evidence. They would certainly be alarmed by
the examples of demonstrably ineffective practices cited above. And
they would probably find it difficult to reconcile such apparent
negligence with their personal experience of their nurses as dedi-
cated, hard-working and concerned professionals. Of course, no
clinician sets out to deliver ineffective care, so there must be reasons
for the persistence of ineffective patterns of practice which relate to

164
the system of care itself - the way in which we organise, fund and
manage health care. The problems seem partly to relate to the
quality of research itself, partly to the way in which research
findings are disseminated and brought to the attention of clinicians,
and partly to the mechanisms for securing change in clinical practice
where a change is indicated.

THE QUALITY AND USEFULNESS OF RESEARCH

The first, and most fundamental reason why non-research based

practices persist is the poor quality, quantity and utility of the
research on which community nurses and other health care profes-
sions are expected to base their clinical practice. Nursing research is
a relatively young discipline, with a history of not much more than
30 years in the UK. It still struggles to compete with other health
care disciplines, particularly medicine, for status and research
funding. In a review of nursing research in 1992, Smith (1994)
reported that nursing departments in UK universities had the
dubious distinction of an average rating for the quality of their
research that was lower than any other subject area. She also
highlighted the shortage of clinical research, the predominance of
theoretical papers and research into nurses themselves (rather than
their patients), and the obsessive methodological debate about the
relative merits of qualitative and quantitative research methods. In
passing, she noted the scarcity of community research, and she
concluded that there was a need to make nursing research more
clinically relevant and useful.
Hopps (1994), reviewing the development of nursing research in
the UK, pointed to a number of developments which bode well for
the future of research in nursing such as recent changes to nurse
education and the organisation of academic nursing departments,
and argued that nursing was starting to build the effective reposi-
tory of research-based knowledge it needed. But she too highlighted
the problems of available research not being taken up and used by
practising nurses. In a wider-ranging review of the literature on the
effectiveness of nursing interventions, Thomas and Bond (1995)
found that while there were a variety of studies reported in the
literature, they were frequently methodologically flawed, based on
inadequate sample sizes, and unable to support wider generalisation
of their results. They argued for greater attention to methodological
rigour, more experimental studies because they provide the best

165
evidence of effectiveness, greater attention to theory development,
concerted action to build up a coherent body of research knowledge
in any particular topic, and more clinically focused research.
Nursing is not alone in being unhappy with the quality of its
research base. Other clinical professions, such as physiotherapy and
speech therapy, have similar problems. And although the volume of
research into medical care is much greater, and there is a much
longer history of such work taking place, the quality of much of
that research and its usefulness to clinicians is just as questionable.
The weaknesses which have been described above are found in all
areas of health care research and development, and they led the
House of Lords Select Committee on Science and Technology to
observe in 1988 that there were serious problems which needed to be
addressed by the NHS as a whole, concerning the quality, relevance
and utility of research in health care (Coulter, 1995). It particularly
highlighted the absence of any mechanism by which the NHS could
articulate its own research needs, fund and organise research
programmes to meet those needs, or ensure that the findings from
such research were disseminated and acted on.
As a result, in 1991 the first ever Director of Research and
Development for the NHS was appointed, with the remit to create
a research and development strategy for the NHS which was
relevant to NHS needs, was multidisciplinary, and which particu-
larly addressed the evaluation of the effectiveness of clinical inter-
ventions and approaches to service-delivery and organisation. In
the last five years that ambitious strategy has done much to trans-
form the place of research in the NHS, through a number of large
new programmes of commissioned research. The funding of re-
search in the NHS is changing, with a target that 1.5 per cent of
NHS revenue should be dedicated to research and development,
and a new national strategy for research in nursing, midwifery and
health visiting has been developed which places the issues of
evidence-based health care at the top of the research agenda, stating
that 'the fundamental task is to evaluate the effectiveness of clinical
procedures, practices and interventions' (Department of Health,
1993a).
Researching the effectiveness of community nursing, though it
may deservedly receive more attention in the future, will remain an
enterprise fraught with methodological and practical challenges
(Barriball and Mackenzie, 1993). Nursing interventions are hard
to define in terms which support the quantitative measurement of
their impact on patients. Indeed, their impact can also be difficult to

166
measure, and there is sometimes a risk that poor research designs
will make them appear to have limited quantifiable benefits to
patients. Also, the community is not an easy environment in which
to research, because of the multi-disciplinary, fragmented service
environment and the difficulties of controlling research conditions.
These pressures make it difficult to carry out good, high-quality
research of any kind, but particularly hard to design and execute
quantitative, experimental studies such as randomised controlled
trials.
The debate about what constitutes good research evidence and
what appropriate qualitative and quantitative methods should be
used to obtain it is likely to continue. In other professions, notably
medicine, quantitative methods including experimental designs are
used much more widely than they are in nursing, where they
sometimes inspire opposition because they are argued to be incap-
able of dealing with the ineffable nature of nursing practice
(MacLeod, 1994). It is sensible to acknowledge that different
research questions and contexts require different approaches or
research designs, that complex and varied interactions may be less-
suited to experimental methods, and that there are strengths in
combining experimental and non-experimental methods within a
study (Wilson-Barnett, 1991).
The aversion to experimental methods so evident in nursing
research has left the profession without many researchers skilled
in their use. Evaluating the effectiveness of nursing interventions is
sure to make more use of such quantitative, experimental methods
than other forms of nursing research, and so the need for nurse
researchers with these skills is likely to grow.

HOW RESEARCH FINDINGS ARE DISSEMINATED

Even after all the caveats about the quality and nature of nursing
research discussed above, there is still an enormous volume of
existing research which nurses, including community nurses, can
and should be using to inform their clinical practice. The main
mechanism for disseminating research findings continues to be
publication in an academic, refereed journal. The Cumulative Index
to the Nursing and Allied Health Literature (CINAHL), the
primary computerised index of nursing and allied health literature,
indexed 27898 papers published during 1994, approaching three-
times the number indexed in 1982 as Figure 7.2 shows. But the act

167
 Figure 7.2 Publications indexed on CINAHL by year of publication

30

25
Publications (thousands)

20

15

10

0
82 83 84 85 86 87 88 89 90 91 92 93 94
Year

of publication, seen as the end-point by many academics, is far from

effective in disseminating the results of research. A small survey of
94 nurses showed that while popular nursing journals like Nursing
Times and Professional Nurse were read regularly by about half the
nurses surveyed, only a very small minority regularly read academic
journals like the Journal of Advanced Nursing or the International
Journal of Nursing Studies (Webb and MacKenzie, 1993).
There are three related sets of problems which act to constrain
and prevent nurses accessing the results of research more readily.
Firstly, and perhaps most importantly, there are attitudinal barriers
to overcome, as Webb and Mackenzie's survey (1993) also demon-
strated. Some nurses see research as irrelevant, over-academic, long-
winded and foreign to their own ways of working. In part this
reflects the fact that attempts to shift towards being a research-
based profession are relatively recent in nursing. It may also
demonstrate an understandable, common-sense reaction to some
of the introspective, theorising research into nurses rather than
nursing that was mentioned above. Either way, nurses who see little
benefit in research are unlikely to make any effort to obtain
research findings, let alone incorporate them into practice.

168
 Secondly, many nurses lack the skills they need to find relevant
research, to appraise its quality and relevance to their clinical
situation, and to comprehend its implications for their clinical
practice (Avis, 1994a, 1994b). Literature searching, the critical
appraisal of research studies and the distillation of conclusions
and recommendations for clinical practice are not skills which are
taught extensively or practised widely (Pearcey, 1995). It does not
help that, as Figure 7.2 shows, the volume of material which needs
to be searched is growing steadily. Moreover, the language in which
many research articles are written could almost be designed to deter
clinicians and to hinder comprehension. The dense, long sentences,
obfuscating terminology and over-referencing beloved of some
academic journals mean that even once nurses have found reports
of the research they need, they may find understanding and inter-
preting them difficult.
Thirdly, nurses face a host of practical and logistical problems in
accessing research findings. Many nurses have poor or non-existent
library facilities in their place of work. Community nurses, in
particular, are likely to have to travel some distance to access books
and journals, especially since changes in nurse education have
meant that there are now fewer schools of nursing and so fewer
libraries. Hospital and community trust libraries are often oriented
towards the needs of medical staff, with limited resources and
sometimes limited access for nurses. Even if access is possible, the
pressures of work make it difficult to make time to use these
facilities during the working day.
The inadequacies of journals as a mechanism for disseminating
research findings have been recognised, and a number of alternative
approaches are increasingly being used. Firstly, the review article,
which provides a systematic and objective synthesis of the research
evidence on a given topic, has become more common and more
important. Of course review articles themselves are open to bias,
and there is some evidence that different expert reviewers can reach
quite different conclusions in review articles which draw on the
same primary research. For these reasons, considerable effort and
resources are being invested in undertaking systematic reviews,
which follow a rigorous methodology focused largely on combining
the quantitative evidence from multiple randomised controlled
trials (Chalmers and Altman, 1995).
Secondly, the republishing of summaries of research articles in
more digestible and structured forms is becoming common. In
medicine, the value of carefully selected reports of research,

169
quality-assured for their sound design and methods, is now the
basis of two dedicated journals (Sackett and Haynes, 1995). In
addition, the NHS research and development programme has
invested heavily in producing and disseminating systematic reviews
through a series of Effective Health Care bulletins (listed in Table
7.1) and through the creation of a Centre for Reviews and
Dissemination based at the University of York.
Perhaps, however, the most exciting and potentially significant
development of the last two years has been the development of the
Cochrane Collaboration, an international partnership aimed at
developing and maintaining systematic reviews of the literature on
the effectiveness of health care interventions in a wide range of
disciplines. Named after the epidemiologist who did so much to
found the science of evaluating health care interventions (Cochrane,
1972), the Cochrane Collaboration consists of a number of coordi-
nating centres in the UK, North America, Europe and Australia,
which host a growing number of interest groups of clinicians and
researchers. Each group takes responsibility for searching for and
identifying all the available experimental evidence on a given topic
or issue, producing a systematic review of that literature in a
standardised format, and keeping it up to date by adding new
evidence as it becomes available.
The Cochrane Collaboration has been founded on the work
undertaken by Chalmers and others over the last two decades to
develop and maintain Effective Care in Pregnancy and Childbirth, a
comprehensive and structured collection of systematic review of the

Table 7.1 Effective Health Care bulletins

Screening for osteoporosis to prevent fractures

Stroke rehabilitation
The management of subfertility
The treatment of persistent glue ear
The treatment of depression in primary care
Cholesterol screening and treatment
Brief interventions and alcohol use
Implementing clinical practice guide-lines
Menorrhagia
Benign prostatic hypertrophy
Pressure sores
Cataracts
Hip replacement

170
literature on caring for women during pregnancy and childbirth
(Chalmers, Enkin and Keirse, 1993). The work involved is time-
consuming and laborious, and participants are not financially
remunerated for their efforts. The output from the Cochrane
Collaboration is published on CD-ROM as the Cochrane Database
of Systematic Reviews, which is now widely available in the UK and
elsewhere. The main criticism of the Cochrane Collaboration's
work is that it focuses solely on randomised controlled trials, and
takes little or no account of other quantitative and qualitative forms
of evidence.

IMPLEMENTING CHANGE

Even when the research evidence is clear, and the information is

made freely and easily available to clinicians, changes in clinical
practice can be frustratingly slow to result. For example, the
Effective Health Care bulletin on Selective Serotonin Reuptake
Inhibitors or SSRIs (a new form of antidepressant drug) said that
they should not be prescribed as they cost much more than
traditional antidepressants and were not significantly more effective
(Freemantle, 1994). The rate of SSRI prescribing, however, has
since risen dramatically, driven by strong marketing by the phar-
maceutical companies concerned, and apparently unaffected by the
evidence presented in the Effective Health Care bulletin. More
proactive and powerful mechanisms for ensuring that information
on effectiveness is understood, accepted and adopted by clinicians
are needed.
Although the process of changing practice is not well-understood,
and may be the most complex and challenging stage in the evidence-
based health care model set out in Figure 7.1, it has been the subject
of relatively little attention from researchers. One model, which
serves to highlight the complexity of the task of changing practice,
suggests that there are four dimensions or attributes of any change
which need to be considered (Department of Health, 1995). Firstly,
there is the nature of the change itself - what is entailed in bringing
it about, what benefits it will offer and for whom, how easy it is to
implement and monitor, and so on. Secondly, there are the players
or participants in the change process - those with an interest or
involvement in the area of practice being changed. This may include
clinicians, managers, purchasers, patients, researchers and policy-
makers, and any strategy for bringing about change has to take

171
account of their respective roles. Thirdly, there are the many
different interventions which can be used to cause change. There
is a huge variety of techniques or methods which can be used, and
they can be difficult to categorise, but a selection of common
approaches is listed in Table 7.2. Finally, there are the levers and
barriers which are likely to promote or hinder change. These are the
factors such as funding arrangements, financial incentives, organi-
sational structures and other characteristics of the environment in
which the change is to take place.
In researching the way in which clinicians change their practice in
response to research findings, Oxman (1994) concluded that there
were 'no magic bullets'. In other words, no simple approaches
existed which could be used singly, applied widely and easily, and
which would be effective in changing practice. Rather, the research
suggests that approaches to changing practice are highly context-
dependent, and it is difficult to generalise about their effectiveness.
Approaches seem to be more successful when they are fitted to the
organisational and social context in which they are to be used, and
take account of the people and organisations they are trying to
change. It also seems that multiple approaches, which are comple-
mentary or even overlapping, are more successful than single
techniques used alone.
One development, however, which has taken place over the last
five years may hold the key to the complex and challenging business
of implementing change in the NHS and promoting the develop-
ment of evidence-based health care. Since the introduction of
clinical audit as part of the NHS reforms in 1989, about £220
million of special funding has been invested in creating an infra-
structure for auditing the quality of clinical care in every health care

Table 7.2 Interventions to promote change

Academic detailing, or educational outreach visits

Audit and feedback of results
Attendance at conferences
The development and distribution of educational materials
The use of guide-lines and protocols
Marketing
The use of opinion leaders to influence others
Patient-mediated interventions
Reminder systems
Decision support systems

172
provider in England (Department of Health, 1993b). Every trust
now has some form of clinical audit department, staffed with
personnel whose primary remit is to help clinicians to examine the
quality of care they deliver and to identify opportunities to make
improvements. All trusts have some form of clinical audit commit-
tee, usually responsible to the trust board for clinical quality issues.
These committees bring together senior clinicians from across the
provider organisation to talk about the quality problems they face,
often for the first time. Studies have shown that more clinical
professionals than ever before in every discipline are now taking
part in some form of regular clinical audit activities, with 95 per
cent of departments holding some form of regular audit meetings
(Buttery, Walshe, Coles et al., 1994).
Of course, the content and effectiveness of these clinical audit
activities varies tremendously. Current clinical audit activities in
health care providers have many flaws, among them poor strategic
direction, limited links to wider corporate goals and processes,
inadequate planning and project management, little investment in
training for audit staff and clinicians, few incentives or sanctions to
promote participation, and an unhealthy medical dominance of the
audit process. There are certainly many opportunities to improve
the effectiveness of audit itself, and a growing body of research
exists to inform the development of the clinical audit foundation
(Walshe, 1995a,b). But the achievements of the last five years
should not be underestimated. Firstly, an infrastructure for clinical
audit has been established which, despite its weaknesses, is a
formidable and available mechanism for implementing change
and monitoring clinical practice. Secondly, attitudes of clinicians
(particularly, but not only, doctors) towards the systematic assess-
ment and improvement of clinical performance have changed. In
the 1980s doctors were described as 'collectively allergic to rational
examination of the case for medical audit in any form' (Maxwell,
1984). Yet, more recently, a British Medical Journal editorial urged
doctors to 'claim ownership of audit, and see a constant search for
improvement as a central part of being a doctor' (Moss and Smith,
1991). While clinicians who treasure their notions of clinical free-
dom and professional self-rule above all else can still be found, they
no longer predominate. In most clinical professions, the need for
quality management, accountability and performance measurement
is increasingly accepted.
Provider audit programmes are a readily available and existing
channel through which the growing volume of information on

173
clinical effectiveness can be used. Clinical audit provides a natural
mechanism both for implementing changes in clinical practice and
for monitoring practice to ensure that lasting change has occurred.
But without a sound basis of evidence, clinical audit activities can
become muddled and confused, and are unlikely to be able to
convince clinicians of the need for changes in clinical practice. For
that reason, clinical audit and clinical effectiveness can be seen as
natural partners, neither of which can really work without the
other. Certainly, clinical audit seems to offer the most immediately
available and apparently suitable mechanism for starting to imple-
ment evidence-based health care.

CONCLUSIONS

It seems certain that health care professionals will increasingly be

asked by those who use their services and those who fund them to
demonstrate the effectiveness of what they do. Those professionals
who cannot or do not meet this challenge and address it put at risk
the future of their own working lives, their profession, and the
benefit they undoubtedly believe they are bringing to patients.
Up to now, as in too many other things, the medical profession
has dominated the debate about clinical effectiveness, and has
marked out the territory of evidence-based health care as its own.
Perhaps understandably, since medical research has been estab-
lished for longer, is better-funded and more quantitative in orienta-
tion than nursing research, the development of evidence-based
health care and the NHS research and development programme
has been biomedically-led. It is now essential that nurses stake their
claim to an important role in this developing arena. Firstly, there is
a pressing need for a more strategic and planned approach to
research in nursing, focused on identifying priority areas for
research and commissioning studies to meet those needs. Secondly,
nurses need to learn from the example of the Cochrane Collabora-
tion (though not necessarily to adopt their methods), and to start to
organise their body of research knowledge in a systematic and
orderly fashion which makes it accessible and usable. Thirdly,
nurses working in clinical practice and their managers have to be
persuaded to take research findings more seriously than they have
done to date. The challenge of creating community nursing services
which are clinically effective and can be shown to be so is a

174
considerable one, but it is a challenge that nurses cannot afford to
ignore.

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Williamson, J. W., Goldschmidt, P. G. and Jullson, I. A. (1979)
Medical Practice Information Demonstration Project: Final Re-
port. Baltimore: Policy Research.
Wilson-Barnett, J. (1991) The experiment: is it worthwhile? Inter-
national Journal of Nursing Studies, 28(1), pp. 77-87.
Yates, J. (1995) You want to buy more surgery? Health Services
Management Centre Newsletter, 1(1), p. 7.

177
=============CHAPTEREIGHT=============

Palliative Care in the Community

Neil Small, Audrey Ashworth, Douglas

Coyle, Sue Hennessy, Sue Jenkins-Clarke,
Nigel Rice and Sam Ahmedzai

INTRODUCTION

This chapter is concerned with the provision of palliative care.

Palliative derives from the Latin word pallium, meaning a cloak or
cover. In this context it refers to the provision of active care for a
person whose condition is not responsive to curative treatment. A
more developed definition is that palliative care is

'The active total care offered to a patient with a progressive

disease and their family when it is recognised that the illness is no
longer curable, in order to concentrate on the quality of life and
the alleviation of distressing symptoms within the framework of a
coordinated service. Palliative care provides relief from pain and
other distressing symptoms, it integrates the psychological and
spiritual aspects of care and it offers a support system to help
friends and relatives to cope during the patient's illness and in
bereavement. '
(SMACjSNMAC, 1992)

Modern approaches to palliative care began in the UK after the

Second World War and were concentrated in those first years in
hospices. Dame Cicely Saunders, first at St Joseph's in Hackney and
then St Christopher's Hospice in Sydenham, demonstrated a con-

178
cern both to offer holistic care and to incorporate advances in
symptom, and especially pain, control. In part, the development of
the hospice movement was built on the observed deficiencies of the
existing system, and in part it was a positive affirmation of a new
way of approaching a need that crossed medical, social and spiritual
boundaries.
Through the 1960s and 1970s in-patient hospices were the
principal type of specialist palliative services developed. Some grew
up within the NHS, others were run by voluntary organisations,
charities and churches. Although the number of hospices grew, and
in some places developed education and training functions, the
great majority of patients who were eligible for palliative care were
cared for in primary care settings or in ordinary hospital wards. The
need, if the maximum benefit was to be gained from the progress in
the hospices, was to disseminate practice into the community and
the general hospital. Indeed the 1980 Wilkes Report argued that
there was no reason why the hospices should continue to prolifer-
ate. It was preferable to 'encourage the dissemination of the
principles of terminal care throughout the health service to develop
an integrated system of care with the emphasis on co-ordination
between the primary care sector, the hospital sector and the hospice
movement' (Wilkes, 1980, p. 10).
The hospices did continue to grow in number, but in the 1980s
there was also a growth of support teams. These consisted of
specialist staff who would offer advice and support to health
workers in the community or in hospitals. Trained nurses, often
initially funded by the Cancer Relief Macmillan Fund, were at the
centre of many of these teams. Medical social workers played a role
as did doctors, physiotherapists and occupational therapists in the
larger teams (Higginson, 1993a).
Subsequent developments have included the provision of day-
care, either by an in-patient hospice or by a palliative-care team; the
development of 'hospice at home' in which existing community
services were augmented so that a twenty-four hour nursing or
sitting service was provided (sometimes in collaboration with an
existing Marie Curie provision); and specialist outpatient clinics
which may concentrate on specific medical or social needs.
The resulting picture of services, summarised in Table 8.1, is a
complex one. It is made more complex by the variation in funding
arrangements, the local variation in service-provision, and the
shortcomings of palliative care in any setting for people with an
illness other than cancer.

179
 Table 8.1 Hospice services in the UK and Republic of Ireland

In-patient hospices (3182 beds) 208

Type of in-patient unit Number of Units Number of Beds

Independent or Voluntary 142 2196

NHS Managed Units 46 533
Marie Curie Cancer Care Centres 11 290
Sue Ryder Homes 9 163

Community based palliative care teams + 400 (260 freestanding and 150
attached to hospice in-patient units)
Day care hospices + 200
Support nurse/teams in hospitals 250

Source: Adapted from Directory of Hospice Services, St Christopher's

Hospice Information Service, 1994 and 1995.

THE NEED FOR PALLIATIVE CARE

The UK, in common with other advanced industrial countries, is

characterised by an ageing population. Life expectancy has in-
creased; in 1991 it was 73.2 years for men and 78.2 for women,
and the survival of the very elderly has continued to improve, with
2.1 million people over 80 in 1991 (Central Statistical Office, 1992).
Strongly related to these changes is a shift in the nature and pattern
of disease. Diseases of the heart and circulatory system continue to
be major killers but very many deaths are primarily caused by
chronic degenerative diseases of the circulatory and respiratory
systems and by cancers. These are predominantly diseases of the
elderly. The number of people dying of cancer has not changed
(although the primary sites of the cancer might have) throughout
the life of the NHS. What has happened is that cancer deaths are
occurring in older people. Often first manifestations of cancer can
be responded to in such a way as to allow many more years of life.
Table 8.2 provides a summary.
As well as there being a clear picture of considerable need, figures
on where people with palliative-care needs die illustrate the im-
portance of disseminating palliative care expertise to hospitals and
the community, including to nursing and residential homes (see
Table 8.3).

180
Table 8.2 Death rates per million population from common conditions in
England

Age Sex Neoplasms Disease of the Disease of the

circulatory respiratory
system system

all ages M 3017 4830 1174

F 2648 5016 1175
65-74 M 12621 17517 3376
F 7668 9034 1876
75-84 M 23532 43559 11575
F 12404 29517 5492
85+ M 34529 88641 37272
F 16868 76305 22709

Source: Adapted from opes, 1993.

Table 8.3 Place of death in 1991 of patients who were identified as having
a terminal or palliative period in one health region.

Place of death Cancer deaths (N 2074) Non-cancer deaths (N 1622)

Home 29% 22%

Hospital 50% 57%
Hospice 13% 0%
Nursing/residential home 7% 16%
Ambulance/street 0% 5%

Source: Adapted from Addington-Hall, 1993.

'THE DYING TRIAD'

Consistent with the development of the hospice approach has been

the recognition that there is a 'dying triad' - the patient, the
professional and the informal carer (Gilley, 1988). In practice,
informal care usually means care by family members, usually with
one person carrying out the bulk of activities. That person is most
often a spouse, is often of a similar age to the person being cared
for, and is usually a woman. It may be that as a death approaches
the network of carers expands, as compared with the pattern of care
for a chronically sick person. But in the majority of cases the
contribution of those other than the principal care-giver is in the
area of emotional support (Seale, 1990).

181
 Much recent health and social care policy has been predicated on
the belief that there is a popular preference for informal care. It is a
preference considered to be in the interests of a public policy that
wishes to reduce the role and financial outlay of state services. In
practice much informal care is not adequate, either emotionally or
practically (Twigg, 1989). Further, 'Informal care is an uncom-
mandable, unspecifiable resource that is unevenly distributed'
(Neale, 1993). Even when informal care is available, there is a need
to combat the often experienced social isolation of carers and to
offer support to the carers in areas where they feel least able to meet
the needs of the person they are caring for. In palliative care the
emotional demands any caring entails can be compounded by the
anxiety over impending death. In addition people in the last year of
life often have particularly high levels of dependency, which results
in severe restrictions on the carers' lives (Dand et at., 1991).
Neale (1993) identified two trends in the last decade in palliative
care which may impact on support for carers and influence the
workings of the 'dying triad'. First is the development and changes
evident within the hospice movement. Second is the trend in
palliative care towards care in the community. A third can be
added, the development of professional specialisms.
It may be that, although carers rate hospice care as better than
mainstream provision (Seale, 1991), there is not as much attention
given to carers' needs and views as the model would presume (see
Dand et at., 1991). This may be because of the pressures of
responding to the 'new' NHS with its purchasers and providers
(see Clark, 1993), or to a routinisation of the hospices as the
approach expands and moves from being innovatory to established
(James and Field, 1992).
As well as changes within hospices there has been the shift
towards care in the community. This provides opportunities to
disseminate the ideas of palliative care to that area where most care
takes place; on average patients spend 90 per cent of their terminal
year at home being cared for by informal carers with primary
health care team back-up (Neale,1993). It also provides challenges,
for example providing the appropriate level of support to lay carers
and effecting a co-ordinating role over the complex array of
potential sources of help available. Blyth (1992) identified up to
25 different professional and voluntary groups who could play a
part. Although structurally in a crucial place, GPs, either through
training, finance or time constraints, would find such co-ordination
problematic.

182
 As well as changes in hospices and in community care, a third
development of importance is that of medical and nursing special-
isms. Palliative medicine was established as a specialism by the
Royal College of Physicians in 1987. It would appear that, so far,
accreditation has concentrated on hospital doctors trained in inter-
nal medicine and in specialities like oncology. In nursing, the
English National Board for Nursing has established two higher
qualifications for nurses who wish to practise palliative care. One
result of these developments has been to start a debate about the
extent to which dying is being medicalised (see Ahmedzai, 1993;
Biswas, 1993)

THE YORK PALLIATIVE CARE STUDY

To examine the dying triad in more detail we will continue with a

consideration of data identifying the experience of palliative care in
the UK today. The Centre for Health Economics at York Uni-
versity has been carrying out a Department of Health funded study
designed to identify costs and impact on patients and carers of a
range of palliative care services. Following a pilot study, the main
period of data collection was between March and December 1994 in
eight health districts in the north of England. The districts were
selected according to the following criteria. First they had to have a
hospice so that the study could look at the three key settings for the
delivery of palliative care, hospice, hospital and community. Sec-
ond, districts were selected with a high proportion of ethnic
minority groups relative to the general population, but with a
population that resembled England and Wales as a whole in regard
to age and socio-economic factors. The result was that four districts
were identified within Yorkshire Regional Health Authority and
four in the North West Regional Health Authority.
Research nurses, with experience of working in palliative care,
were appointed and began to recruit patients to the study. Inclusion
criteria for patients were that they should be aged over 21 and that
they should have an active progressive disease where the intention
of treatment was not curative. Further, they should not show signs
of cognitive impairment or psychotic disease. Patients were also
excluded if they were considered too ill to complete the question-
naires which formed the basis of the research data.
In total 661 patients were recruited to the study of whom 280
were in hospices, 212 in the community and 169 in hospitals. In

183
what follows we will concentrate on the 212 patients who were
receiving palliative care in the community. Details of their socio-
demographic and medical characteristics are presented in Tables 8.4
and 8.5. The majority of patients were female, did not live alone and
had a carer. However these majorities were not overwhelming, 23
per cent of patients not having a carer, or 31 per cent aged under 59
represent a large proportion. Seventy per cent of patients had
cancer as a main diagnosis. This is a lower percentage than in the
total patient sample where the figure was 87 per cent. Those people
identified as receiving palliative care in hospices and hospitals
overwhelmingly are cancer patients, 97 per cent of hospice patients
and 91 per cent of hospital patients. It can be noted that despite
choosing areas of study with disproportionately high ethnic minor-
ity populations, we did not recruit people from any ethnic group
other than white British. The problems of access to hospice and
specialist palliative care services by members of black and ethnic
minority populations are being increasingly recognised (Hill and
Penso, 1995).
People receiving palliative care in the community in our study
often had a prognosis of over 12 months, although 42 per cent were
expected to live less than a year. The WHO score, completed by the
patients' doctor at the point at which they were admitted to the
study, is a measure of dependency, as identified by a five-point scale
of ability or restriction, ranging from zero which is free from
restriction to four which means incapable of self-care and comple-
tely confined to bed or a chair. We can see that 53 per cent of our
study population had scores of three or four and, in consequence,
can be seen as having very considerable restrictions on their every-
day lives.
As already described, the role of lay carers is crucial to the nature
and experience of care. In our study we recruited 99 lay carers, and
their profiles are summarised in Table 8.6. Of those carers in the age
group 21 to 59, 30 were not employed, nine did part-time work and
11 were employed full-time. None of the other carers in older age
groups were employed. Twenty-five people being cared for in the
community reported that they had nobody they could turn to for
emotional support.
The majority of medical and nursing care was delivered at home.
During the week before the completion of our baseline questionnaire
only 13 patients had attended their GP's practice. Almost a third, 59,
had been visited by their GP and 124 had received a visit from a

184
district nurse. The majority of patients who received a visit from
their GP were visited once, and half the patients having a visit from
a district nurse were seen once. However some patients had much
more frequent attention. Nineteen received two visits from district
nurses, 14 had seven visits and six had 14 visits. Visits by both GPs
and district nurses lasted an average of 25 minutes, with a maximum
recorded as 90 minutes (excluding one exceptional visit by a district
nurse which lasted over five hours) (Table 8.7). Apart from medical
and nursing staff a considerable range of other professional groups
were mentioned as visiting patients during the week: the vicar or
priest (14 people) private carer (six), Crossroads sitter (five), home-
care helper (five), private cleaner (five), physiotherapist (four).

Table 8.4 Socio-demographic characteristics of patients, recruited from

the community (n = 212)

Sex
Male 85 ( 40%)
Female 127 ( 60%)

Age Group
21 to 59 66 ( 31 %)
60 to 74 102 ( 48%)
75 and over 43 ( 20%)

Ethnic Group
White 212 (lOO%)
Black Caribbean
Asian

Marital Status
Married/co ha bi ting 121 ( 57%)
Widowed 60 ( 28%)
Di vorced/ separated 13 ( 6%)
Single 18 ( 8%)

Does patient live alone?

Yes 56 ( 27%)
No l 152 ( 73%)

Does ~atient have a carer?

Yes 160 ( 77%)
No 47 ( 23%)

1 Includes patients living in residential accommodation.

185
Table 8.5 Medical characteristics of recruited patients, community
(n = 197)

Main Diagnosis
Cancer 136 (70%)
COAD/Emphysema 5 (3%)
Motor Neurone Disease 5 (3%)
Multiple Sclerosis 34 (17%)
Other 17 (9%)

Prognosis
Less than one month 1 « 1%)
One to six months 39 ( 21 %)
Six to twelve months 37 ( 20%)
More than 12 months 105 ( 56%)
Unknown/refused to state 5 ( 3%)

WHO Score at Baseline completed by doctors

Without restriction 8 ( 4%)
Restricted but ambulatory 36 ( 18%)
Ambulatory but unable to work 67 ( 34%)
Confined to bed or chair 39 ( 20%)
Completely disabled 45 ( 33%)

Number of Patients Reported by Doctor as Receiving:

Pain control 125 ( 63%)
Respite care 26 ( 13%)
Assessment/investigations 66 ( 34%)
Emotional support 130 ( 64%)

NB: Medical details not provided for 15 community patients.

With this wide range of services on offer, the extent to which the
services are getting to the patients that need them is crucial. In order
to identify unmet need, at our first follow-up interview patients
were asked if there was anyone they would have liked to have seen
in the previous week but did not. Twenty-one patients said there
was such a person, nine mentioned a doctor, seven a nurse and five
a therapist.
At the baseline interview, lay carers were asked whether they
would have liked any extra help during the previous week and 63
said yes. It was possible to specify more than one sort of help and,
in order, the following were identified: give carer a break - 16;
physical care of patient - 13; medical help - 12; help at night - 8;
'more help' - 6; housework - 5; other - 14.

186
 Table 8.6 Profile of carers in the community

Community (n = 99)

Sex
Male 39 (39%)
Female 61 (60%)

Age Group
21 to 59 50 (50%)
60 to 74 41 (40%)
75 and over 9 ( 9%)

Relationship to Patient
Spouse/Partner 77 (76%)
Child II (11%)
Parent 2 ( 2%)
Other Family 8 ( 8%)
Friend 2 ( 2%)

Does carer live alone?

Yes 4 ( 4%)
No 96 (95%)

Does carer have paid employment?

Yes, full-time II (11%)
Yes, part-time 9 ( 9%)
No 80 (79%)

Does carer have someone to turn to for emotional support?

Yes 74 (74%)
No 25 (26%)

Quality of relationship between carer and patient

Very good 87 (86%)
Good 10 (10%)
Fair 2 ( 2%)
Poor I ( 1%)

Carer's health
Very good 18 (18%)
Good 49 (49%)
Fair 26 (25%)
Poor 7 ( 7%)

Contact with voluntary group

Yes 32 (32%)
No 67 (68%)

Reason for contact with voluntary group

Advice and information 16
Practical help 13
Financial help 7
Emotional support 11
Other 4

187
Table 8.7 Number of patients receiving visits from GPs and nurses in the
week before completion of baseline data (n = 212)

Visit/rom: No. 0/ patients (%)

GP 59 (28)
Hospital/Hospice Doctor 3 ( I)
District Nurse 124 (58)
Auxiliary Nurse 14 ( 7)
Macmillan Nurse 1 (21)
Marie Curie Nurse 6 ( 3)
Hospice Home Care Nurse 1
Stoma Care Nurse I
Oncology Nurse I
Total 210

Although receiving most of their care in the community, some of

the community sample were using services provided in in-patient
settings: eight patients had such a stay during the week before the
completion of the baseline questionnaires and 40 had attended an
out-patient clinic. In addition, 58 had attended a hospice day-
centre, a day-hospital or other day-care centre during the previous
week. Thirty-four patients had received treatment other than their
regular medicines. These treatments included chemotherapy (five
patients), radiotherapy (four) and oxygen therapy (four). Twenty-
five patients had tests or investigations performed, of whom the
majority (16) had blood tests.
When we move from a presentation of these figures to a
consideration of what they might mean for service providers we
can see that, at the very least, it is necessary to take into account the
complex picture that palliative care in the community presents.
It is complex at the level of service provision. We have health and
social care agencies involved in both statutory and voluntary
sectors. Care primarily in the community does not mean that other
care settings do not playa part in the day-to-day experience of the
patient. The range of professions and the skill-mix involved in the
care of patients varies greatly. We must note the considerable
demands evident on community care providers; district nurses
visiting in the previous week in two-thirds of cases, sometimes
making multiple visits, and GPs visiting in over one-third. Specialist
nursing is spread thinly: these nurses account for 11 per cent of
visits reported in the previous week. One can argue that for most
patients, in their day-to-day care, it is district nurse teams who are

188
carrying out the bulk of the work. In some situations the tasks they
perform will be within the generic remit of their usual role. But the
specific circumstances of the palliative care population, its high level
of need, the prevalence of pain (71 per cent of patients at baseline
and 73 per cent at first follow-up reported they had experienced
pain in the previous week), and the emotional and physical
demands on carers mean, in effect, that the district nurse is
providing a somewhat specialised service.
Palliative care is complex at the level of informal care. Carers'
views express, in the high level of need they identify for some sort of
respite, the extent of demands being made upon them by a group of
patients who, in the majority of cases, are severely restricted in their
ability to perform the basic activities of daily living.
It is also complex because of the variation within the patient
group where there are a range of diagnoses, differing home circum-
stances and changing needs over time.

QUALITY OF LIFE AND PALLIATIVE CARE

It is of course not possible to identify outcome in relation to

palliative care using commonly-held measures from other areas,
for example mortality or morbidity. Rather one must devise a
means of identifying, recording and analysing those things impor-
tant to patients with progressive disease and, consistent with the
holistic approach of palliative care, those things important to lay
carers and family both during the illness and after bereavement.
There have been a number of attempts to create quality-of-life
measures, both in relation to oncology patients in total, and to
patients receiving palliative care in particular. In the main they seek
to identify potential problem areas such as pain, anxiety and
symptoms. Quality is equated with the extent to which these
problems are absent. More ambitious is the attempt to do two
things, first to identify the relative weight of each of these problem
factors. For example is it the effective control over pain that really
predetermines quality oflife? Or, how can one balance pain control
with side effects in terms of alertness or digestive problems? The
second challenge is to identify positive, life-enhancing features
occurring during the palliative care phase of a person's life. The
possibility of these was certainly of central importance to Dame
Cicely Saunders and colleagues in the thinking that underpinned the
modern hospice movement (see Du Boulay, 1994).

189
 Quality-of-life measures now generally include physical, emo-
tional and social functioning. They also consider spirituality and
sexuality (see Bowling, 1991; Doyle et aI., 1993). The York Study
used a measure called the EORTC QLQ-C30 (Aaronson et at.,
1993) which has been developed out of an international collabora-
tion for use with cancer patients, and is now being increasingly used
for palliative care. The questionnaire, which takes about 11 minutes
to complete, incorporates nine multi-item scales, five functioning
scales (physical, role, cognitive, emotional and social); three symp-
tom scales (fatigue, pain, and nausea and vomiting) and a global
health and quality of life scale. Several single items are also
included.
If, in palliative care, we take quality of life as a concept appro-
priate to assessing the outcome of any treatment, we have to ask
which measure is the best way of gathering information on what
quality consists of. But secondly we have to ask what this says
about resource use. What structures and practices would maximise
the achievable quality of life?
In the York study the overall mean quality of life increased from
baseline to first follow-up (seven days later), and then decreased by
the third follow-up (28 days later). In general this increase was
associated with an improvement in functioning and a decrease in
symptoms. We can hypothesise that the main impact of introducing
palliative care occurs in the initial stages. This is a stage in which
effective symptom control is achieved in most cases and underlines
the value to the patient of a focus on palliative approaches. What
we cannot do is be any more definite. Some patients in our study
had been receiving palliative care for some time when we first
recruited them. In addition, the point at which a patient is defined
as entering a palliative phase is somewhat arbitrary. Further, it is
not clear how far implementing palliative approaches necessitates
the intervention of specialist workers. It is not surprising that, over
time, quality of life deteriorates as even effective symptom control
cannot overcome the progression of the disease being treated
palliatively.
It does appear that, in medicine in general, there is an increasing
recognition that biological end-points are not sufficient to define
outcome, and measures of functional status, or health-related
quality of life, are appearing with more frequency in the medical
literature (Hopkins, 1992). In the USA, quality of life is being used
increasingly as an outcome in clinical trials. In oncology, research-
ers are predicting that clinicians will begin to routinely evaluate

190
quality of life in their patients and use these evaluations as part of
the clinical decision-making process for individuals. It may be that,
ultimately, policy decisions also may incorporate some form of
quality-of-life assessment (Ganz, 1994).
This is not to say that the controversy that accompanies quality
of life is abating in its detail. Which measures to use, as different
instruments proliferate, how to include economic analyses including
utility and cost-effectiveness, and how to reconcile potential conflict
between the needs of individuals and societies are all areas still
unresolved.
In the UK, although the main trends identified by Ganz are in
place, the specific way the purchasing function has developed means
that some of the questions as to the relationship between resource-
use, cost and outcome are likely to be central, particularly in those
local 'political' encounters between purchasers and providers of
health and social care.

FUNDING PALLIATIVE CARE

We can see the patterns of historical development in palliative care

and the fluctuating interactions within the 'dying triad'. But shaping
the past, and crucial to the future of palliative care, is the extent and
pattern of funding.
The voluntary sector was responsible for the development of
many of the first palliative care services, particularly the in-patient
hospices. Local groups in particular were heavily involved in raising
funds. By 1995, 75 per cent of in-patient hospice care was provided
by voluntary or independent units. Some of these were linked to
national charities, Marie Curie Cancer Care and the Sue Ryder
Foundation. In practice, links have developed with the NHS from
which hospices receive varying amounts of funding to supplement
that raised in local communities.
In 1988, the Department of Health began to allocate money to
Regional Health Authorities, specifically for voluntary hospices and
specialist palliative care services. The amounts so allocated rose
rapidly: £8 million in 1989; £17 million in 1991 and £37 million in
1992. By 1994/5 the allocation was £35.7 million for specialist
palliative care services plus £12 million for voluntary hospices, a
figure which included an allocation of £6.3 million for drugs (NHS
Executive, 1995). Beyond 1995/6 these allocations are to be built

191
into general funding to health authorities and will not be separately
identified for palliative care.
Because of the presence of special ring-fenced allocations we see a
scenario in which the advent of the Working for Patients reforms
(Department of Health, 1989), and the development of purchasing,
was delayed for palliative care. In part this delay can be attributed
to the wish to have in place a network of specialist palliative care as
developed as possible, before exposing it to the health care market.
In part it reflected the complexity of palliative care in itself. This is a
service that crosses the divide between activities mostly under the
jurisdiction of the Working for Patients changes and mostly under
the NHS and Community Care Act (Department of Health, 1990).
It also relies on a combination of statutory sector provision and
voluntary, charitable and private sector input. It might be described
as a working example of the mixed economy of care.
In a series of Department of Health circulars between 1987 and
1993 we can see the emergence of, first a role for District Health
Authorities as lead bodies in planning and co-ordinating an inte-
grated range of services for the terminally ill, and then the emer-
gence of a funding partnership between the health authorities and
the voluntary sector (for a summary see Neale, Clark and Heather,
1993). Specifically, in the area of home and hospital support teams,
the NHS was encouraged to take on an active role in the develop-
ment of services; to take over funding for Cancer Relief Macmillan
Fund nurses after the initial three years in which they would be
supported by the charity; and to maintain a commitment to Marie
Curie Nursing Services. It was the intention of the government,
expressed in documents like EL(94)14 (NHS Executive, 1995), to
maintain existing levels of financial support and to continue the
partnership with the charities.
The financial year 1995/6 is the first year during which palliative
care enters the purchasing cycle. Current guidance identifies the
nature of responsibilities within that cycle. Purchasing authorities
are responsible for ensuring a comprehensive and integrated range
of palliative care services for patients and their informal carers,
across a range of individual diagnoses and care settings; these
include hospital, in-patient hospice, day and home-care services
and respite care. They are encouraged to make strategic plans based
on aggregate needs assessment, operational research data and
consumer feedback; to identify the range of existing provision
available and gaps in provision which are to be filled consistent
with consumer choice; to produce joint purchasing strategies

192
through joint and multi-disciplinary planning groups; to negotiate
contracts with both NHS and independent-sector providers, and to
promote a partnership between them; and to monitor provision
through audit processes based on agreed quality standards and
outcome measures.
It was envisaged that it would be through the contracting process
that authorities should aim to increase understanding between
service providers across all care settings and sectors, and raise
standards of care through staff development programmes (see
Neale et at., 1993, pp. 16-17). In practice, the process of purchasing
palliative care is little-developed. It is an area that requires close
collaboration across sectors and involves a careful examination of
what standards and outcome might be. There has been development
of audit measures for palliative care in the UK and abroad and
some progress which links audit procedures with improvements in
care for patients (see Higginson, 1993b). Indeed, in a recent pub-
lication from the National Council for Hospice and Specialist
Palliative Care Services (1992) it was possible to list eight different
examples of audit being developed in palliative care.
Provider units and teams are also becoming clearer as to how
they should negotiate with purchasers. Those units that are part of a
larger national organisation, Marie Curie Cancer Care for example,
have help from their headquarters about adapting to the new
scenario. But for many the different demands it makes, for example
in drawing up business plans, require a considerable change in the
ethos of the establishment. It is, in short, a time of flux and
uncertainty on the part of both providers and purchasers of
palliative care. It is an uncertainty likely to continue for some time.
With the piloting of total fund holding by general practitioners,
which would involve GPs purchasing palliative care, we have
further possibilities of continuing change.

FUTURE SCENARIOS

Some features of the coming years are relatively predictable. The

changing demographic profile of the population, allied to the long-
term shift in patterns of mortality in which more people die from
chronic conditions late in life, will continue. These shifts will ensure
that the demand for palliative care will increase. It is likely also that
most patients with a progressive illness that is no longer curable will

193
receive much of their care outside a hospital or hospice, in the
community. Secondary care settings will tend to concentrate on
those patients with the most severe symptoms or for whom lay-carer
distress is greatest (see Higginson, 1993a).
Less easy to predict is the likely development of patterns of
service. It appears that the general public places care for people who
are dying high on lists of priorities (Heginbotham, 1992), and so
there is likely to be both public support and increasing demand
encouraging the growth of palliative care. Health districts will seek
to identify levels of need but will then have to decide on what mix of
services should be developed locally. The balance they strike
between cost and quality will be the important variable in patterns
of future service development. There is some concern amongst
hospice providers that care will shift to nursing homes and will be
pursued by non-specialist trained personnel.
The 1992 SMACjSNMAC report recommended that all patients
needing palliative care services should have access to them. As yet
there is a disparity between services for people with cancer and
those needing palliative care but with non-cancer diagnoses. Dis-
cussing motor neurone disease as recently as 1992, a British Medical
Journal article could say with confidence that:

'Many doctors and especially neurologists (ninety per cent in our

experience) continue to offer no care to patients suffering from
this fatal paralysis, as though the lack of cure is somehow
equated with the absence of any treatment. This is curious
because patients with many other fatal diseases receive supportive
care or palliation from their doctors (including neurologists). Yet
a paralysed patient with motor neurone disease is often neglected
despite the availability of many symptomatic treatments.'
(Norris, 1992; see also Norris et aI., 1985)

One possible future would be for more concern with non-cancer

diagnoses to be evident in planning and delivering palliative care.
Another, allied, possibility is for the original message of the Wilkes
Report to be more systematically pursued, that is the dissemination
of the principles of terminal care across all sectors with an emphasis
on the need for coordination between sectors. Certainly the York
study underlined the complexity of delivering palliative care. It also
reinforced the already widely recognised importance of the role of
lay carers. For all the discussion about the development of speci-
alisms and the advance of palliative medicine, indeed of the

194
medicalisation of dying, most people for most of the time during
illness are cared for by their family at home. When they do see
health service staff it is usually those who are local and generic.
The York Palliative Care Study was funded by the Department of
Health but views expressed here are those of the authors.

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European Organisation for Research and Treatment of Cancer
QLQ-C30: a quality of life instrument for use in international
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Addington-Hall, 1. (1993) Regional study of care of the dying.
London, Department of Epidemiology and Public Health,
University College.
Ahmedzai, S. (1993) The medicalization of dying. In D. Clark (ed.)
The Future for Palliative Care. Buckingham: Open University
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Biswas, B. (1993) The medicalization of dying. In D. Clark (ed.) The
Future for Palliative Care. Buckingham: Open University Press.
Blyth, A. (1992) Audit of terminal care in a general practice. British
Medical Journal, 300, pp. 983-6.
Bowling, A. (1991) Measuring Health. A Review of Quality of Life
Measurement Scales. Milton Keynes: Open University Press.
Central Statistical Office (1992) Social Trends 92. London: HMSO.
Clark, D. (1993) Whither the hospices? In D. Clark (ed.) The Future
for Palliative Care. Buckingham: Open University Press.
Dand, P., Field, D., Ahmedzai, S. and Biswas, B. (1991) Client
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Doyle, D., Hanks, G. and MacDonald, N. (1993) Oxford Textbook
of Palliative Medicine. Oxford: Oxford University Press.
Du Boulay, S. (1994) Cicely Saunders. London: Hodder & Stough-
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Ganz, P. A. (1994) Quality of life and the patient with cancer.
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Gilley, J. (1988) Intimacy and terminal care. Journal of the Royal
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Higginson,!. (1993a) Palliative care: a review of past challenges and
future trends. Journal of Public Health, 15 (1), pp. 3-8.
Higginson,!. (1993b) Clinical Audit in Palliative Care. Oxford:
Radcliffe Medical Press.
Hill, D. and Penso, D. (1995) Opening Doors. London: National
Council for Hospice and Palliative Care Services, Occasional
Paper 7.
Hopkins, A. (1992) Measures of the Quality of Life. London: Royal
College of Physicians.
Hospice Information Service (1992) Directory of Hospice Services.
London: St Christophers Hospice.
James, N. and Field, D. (1992) The routinisation of hospice:
bureaucracy and charisma. Social Science and Medicine, 34
(12), pp. 1363-75.
National Council for Hospice and Specialist Palliative Care Services
(1992) Quality, Standards, Organisational and Clinical Audit for
Hospice and Palliative Care Services. London: Occasional Paper
2.
Neale, B. (1993) Informal care and community care. In D. Clark
(ed.), The Future for Palliative Care. Buckingham: Open Uni-
versity Press.
Neale, B., Clark, D. and Heather, P. (1993) Purchasing Palliative
Care. Trent Palliative Care Centre, Occasional Paper 11.
NHS Executive (1995) Specialist Palliative Care Services including
Drugs for Hospices scheme. EL(95)22. Leeds: NHS Executive.
Norris, F. H. (1992) Motor neurone disease. Treating the untreated.
British Medical Journal, 304, pp. 459-60.
Norris, F. H., Smith, R. A., Denys, E. H. (1985) Motor neurone
disease: towards better care. British Medical Journal, 291,
pp.259-62.
Office of Population Censuses and Surveys (1993) (Winter), Popu-
lation Trends 74. Death Rates by Age, Sex and Selected Causes.
London: HMSO.
Seale, C. (1990) Caring for people who die: the experience of family
and friends. Ageing and Society, 10 (4), pp. 413-28.
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The Standing Medical Advisory Committee and Standing Nursing
and Midwifery Advisory Committee (SMACjSNMAC) (1992)
The Principles and Provision of Palliative Care. London:
SMACjSNMAC.
Twigg, J. (1989) Models of carers: how do social care agencies
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Wilkes, E. (1980) Report of the Working Group on Terminal Care.
London: DHSS.

197
 CHAPTER NINE

How to Deliver Effective

Community Health Care

Lucy Hadfield

INTRODUCTION

This chapter examines the traditional community health services

and considers how they might move forward in tandem with the
many other drivers for change in the NHS. It starts by defining
community health services and then considers what is the nature of
an organisation delivering community health care by looking at its
function, culture and environment. From this, five criteria are
derived that are used to appraise the effectiveness of current
provider organisations in delivering community health care, that
is NHS trusts, general practice and independent sector organisa-
tions. Finally, the strengths and weaknesses of the current organisa-
tions are taken forward into implications for the future of
community health organisations and their staff.

DEFINITION OF COMMUNITY HEALTH SERVICES

When we consider how community health services can be provided,

we need to know what we mean by the term, community health
services. There is no universally accepted simple definition and they
are often defined by what they are not:

• health care not in hospital or in an institution;

• not GP services;
• not social services.'

198
 For a future health professional in pre-registration training, they
are rather a nebulous concept, a tangle of spaghetti around a clear
central point, the patient. For hospital staff, they lack the clarity
and boundedness of services in a hospital, which a patient clearly
enters and leaves. For the general public, it is just one of a number
of virtually meaningless terms that the modern confusing NHS
seems so keen on. For a politician and/or social idealist, it is
inherently good, like motherhood and apple pie and it is one answer
to containing health care costs (because buildings do not have to be
paid for) and improving responsiveness to consumers (and voters)
because of their localness. For a practitioner and a patient engaged
together in an episode of community health care, they are just a
straightforward, no-nonsense way of tackling whatever is the health
need or problem. For an NHS manager, they are a collection of
services that evolved separately from hospital and GPs. They either
originated in the public health arm oflocal authorities (for example,
community nursing and child health), or grew out of transferred
resources when long-stay hospitals closed down (for example
mental health and learning disability services), or were deliberately
moved from district general hospitals' management to change the
ethos of 'complex health care automatically equals hospitalisation'
(for example therapy services).
In the world of the NHS market and contracting, community
services are currently purchased on the basis of patient contacts
with a health professional (face-to-face contact) or on the basis of
whole-time-equivalent (WTE) staff, whereas hospital services are
mainly purchased on the basis of a 'finished consultant episode' of
care. Both community and hospital services are purchased from
the Department of Health's financial allocation for hospital and
community services, which is kept rigidly separate from funding
for family practitioners' services or general medical services
(GMS).
In the spectrum of health care, community health services cover
health promotion, prevention, surveillance, diagnosis, treatment,
rehabilitation and palliative care. The focus of most of community
health care is on the prevention of disease and disability in
children, and managing the impact and consequences of chronic
disease or disability in all age groups. The largest numbers,
however, are amongst elderly people. Most diagnosis and treatment
is undertaken by doctors, and most doctors work either in general
practice or are specialists in hospitals. The main providers of
community health services are nurses and professionals allied to

199
medicine. Often, there is direct access by the patient to community
services, and assessment and interventions are undertaken without
the involvement and intervention of a doctor, for example speech
and language therapy, or chiropody. The few doctors that do work
in community health services are not generally body system or
organ specialists, but specialists in the pathology associated with
particular client groups (for example paediatricians, geriatricians,
psychiatrists, family planning specialists) or in the stage of disease
(for example, rehabilitation or palliative care). The dominant
paradigm in doctors' training is diagnose - treat - cure. Doctors
who choose to work in community health services (other than
general practice) are often still regarded by the medical profession
as either heroic, or of lesser calibre (and status) than a traditional
organ/system specialist.
Another notion to consider in trying to define community health
services is the degree to which they can honour values such as
patient choice and equity of access, better than institutionally-based
care. The patient is in a more powerful position vis-a-vis the health
practitioner when they are in their own home or in a known
environment.
Community health services have been distinguished from social
care by separate public sector funding streams. But every district
nurse will be familiar with the conundrum of, when is a bath a
medical one or a social one? The difficulties of this separation for
clients is now becoming highlighted politically following the Com-
munity Care Act 1991, and, more recently, guidance from the NHS
Executive on the responsibilities of the NHS for continuing health
care (DoH, 1995). The separation of purchasing and providing in
health and social care opens up the potential for more imaginative
ways of bridging the divide for so-called seamless care.
A major problem, and therefore a major challenge, for commu-
nity health services is the lack of evidence for their effectiveness (see
for example the National Association of Health Authorities and
Trusts, 1995). Research is difficult and expensive to undertake in
such an uncontrolled environment and, therefore, has traditionally
been neglected. Outcome measures associated with quality of life
are far less accessible than those that show presence or absence of a
disease.
I will finish this section with a list of the main services you would
expect to see in a description of community health services. It is not
intended to be comprehensive:

200
• Community nursing:
district nursing
health visiting
community psychiatric nurses
community mental handicap nurses
school nursing
midwifery
nurse practitioners
• Therapists:
occupational therapy
physiotherapy
dietetics
speech and language therapy
• Other professionals allied to medicine:
psychology
chiropody
podiatry
• Medicine:
geriatrics
paediatrics
psychiatry
rehabilitation
obstetrics and gynaecology
population prevention, screening and multi-disciplinary teams
for surveillance programmes, for example immunisation,
child health, breast, cervical cytology
family planning
mental health
adults with learning disabilities
children with disabilities
drug and substance abuse
people with physical disabilities
people with terminal illness

DO COMMUNITY HEALTH SERVICES NEED TO BE

ORGANISED?

Few would seriously argue that there should be no organisation of

community health care. Without organisation, there would be a

201
totally free market with health care from individual practitioners
available only to those who could pay on demand. The question for
now is how should they be organised and where should choices
be made on the trade-offs amongst cost, quality and amount of
health care?
The NHS, since the reforms of the early 1990s, now has a
complex system to balance supply and demand in health care, using
a mixture of market and collectivist principles. Community health
services must be organised in the context of the macro-perspective
of the new NHS, which is no longer a closed system as it was from
1948 to 1990. Figure 9.1 gives an overview of the key stakeholders
in the NHS and their roles, showing how they interact to create a
balance between demand and supply for health care.

CRITERIA TO DETERMINE AN ORGANISATION'S FITNESS

TO DELIVER EFFECTIVE COMMUNITY HEALTH CARE

Before proposing criteria to judge whether an organisation is fit to

deliver effective community health care, it is useful to explore the
context for community health services, looking at:

• Current management theories of organisational structure and

design, for example Mintzberg (1979);
• The forces in the environment around community health services;
• The nature of the services themselves.

Some questions are posed (see also Johnson and Scholes, 1993,
chapter 10) and addressed in order to describe the context, as
follows.

How answerable is the organisation to external stakeholders?

Most community health services are currently provided by NHS

trusts, which are run by a trust board appointed by and accountable
to the Secretary of State for Health. A minority of community
health services are provided bynot-for-profit organisations, for
example charities, and accountability is to the board of independent
trustees. The managers of community health services are open to
quite a high degree of public scrutiny and have many stakeholders
to please, not least the local community and the patients they serve.

202
 Figure 9.1 NHS key stakeholders and their roles

DEMAND BOTH SUPPLY

Patient - needs or"'- Voting Citizen -----.. Tax Payer - pays a

demands NHS fair share
Individual health care to indirectly to ensure
prevent, treat or universal health
manage disease care when needed

Helps assess need Health Practitioner Direct supplier of

for health care . . . - (and patient's carers) --.... health care

Health Authority . . . - Service Contracts ~ Health care

or GPFH- providing
decides what organisations -
health care to general practice,
purchase on behalf NHS Trusts and
of the population independent
they serve to organisations
maximise the assemble the
health benefit for delivery of health
each £ spent care services and
contract wi th
purchasers
Local

Consumer groups ...-Lobbying Interests - - . Health

- advocate the professional
needs on behalf of bodies - set
sections of the standards and
population support the
interests of
members of the
profession

Promotes . . . - The Media - - - - - - . . Promotes

awareness and awareness and
debate debate

Sets policies which +--- NHSE/Department ---+ Sets policies which

shape demand of Health shape supply

Government
National +--- determines the •
health care system
and the amount of
GNP spent on public
health care

203
What about reliance on simple or complex technologies?

Community health service providers are traditionally the least

technical part of health care. Most procedures dependent on
technological support have been confined to hospitals, for reasons
of cost, scarcity and immobility. Community services are dependent
mainly on human skills, supported by simple, often portable
technology. Their benefits are either taken for granted or viewed
by some with scepticism or agnosticism. However, the nature of
health technology to assist diagnosis and the treatment is changing
rapidly - in many areas it is becoming more sophisticated and more
flexible, both in where it can be used and the level of skill needed to
use it - and becoming cheaper. This is changing the boundaries of
community health services - they are no longer just the low-
technology services. Technological developments in intravenous
infusion therapy mean that complex and high-dosage drug therapies
can be administered to heavily-dependent patients by community
staff, enabling such patients to lead more normal life-styles in the
community, and often administered even by the patients themselves
as in the case of cystic fibrosis.
Developments in information technology are also having a major
impact on community services. Not only do they enable profes-
sional staff to plan, manage and evaluate packages of care to
chronically-ill patients over long periods of time, they enable
information to be easily shared by the many professionals involved
in the cases of patients with complex problems. They also enable the
clear identification of resource inputs and the ability to relate these
to clinical outcomes.

How diverse is the organisation?

The diversity of community health services can be seen from the list
on p. 201. Diversity is in terms of the number of different types of
client groups served, the different elements in the services them-
selves, the different locations from which services are provided and
so on. Most community health services are currently provided by
NHS trusts that supply at least 15 or so of the services listed to a
population of usually over 200000. An increasing minority of
community services are provided by small independent organisa-
tions serving a smaller number of patients with a special problem or
set of problems, for example HIV services.

204
Is the environment complex and changing or stable?

Other chapters in this book explain at some length the historical

context for the enormous changes that are happening within
and around the NHS in the 1990s. Some of the major factors at
work around the NHS are as follows:

• Economic The UK economy (and those of other European

states) are not growing as fast as Far East economies, and there
are major changes taking place in the balance of world econo-
mies. Increased taxation to enable the NHS to grow is unlikely to
be acceptable to the electorate (see for example Healthcare 2000,
1995). Any growth in health care would have to be from
individuals choosing to spend more of their disposable income
on health care, which erodes the principles of the NHS.
• Sociological The population is ageing, placing an increased
burden on the NHS. At the same time, the numbers of people
of working age to support the growth in demand for care of
elderly and other dependent people is decreasing. One of the
consequences of an ageing population is an increasing reliance on
close family and friends for informal caring. Carers have become
recognised in the 1990s as a distinct client group with rights and
needs independent from the person being cared for. Caring for
the carer has become a vital component of our health and social
system and is of great significance to the provision of community
health care.
• Technological Developments in information technology are a
major force behind the increased power of world markets and the
relative decline in the power of individual state governments.
There are, and will continue to be, quantum leaps in medical and
scientific technology particularly in the areas of pharmaceuticals,
biological sciences and genetics.
• Political The results of the changes in the economic, socio-
logical and technological environments are increasing difficulties
with predictability in politics. Despite government of the UK by
one party for the past 16 years, instability is increasing and this
has a major impact on a major public sector organisation such as
the NHS.
Because of the need to remain competitive in world markets,
political parties in western countries are tending to move further
to the right of the political spectrum and a result is an increasing

205
 polarisation between 'haves' and 'have-nots'. Health status is
closely associated with economic and social status. Amongst
the 'haves', consumerism is a significant sociological phenom-
enon.

Within the NHS, we are also working through major structural

reforms put in place in the early 1990s (DoH, 1989a, 1989b). These
include:

• separation of purchasing from providing;

• changes to the GP's contract;
• the development of NHS trusts as semi-independent organisa-
tions;
• the emergence of general practice fundholding (GPFH) as a new
form of purchasing;
• reforms to the funding and organisation of community (social)
care and its relationship to the NHS;
• mergers between District Health Authorities and Family Health
Services Authorities;
• a framework of Health of the Nation targets;
• the Patient's Charter;
• an increased emphasis on evidence-based medicine.

These policy initiatives or changes are described in more detail

elsewhere in this book, but it is important to emphasise the
collective intended impact of these reforms to overhaul the provi-
sion of primary and continuing health care as part of an evolution
to 'a primary care-led NHS'. The aim is for decisions about
purchasing and providing health care to be taken as close to the
patient as possible by GPs working closely with patients through
primary health care teams. This requires major shifts in the roles of
both GPs and community health providers, and exploration of how
the concept of a primary health care team can be turned into a
robust organisational reality offering an equitable primary health
care service in both inner city and rural area alike.

What are the types of problems facing the community health

organisation?

The types of problems facing community health service providing

organisations reflect the many factors discussed above. These can
be summarised as problems around:

206
• political accountability;
• diversity;
• complex and rapidly-changing external environment;
• changing technologies.

In addition, there are two further specific problems deriving from

the dependence of community health service provision on a
controlled supply of human resources in the form of health
professionals trained to apply their competence in a community
setting:

1. Alignment of the purpose of the organisation with attitudes of

health professional staff and their professional bodies. The pres-
sures that a rapidly changing environment place on health
professional bodies are considerable. Their traditional role of
ensuring and monitoring standards to protect individual pa-
tients largely through control of skills, works on long time-
scales. Legitimising changes in standards and implementing
changes are very slow, delicate processes. There is a fine line
between taking on board pressures for change very slowly and
carefully, and actually trying to resist the pressures. The ten-
sions and pressures of the interface between the changes de-
scribed above and the actions of health professional staff lie
within the culture of the organisation. An example of this type
of pressure is around the UKCC's classification of specialist
community nursing (UKCC, 1994). Whilst the reforms to the
classification were long-awaited and welcomed when they came,
are they over-specialised for the needs of the primary care team
as we see it emerging?
2. Nature of the physical working environment for health staff
Organisations providing community health services need to
understand the factors that motivate their health professional
and support staff. We assume that health staff in whichever
sector are motivated by feelings of intrinsic value that derive
from promoting good health and helping to make the lives of
sick people better. Other motivational factors such as pay, job
security, sense of identity, relationships, intellectual stimula-
tion, and so on are also very important. However, there are
particular problems of staff motivation in community services
which come from the nature of the physical working environ-
ment:

207
• Locus of care
Care is provided in patients' homes (or other locations which are
part of their daily lives, for example schools, day-centres and so
forth), or in local health clinics, GP surgeries or health centres. Staff
either work in small-scale health clinics or are peripatetic and spend
a proportion of their time travelling from place to place. Although
individuals vary in their preferences to be 'roamers' or 'homers',
most health staff would regard excessive travelling time as dead
time and demotivating. The quality of the physical environment
that staff work in is important and has an impact on the quality of
their work. Working in people's homes is particularly challenging
because health staff have no control over the environment which
can be perceived as ranging from luxurious to ghastly. The ability of
staff to overcome the negative effects of unpredictable and poor
physical environments, or excessive travelling time, is aided by the
knowledge that they are providing health interventions in situations
where access is critical and where people would not otherwise
benefit from help.
A sense of isolation is another feature of the community health
worker's environment, and a clear sense of identity is often an issue
for community staff. Peripatetic working can make staff invisible
and they have a hazy image with the public. Do community staff get
their sense of identity from being a member of a profession, an
employee of a particular organisation, a member of a team or as a
person serving a local community? Contact with other health staff
can be infrequent and communication is often a logistical challenge.
The problems of a peripatetic working environment are most
extreme in inner cities or remote rural areas and in providing
'out-of-working-hours' services. Fears for personal safety and
security of largely female staff is a major problem, particularly in
areas of high crime .

• Locus of training and education

The problems of delivering health care in community settings also
apply to training and education of health professional staff. The
traditional pattern of health education has been to train staff in an
environment designed for group learning (that is in a college etc.)
and to get practical experience of patients in a convenient setting for
group learning (for example a teaching hospital). Learning how to
apply core health skills in an uncontrolled environment such as a

208
person's own home and in a peripatetic mode of working IS
currently a post-basic set of competences to acquire .

• Hospitals - large-scale health centres of convenience?

It can be seen that hospitals as large-scale 'centres of health care' are
very convenient places for health staff to train in and to work in.
They offer an environment that can be controlled for health staff,
removing risk and unpredictability in their working lives and
offering benefits such as easily accessible catering, social and sports
facilities. This, of course, has to be balanced with considering the
needs of the patients they exist to serve. We know that hospitals are,
at worst, risky or dysfunctional places for ill people (risk of cross-
infection, risk of loss of self-caring skills) as well as, at best, curative
or life-saving centres. A major problem for community health
organisations is to wean the mainstream of health professionals
away from the immediate comfort and security of the hospital
institution and to inspire their confidence that large-scale improve-
ments in quality for people with common, chronic disease would be
achieved if far more services and training were community-based.

Are traditional centralised and top-down methods of direction and

control still appropriate for the NHS?

Community health services, as part of the NHS since 1974, have

been part of a bureaucratic organisation where strategy has been
formed at the top (Department of Health/NHS Executive/Regions)
and health authorities, and NHS trusts are means of implementa-
tion. In Mintzberg's (1979) categorisation of organisations, the
NHS is most similar to a 'professional bureaucracy' where the
skills of health professionals are standardised by statutory and
professional bodies' accrediting mechanisms. Power has rested with
the professionals; the hospital-based medical profession being the
most dominant.
Community health service organisations have also had elements
of a 'machine bureaucracy', where work has been standardised (for
example immunisation protocols), and a 'missionary' organisation
where the organisation is brought together by shared core beliefs
(for example that the inexorable pull towards hospital-based and
specialist care should be resisted). The nature of the direct account-
ability of the Secretary of State for Health to Parliament for the

209
NHS, also gives the NHS the characteristics of a centrally-con-
trolled organisation.
The purpose of the NHS reforms has been to open the NHS to
new forces such as those of competition and the market, to achieve
the government's aim of a publicly-funded and accountable NHS
that is more cost-effective. We are now living through the con-
sequences of a massive organisational experiment - seeing whether
we can retain a universal public health service whilst increasing the
forces that also have a risk offragmenting the NHS. We cannot put
the genie back in the bottle, so we have to find new ways of
managing the conflicting forces in the NHS (which many would
argue were always there), including creating new forms of organisa-
tions and new ways of running them. Traditional methods of
direction and control are no longer appropriate. The NHS, and
community health service providers, need to become far more
decentralised and able to work across several horizontal dimensions
(that is with different purchasers - GPFHs and health authorities -
and with partners such as social services and GPs etc.), in the drive
to become more responsive to the consumer.
Through addressing the above questions, I have derived five
criteria to judge an organisation's fitness for delivering effective
community health care.

ORGANISATIONAL FITNESS CRITERIA

These criteria will be used to appraise the effectiveness of current

organisations in delivering community health care.

Current provider organisations

Most community health services are currently provided by NHS

trusts. However, as purchasing becomes more creative either
through health authorities or GP fundholders, an increasing num-
ber of services are being provided by the independent sector or by
staff employed by GP practices.
The configuration of NHS trusts varies across the country and
most are made up of the collection of services put together when
district health authorities were formed (on the abolition of area
health authorities, when their new units of service were identified in
1982 (DHSS, 1981). Units of management were strengthened when

210
general management was introduced in 1985 (DHSS, 1985) and unit
general managers were appointed, accountable to the district gen-
eral managers. Most units have changed little in their configura-
tions over the 1980s and passed into their current quasi-independent
status as NHS trusts over a five-year period in the early 1990s
(DoH, 1989a, 1989b).
Some NHS trusts provide a combination of acute hospital
services, mental health and learning disability and other community
health services. Such a combined NHS trust occurs most frequently
in rural areas. Other, more frequent, permutations include 'priority'
services trusts, that is community, mental health and learning
disability services, or acute services and community services (with-
out mental health), or mental health services alone, (with or without
learning disabilities), community services alone or acute services
alone. Across the country, most community services are provided
separately from acute hospital services. The policy underpinning the
creation of NHS trusts did not prescribe the precise configuration
of services, except in the case of inner London, where the recom-
mendation of the Tomlinson report (Tomlinson, 1992) that com-
munity health services should not be combined with London
teaching hospitals in the same trusts, was adopted by the Secretary
of State. This was because it was believed their interests would be
subsumed in the interests of survival of secondary and tertiary
services in an intensely competitive market.
GP practices are currently heavily restricted by the terms of GPs'
national contract, in the range of staff the practice can employ to
support the core work of the GP. They can employ administrative
staff and practice nurses and the practice must pay 30 per cent of
the salary of the employee. Practice staff do not have the same
framework for their terms and conditions as NHS trust staff, that is
based on the Whitley Council's system (Whitley Council, 1973) and
a significant difference is they do not benefit from public sector
pensions. However, the number of practice nurses employed by GPs
has grown rapidly and studies show that they are largely satisfied by
the role, in particular the close identity with a defined population
and the responsibility/flexibility of working in a small organisation.
GP fundholding gives a practice considerable freedom to determine
how a wide range of community services will operate in respect of
its practice population by having the budget to purchase those
services. This includes the freedom to directly employ community
health staff, with the exception of community nurses whom they
must purchase currently from NHS trusts. Many GP fundholders

211
would like greater freedom to employ community health profes-
sionals and provide the services themselves.
Certain community services, usually those serving a clearly
definable client group, are provided by independent providers,
either not-for-profit organisations or private sector organisations.
Some have been provided in this way for some time, for example the
Family Planning Association or Macmillan Nurses for Cancer, and
are purchased by NHS trusts, health authorities and GPFHs.
Others are being stimulated to come into the NHS and community
care market for the first time, for example nursing home providers.
The five criteria for organisational fitness will now be applied in
turn to NHS trusts, to general practice, and to the independent
sector.

Criterion 1

Capable of development of professional standards both in line with

evidence of effective outcomes and with the needs and preferences of
individuals?

NHS community trusts

The identification of professional or clinical standards of practice is
vital for the effective management of health services. We know that
identification alone is not sufficient, they must be constantly subject
to review in the light of any new evidence about the outcomes of
application of the standard, and sensitive to the diversity of
individual need and preference of any given population. Most
community trusts operate through a multi-dimensional matrix
structure of professional group, locality, and client group to try
to ensure clinical standards are relevant, for example a health visitor
in general practice delivering child health services. It requires
considerable managerial skill to get these forces in an optimal
balance and to demonstrate accountability.
However, most mature community trusts would regard this as
very close to their approach to ensuring quality, using techniques
such as clinical audit or service reviews. Accountability to the trust
board is clear in the case of the medical and nursing professions,
that is through the medical director and director of nursing, but less
clear for other professional groups. Weaknesses include the paucity
of scientific evidence of effectiveness of clinical outcomes in many
aspects of community health services (see for example the National

212
Association of Health Authorities and Trusts, 1995), and the
difficulty in monitoring the practice of semi-autonomous profes-
sionals who are peripatetic. The structural divide from GPs dilutes
the feedback loop of information from service users that both
clinical staff and their managers badly need. There are many
examples, however, of community trust staff changing clinical
standards and influencing the wider clinical bodies as a result of
taking on board the views and needs of their individual clients, for
example HIV services. Community trusts can enable a critical mass
of professionals to come together and learn from each other.

NHS combined NHS trusts

Many points made in respect of community trusts apply, but
combined trusts have a further dimension or dimensions in their
structure which tend to dominate the rest, that is disease or medical
speciality. The disease dimension should be a very useful addition as
it offers good potential for evidence-based outcome information,
but only if it is in balance with, rather than dominant of, the other
dimensions.

General practice
Progressive general practices are strongly committed to medical
audit and, increasingly, multi-professional audit supported by
health authority-led initiatives. A strength of general practice is
its closeness to its practice popUlation, and its patients theoretically
can vote with their feet if standards of practice do not meet their
needs or preferences. Patients do not have that option for commu-
nity services provided by NHS trusts. However, there is a wide
spectrum in different parts of the country between practices that
inspire the full confidence of their practice populations and other
primary care workers, and those that do not. Concerns are greatest
where the practice population is deprived (socially or economically)
and/or vulnerable, for example the disabled or chronically sick, or
where English is not the first language. Patients in this situation find
it hard to change GPs and the apparent choice many not be real.
GPs have considerable freedom to determine the development of
clinical practice standards themselves through their national con-
tract, with 'light' accountability to their local health authority. This
leads to a wide range between excellent and poor practice. The
partnership structure of general practice does not appear a very
robust organisational form on which to build greater responsibility

213
for the development of a wider range of clinical standards of
practice of other community health professionals, if equity of access
is an important policy aim.

Independent sector
Independent community providers tend to operate in niche areas,
where needs are highly specific. Their strengths lie in the develop-
ment of clinical standards of practice tending to be very sensitive to
the views of the user. However, they may be less strong on basing
standards on evidence of successful outcome. Audit methods to
ensure consistent applications of standards are likely to be unregu-
lated and therefore subject to wide variations between good and
bad.

Criterion 2

Capable of being an effective part of a wider health care network?

NHS community and combined trusts

Most senior community health staff understand that their contribu-
tion to health care is part of a wider system and they are part of a
complex network of potential and actual interventions in the life of
an individual patient with health or other associated needs. This
perspective is inherent in the training that health care staff have to
operate in the community (for example for community nursing and
health visiting). The effectiveness of any individual professional's
input to a particular case or package of care for a patient (parti-
cularly one with complex needs) is limited if it is not integrated and
connected with the total experience of the patient, for example,
prescribing a complicated hearing aid for a confused elderly person.
Often it is as important for a health professional to manage how
their unique contribution will impact and connect with other
aspects of the patient's life as it is to provide their discrete service,
item of equipment or drug.
The concept of being part of a network starts with the way
services are delivered, keeping the patient in the centre of the
process. It is well illustrated by the Department of Health's care
management approach for social care (DoH, 1989a, 1989b). This
approach then needs to pervade the whole culture of an organisa-
tion providing community health care - the organisation is no more

214
than a node in the care network, it is not an end in itself or the
centre of the universe. Trusts' cultures vary as to how internally or
how externally they are focused. Large hospitals find it harder to
operate within the concept of a network; they are more used to
being fixed points in the centre of a local health care system. In
combined trusts this culture can constrain the flexible provision of
community services, where sensitivity to diversity of need is vital.

General practice
General practitioners vary considerably in their ability and inclina-
tion to operate within the context of a wider network of health care
provision for their patients. Medical training concentrates on
diagnosis and treatment, which demand skills of convergence rather
than divergence. Many doctors find that putting large amounts of
effort into communication and managing their role in the network,
with inconclusive outcomes, is frustrating. Also, the demands on
GPs' time are very heavy - most problems presented to them are in
fact trivial and self-limiting, but every so often there is the serious
case to be spotted amongst the trivia. The numbers of patients they
see in a day are large - 50 would be a typical number. It is a
dilemma for GPs - do they have fewer patients on their list so they
can personally manage their care holistically, as part of a network,
and have less financial reward for doing so, or do they maximise
their income and manage less of a slice of the care for a larger
number of patients, who may then have to depend on a wider range
of other health professionals or to take more responsibility for
managing their own network of care? Most GPs are dependent on
the network around them, but cannot give priority to actively
maintaining it. Size of practice is less of an indicator of how well
the practice performs as a node in the network of care than the
culture and attitudes of the GP and their staff.
GP fundholding offers a development opportunity for GPs to
become less isolated and to work more collaboratively with other
parts of the care network. The power that fundholding gives to GPs
can be used positively to enhance the connectedness of the network
for patients, or negatively to fragment the network even further.
The total-purchasing pilots for GP fund holding give great scope for
developing networking around the needs of patients.
GPs' training has developed enormously in the last couple
of decades and great emphasis is placed on communication and
team-working skills. This is a good foundation for the potential

215
development of general practice into an organisation providing
community health services.

Independent sector
Independent organisations are often more effective than statutory
organisations at networking with other key players. However, they
are not always seen as critical to the network, their survival depends
on their sensitivity to their users' and sponsors' needs and to their
environment. Successful organisations place emphasis on provision
of information and communication.

Criterion 3

Capable of planning and implementing strategies for key resources -

that is human, financial, buildings, equipment/supplies and informa-
tion technology?

NHS community and combined trusts

NHS trusts have been set up to have the capability to undertake
strategic planning and to manage the above key resource inputs
strategically, that is with a view to where the trust might be in the
future, beyond the next couple of years. Trust boards are monitored
by the NHS Executive on their management performance through
adherence to financial targets, evidence of robust business planning
and strategic planning processes, and through the submission of
proposals for any major development requiring a significant
amount of capital investment. Accountability for strategic manage-
ment of resources is tight - executive managers are accountable to
trust boards with equal numbers of non-executive directors, many
appointed for their expertise in these fields.
It is rather early to tell how successful trusts are in strategic
management, and the situation is complicated by the complexity of
measuring their performance in terms of health outcomes. The jury
is still out, particularly on human resources where the two major
issues for all trusts are the devolution of the national machinery (the
Whitley Council system) for negotiating pay, terms and conditions
to the local control of trusts and their staff (Langlands, 1994), and
also the introduction of NHS contracting with higher education for
the education of most non-medical health professional staff
(NHSME, 1995) and the continuation of tight controls on the

216
numbers of training places for all other health professional staff,
including doctors.
The use of information technology is not an area in which NHS
trusts have excelled themselves to date. The technical solutions are
there to revolutionise the way all types of health care information
are collected, communicated, analysed and stored, but many com-
plex factors hold NHS providers back in exploiting information
technology as much as other industries such as banking, insurance,
airlines and so forth.
An NHS trust's ability to manage its resources strategically has a
cost, and would be identifiable as a significant element of its
management costs (which are typically around 3-6 cent of total
income, using Audit Commission (1995) definitions. Community
trusts and combined trusts would not be significantly different in
this criteria, though community only trusts would be more focused.
They also would tend to be smaller, which may have disadvantages
for attracting and retaining managers of appropriate calibre. An
NHS trust providing a significant range of community services (that
is at least 15 different services) with an income of less than around
£14 million would find it difficult to sustain a strategic management
performance without disproportionately high management costs.

General practice
Most general practices are much simpler organisations than NHS
trusts, and most GPs and their staff have little experience of
strategic management of the key resources for community health
services. GPs do, however, have the intellectual capacity to learn
how to undertake strategic management and many are demonstrat-
ing their enthusiasm and commitment in their purchasing role as GP
fundholders, particularly in the total-purchasing pilots. Many also
have some experience of developing their own premises with exam-
ples of large, complex schemes; for example a GP fundholder in
Epsom, Surrey, entering a joint venture with developers to create a
combined GP surgery and surgery day-care centre, again stimulated
by the wider freedoms of fundholding. Many GPs have been able to
harness the benefits of information technology for their practices
more quickly than many NHS trusts, and there are examples of
several practices close to achieving systems of paperless medical
notes. GP fundholding is dependent on information technology.
The organisation model of partnership is one that best suits a
stable environment. Rapid and un.predictable change can challenge

217
relationships built on simple joint aims and assumptions. The
incidence of break-ups of GP partnerships is increasing and is not
conducive to effective strategic management.

Independent sector
The independent sector is finding it difficult to enter into the
community health market by providing a diverse range of services
to compete directly with NHS trusts. In economic terms this would
be described as due to the high barriers to market entry.
Generally, they are not sophisticated organisations able to make
large-scale investments in any of the key resource areas. The
strength of independent sector organisations in these areas depends
in part on their size and the strength of their financial viability.
They can display innovation on a small scale in any of these areas.

Criterion 4

Capable of maintaining motivation of the work-force of key health

professional staff?

NHS community trusts

Most community health professional staff (nurses, therapists and
other professionals allied to medicine and doctors) are conservative
by nature and prefer continuity of employment to offer continuity
of service to the population they are serving. Many staff live in the
locality they are serving and work autonomously. They generally
prefer not to take risks, but are willing to innovate to improve care
because they feel that care can be improved, mainly through
additional funding. They do not like innovation imposed from
outside. Traditionally, employment in an NHS organisation has
offered security, both in employment and as a base to develop or
maintain professional practice in a safe environment. Some com-
munity trusts have had command-mid-control management cul-
tures, where field staff have been constrained in their autonomous
decision-making and development, and discouraged from working
collaboratively with GPs. Community trusts will vary in their ability
to maintain the motivation of their staff. They mostly have the
loyalty of their staff and if they are able to continue to offer
competitive reward packages that are not just monetary but include
imaginative use of benefits such as flexible working and training
opportunities, they will be in a good position to retain loyalty.

218
NHS combined trusts
Much of the above can apply to combined trusts, and they have the
advantage of being able to develop more effective ways of managing
the hospital/community interface, for example on admission and
discharge. But they also have the risk of being less sensitive to the
characteristics and needs of community staff that distinguish them
from hospital staff, and the prevailing culture within some com-
bined trusts is still one where community services are 'Cinderella'
services in relation to hospital specialist services.

General practice
The advantages of general practice are that it is small and highly
focused; communication amongst staff and patients can be on a
personal scale. Most GPs employ administrative staff and practice
nurses who are mainly loyal, long-serving employees. However,
there are wide variations in employment practices - for example
between single-handed and large practices - and stress levels can be
high. Expanding into direct provision of community health services,
and employment of community health professionals, is a new
experience for general practice. Focusing on the holistic needs of
individuals and the practice population, and working in well-
ordered multi-disciplinary teams where goals, methods of commu-
nication and performance review are mutually agreed, will be
motivating factors for most health professional staff. However, to
sustain the motivation and development of staff, general practice
needs to become a more sophisticated organisation, capable of
offering personal benefits at least as good as or superior to those
of an NHS trust. These would include pay, hours of working, a
sense of value and belonging, a good working environment, training
and development opportunities, and minimising non-productive
time (for example travel time, duplicate data entry or attending
inappropriate meetings).

Independent sector providers

The independent sector, like GPs, has to entice health professional
staff away from perceivedly more secure employment in NHS
trusts. Without GPs, the independent sector cannot offer holistic,
multi-disciplinary services to a large population. However, by
focusing on particular, niche areas of the market usually associated
with a defined client group, the independent sector can attract

219
health professional staff who prefer a focused, specialist commit-
ment to particular client need, for example dentistry or chiropody.

Criterion 5

Capable of offering value for public money by minimising expenditure

on overhead cost or transaction costs?

Any organisation should strive to add value to those who have

invested their money in it. A private sector company aims to give
profits to its shareholders, and a public sector organisation to give
special benefits that outweigh its costs, borne to some degree by the
tax-payer. Pressure comes from both customers and funders to
minimise any non-essential costs, and overhead costs will always be
an element that needs to be justified in terms of the extent to which
they improve the quality, efficiency or effectiveness of the product
or service provided.
Overheads are made up of management costs, costs of running
buildings, administrative support, and anything else that cannot be
identified as a direct cost associated with a particular service or
product.
Definitions of many elements of services and their costs are
undeveloped in the NHS and comparisons are very difficult,
particularly across totally different organisations.

Community trusts and combined trusts

NHS trusts are viewed by their purchasers, particularly GPs, as
having a natural tendency to inefficiency. Annual requirements for
a percentage across-the-board cost-improvement programme by
health authorities are a response to this belief. An organisation
which has for so long been part of a monolithic bureaucracy which
was not always cost-conscious, is suspect.
There is quite a large range of management costs in different
trusts across the country, as shown by the Audit Commission's
(1995) work. There is often a relationship to size - most larger trusts
have lower management costs proportionate to income than most
smaller trusts. However, whether larger trusts give better value for
their management costs depends on their performance under other
criteria. Although there is public perception that management costs
are excessive, when compared with the private sector NHS manage-
ment costs do not seem excessive and there may even be under-

220
investment in management. Costs of administration are probably
high though, due to under-investment in information technology.
Investment, say in fully automated patient records, would have a
high impact on overhead costs. Trusts differ in the amount of
capital assets they own. If they have inefficient buildings to run (for
example buildings that are not fully occupied or are inefficient in
their use of energy, such as an old mental illness hospital in the
process of being closed), their overhead costs may appear inefficient
and uncompetitive in the short term.

General practice
GPs regard themselves, and are regarded by the public, as the least
bureaucratic part of the NHS, offering excellent value for money in
their gate-keeper role for the whole population. Their overhead
costs are transparent because they are small organisations - in terms
of the cost of premises, support staff and so forth. However, there
are also the costs of administering their elaborate contracts to
consider, which lie in health authorities. This is another area that
has been slow to reduce costs through use of information and
communication technology. As GP fundholders move into purchas-
ing other aspects of health care on behalf of their patients, overhead
costs go up to pay for the transaction process of contracting for
services. These transactions are on behalf of individual patients, and
when added together, represent a significant increase in overhead
costs for the NHS as a whole. Again, their value depends on
whether patients receive better care as a result. There is likely to
be an optimum size for GP practices as efficient purchasing entities
which is well above the single-handed practitioner level.
As the market for health care becomes more and more sophisti-
cated and more fragmented, the costs of contracting are bound to
increase and will be present in all organisations, purchasing and
providing. The question is, can the costs be justified in terms of
improved performance from the NHS as a whole and can informa-
tion and communications technology be used more extensively to
reduce administration costs?

Independent sector
Independent sector organisations can be very effective in minimis-
ing overhead costs. They are less-regulated than NHS trusts and can
be far more flexible in the way they manage the business. Their

221
survival depends on tight control over the quality, volume and costs
of their service.

FUTURE IMPLICATIONS FOR COMMUNITY HEALTH

ORGANISATIONS AND THEIR STAFF

Dr Paul Lambden was a first-wave GP fundholder in Hertfordshire

who became a chief executive of an NHS combined trust and has
now returned to general practice. When asked in 1995 about his
views on the future he said:

'It is quite clear that health provision still has to undergo some
very fundamental changes and they will probably happen irre-
spective of which political party is in power. I think there has to
be a continuing move from secondary to primary care. There has
to be rationalisation of GP and community services and rationa-
lisation of hospital management to ensure cost-effective service
provision. The number of hospitals will decline dramatically over
the next 10-15 years and one of the biggest challenges will be
persuading the public that they no longer need them.'
(Hadfield, 1995)

Providers of community health services are involved in a massive

sea-change, starting in the 1990s, in the way health care is perceived,
organised and delivered. It can best be summed up as moving
Towards a Primary Care Led NBS (NHS Executive, 1994). This
chapter has been written particularly about community health
services as they have been traditionally defined and understood,
in order to illuminate their essence, character and strengths and
weaknesses, to be considered alongside the futures of health service
purchasing, general practice, social care and hospital provision.
Perhaps least has been written about community health services,
which appear at times invisible behind the limelight placed on GPs.
Yet over a third of all face-to-face contacts patients have with
health professionals in primary care are with community health
staff. The reality of primary care in its many forms today is a highly
complex web of services that are not well integrated, and of which
general practice is a significant, but incomplete, part.
The greatest strengths of the traditional community health ser-
vices are in promotion of health and prevention of ill-health and in

222
care of chronically-ill people. These lie alongside the traditional
strengths of the medical profession, which are in the ability to
diagnose, treat and cure illness. Community health services deal
mainly with the politically unpopular parts of the NHS, patients
whose stories are undramatic and do not make the story line of
'Casualty', but who suffer silently day-in and day-out from the
effects on their lives of the pain, functional immobility and psycho-
logical distress that derives from chronic disease. The term 'Cinder-
ella services' still applies.
The future for community health services lies in their taking their
place alongside general practice in a reformed and truly integrated
primary care service, which is funded through a simplified, unified
weighted capitation formula to ensure equity. The challenge is to
build on the strengths of primary care as we know it today, and to
enable health and social care professionals to work together as part
of flexible teams that can adapt themselves to meet the diverse needs
of the population served.
The vision of truly integrated primary care services with the
combined strengths of their traditional separate branches will
require new forms of primary care organisations by the end of the
1990s. Both general practice and NHS trusts, as we know them
today, will be too rigid to allow the degree of integration that is
required to best meet the fitness criteria.
Reform of primary care is dependent on an informed public
engaging in the debate. Very few people have a clear overview of
primary care and there is a lack of appreciation of its potential to
improve the quality of health care and to tackle the negative effects
of over-specialisation of health care, that is iatrogenesis and ex-
cessive costs. We need to gain greater clarity about what are the
core inputs for a primary care centre or team serving an optimum
size of population in terms of skills, buildings and technological
support. Then there will be legitimacy in allocating a budget for the
primary care organisation to use to provide primary care, buying in
any elements it chooses from other providers; and to be used in
referring to, or purchasing, secondary care when necessary. This
process has already started through GP fundholding or through
alternative approaches of locality purchasing.
Community health staff need to be involved as key players in the
reform of primary care. They will respond well to the prospect of
improving patient care, providing the process is not handled in an
autocratic manner and that the reforms are not based on the
assumption that the GP's clinical expertise is universally superior

223
to that of other community health professionals. In turn, commu-
nity health staff need to accept greater personal responsibility for
the development of their clinical practice, informed by the diverse
and changing needs of the population, and for deteJIllining their
terms and conditions of work as responsible members of new
primary care organisations.

References

Audit Commission (1995) A Price on their Heads: Measuring

Management Costs in NHS Trusts. London: HMSO.
Department of Health (1989a) Working for Patients. London:
HMSO.
Department of Health (1989b) Caring for People: Community Care
in the Next Decade and Beyond. London: HMSO.
Department of Health (1993) Making London Better. London:
HMSO.
Department of Health (1995) Responsibilities for Meeting Continu-
ing Health Care Needs. HSG(95)8jLAC(95)5. London: NHS.
Department of Health and Social Security (1981) Patients First.
London: HMSO.
Department of Health and Social Security (1985) Report of National
Health Service Management Enquiry. London: HMSO.
Hadfield, L. (1995) Personal knowledge.
Healthcare 2000 (1995) UK Health and Health Care Services,
Challenges and Policy Options. Manchester: Healthcare 2000.
Johnson, G. and Scholes, K. (1993) Exploring Corporate Strategy
(Chapter 10). New Jersey: Prentice Hall.
Langlands, A. (1994) Letter to NHS Trust Chief Executives. Local
Pay Determination. Unpublished.
Mintzberg, H. (1979) The Structure of Organisations. New Jersey:
Prentice Hall.
National Association of Health Authorities and Trusts (1995)
Acting on the Evidence. Research Paper Number 17. Birming-
ham: NAHAT.
NHS Executive (1994) The Development of Purchasing and GP
Fundholding: Towards a Primary Care Led NHS, [EL94(79)].
Leeds: HMSO.
NHS Management Executive (1995) Education and Training in the
New NHS. EL(95)27. Leeds: NHSME.
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) (1994) Programmes of Education

224
 Leading to the Qualification of Specialist Practitioner. Regis-
trar's Letter 20. London: UKCC.
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Nurses and Midwives Council Pay and Conditions of Service:
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London: Whitley Councils.

225
 CHAPTER TEN

The Effects of Changes in Hospital

Care on Community Health Care

Sandra Legg and Helena Ellerington

INTRODUCTION

'With a lever long enough . . . single-handed I can move the

world.'
(Archimedes)

Health care is being affected by a number of trends, all of which will

impact upon the delivery of services within the NHS and beyond.
Fundamental changes in the delivery of services within acute and
primary care, together with the changing shape of nursing, have
created opportunities for the profession to influence the alternative
patterns of health and social care delivery. These issues will be
addressed in this chapter, together with the opportunities that exist
for building bridges between the plethora of health and social care,
and voluntary organisations. Lessons learnt from the challenges
and opportunities that hospital nurses face will be applied to
community nurses as they develop the government agenda of a
more primary care led service.
The policy debate around the future of acute services and the role
that hospitals will play in the future is gaining momentum. The
move towards replacing existing provision in the UK with fewer
accident and emergency departments and separating more locally-
based, elective facilities from tertiary care services, faces health
professionals and managers with difficulties in achieving change on
the ground. Recent attempts, therefore, to re-configure acute
services around the country seem timely but, by tracking the

226
process, Turner (1994) shows the difficulty that health authorities
are facing in trying to deliver change.
Recent changes have introduced many uncertainties, and for
most parts of the service the future seems unclear. It is with this
background that nursing moves forward into the millennium,
assessing where its future contribution lies and identifying ways
and means of moving the service forward. Nurses working within
acute and community care must identify the forces for change, and
in so doing learn how to accommodate these by protecting what is
good from what is not, and having open minds for future develop-
ment. Nurses must therefore be in the forefront of change; purcha-
sers of health care and patients look to them for continuing
guidance and direction.
Early in the 1990s, health planners began to discuss how health
and social care might be delivered in the early part of the twenty-
first century. Similarly, the Chief Nursing Officers of the United
Kingdom met to discuss health care in the twenty-first century and
beyond (DoH, 1994, the Heathrow Debate). It was evident in these
debates that the current patterns of service would change in
response to various social, technical, economic and political pres-
sures. Government policy-makers wanted to ensure that there
remain sound, clear and logical patterns of service because of the
cost of health care and its importance to the public. Politicians must
therefore find a balance, framing a policy that trades-off the
public's expectations, their own philosophy and vision of the future,
and the economic realities. Three areas have recently received
particular attention and are likely to have a long-term impact:

• A focus on the individual, with consumer-empowerment, citizen-

involvement and health promotion, sharpening the focus on
individual needs and demands.
• A shifting of the balance between care in institutions and in the
community.
• The use of resources must be efficient as the pressures of an
ageing population, new technology, restructuring the medical
workforce, and a new emphasis on quality and choice take effect
(Warner and Riley, 1994).

The reforms, with the formation of trusts and trust boards, have
sent shock waves throughout the service, having a marked effect on
nursing and medical services. Overnight, new organisational struc-
tures, new information, and the requirement of new management

227
skills have been required. These challenges have excited many
nurses and doctors, though some observers have been concerned
at the scale of change and the lack of evaluation as the reforms
progress. There is little slack in the system, with the services facing
tight financial limits and the reluctance of many professionals to
take on further work. There are also pressures to reorganise care
away from institutions to the community, and a further complica-
tion is the mounting evidence from the World Health Organisa-
tion's Health For All Targets (WHO, 1991) of the limited role of
health care services in influencing health and well-being.
Nursing's response to these changes can best be described in
terms of shifts in thinking and practice. Key areas of change are new
technologies, new locations for care, new skills and manpower
substitution, and new ways of working across structures through
inter-agency collaboration. Nurses within the acute care setting
have demonstrated new and innovative ways of handling some of
the complexities within acute health care today. Innovations such as
reinventing Florence Nightingale's insight into nursing leadership
and management, developing a transformational leadership style,
identifying the nurse executive's contribution to the board agenda,
working within a clinical empowerment environment, developing
clinical supervision for the practitioner, contributing to technolo-
gical assessment, working with more flexible work patterns, and
introducing case-management systems of service delivery, are all
structures and systems which community nurses will need to think
about as the primary care led service is developed. All these issues
will be highlighted in this chapter, together with the effects that such
changes and innovations will have on nurses working within the
community services.

THE CHANGING SHAPE OF HOSPITALS

It is not possible to consider the changing shape of hospitals

without first considering how they have emerged in history, and
what have been the catalysts producing the changes.
At the end of the Second World War, the formation of the
National Health Service in the UK was the cornerstone of the
Labour government's welfare state. For the first time in Britain
health care was free, and for many the 'promised land' had arrived.
Freedom from the fear of illness, injury or disability, together with
the ensuing poverty which always accompanied ill-health, became a

228
reality. Initially it was thought that the cost of the health service
would be high, but as the population became healthier, so would the
costs decrease. The health service, therefore, became a 'sacred cow',
and it is easy to see why the vast majority of people were prepared
to campaign to keep their local hospitals open, and were happy to
wait for hours in out-patient departments, or to spend years on
waiting lists for surgery.
The separation of the purchaser and provider roles is the biggest
change in the NHS since its inception. This has brought about
significant changes in many parts of the United Kingdom, particu-
larly in large conurbations, but most extensively in and around
London. This, and the contribution of capitation funding, has
highlighted the vulnerability of London's major teaching hospitals,
which were already facing reductions in their relatively well-funded
positions as a result of the move towards Resource Allocation
Working Party targets. It is patently clear that a number of
London's teaching hospitals will not be viable in their present form
when purchasers plan services on the basis of their assessment of the
needs of the resident population.
Debate on the future of hospital services within London, follow-
ing the publication of the inquiry by Sir Bernard Tomlinson (1992),
has been extensive and time-consuming. This situation mirrors the
thinking about acute care across the country. Expenditure of £17.7
billion was spent on hospital and community health services in
England in 1989 to 1990 of which approximately £3.3 billion was
devoted to London, although only 15 per cent of the population live
in the area covered by the London health authorities (King's Fund,
1992). It is perceived that in the twenty-first century only diagnoses,
investigations and treatment which require the use of expensive
equipment and a range of highly skilled personnel will take place in
acute-care hospitals. Accident and emergency facilities will be
linked to acute tertiary hospitals. Special trauma units will serve
patients with major and multiple injuries, using skilled teams of
clinicians expert in this type of emergency work.
Outside London there will be a fundamental reassessment of the
district general hospital, both in size and role. The hospitals will
become more highly specialised units treating only acutely ill in-
patients and day-cases. Beds will be reduced to approximately 250
per hospital, and the less-acute care will be provided by local
community hospitals serviced by general practitioners and peripa-
tetic hospital consultants. Maternity care will be provided on both
sites but only high-risk cases will go to the specialised obstetric

229
units. More births may occur at home, and since the publication of
Changing Childbirth (DoH, 1993), the government appears to be
willing to provide more support for home deliveries.
The Heathrow Debate (DoH, 1994) outlined a scenario for
hospitals in the year 2010, not only supporting the overall direction
of the above new paradigm in health care, but also providing a useful
template for discussion and thought about the possible configura-
tion of services. The report describes the pattern of care in terms of a
circle, with general care teams on the periphery and specialised care
services in the centre. The specialised care services will remain
centralised services for the severely-ill and for major surgery, offer-
ing high-technology and very specialised services. Other services
currently provided by larger hospitals, including laboratory, diag-
nostic and surgical facilities, will move to the community along with
40 per cent of out-patient consultations. By the year 2002, it is also
predicted that the current distinction between health services and
social services will have blurred, everyone over 85 will have a key
worker, 15 per cent of births will take place outside hospital, and
acute beds in district general hospitals will be reduced by at least 40
per cent. Without doubt if these proposals are adopted the greater
amount of care will be offered in the community by the general care
teams, and the changes will dwarf the very radical and 'painful'
fallout of the Tomlinson Report (Tomlinson, 1992) in London.
Figure 10.1 illustrates the complexity of organisational change
resulting from the impact of the new technologies.
Since the health reforms the population has begun to think
increasingly of health care as a service industry rather than part
of the welfare state, and has undoubtedly become more demanding.

Figure 10.1 Organisational change resulting from new technologies

Day-case Day-case
Surgery Surgery

Smaller Highly
Home Care GP Clinics local DGH Specialised
hospitals Units

Source: Warner and Riley (1994). Closer to Home, Health Care in the 21st
Century. Research Paper 13. London: NAHAT.

230
The publication ofleague tables and The Patient's Charter initiative
by the NHS Executive (DoH, 1991), have all raised awareness and
expectations of the services, and the rights of the individual to
demand quality. This has ultimately received the persistent atten-
tion of the press on all matters related to health. The unremitting
demands for high-quality service and treatment, together with the
shift towards a more primary care led service, have therefore led
health planners to think more strategically across the great organi-
sational divide. Some of the trends affecting changes in the area of
acute care are shown in Figure 10.2.

Figure 10.2 The political, social, economic and technical trends which
have influenced changes in acute care

Political Economic
• Spiralling health expenditure • Postwar UK economy
• Keeping patients in their local characterised by 'boom' - 'bust',
community - a cheaper option but also periods of substantial
than hospitalisation growth
• Concept of health moving from • UK economy affected by the
welfare to a service industry global economy
• Future issues (Warner and • Recession in the 1970s, the late
Riley, 1994) 1980s, and the 1990s, have made
• A focus on the individual rights many western countries target
vs responsibility health spending
• Efficiency and effectiveness • Control of inflation - driving
force in the UK

Social Technical
• Demographic problems not only • Escalating advances in
in the UK, but also in western technology
Europe • Developments in the
• Birth-rate does not match the information 'superhighway' and
replacement rate - in the UK 'superjanet' .
• Growth in higher education in • The NHS information network
the UK influences attitudes and strategy launched in 1993
produces a healthier population • More access for customers and
• Education raised expectations consumers of health to
and demand as people become information on services, waiting
more aware of factors lists and performance indicators
influencing their own health • Medical advances in
• More divorce and family miniaturisation, imaging,
breakdown, mobile families, ultrasound and keyhole surgery
nuclear families and working having a radical effect on the
women reduced the number of service, its delivery and patient
'traditional' carers length of stay

231
The business environment and health care

With the introduction of key business ideas into the health service
the internal market has developed and taken shape. Marketing, a
key idea, has become essential for the efficient and effective delivery
of services. 'Branding' of services and organisations has become a
must, and the corporate 'logo' and mission statement are visible
examples of this process.
Branding is not a new concept, in fact, it started in the middle
ages when craft and merchant guilds required that each purchaser
should mark goods, so that the output could be restricted and
inferior goods traced to the producer. Today, a brand name, design
or symbol identifies the products or services of a seller or group of
sellers. Evans and Berman (1985) emphasise that by establishing
well-known brands, companies are usually able to obtain accep-
tance, extensive distribution and higher prices.
Another key business idea, adapted for a health environment, is
the concept of Business Process Re-engineering. Developed by
Hammer and Champy (1993) re-engineering has become the radical
re-design of a company's processes, organisation and culture.
Hammer and Champy show how some of the world's premier
organisations use the principles of re-engineering to save millions
of pounds in resources, to achieve unprecedented levels of customer
satisfaction, and to speed up and make more flexible all aspects of
their operations.
The concept is considered to be one way of revolutionising health
care organisations today, and has been tested at the Leicester Royal
Infirmary. The initial results of this pilot project were so promising
that a project has been funded by the NHS Executive at King's
Health Care Trust, a London teaching hospital. The project is
summed up as a 'root and branch' look at services and their
delivery. The process involves all grades of staff, who pool their
ideas and skills and 'map' the processes of service delivery. Staff
belong to what are called 'laboratories' which decide on the redesign
of processes. Leicester took the 'patient visit' as one of the first
processes to be mapped. The processes were mapped from the
patient's referral by the OP, through the hospital out-patient
department, day-case or ambulatory service, and back to the
patient's home. Following this mapping process the trust's neurol-
ogy clinic was revolutionised.
Precision marketing such as branding and business process re-
engineering are considered to be two key business elements in the

232
new health environment. Nurses have therefore had to readjust
their ways of working within this new environment, and have
ultimately become more flexible and more collaborative in their
approaches. As yet, planners have not considered the benefits of re-
engineering in community services, though work is already estab-
lished across the interface of care. This concept, nevertheless, is
worthy of note.

THE CHANGING SHAPE OF NURSING

Health sector reform has had a huge impact on nurses and nursing
within the acute and community care settings, and in particular on
nursing leadership. In the United Kingdom, and elsewhere, there
has been a gradual demise of nursing leadership with a political
agenda entirely focused on general management issues such as
efficiency and effectiveness, which has continually pushed nurses
to the periphery of decision-making. It is also evident that since the
reforms the reconfiguration of management structures within orga-
nisations, is at great odds with the centrality of caring, and with the
role that nursing leadership plays in the management of nurses and
patient care. It is not before time, therefore, that organisations
should be redesigned, so that nurses may hold strategic leadership
positions which ensure that the core values of health care become
central, once again, to these organisations.
The nursing profession has to ask fundamental questions about
its future direction if services polarise, as suggested by The Hea-
throw Debate (DoH, 1994), between the new-style acute hospital
offering a high-technology centre and the community-based ser-
vices. The acute hospitals will need highly-skilled technicians but
will they need nurses? With boundaries blurring and many more
agencies and voluntary bodies providing care, what role will nurses
have? Traditionally, nursing has focused on the patient as an
individual, not on a specific clinical problem. This co-ordinating
role will become more important as care diversifies, and will be
enhanced by the continued development of the specialist-nurse role
across all the new divides. This will be an important thread in the
new tapestry of care.
Nurse executives have a major responsibility in leading organisa-
tions through the management of change agenda and into the new
reality of health care, and perhaps lessons should be drawn from
American colleagues who are at the forefront of some of these

233
changes. Time and resources in the USA are committed to prepar-
ing leaders for the future, and a total shift of mind enables
organisations to flourish in a learning environment.

Nightingale onwards

One of the key lessons learnt from America is a more in-depth

understanding of Nightingale's work in preparing leaders for the
future. Professor Beverly Henry, from the University of Illinois, is
running a joint masters programme on nursing and business
administration, and within this curriculum, she places a major
emphasis on Nightingale's thinking and writing (Henry, Woods
and Nagelkerk, 1990). Nightingale stipulated that nurse leaders
should be:

• Educated leaders;
• Clear-thinking and decisive;
• Collaborative and capable of managing complexity;
• Imaginative and have the ability to grasp technical details of a
vast range of subjects;
• Capable of organisational design and governance;
• Capable of personnel management;
• Capable of financial management and patient classification.

Henry et al. (1990) maintain that the administration of nursing

services is done best by educated and experienced nurses who
understand the nursing processes required for patients, and their
twenty-four hour nursing and health care requirements.

Transformational leadership

Encompassing Nightingale's criteria for effective leadership is the

style and form of leadership. Transformational leadership is a style
of leadership which stems from the creative work of Benis and
Nanus (1985), who hold the view that 'a leader who transforms, is
one who commits people to action, who converts followers into
leaders, and who may convert leaders into agents of change'. It is
evident that this style of leadership fits very well with nursing
ideology, which is based on concern for others, and on interaction
with patients.
Throughout the USA this style of leadership is practised widely
and is very effective in bringing together the whole multidisciplinary

234
team. In these times of change and the re-configuring of services,
leadership which empowers and enables practitioners to make
decisions at the point of delivery can only be enhancing.
Senge's (1990) ground-breaking work in The Fifth Discipline
further develops our thinking around styles of leadership, suggest-
ing that participative management is not merely a new form of
entitlement, but a basis for learning. Senge's learning organisations
are organisations where people continually 'expand their capacity
to create the results they truly desire, where new and expansive
patterns of thinking are nurtured, where collective aspiration is set
free, and where people are continually learning how to learn
together' (ibid., p. 4). Organisations such as these, therefore, offer
a marvellously empowering approach to work.

The board

By statute, nurse executives in both acute and community care act

as representatives of the nursing profession on trust boards. Their
roles have never been completely clear to themselves or to others,
and some would argue as to their effectiveness and their contribu-
tions to the board agenda.
The Department of Health's One Year On (NHSME, 1992) study
of trust nurse executives found that many of them were prepared to
sacrifice their nursing role and to declare that they were executives
and not nurses. Similarly, a recent survey by the NHS/Newchurch
and Company (1995), reported that chief executives believe nurse
executives lack strategic skills, and nurses down the hierarchy think
that nurse executives are far removed from hands-on care. Clearly
there is a role crisis here which may never be resolved.
Most worrying of all, however, is the finding from the New-
church survey that nearly 30 per cent of nurse executives in acute
and community trusts manage no nursing services whatsoever. This
highlights grave concerns which Porter-O'Grady in Naish (1995)
warns is 'slow suicide', in that having someone on the trust board
with whom you have no real relationship widens the policy/practice
gap even further. The nurse executive is the person with the
information that other nurses need, but the further that person is
removed from practice, the less relationship he or she is going to
have with the staff whom he or she is supposed to be leading.
Clearly, the report also identified the problems that chief execu-
tives have in pigeonholing nurse executives into their idea of what
nurse executives can contribute to the board agenda. Most chief

235
executives seem ambivalent, and suggest that on the one hand
nurses are good at and should be seen to be leading in traditional
nursing areas such as quality and clinical-practice development,
while at the same time believing that nurse executives should be
making a corporate contribution.
If chief executives have the wrong idea about nursing's contribu-
tion to the board, then nurses, themselves, must surely put the
record straight and take ultimate responsibility for shifting this
thinking and clarifying the nurse executive's raison d'etre. Naish
(1995) goes further to suggest that 'nursing is in danger of having to
declare itself clinically bankrupt as trusts demand, in response to
ministerial dictates, that health care professionals establish the
worth of their work' (ibid., p. 6). If nurse executives are to survive,
Naish is adamant that they 'must reassert their professional leader-
ship by linking strongly with their hands-on nurses, and with
researchers, to develop the new effectiveness agenda and nail it to
the heart of their corporate trusts' agenda' (ibid., p. 6). In response
to the nurse executive's question, then, 'what do I bring to the
board?', surely the answer must lie in the 'clinical effectiveness'
debate. Nurse executives, in both acute and community care, must
therefore prove that their interventions benefit patients, at all costs.

Clinical empowerment

Since the 1960s, many hospital nurses in America have been making
changes in the clinical setting which directly improve the delivery of
patient care. The introduction of primary nursing has enhanced the
nurse-patient relationship and placed higher accountability for
patient care with the primary nurse. Similar needs have sparked
the development of shared governance structures in nursing. Whilst
traditionally implemented within hospital services, shared govern-
ance is now being considered as a valued systems model within
community services. Its main focus is that of developing leaders and
bridging the great policy/practice divide between clinical practi-
tioners and nurse executives.
What then is shared governance? It is a decentralised approach
which allows nurses to retain their influence about decisions that
affect practice, the work environment, professional development
and personal fulfilment. As an organisational structure, it also
requires practitioners to assume higher levels of accountability for
patient care, clinical practice and professional activities. By building

236
peer relations, governance can enhance the staffs ability to take
more responsibility and accountability for themselves and their
peers. Its committee structure fosters teamwork, thus allowing staff
nurses a more active role in developing and implementing systems
designed to achieve patient care outcomes and develop nursing
practice.
In 1994 a shared governance structure was implemented in St
George's Health Care Trust (Legg and Hennessy, 1996), a London
teaching hospital, following a two-year preparation for implemen-
tation. Following a year's implementation phase, a survey was
carried out throughout the trust to gain the views of professional
and administrative staff. It was apparent from the survey findings
that all staff interviewed were in favour of empowering nurses.
Some, however, questioned the readiness of nurses to take on such
accountabilities. For example:

• All nurses were in favour of shared governance, but questioned

whether this was the right time.
• Staff nurses generally did not feel confident about making
autonomous decisions, whereas staff nurses in specialist areas
were more confident and had more equitable relationships with
their medical colleagues.
• Some middle-level nursing managers were uncertain about the
feasibility of a staff nurse taking the chair of the nursing practice
committee.
• General managers were in favour of nurse empowerment, yet at
the same time felt that nurses would find the chance of moving
beyond the boundaries somewhat daunting. Perceptions such as
these, however, may be influenced by the unwillingness of general
managers to relinquish their own status and territory.

Findings from the St George's experience, however, suggest that

when culture change occurs in an organisation, which requires a
paradigm shift, the leader should be totally involved and committed
to the change process. Research findings also suggest that the
implementation of shared governance requires a champion, who
will envision, lead, facilitate, support and drive when necessary.
Shifting the balance in thinking, behaviour and attitudes can also be
translated across service and professional boundaries, and ulti-
mately has the potential for assisting professionals in moving
towards new areas such as primary care led services.

237
Clinical supervision

The concept of clinical supervision has both excited and bewildered

the profession in a manner reminiscent of other nursing innovations
in the past. Whilst new in its implementation, this innovation,
however, like shared governance, is such a good idea because of
its potential to produce change and assist nurses through a period
of paced change. Described as a professional relationship between
practitioner and supervisor, and aimed at encouraging self-assess-
ment, reflection on practice, therapeutic proficiency and the pro-
motion of innovation, its potential for guiding nurses through
periods of great change, and in particular crossing the boundaries
of care, is enormous. Clinical supervision supports nurses in meet-
ing the changing circumstances in acute services, and in developing
a more strategic approach to their own development.
Clinical supervision therefore provides nurses with an effective
'tool' for monitoring, supporting and developing the profession,
and also has the potential to become an important factor in the
development of improved services to patients and clients. Potential
benefits, nevertheless, are not limited to the patient, client or
practitioner. A more skilled, informed, aware and articulate profes-
sion will contribute strongly to the ability of an organisation to
meet its objectives.
The United Kingdom Central Council for Nursing, Midwifery
and Health Visiting (UKCC) is clear that 'clinical supervision will
play an increasingly important part in ensuring safe and effective
practice' (UKCC, 1996). This is supported by Butterworth and
Faugier (1994), who postulate that the 'exchange' or 'relationship'
existent in clinical supervision, has a range of benefits which
include:

• Improved patient and client care;

• Improved staff performance;
• Improved managerial performance;
• Reduced risks.

However, the UKCC stresses that clinical supervision is not the

exercise of overt managerial responsibility, a system of formal
individual performance review, or intended to be hierarchical in
nature.
Various trusts and health care organisations in acute and com-
munity care are developing models of supervision, and it is timely

238
that nurse managers throughout the health service should co-
ordinate evaluation of clinical supervision to demonstrate effective-
ness and service benefits. As the balance in health care shifts from
the hospital to the community, it is essential that a better mutual
understanding exists between all professionals, and that a common
method of monitoring and support exists for all concerned. The
United Kingdom is clearly at the forefront of these innovations, and
should publicise its findings as soon as possible in order to influence
global trends elsewhere.

Nurse development units

Demonstrating the worth and value of nursing is becoming increas-

ingly important. Why should the commissioner of services in the
new century employ registered nurses? With a cost-effective agenda
cheaper staff substitution will become the order of the day. If nurses
and nursing skills are perceived as more expensive and less effective
than alternatives, the alternatives will be purchased.
The work undertaken at Burford Community Hospital in Oxford
by Pearson (1983) has been the catalyst and has inspired the
development of nurse-led services. The philosophy at Burford
aimed to maximise the therapeutic potential of nursing for patients
who were admitted to the unit. The prime objective of nurse
development units (NDUs) is the provision of client-centred care
by nurses who are questioning and autonomous practitioners within
the health care team, and the implementation of processes of
nursing care based on research (Redfern and Norman et al., 1994).
Looking at the theory supporting the development ofNDUs, the
work of Pearson (1983) and Ersser (1988) is of particular interest.
Ersser looked at the individual needs of hospital patients and argues
that health needs were not synonymous with medical needs. This
fact becomes increasingly significant when patients in hospital are
reviewed and found to have become medically stable, but still
require some form of therapy.
This therapy could take the form of adjustment to a disability, or
regaining independence. Estimates of the number of patients in
hospital who do not require acute medical care range from 15 per
cent to 48 per cent of acute medical patients and absorb, therefore, a
significant chunk of the health service budget (Audit Commission,
1992).
Pearson believes that therapeutic nursing care is the major factor
in patient recovery, and the presence of such care is a major

239
determinant of recovery. Pearson also postulates that the therapeu-
tic aspects of nursing are impeded by the contrasting demands made
on nurses' time in an acute area. The rationale for placing patients
in a clinical nursing unit was to 'create a unit where an ideology of
therapeutic nursing could prevail' (Pearson, 1983).
Looking towards the future polarisation of hospital services, it
becomes apparent from Pearson's work that the concept of only
technicians in acute areas may become a reality as the value and
importance of nursing evolves, and the majority of care and services
move into the community.
The development of the 30 Department of Health-funded nursing
development units (NDUs) has gone further to tease out the true
value of nursing in its own right. The King's Fund has also been
instrumental in evaluating four of these units over the first two
years, namely, Brighton - a 22-bedded rehabilitation unit for
elderly patients; King's College Hospital- an 18-bed acute general
medical ward for female patients; Stockport - a 27-bed rehabilita-
tion ward for care of the elderly; and West Dorset - a 24-bed acute
general medical ward for female patients (Shaw and Bosanquet,
1993). The King's Fund NDU programme now encompasses
specialities as diverse as forensic psychiatry, intensive care, accident
and emergency, and occupational health (Griffiths and Evans,
1995).
The development ofNDUs is dependent upon the commitment of
staff and leaders. The leaders are important as key agents of change.
In the King's Fund study of 1993, all units identified leaders, job
descriptions of the ward sisters were reviewed, and development
posts were created (Shaw and Bosanquet, 1993). The development
posts were slightly different in each unit, but all had the overall aim
of assisting the development of nurses' skills in enquiry and
research, enabling practitioners to use the findings to adapt their
clinical practice.
One of the units in the King's Fund study created the post of
lecturer/practitioner. This was a joint appointment between the
NDU and a university Department of Nursing Studies (ibid.).
The lecturer/practitioner post was reviewed during the study and
considered to have been useful especially at an early stage of
development, but it was felt that the resource implications restricted
the development or replication of other similar posts. The lecturer/
practitioner was replaced for the final year by a full-time researcher
with the emphasis on 'outcomes of nursing care' (ibid.).

240
 It is recognised that not all nurses would wish to pursue the
intense educational and research activities which are the hallmarks
of a nurse development unit. Some of the negative attributes of
NDUs include feelings of professional isolation and alienation. The
continued questioning and high pressure of expectation from out-
side can also be overwhelming. However, despite the difficulties, the
contribution of the NDUs to the nursing profession and its devel-
opment cannot be underestimated.

Developments in technology and technology assessment

Probably the most profound development of the latter half of this

century has been the increasing place technology plays in our
everyday lives. Nowhere have these changes been felt more acutely
than in the health care arena. The developments in medical tech-
nology have been staggering, and will be one of the issues that
determine how services develop into the next century. Alongside,
and in addition to the advances in medical technology, are the
developments in information technology which have revolutionised
many traditional services such as banking, as well as industry.
One of the driving forces behind the NHS reforms of the 1990s
was the need to optimise the quality of patient care and outcomes
within the constraints of affordable resources. The greatest problem
was that although the health service was awash with paper, there
was little information easily accessible to assist with the develop-
ment of. the services and the internal market. It was against this
background that Stephen Dorrell opened the NHS Centre for
Coding and Classification in Loughborough, Leicestershire in
1990, with Dr James Read as its first Director. The function of
this centre was to assist the health service to join the information
technology revolution by developing codes which convert medical
terms into numbers for computers (Read codes).
The codes are owned by the Secretary of State for Health and are
crown copyright. The Secretary of State also licensed Computer
Aided Medical Systems Limited (CAMS) to market and make
available the Read codes to all users both inside and outside the
NHS (CAMS, 1991). Although Read codes were originally devel-
oped only for terms used by general practitioners, they are now
widely used throughout the NHS in both primary and secondary
care settings.

241
 The crucial difference between this system and other coding
systems, is that Read codes were developed for use by clinicians
with direct responsibility for patient care, and not just for research.
Therefore, it was envisaged that with the appropriate technology
and software, Read codes could be used to support the management
of patient care, as well as clinical audit and resource management.
In addition to the work undertaken by the medical profession,
work has also been completed on the 'terms project' to be described
in the following section. This project looked at the needs of nurses,
chiropodists, speech therapists, occupational therapists, phy-
siotherapists and dieticians. The value of this work is that it
assembles agreed comprehensive terms for patients' records en-
abling the records from doctors, nurses and all other professions
allied to medicine to be incorporated into Read codes in a format
suitable for the NHS information systems.

The nursing terms project

. The objective of this group was to look specifically at the needs of
nurses, the terminology used by nurses in their practice, and to
identify all codes and terms. It was accepted that the terms nurses use
may be different from those used by doctors. The nursing profession
was represented by the Strategic Advisory Group for Nursing
Information Systems (SAGNIS). The task of identifying all the
terms required for nursing was assessed so that the resources needed
to develop nursing terms into Read codes would be suitable across
the whole NHS (NHS Centre for Coding and Classification, 1993).
Although this work is now complete, the whole Read Code
project appears to be in question. The cost thus far is £3.7 million
and has involved 55 working groups and over 2000 clinicians. The
present edition, version 3, which the NHS Executive describe as 'a
national thesaurus of clinical terms' has had some fairly major
teething problems (Cross, 1996a). It was envisaged that this version
would enable the creation of an individual's clinical record. The
resolution of the current problems will be essential if the original
vision of the NHS IT strategy is to be realised.

Technology assessment
Working across the whole spectrum of services, nurses have major
responsibilities in disease prevention, health maintenance, care of
the sick, health education and management. Improvement of health

242
depends, in part, on the selection and use of appropriate technology
to prevent disease, to care for patients, to educate patients and staff,
and to manage data.
Attainment of these goals is essential for nurse executives in acute
care, and increasingly in community care, and depends in part on
their selecting and using appropriate technology. Similarly, match-
ing the highest quality of health care to available resources requires
the involvement of nurses in the assessment of technology. Within
community services there is now a greater emphasis on more
technical and advanced care following earlier discharge home,
and the development of more acute care within the home or local
community setting.
The US Office of Technology Assessment (1982), describes
technology assessment as 'a pragmatic, dynamic, interactive process
with many applications. Used when a technology is introduced,
extended, or modified, technology assessment is a comprehensive
form of policy research that explores short and long-term conse-
quences of technologic applications.' McConnell (1992) suggests
five steps of assessment - need, safety, effectiveness and efficiency,
economic appraisal, and social impact - which can be applied
individually or comprehensively.
Health care technology is challenging because it generates ques-
tions from patients, providers and purchasers of health care,
educators, lawyers, policy-makers and judges. Representing various
perspectives, interests and philosophies, all have a stake in techno-
logical decisions. Nurses encounter these stakeholders in a variety
of ways, and can promote intelligent deliberation and facilitate the
selection of appropriate technology by using the framework of
technology assessment.
There is no one better able than nurses to be at the forefront of
technology assessment in diverse settings, but involvement does
demand, however, that nurses be proactive and knowledgeable.
Nurses can select technologies to be used with individual patients by
being aware of suitable alternatives, and by collaborating with the
patient, the patient's family and other health care providers.
Suggesting the trial of certain technologies and participating in
the evaluation of 'new' technologies are other ways in which nurses
can be involved. By networking and collaborating with a multi-
plicity of agencies at local, national and international level, nurses
increase their opportunities to have input into design, selection and
use. Joining and participating in international organisations have
many advantages as well.

243
 Technology abounds in the acute services, and continues to
escalate in the community setting. Nurses, therefore, taking a lead
in technology assessment are well-positioned to improve the health
of all people by promoting the efficient and effective allocation of
health resources. Similarly, as advocates for patients, nurses as part
of the multidisciplinary team are 'Well-placed to guide and monitor
the myriad of ethical issues surrounding the use of technology and,
in particular, to assess the impact of technology on the quality of
life of patients.

The flexible firm and the twenty-three-hour patient

The devolution of management responsibility and the creation of

NHS trusts has, in theory, enabled managers to become far more
flexible in determining priorities and achieving strategic goals.
Greater flexibility in developing staff has also been cited as giving
more freedom to trusts.
Flexibility issues have been particularly prominent in the context
of the health service's employment of nurses over recent years, yet
nurses remain somewhat sceptical about the underlying reasons for
flexibility, such as cost-cutting, and the casualisation of their
employment conditions.
However, the Institute of Manpower Studies (Atkinson and
Meager, 1986) has carried out a series of influential studies and
has developed the concept of the 'flexible firm'. Similarly, Handy
(1989) has developed the idea of a 'shamrock' organisation. These
models suggest that there is a core group of permanent employees,
supplemented by one or more groups of peripheral workers, who
mayor may not be employees of the 'firm'. More recent research by
MacGregor and Sproull (1991) has confirmed that UK employers
have rarely shown a strategic approach to changing working
patterns.
Armstrong (1992) has developed a typology of different forms of
flexibility which highlight the variety of flexible approaches to
managing a work-force. These include contract-based, time-based,
job-based, skills-based, organisation-based and pay-based ap-
proaches. This typology is relevant to all nurses across the spectrum
of care, since most of its elements are being actively applied by NHS
managers. Short contracts and temporary staff are therefore be-
coming more common within the acute services as a way of
improving deployment. Buchan (1995) suggests that some are

244
now arguing strongly that NHS trusts will have to 'flex' their
staffing levels in order to survive in competitive markets. This
argument, therefore, needs to be applied to all trusts as a matter
of some urgency, and in particular to community trusts. However,
there is growing concern within the nursing profession that flex-
ibility of staffing and short-term contracts affect the quality and
continuity of care. A recent report by the Health Service Ombuds-
men (NHS Executive, 1995) has highlighted the problems of com-
munication amongst health care staff themselves, and between
patients and staff. This clearly demonstrates that good communica-
tions have to be a major priority for the 'flexible firm'.
Further work-force issues gaining momentum within acute care
are the drives to re-profile the nursing work-force, and to engage in
skill-mix exercises. This has been a major political agenda, with the
driving force of motivation, undoubtedly, being cost-containment.
Decreasing length of in-patient stay and increasing the number of
out-patient procedures within the acute services has led to what is
often called the twenty-three/twenty-four hour observation patient.
This patient spends a few hours in acute care, followed, ideally, by
an overnight stay in a patient hotel facility. However, the reality is
that there are very few patient hotel facilities in existence, and so the
twenty-three/twenty-four-hour patient spends his or her total in-
patient stay in an acute-care facility. Kumarich, Biordi and
Milazzo-Chornick's (1990) study demonstrated that the addition
of day-case patients to the aggregate workload data on an acute-
care ward created a definite staffing deficit in 60-90 per cent of
clinical areas. In other words, patients who are admitted to in-
patient facilities for a day-case period of 23 hours do, contrary
to general opinion, require more than observation, and therefore
generate a higher workload on those units.
Findings such as these dispel generally-held beliefs that day-case
patients of 23-24 hours duration reduce staffing levels and work-
load, and are therefore more cost-effective. In order to smooth
variations in workload for these patients, a more flexible approach
to staffing levels is required. Kumarich et al. suggest several
strategies which include:

1. flexibility around shift patterns;

2. the opportunities for cross-training of staff to cover fluctuating
census and the associated workload;
3. limit the admission of day-care patients to one specified unit;

245
4. maximise the more efficient use of staff skilled III specialist
treatments, such as chemotherapy.

Studies such as these clearly highlight the flexible use of skills and
staffing patterns, and also provide opportunities for a more creative
and flexible approach to them across a whole range of services,
especially when working across a more seamless service of care.
Community nurses will therefore need to think creatively around
these issues, as more and more acute care is transferred to commu-
nity facilities.

Case-mix and nursing management

Nurse managers are now accountable for an increasingly complex

matrix of health care planning, organisation, delivery and manage-
ment. The efficient management, however, of these services is often
severely hampered by crude resourcing formulae and management
information systems. With few exceptions, it is still difficult to
determine accurately the cost of a patient's episode of care, or what
is the most effective treatment known, or what quality indicators
should be used, and what outcomes should be expected from health
care interventions. Given that nursing costs generate the largest
component of the budget, it is essential that the accuracy of related
nursing costs is verified and models developed to determine how
these costs will behave over a period of time.
Across the whole spectrum of care, nurses are now faced with the
responsibility of managing resources within budget constraints in
business units. The development of case-mix information systems
provides nurses with the opportunity to manage both their services
and their patients with the benefit of good management informa-
tion. When case-mix information is combined with patient depen-
dency or nursing intensity measures, the resulting data are powerful
sources of information for planning, cost-measurement and control,
and for assessing the quality and outcome of care provided.
The Australian Commonwealth Department of Human Services
and Health Care (1994) has undertaken a major national pro-
gramme on case-mix, and senior nurse leaders have been involved
in the development of this programme at the highest levels. Nurses
in Australia are determined that rather than have the agenda set for
them, they are instead going to make case-mix 'work for them', and

246
to their own advantage. Several projects in acute and community
care are now underway in Australia, and some are in the process of
being evaluated. The impact that case-mix methodologies may have
on nursing care is still not clearly defined, but Australian nurses are
working hard to find solutions from evaluations already under-
taken. The first challenge, however, for nurses over the next decade
will be to set the standards of clinical practice, for it is only through
the setting of such standards that problems can be identified, such
as over-use or under-use of services, the wrong location or the
improper use of services. Setting standards in respect of outcome
measures is therefore critical to the future development of quality
care.
Closely associated with and allied to case-mix is case manage-
ment, a multidisciplinary problem-solving system designed to ensure
continuity of services through a restructuring of the clinical pro-
cesses. Nursing expertise is essential to a patient's episode of care,
whilst acknowledging the rest of the team's contribution. It is noted
that in Australia, nurses have been very proactive in leading this
initiative together with the development of critical paths.
Critical paths form a dynamic management tool which organises,
monitors, and sequences the delivery of patient care by a multi-
disciplinary team. Such a tool has great potential for linking an
episode of care across the spectrum of care, thus ensuring continuity
and quality of care for the patient. According to Ferguson and
Picone (1994) the benefits of managed care with critical paths being
a major component are enormous; such an approach:

• Leads to common language between care givers and patients;

• Reduces workload pressure because it sets realistic outcomes;
• Aligns all staff working with a case type into a collaborative
practice;
• Ensures predictability and control over the processes of care
which establishes optimal delivery of care;
• Decreases isolation of clinicians and thereby each profession has
an understanding of the other's role in care delivery;
• Provides expertise in forming a set of problems into meaningful
outcomes. (Ferguson and Picone, 1994)

Within the United Kingdom, hospital and community nurses must

therefore ensure that, together, they are at the leading edge of
developing managed care systems.

247
BUILDING BRIDGES AND THE IMPACT ON SERVICES

The transferring of health care from acute services to primary

health care will only be made if everyone with an involvement in,
or an influence on, health care, thinks in terms, first, of the needs of
patients, clients and communities; next, of the skills required to
meet those needs; and, then, of the ways of harnessing skills in order
to fulfil the primary care objectives. Collaborative working and
team-building across the primary/secondary interface is probably
one of the most difficult for many nurses to come to terms with, but
it is essential if the range of skills, and the resources to deploy them,
are to be channelled to the maximum benefit of people in the most
cost-effective way.
Community nurses have been challenged by the social services'
'army' of care workers, and by 'outreach' workers from the acute
hospitals. Nurses in the community have a unique opportunity to
lead the way by challenging some very well-established principles,
such as for example the community nurse as the 'primary' nurse
following the patient's progress from home to hospital, and back
home again. This requires that hospital and community nursing
staff work closely together to ensure a seamless continuum of care.
Such a model would have enormous benefits for patients, reducing
the amount of time currently spent on discharge planning, and
assisting in the breakdown of professional tribalism.
Within hospitals, working with social services and the voluntary
sector does not create as many problems as it does across the
interface, and in primary care where it is a real challenge. Commu-
nity nurses have real conflict with issues such as confidentiality,
accountability and shared records. However, the UKCC offers the
registered practitioner guidance and direction in the Code of
Professional Conduct (UKCC, 1992). Paragraph 6 of the Code
states that registered practitioners should 'work in a collaborative
and co-operative manner with health care professionals and others
involved in providing care and recognise and respect their particular
contribution within the care team' (our emphasis).
Practical progress will depend on the development of collabora-
tion between different sectors. The training of all staff across the
interface will help the transition. A beginning has been made with
Project 2000 (UKCC, 1987), but continuing attention to post-
registration education strategies will be important in order to
transfer knowledge of developments of nursing in acute services
to the community, and vice versa.

248
CONCLUSION

Health care has always been, and will continue to be, a political
'animal', and nurses working within the acute care environment
since the reforms are only too mindful of this ethos. In this respect
community nurses have a unique opportunity to learn from their
colleagues, and as the concepts of a primary care led service develop
they are ideally placed not only to lead change, but also to place
nursing firmly on the map. It is recognised that this process will not
be easy.
Perhaps, faced with this political environment, nurses should
therefore follow the lead of the first Duke of Wellington. This wise
statesman, like many nurses today, felt totally exasperated with the
demands of his political masters, but he made absolutely sure that
they were aware of his main priorities, by insisting that the officers
in his command maintain independence from all political adminis-
tration.
Contributions made by nurses working within acute care cover
a broad range, from policy formation to direct patient care.
These suggest how progress can be made - authoritative leadership,
political acumen, strategies, practice development, bridging
the policy/practice divide, work-force planning and technology
assessment.
A checklist of progress for all nurses, whether on the board or in
clinical practice, is offered below:

1. Lead the nursing agenda with authority and conviction, ensuring

they have a 'locus of control' in all matters related to strategy,
patient care, nursing resources and professional development.
2. Bridge the policy/practice divide, ensuring direct links between
nurse executives and clinical practitioners, for example the use
of models such as shared governance and clinical supervision.
3. Be at the leading edge of change, by managing the process.
4. Be radical and innovative in strategic thinking and organisa-
tional behaviour, ensuring effective paradigm shifts.
5. Make in-roads into the competitive environment, ensuring that
competition does not decimate care.
6. Adapt and develop business ideas and techniques from industry,
such as re-engineering processes, branding, marketing-mix and
information 'networks'.
7. Develop new skills and be abreast of technological advances and
their assessment.

249
 8. Become more flexible in work-force patterns and planning,
9. Build bridges in a collaborative way with all other stakeholders.
10. Be cognisant of the value of nursing and communicate this
effectively.

It is envisaged that this checklist may assist all nurses working

across the divide of care, as they demonstrate their ability to be in
the forefront of leading edge change and development.

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 ======
ELEVEN
Epilogue

Deborah Hennessy and Geraldine Swain

'We have seen a massive increase in the numbers of young people

forced on to the streets, more mentally ill people in the streets,
more people dying, often literally of the cold. The change has
been horrifying and yet what has been far worse has been the way
in which so many of us have become acclimatised to the situation,
inoculated against it. There has been a loss of passion, a loss of
anger, and of the impetus of change.'
(Garth Hewitt (1995) Pilgrims and Peacemakers. Sutherland,
Australia: Albatross Books)

At the beginning of this resource book we looked at the values

which are at the core of the work of the community nurse engaged
in community health care development. An essential value is the
belief in individual human worth and potential, a valuing too of our
humanity, as a prerequisite for valuing others. We emphasised that
whatever changes may lie ahead, and change is inevitable, the values
that we hold at the core of our work essential to community health
care development do not change. They form the backbone of our
work together with a commitment to social justice.
Whatever changes take place, and there will be many more -
resources for health care are very unlikely to increase - the demand
for nurses to continue to develop compassionate and knowledge-
able care will always be there. The need will continue also, to work
alongside individuals, families, groups, communities and colleagues,
constructively and energetically, recognising that challenges can
provide opportunities for creative imaginative response rather than
despair.

253
 We stressed the importance of nurses being fully involved in the
policy processes, that is in influencing the development of policies in
health and all other areas of community-living that impinge on
health, such as education, housing, child care services, employment
and income distribution. There is no area which it is inappropriate
for nurses to attempt to influence. The role of advocate requires a
certain fearlessness even when fearful.
This book is an example of multidisciplinary endeavour. Working
in concert with all colleagues is essential. It is destructive to
maintain inter and intra-professional and disciplinary barriers
where professional rivalries and jealousies invade the work. There
is not time for this, and anyway it is so exhausting and the work
demands sufficient of our energies. Interprofessional barriers are so
unhelpful to our client groups as is the supposing that one group of
workers has the monopoly of compassion, and another of science.

'As all ... patients know intuitively, after all their needs include
both humanity and expertise; it requires little additional thought
to realise that fragmentation of these qualities between different
medical personnel, with the doctor providing only science and the
nurse only sympathy, is ... neither humane nor scientific ... We
are all of us ... in need not of alternately science and tenderness
but of a humane expertise from every sort of [health care] worker
we encounter.'
(Marks, S., 1994 Divided Sisterhood, London: Macmillan, p. 213)

Contributing to the shaping of a more 'appropriate model of human

encounter' in community health care development is within the gift
of every community nurse.

254
 INDEX OF NAMES

Aaronson, N. 190, 195 Butterworth, C. 238, 250

Acheson, D. 86, 105, 106 Buttery, Y. 173,175
Addington-Hall, J. 181, 195
Ahmedzai, S. vii, xvi, 178-97 Cain, P. 126, 149, 154, 155
Altman, D. 169,175 Carey, L. 137, 154
Appleby, J. 161,175 Carstairs, V. 107, 112, 121
Armitage, L. vii, xvi, 37-61 Cartwright, A. 39, 59
Armstrong, M. 244, 250 Casement, P. 21, 33
Ashworth, A. vii, xvi, 178-97 Chalmers, I. 169,170, 171, 175
Atkinson, J. 244, 250 Champy, J. 232, 251
Avis, M. 169,175 Clark, D. 182, 192, 193, 195
Clark, J. 123, 154
Bahrami, J. 124, 153 Clarke, K. 17
Barr, H. 125, 149, 153 Clifton, M. 123, 154
Barriball, K. 166, 175 Cochrane, A. 160, 170, 174, 175
Bartley, M. 107, 122 Coles, J. 173, 175
Bates, E. 13, 25, 33 Collier, J. 47, 60
Beattie, A. 112, 153 Conchie, K. xv
Bell, R. vii, xvi, 123-58 Coulter, A. 165, 175
Benis, W. 234, 250 Coyle, D. vii, xvi
Bennett, J. 173, 175 Cross, M. 242, 250
Benzeval, M. 7, 8, 11, 20, 23, 26, Culyer, A. 88, 104
33, 39, 59, 107, 116, 121 Cumberlege, J. 66, 130, 154
Bergman, B. 190, 195 Cunningham, D. 106, 121
Berlin, A. 151,152,153 Curie, M. 10,179,180,191, 192,
Berman, B. 232, 251 193
Biordi, D. 245, 251
Birt, C. 56 Dand, D. 182, 195
Biswas, B. 182, 183, 195 Darvill, G. 152, 154
Black, D. 39,59 Davey, P. 156
Black, S. 107, 108 Deal, L. 163, 175
Blance, D. 107, 122 Denys, E. 194, 195
Blyth, A. 182, 195 Dickens, C. 107
Bolden, K. 107, 121 Donaldson, L. 162, 176
Bond, S. 165, 177 Donovan, J. 163, 176
Bosanquet,N. 113,114,115,121, Dorrell, S. 13, 17, 241
122, 240, 252 Doyle, D. 190, 195
Bottomley, V. 17 Du Boulay, S. 189, 195
Bowling, A. 109, 121, 190, 195 Dubinsky, M. 162, 176
Bowman, M. 123, 153
Bray, C. 25, 35 Efstratiou, A. 53, 60
Britton, B. 112, 121 Ekstein, R. 3, 33
Brody, H. 32, 33 Ellerington, H. viii, xvi, 226-52
Buchan, I. 39, 59 Elliot, A. 150, 154
Buchan, J. 244, 250 Ellis, J. 162, 176
Burton, J. 153 Emond, A. 164, 177
Butler, J. 33, 153 Engels, F. 107

255
Enkin, M. 171,175 Hasler, J. 124, 155
Ersser, s. 239, 251 Hawkins, P. 30, 33
Etzioni, 145 Haynes, B. 170, 177
Evans, A. 240,251 Healing, T. 53, 60
Evans, J. 232, 251 Heather, P. 192, 193, 195
Heginbotham, C. 195
Farquhar, M. 109, 121 Hennessy, D. ii, vii, viii, xvi, 1-2,
Faugier, J. 238, 250 3-36, 79, 84, 133, 151, 155
Fawcett-Henesy, A. vii, 78, 80, Hennessy, M. 237, 251
84, 106-22 Hennessy, S. vii, xvii
Ferguson, J. 162, 176 Henry, B. 234,251
Ferguson, L. 247,251 Hewitt, G. 253
Field, D. 182, 195 Hicks, C. 133, 155
Fletcher, S. 123, 124, 130, 155 Higginson, I. 179, 193, 194, 195
Forster, D. 39, 60 Hill, D. 184, 195
Francombe, C. 128, 155 Hill, J. 30, 35
Frankel, S. 163,175 Hingston, E. 125, 153, 154, 158
Freemantle, N. 171,176 Hoare, G. 144, 145, 155
French, J. 39, 60 Hopkins, A. 32, 35, 190, 195
Fry, J. 124, 155 Hopps, L. 165,176
Fulop, N. 252 Horder, J. 125, 134, 136, 143, 148,
Funnell, P. 134, 147, 149, 155 152,155
Howkins, E. 128, 130, 134, 136,
Ganz, P. 191, 195 138, 143, 149, 154, 155
Garner, L. 4, 33 Hudson, M. 252
George, R. 53, 60 Hughes, J. 156
George, V. 128, 155 Higman, R. 129, 134, 142, 156
Gilley, J. 181, 195 Hyde, V. 143,149,154,156
Gilling, C. 142, 155 Hyland, T. 133, 149, 151, 156
Glennester, H. 129, 155
Glynn, J. 129, 155 Iliffe, S. 64, 84
Goldschmidt, P. 162, 177
Gordon, P. 67,84 James, A. 10, 35, 123, 125, 130,
Gould, M. 64, 84 156
Griffiths, P. 240, 251 James, N. 189, 195
Griffiths, R. 16, 39, 90, 104 Jarman, B. 112, 121
Grundy, E. 109, 121 Jenkins-Clarke, S. vii, xvii, 179-97
Johnson, G. 202, 224
Hadfield, L. viii, xvi, 198-25 Johnson, K. 123-58
Haggard, L. vii, xvi, 62-85 Jones, G. 44, 60
Hall, D. 45, 60, 65, 84 Joule, N. 118, 121
Ham, C. 14,16,17,20,24,33,35, Judge, K. 7, 8, 11,20, 22, 23, 26,
161,175 33, 39, 59, 107, 116, 121
Hamilton, G. 63,60 Jullson, I. 162, 177
Hammer, M. 232, 251
Handy, C. 244, 251 Keirse, M. 171,175
Hanks, G. 190, 195 Kenny, A. 47, 50
Harding, K. 39, 60 Ketley, D. 162, 176
Harley, M. 65, 84, 164, 176 Kitzhaber, J. 47, 60
Hart, J. 113, 121 Kumarich, D. 245,251

256
Lambden, P. 222 Neale, B. 182, 192, 193, 195
Langlands, A. 216, 224 Neuberger, J. 35
Lawson, P. 18, 35 Newman, C. 53, 60
Le Grand, J. 14, 15,22,25,28,35 Nightingale, F. 228,234-5
Lee, K. 144, 145, 155, 156 Nocan, A. 125, 130, 157
Leese, B. 114, 115, 121, 122 Norman, I. 239, 252
Legg, S. viii, xvi, 226--52 Normand, C. 152, 157
Levenson, R. 119, 122 Norris, F. 194, 195
Lewis, B. 163, 176
Liaschenko, J. 12, 13, 35
O'Brien, M. 39, 59
Littlewood, J. 155
O'Hare, L. 164, 176
Long, A. 144, 145, 155
O'Keefe, E. 125, 127, 129, 157
Lunt, N. 67,84
Ollin, R. 130, 157
Lynch, B. 156
Orr, J. 6, 9, 35, 36
Orrewill, R. 125, 127, 129, 157
MacDonald, N. 190, 195 0vretveit, J. 11
MacGregor, A. 244, 251 Oxman, A. 172, 177
Mackay, L. 127, 130, 134, 145,
149, 150, 153, 156, 157
Payne, M. 139, 157
Mackenzie, A. 166, 175
Pearcey,P. 169,177
Mackenzie, J. 168, 177
Pearson, A. 239, 240, 252
MacLeod, M. 167, 176
Peckham, C. 44, 60
Malek, M. 156, 157
Penso, D. 184, 195
Marks, D. 128, 155
Perkins, D. 129, 155
Marks, S. 254
Perry, C. 3, 35
Martin, J. 10, 35
Perry, R. 156
Mason, C. ii
Philimore, P. 112
Mathias, P. ii
Picken, C. 60
Maxwell, R. 173, 176
Picone, H. 247, 251
McConnell, E. 243, 251
Pill, R. 39, 60
Meads, G. vii, xvi, 86--105
Pollock, A. 25, 35
Meager, N. 244, 250
Pomfret, I. 164, 177
Milazzo-Chornick, N. 245,251
Porter-O'Grady, 235
Miller, B. 44, 60
Miller, E. 44, 60
Miller, S. 128, 155 Quick, A. 7,35
Mills, A. 156
Mintzberg, H. 202, 209, 224
Raftery, J. 54, 60
Moffat, C. 164, 176
Ranade, W. 21, 22, 27, 35
Morris, J. 39, 59
Rasquina, J. 156
Moss, F. 173, 177
Read, J. 241-2
Mott, A. 164, 177
Redfern, S. 239, 252
Mulligan, I. 162, 175
Rice, N. vii, xvii, 178-97
Richardson, A. 25, 35
Nage1kerk, J. 234,251 Richardson, I. 39, 59
Naish, J. 235,236, 251 Riley, C. 227, 230, 232, 252
Nanchahal, K. 163, 175 Robinson, R. 14, 15, 22, 25, 28,
Nanus, B. 234, 250 35
Nazare.th, B. 252 Rowe, J. 162, 175

257
Rowntree, J. 107 Tomlinson, S. 151, 155
Royle, S. 116, 122 Tookey, P. 44, 60
Rule, J. xv Townsend, P. 39, 59, 112
Ryder, S. 180, 191 Tremblay, M. 20, 24, 35
Trnobranski, P. 137, 157
Sackett, D. 160,161,170,177 Tucker, J. 130, 157
Saunders, C. 178, 189 Turner, J. 227, 252
Scholes, K. 202, 224 Turton, P. 6, 9, 35
Scott, H. vii, xvii, 123-58 Twigg, J. 182, 195
Seale, C. 181, 182, 195
Senge, P. 235, 252 Vacani, J 156
Shaw, I. 149, 153 Vaile, S. 153
Shaw, J. 240, 252 Vanc1ay, L. 125,142,147,151,
Shohet, R. 30, 33 153,154,157,158
Sines, D. ii Victor, C. 252
Skillbeck, M. 142 Vurdien, J. 44, 60
Smaje, C. 116, 122
Small, N. vii, xvii, 178-97 Wade, D. 163,177
Smith, C. 39, 59 Waight, P. 44, 60
Smith, L. 165, 177 Waldegrave, W. 17
Smith, R. 173,177,194,195 Wall, A. 125, 127, 129, 157
Soloman, M. 116, 121 Wallerstein, R. 3, 33
Soothill, K. 127, 130, 134, 149, Walshe, K. vii, xviii, 159-77
150, 153, 155, 156, 157 Warner, M. 227,230,231,252
Sproull, A. 251 Webb, C. 127, 130, 134, 145, 149,
Spurgeon, P. 60, 151, 157 150, 153, 15~ 157, 168, 177
Stacey, M. 59 White, J. 44, 60
Stevens, A. 43, 54, 60 Whitehead, M. 7,8, 11,20,22,23,
Stott, N. 39, 60 25, 26, 33, 39, 59
Swain, G. vii, viii, xvii, 3-36 Wilkes, E. 179, 194, 195
Wilkinson, R. 7, 35
Talbot, L. 126, 127, 145, 157 Williamson, J. 162, 177
Taylor, C. vii, xv, xvii, 86-105 Wilson-Barnett, J. 167, 177
Taylor-Gooby, P. 18, 36 Winnicott, D. 8, 36
Thatcher, M. 5,17,18,35 Wood, J. 107, 122
Thomas, L. 165, 177 Wood, N. 36
Thomasson, G. 64, 84 Woods, K. 162, 176
Thompson, T. ii Woods, S. 234, 251
Thornton, C. 149, 157
Titterton, M. 129, 157 Yates, J. 19,36,163,177
Tomlinson, B, 88, 104, 108, 113,
114, 116, 122 Zahir, K. xv

258
 INDEX OF SUBJECTS

A&E (accident and emergency) BPH (benign prostatic

departments 226, 229 hyperplasia) 163
acceptability branding 232
as curriculum planning bureaucracy 249
component 150-1 see also anti-bureaucracy
as key element of health business
care 124, 148 environment 232-3
accessibility general practice as 91
as curriculum planning general practice examples 96
component 148-9 principles of, in the health
as key element of health service 67-8
care 124, 148 business process re-engineering
Acheson Report 106, 114 232-3
acute care 226-7, 229, 231
future of nurses in 233, 240 CAMS (Computer Aided Medical
see also hospitals Systems Ltd) 241
advocacy cancer
as means of death rates 180, 181
disempowerment 58 palliative care 194
nurses' role 14, 24 care
ageing see elderly for carers 205
anti-bureaucracy 94 description 8-9
general practice examples 96 informal 182
assessment see under health needs locus of 12-13, 208
attitudes see also health care; hospices;
to health reform 32 palliative care
of professional staff 207 care agencies 82
to research 168 care in the community see
to social workers 139 community care
audit carers
clinical 32, 88, 172-4 care for 205
medical 88 profiles 187
palliative care 193 support for 182
Australia 246-7 case management 247
autonomy, of nurses 81-2 case-mix 246-7
availability Centre for Reviews and
as curriculum planning Dissemination 170
component 149 change
as key element of health dimensions of 171-2
care 124, 148 and education 142-4
forces for 123, 127-34
hospitals and acute care 229-31
benign prostatic hyperplasia implementing 171-4
(BPH) 163 key areas 228
beta-interferon 47 in the NHS 103-4, 205-6,
Black Report 38, 107 228-31
bladder washouts 164 Changing Childbirth 230

259
Charter for Public Health 40 local authority planning role 87
Children Act 1989 88 meaning of term 10-11
Church Commission, report on see also community health care;
conditions in urban community health services
areas 107-8 community development 11-12
CINAHL (Cumulative Index to the community health care
Nursing and Allied Health crisis by the year 2000 127-8
Literature) 167-8 definition 11
circulatory diseases, death description 10--12
rates 180, 181 development 9-10
Citizen's Charter 27 see also care; community care;
clients see patients community health services;
clinical audit 32, 88, 172--4 primary health care
clinical empowerment 236-7 Community Health Councils 25
clinical nurse grading and community health services
training 78 definition 198-200
clinical supervision 30--1, 238-9 diversity of 201, 204
Cochrane Collaboration 170--1 effectiveness of 202-10
Cochrane Database of Systematic focus of 199
Reviews 171 machine bureaucracy 209
Code of Professional Conduct missionary organisation 209
(UKCC) 29, 30, 248 organisational fitness 210-22
codes see Read codes organisation of 201-2
Coding and Classification, NHS perspectives of 199
Centre for 241 problems facing 206-9
collaboration, purchase of 199
interprofessional 49, 124, services covered 199, 201
130,248 in UK 12
commercial practice see business work environment 207
commissioning 58-9 see also community care;
basis of decisions 68 community health services;
business principles 67-8 commissioning
commissioning cycle 62-3 community nurse managers 76-8
comparative information 65-6 community nurses
definition 63 action after identification of
of education and training 140--1 health needs 52-3
evidence-based 64-5 assessment of health needs
GPs as commissioners 66-7 49-51, 55
specification stage 70--1 autonomy 81-2
see also purchasing; community awareness of available
health services services 55
communication technology 79 client/patient records 51-2
community, definitions 5-6 education 136-8
community care future trends for 82--4
barriers to progress 128-34 independence of 66
challenges from the centre 128- involving other
30 professionals 50
interprofessional opportunities 41-2
collaboration 130 types of 50

260
 value of services 51 costs 40
see also health visitors; nurses; nursing 246
practice nurses see also costing; funding
community nursing counselling services 26
effectiveness of 163-5 critical paths 247
reasons for ineffectiveness 164-5 Culyer Report 88
research difficulties 166-7 Cumberlege Report 66, 67
services covered 201 Cumulative Index to the Nursing
variations in practice 164 and Allied Health Literature
community workers, general 138 (CINAHL) 167-8
competence 133, 139 curriculum planning and
competition, in the NHS 62 development see under
Computer Aided Medical Systems education and training
Ltd (CAMS) 241
computers
health literature index 167-8 D&C (dilatation and
patient records 65, 241-2 curettage) 46, 163
Read codes 65, 241-2 data
see also technology community nurses' role in
confidence, professional, erosion collecting 53-5
of 3-4 health needs 51-2
consumer groups 25, 54 demand, v. supply and needs 43-5
consumerism 46-8 demographic factors 12
abroad 92 inner city characteristics 109-11
general practice examples 96 dental services 88
in GP-based primary care 92 deprivation
patients' interests and indices of 112
responsibilities 46-7 inner city areas 113
positive contribution 47-8 development, description 9-10
contestability in purchasing 72 DHAs see district health
continuing care facilities, inner authorities
cities 115 dilatation and curettage 46, 163
contracts disease see ill health
basis of 199 disempowerment 57-8
contract priorities v. clinical see also empowerment
judgement 81 district health authorities
monitoring 74 (DHAs) 41, 87
see also General Medical Services commissioning 63, 64
Contract district nurses, palliative
cooperation, interprofessional 49, care 188-9
124, 130, 248 diversity 95, 101, 103, 104
cost effectiveness community health services 201,
as curriculum planning 204
component 149-50 general practice examples 96
as key element of health doctors
care 124, 148 in community health
costing services 200
complex care packages 72-4 see also general practitioners
service provision 71-2 dying triad 181-3

261
economic factors Effective Health Care
affecting changes in acute bulletins 170, 171
care 231 effectiveness of care 88
facing the NHS 205 community health services 202-
education and training 10
academic and vocational 141 community nursing 163-5
acceptability as curriculum definition 160
component 150-1 evidence of 159
accessibility as curriculum inner cities 116-20
component 148-9 lack of, examples 162-3
availability as curriculum studies 65
component 149 Efficiency Index 90
commissioning 140-1 elderly
community nurses 13, 136-8 increasing numbers of 205
competence-based 133, 139 in inner cities 109
continuing 124, 124-5 nursing care for 82
cost effectiveness as curriculum employment, and health 7, 19-20,
component 149-50 39
credit accumulation empowerment, clinical 236-7
systems 140 see also disempowerment
curriculum planning 140-1, English National Board 183
143-4, 144-51 EORTC QLQ-C30 see European
for the disadvantaged 7 Organisation for Research and
evaluation 152 Treatment of Cancer
feedback 152 ethics 31-3
interprofessional 123-58 ethnic minority groups, inner
interprofessional initiatives 136 cities 110
ladders of opportunity 148 European Organisation for
learning organisations 235 Research and Treatment of
lecturer/practitioner role 240 Cancer (EORTC) QLQ-C30
locus of 208-9 (quality of life
nurse training 78, 80, 83 questionnaire) 190
objective 145-6 evidence-based health care
personal education plans 124 and clinical audit 174
planning 140-1, 143-4, 144-51 definitions 160-1
practice or service-based 148, development of 160-3
152 and research 161-3
primary health care 142-4
primary health care taxonomy as Family Health Services Authorities
curriculum (FHSAs) 63, 86-7
framework 147-52 flexibility of staffing 244-6
registration, training as condition flexible firms 244
of 83 fundholding see general
shared learning 143, 147, 149 practitioner fundholding
social workers 138-40 funding
vocational and academic 141 capitation funding of
see also National Vocational hospitals 229
Qualifications; Project 2000 for clinical audit 172-3
Effective Care in Pregnancy and palliative care 191-3
Childbirth 170-1 research in the NHS 166

262
future trends general practitioners (GPs)
community health organisations as commissioners 66-7
and staff 222--4 community nurse managers,
health care trends 82--4 relationship with 77-8
hospitals 229-30 General Medical Services
nurses in acute hospitals 233, Contract 87,90, 95
240 as health service customers 68-9
nursing research 174-5 inner city services 114-15
palliative care 193-5 palliative care visits 188
preparation of nurses for 27-8 and patients' social class 39
relationship with NHS 89, 90
generalism 138 see also general practice; practice
General Medical Services nurses
Contract 87, 90, 95 glue ear 163
General National Vocational GNVQs (General National
Qualifications (GNVQs) 131 Vocational
general practice Qualifications) 131
as a business 91 governance see shared governance
examples 95-100 GPFH see general practitioner
health promotion 21--4, 87 fundholding
history 86-9, 102 GPs see general practitioners
inner city example 95-7 Griffiths Report 90
managed care organisation groups, self-help 25, 54
example 96, 100
nurses attached to 67 Hall Report 65
as part of a wider health care HCAs (health care assistants) 28-
network 215-16 30
prevention, role in 39, 87 health
professional standards altruistic approach 9
development 213-14 definitions 38
as provider 211-12 description 6-7
as purchaser 90 employment and 7, 19-20, 39
resource strategy planning and indices of 112
implementation 217-18 inequalities 7-8, 11-12, 19-20,
rural market town example 96, 25-6
99-100 see also ill health
sIze 102 Health Authorities Act 1995 89
social services staff 82 health care
staff conditions of client/patient involvement
employment 211 in 24-5,32
staff motivation 219 complex packages 72--4
street team example 96, 97-9 future trends 82--4
value for money 221 long-term policy areas 227
see also general practitioners; measurement of 75
primary health care needs, v. health needs 43
general practitioner fundholding new trends in 226-8
(GPFH) 22 patient access to 45
choice of services by 211-12 priorities, contract v. clinical
expansion of 89, 90, 93, 102 judgement 81-2
multifunds and consortia 103 private 18-19

263
health care (cont.) hearing checks, babies 164
raised expectations 231 Heathrow Debate 27, 230, 233
responsibility of HMOs (health maintenance
professionals 37 organisations) in USA 102
v. social care 79-80 Holland see Netherlands
support staff 28-30 home1essness, inner cities 110-11
see also community health care; hospices 178-9
effectiveness of care; hospice at home 179
evidence-based health care; routinisation of 182
inner cities; primary health services, UK and Ireland 180
care see also palliative care
Health Care 2000 142 hospitals
health care assistants (HCAs) 28- accident and emergency
30 departments 226, 229
health care services, inner acute care 226-7, 229, 231
cities 113-16 capitation funding 229
Health for All by the Year 2000 changing shape of 228-33
(WHO document) 24, 106, district general hospitals 229
120 inner city provision of 113-14,
health insurance 19 115, 116
health maintenance organisations as large-scale health centres 209
(HMOs) in USA 102 London teaching hospitals 229
health needs perceived future for 229-30
action after identification policy debate 226-7
of 52-5 shared governance 236-7
assessment, necessity for 40-3 since NHS inception 228-9
assessment, tensions in 41 technicians v. nurses 233, 240
community nurses' role in humanity 4, 5, 33
assessment 49-51, 55
definition 43
demand matching 43-5 ill health
determination of 48-9 determinants 38--40
v. health care needs 43 prevention 39, 87-8
identification of 52 see also health
inner city areas 111-13 immunisation 44, 53--4
meeting 41-2 incidence, definition 56
priorities 55-7, 81-2 independent sector
range of 52 as part of a wider health care
resource matching 42, 52-3, 56 network 216
v. supply and demand 43-5 professional standards
Health of the Nation 23, 26, 87-8 development 214
health professionals see as provider organisation 212
professionals resource strategy planning and
health promotion 21--4, 87-8 implementation 218
target areas 23--4 staff motivation 219-20
UK strategies 23 value for money 221-2
health services, customers 68-9 inequalities in health 7-8, 11-12,
health visiting, principles of 25 19-20
health visitors, influencing policy initiatives
policy 8 influencing 25-{)

264
information sources leadership, transformational 234-
community nurses' role 53-5 5
health needs 51-2 see also nursing leadership
inner cities league tables 231
census of 1991 109 learning organisations 235
Church Commission report lecturer/practitioners 240
on 107-8 leg ulcers 164
continuing care facilities 115 literature search 168, 169, 170
delivering effective care 116-20 LIZ (London Initiative Zone) 116
demographic local authorities, planning role in
characteristics 109-11 community care 87
deprivation 112, 113 London
general practice example 95-7 continuing care facilities 115
GP services 114-15 future of teaching hospitals 229
health care services in 113-16 GP services 114
health needs 111-13 health care problems 116-20
homelessness in 110-11 homelessness in 110-11
hospital provision 113-14 hospital services 113-14, 115,
medical manpower 113-14 116
mental health care 115, 118 Making London Better 88, 116,
minority ethnic groups 110 118-19, 211
morbidity 111-12 mental health care 115
mortality Ill, 112 minority ethnic groups 110
out-of-hours service 118 morbidity III
overcrowding 110 mortality III
population 110 out-of-hours service 118
primary health care primary health care 116-17
provision 114 refugees 110
quality improvement need in St George's, shared
health care 107 governance 237
residents' concerns 112-13 Tomlinson Inquiry 88, 108, 116
socia-economic see also inner cities
characteristics 109-11 London Implementation
substitution policies 119 Group 116, 117
unemployment 110 London Initiative Zone (LIZ) 116
see also London
Inner Cities Directorate 112 Making London Better 88, 116,
insurance, health 19 118-19, 211
interventions managed care organisations 102-3
ineffective 162-3, 164 example 96, 100
research-based 161-3 marketing 232-3
intravenous infusion 204 of community health
involvement services 68-75
of clients/patients 24-5, 32 definition 68
of public 26-7 of individuals 69
maternity care 229-30
medical audit 88
Jarman index 112 medicine
journals, for disseminating research community services
findings 168, 169 covered 201

265
medicine (cont.) National Health Service
manpower, in inner cities Trusts see NHS trusts
113~14 National Vocational Qualifications
mental health care, inner (NVQs) 78, 131~3
cities 115, 118 health care support staff 28
mental illness, and NDUs (nurse development
unemployment 19~20 units) 239-41
minority ethnic groups, inner needs see health needs
cities 110 neighbourhood nursing teams 66
monitoring, of health care Netherlands, health services 91,
contracts 74 92
morbidity NHS see National Health Service
inner city areas 111~12 NHS Centre for Coding and
poverty and 38~9 Classification 241
mortality NHS trusts 91~2
common conditions 181 nurse representation on
inner city areas 111, 112 boards 235~6
poverty and 38~9 as part of a wider health care
motivation see staff motivation network 214-15
motor neurone disease 194 policy practice divide 235, 236
MS see multiple sclerosis professional standards
multifunds 103 development 212~13
multiple sclerosis (MS), beta- as provider organisations 210~
interferon 47 11
resource strategy planning and
implementation 216-17
National Health Service (NHS) staff motivation 218~ 19
change factors 205~6 value for money 220--1
data collection within 51 ~2 Nightingale, Florence, on nurse
formation of 228~9 leaders 228, 234
increasing costs 40 nurse development units
internal market 14-18 (NDUs) 239-41
major reforms 206 nurse executives 233-4
management v. administration on trust boards 235~6
of 40--1 nurse managers 76-8
methods of control 209~ 10 nurse practitioners 80
organisational change 103-4 directly accessible service 119~
primary care-led 66, 86, 93, 101 20
reforms 14-18 nurse-prescribing 75-6
research and development nurses
in 166, 170 advocacy role 14, 24
stakeholders 202~3 autonomy 81~2
technology and 204, 205 co-ordinating role 233
uniformity in 69~70 erosion of confidence 3-4
from universal to in forefront of change 227
personalised 69~ 70 future role in acute
see also marketing hospitals 233, 240
National Health Service and nurse~patient relationship 14,
Community Care 18
Act 1990 14-15, 16, 86-7 opportunities for 23

266
 preparation for the future 27-8 professional qualifications 183
progress checklist 249-50 providers 193
specialist 78-9, 80 purchasing 192-3
supply v. demand 80 quality of life 189-91
understanding of community 6 shift towards community
see also community nurses; care 182
education and training; support teams 179
health visitors; nurse during terminal year 182
practitioners; practice nurses types of unit 180
nursing see also York palliative care
changing shape of 233-47 study
costs 246 patient hotel facilities 245
nursing homes Patient's Charter 27,46, 231
costing care 72 patients
private 82, 83 as individuals 13
nursing leadership involvement 24-5, 32
caring v. management nurse-patient relationship
values 233 14-18
characteristics 234 rights and responsibilities 46-7,
demise of 233 88
Florence Nightingale on 228, twenty-three-hour
234 patients 245-6
transformational 234-5 personal education plans 124
nursing terms 242 PHCTs (primary health care
NVQs see National Vocational teams) 50
Qualifications planning
concept 144-51
occupational standards 130-4 definition 144
opportunity cost 42 interprofessional education
osteoporosis screening 44 curriculum 140-1, 143-4,
out-of-hours service, inner 144-51
cities 118 mixed scanning 145
overcrowding, inner cities 1lO theories of 144-5
policy initiatives 25-7
palliative care political factors
audit 193 affecting changes in acute
black and ethnic minorities 184 care 231
cancer v. non-cancer and the NHS 205-6
patients 194 population, inner cities llO
complexity of service Post-Registration Education and
provision 188-9, 194 Practice (PREP) 31
definition 178 poverty 19-20, 38-9
funding 191-3 practice nurses 66-7, 211
future 193-5 PREP (Post-Registration
history 178-9 Education and Practice) 31
hospice movement 178-80, 182 prescribing, by nurses 75-6
medical specialisms 183 prevalence, definition 56
need for 180-1 prevention, of illness 39, 87-8
nursing specialisms 183 primary care see primary health
place of death 181 care

267
primary care nurses, challenges to their
autonomy 81-2 judgements 75
primary health care co-operation and communication
v. acute sector 22-3 between 49, 130, 248
aims 9-10 dual responsibility 37
anti-bureaucracy 94, 96 erosion of confidence 3-4
barriers to progress 128-34 understanding specifications 71
challenges from the centre 128- Project 2000 28, 50--1, 137
30 promotion of health see health
changing face of 126--7 promotion
collaboration, prostate surgery 163
interprofessional 130 providers 18-19, 210
consultative documents 22 general practice 211-12
consumerism 92, 96 independent sector 212
decision-making within the NHS trusts 21 0--11
NHS 11 no longer a direct public
description 9-10 responsibility 94
development of 86--105 pallia ti ve care 193
diversity 95,96, 101, 103, 104 public involvement 26-7
education, model for purchasing 58-9
change 142-4 contestability in 72
government strategy 13 contract bases 199
health promotion 21-4, 87-8 as a direct public
history 86--9, 102 responsibility 94
inner cities 114 multifunds 103
integration with secondary palliative care 192-3
care 88-9 see also commissioning
key elements 124
in London 116--17 quality of life, palliative care 189-
models of 11 91
motivational matrix 91-5, 96
multidisciplinary rationing of care 92, 94
teamwork 125, 126, 129-30 Read codes 65,241-2
occupational standards 130-4 records 51-2
subsidiarity 92-3, 96 computerised see under
taxonomy, as curriculum computers
framework 147-52 re-engineering
user representation 150 business process re-
value for money 93-4, 96 engineering 232-3
see also community health care; service delivery 75--6
general practice reform
primary health care teams aims 89-90
(PHCTs) 50 attitudes to 32
primary nursing 9 definition 15
priorities, determination of 55-7, in the NHS 14-18
81-2 refugees 110
private sector 18-19 registration, training as condition
see also nursing homes of 83
professionals research
attitudes 207 access to findings 169

268
 attitudinal barriers 168 Scope of Professional Practice
care-based, in nurse development (UKCC) 29,30
units 239, 240 screening, for osteoporosis 44
Cochrane Collaboration 170-1 secondary care, integration with
in community health primary care 88-9
services 200 Selective Serotonin Reuptake
constraints to accessing Inhibitors (SSRIs) 171
results 168-9 self-help groups 54
dissemination of findings 167- service 4
71 service delivery
evidence-based health care re-designing 75-82
and 161-3 specification of 70-1
funding 166 severity 56
interventions based on 161-3 shamrock organisation 244
in the NHS 166, 170 shared governance 236-7
nursing research, future of 174- shared learning 143, 147, 149
5 SMR see mortality
ongoing 31 social care, v. health care 79-80
quality of 165-7 social class, use of medical
relationship with health care 88 services 39
review articles 169 social trends, affecting changes in
reviews of nursing acute care 231
research 165-6 social workers
search and appraisal skills 169 attitude to 139
summary articles 169-70 education 138--40
usefulness of 165-7 society 5-6
residential home care, costing 72 socio-economic characteristics,
resources inner cities 109-11
matching health needs to 42, sociological factors, affecting the
52, 56 NHS 205
need, demand and supply 43-5 specialist nurses 78-9, 80
social and geographical specification stage of
distribution 117-18 commissioning 70-1
resource strategy planning and SSRIs (Selective Serotonin
implementation Reuptake Inhibitors) 171
general practice 217-18 staff
independent sector 218 attitudes 207
NHS trusts 216-17 flexibility 244-6
respiratory diseases, death safety 208
rates 180, 181 work environment 207-9
rights and responsibilities 46-7,88 see also nurses; professionals
rural market town general practice staff motivation 207
example 96, 99-100 general practice 219
independent sector 219-20
NHS trusts 218-19
safety of staff 208 Standard Mortality Rates
SAGNIS (Strategic Advisory (SMRs) see mortality
Group for Nursing standards, occupational 130--4
Information Systems) 242 standards, professional
school entry medicals 45 development of 212-14

269
standards, professional (cont.) Townsend's Overall Deprivation
general practice 213-14 and Health Indices 112
independent sector 214 training see education and
NHS trusts 212-13 training
Strategic Advisory Group for transurethral resection of prostate
Nursing Information Systems (TURP) 163
(SAGNIS) 242 twenty-three-hour patients 245-6
street team primary care
example 96, 97-9 UKCC (United Kingdom Central
stroke treatments 163 Council) 29, 30, 248
subsidiarity 92-3 unemployment
general practice examples 96 and health 7, 19-20, 39
substitution policies 119 inner cities 110
supervision, clinical 238-9 United States of America
supply, v. demand and needs 43-5 (USA) 92, 102
support staff 28-30 user representation 150
Sweden 92
systematic reviews 64-5 value for money 93-4, 220
Cochrane Database of general practice 221
Systematic Reviews 171 general practice examples 96
independent sector 221-2
NHS trusts 220-1
teamwork 49, 124, 130, 248 values 4-5
technology voluntary sector 18-19
affecting changes in acute palliative care services 191-2
care 231 see also nursing homes
codes and classifications 65,
241-2 Whitley Council 211, 216
communication 79 Wilkes Report 179, 194
community health services' World Health Organisation (WHO)
reliance on 204 definition of health 38
and community nursing 79 health targets 24, 106, 120
developments 241-4
influences of 20-1 York palliative care study
and the NHS 205 carers' profiles 184, 187
organisational changes resulting interviews 186
from 230 medical characteristics 186
technology assessment 242-4 methodology 183
tendering, EC regulations 91-2 quality oflife questionnaire 190
therapists, community services sample 183-4, 185-6, 188
covered 201 visits from GPs, nurses and
Tomlinson Inquiry 88, 108, 116 others 184-5, 188

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