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NURSING For HEALTH: TWO YEARS ON

CHAPTER 3 NURSING FOR HEALTH - REPORT CARD

This section of the report looks back to the original recommendations from Nursing for Health, giving each recommendation a score from 1 to 5 to summarise what has been achieved. Local examples from across Scotland are used to illustrate the range of what has been achieved. (These are only examples. There are many more that it hasn't been possible to include.) Any proposals for future actions are then set out.

Represents little or no activity, or a recommendation that has been superseded

Represents some successful development in some areas, but not widespread

Represents some progress in most areas, but further development needed

Represents good progress in all or most areas

Represents excellent progress in all areas or the recommendation has been achieved

DEVELOPING THE PUBLIC HEALTH CAPACITY OF LHCCS

1. The Public Health Institute of Scotland will work with local health communities to support the local development new public health practitioner roles in LHCCs.

2. LHCCs, working with the local Public Health Function should identify and encourage public health champions in all disciplines and agencies.

3. LHCCs should take every opportunity to promote shared learning and problem solving activities which bring to bear the varied skills of different professional groups

Public Health Practitioners

To make into reality the concept that each LHCC should be a focus for public health activity, Nursing for Health recommended that PHIS should work with local health communities to support the local development of new Public Health Practitioner roles. This has been a major development in the public health workforce. A steering group chaired by the lead in public health nursing at PHIS meets on a regular basis and has been actively involved in leading the development. At local level, there has been enthusiastic engagement by LHCCs, Directors of Public Health and Directors of Nursing in recruiting and developing the roles.

A job profile was developed, informed by the Specialist Standards in Public Health (Healthwork UK, 2001). This profile was then used locally to develop job descriptions for PHPs, facilitating a consistent approach whilst allowing for variation to meet local circumstances. Initial appointments were made in October 2001 and all LHCCs in Scotland have now appointed one or more PHPs. The appointees come from a range of professional backgrounds including nursing and health visiting, community education, health promotion and dentistry.

Most PHPs have now been in post for over a year. An evaluation study was commissioned in December 2002 to measure the impact of these new practitioners on public health activity in each LHCC. A three year evaluation will be undertaken by Scottish Health Feedback and the National Centre for Social Research. The aims of the evaluation are:

To assess the contribution of the new PHP posts to:

• The development of the public health capacity of LHCCs

• The wider health improvement system

Skills and Champions

Across Scotland PHPs are active in developing public health skills and identifying champions. In some areas PHPs have begun to map and build directories of public health skills and competencies within the existing workforce. The directories are a useful resource for colleagues across a range of organisations needing to access expertise and make best use of existing resources.

In Grampian, a public health skills audit was undertaken across NHS Grampian, Aberdeen Inner City LHCC, Aberdeen City Council and the voluntary sector. The findings were used to inform a nurse training strategy. The professional HV forum has also identified sub groups to ensure the distribution of skills matches identified need.

In Western Isles, the PHP has mapped skills within the health visiting team, with a view to making best use of the available expertise.

There is also some significant evidence of LHCCs acting as a focal point for joint education and development.

In Argyll & Clyde, the Argyll & Bute LHCC hold an annual joint LHCC/community planning partnership conference on public health, which helps identify priorities for action.

Lanarkshire LHCCs have developed and implemented Public Health skills based training in areas such as CHD pathway, fuel poverty, older people's health and parenting, as well as promoting community development approaches in primary care.

In Fife, West Fife LHCC held a community development awareness day, with an attendance of 50% nurses and 50% local partners. In addition to the training opportunity, commitment was secured to future actions.

Where Next?

The continuing development of PHP roles will take place within an increasingly multi-agency environment as LHCCs mature. The ongoing support network and formal evaluation will provide a framework for continuing to support this key role.

4. LHCC Public Health Practitioners should develop a strategic role, influencing both local and regional strategies.

5. The Public Health Institute of Scotland and the Nursing and Midwifery Practice Development Unit will initiate debate about the development of nursing's strategic contribution to the public health function, in particular learning from the development of nurse consultant posts and the Healthworks UK pilot.

The Strategic Role of PHPs

Nursing for Health recognised that nurses in practice were often far detached from public health strategy and planning. Part of the purpose of creating the Public Health Practitioner role was to close the gap between strategy and practice. Nursing for Health envisaged a role that would be both strategic and operational, developing practice and influencing strategy. Two years on, there is good, although not universal, evidence that PHPs have successfully started to develop that strategic role. Across the country, PHPs are engaged in local strategic and planning fora, often in partnership with other agencies. Particular areas include work with Social Inclusion Partnerships, New Community Schools and in local community planning.

Where PHPs had been most successful in developing strategic roles, three factors seem to be important:

• Relationship to the decision making process within the LHCC. Not all PHPs are members of LHCC Boards or Executive Groups. Even within NHS Board areas there can be wide variations in the extent of influence. Clearly this has an impact on their ability to take a strategic role within the LHCC. It also limits their ability to effectively represent the LHCC in other strategic and partnership fora.

• Areas where the LHCC was broadly co-terminous with Local Authority areas appeared to create greater opportunities for strategic contributions to partnership work

• Where NHS Boards had developed a strong locality focus within their public health function, PHPs were able to develop a stronger role in planning and target setting.

In Ayrshire & Arran, rather than have a PHP in each LHCC, an integrated approach to public health has been developed. The 8 LHCCs have grouped into 3 meta-LHCCs co-terminous with Local Authority boundaries. Each meta-LHCC has a lead PHP, whose focus is strategic, working with the LHCC, NHS Board and Local Authority to deliver joint health improvement priorities; and a PHP, whose focus is more operational, with an emphasis on service development.

Nursing's Contribution to Strategy

In addition to the development of the role of PHPs, the strategic role of nurses in public health has continued to develop in other ways. There are now two Nurse Consultants in Public Health, with a further post proposed in the field of Health Protection. In developing these roles, NHS Boards are increasingly acknowledging the different perspective that a nurse brings to the clinical team. A learning set, facilitated by PHIS has brought together a range of people, including a number of nurses, with aspirations to achieve specialist status in public health, using the specialist standards developed by Healthwork UK (now Skills for Health). A UK wide voluntary register for non medical public health specialists will shortly be established, enabling those nurses able to demonstrate the competencies to practice at specialist level, equivalent to a Consultant in Public Health Medicine. The effect of these developments within the multi-disciplinary public health workforce has largely superseded the proposed debate on nursing's contribution to strategy, although it was the subject of some discussion at the PPHiN conferences. The development of the nurse consultant network led by NMPDU and the evaluation of the nurse consultant role will further inform the debate. Therefore, while the debate proposed in Nursingfor Health did not develop as anticipated, nursing's strategic contribution to public health has continued to develop.

Where Next?

The Primary Care Modernisation Group in taking forward actions from the White Paper, Partnership for Care will specifically address the role of LHCCs in Health Improvement, giving a further opportunity to consolidate and develop the strategic role of the PHP.

6. The Scottish Executive will support leadership development for nurse team leaders in primary health care teams.

7. The Public Health Institute of Scotland will establish an ongoing development network for LHCC public health practitioners, based around the competency framework identified in the Healthworks UK standards.

8. The Nursing and Midwifery Practice Development Unit will map new and creative career pathways as a means of developing future leaders in public health nursing.

9. The Public Health Institute of Scotland will have a key leadership role for nurses in public health, alongside a broad range of other professionals.

10. Directors of Public Health should put in place the right systems to provide effective leadership to the public health workforce.

Clinical Leadership

Nursing for Health recommended that community nurses in primary health care teams develop effective clinical leadership skills in order to act as a local force for practice development. The importance of developing clinical leadership skills was also laid out in Caring for Scotland and more recently in Facing the Future. Funding of 0.75M was made available in 2001 to enable community nurses to develop leadership skills. Reports indicate that almost 700 community nurses have benefited from leadership development programmes. A variety of different approaches have been used in response to local needs.

In Highland, Western Isles and Ayrshire & Arran, a number of staff have undertaken the RCN clinical leadership programme.

In Ayrshire & Arran, a successful in house clinical leadership programme delivered initially to hospital based staff was offered to 45 community nurses.

In Renfrewshire & Inverclyde PCT leadership development training was used as part of the development of integrated primary health care teams to help form effective teams.

Developing Public Health Practitioners

Public Health Practitioners came to their roles from a wide variety of backgrounds. Together they brought a wealth of expertise, but coming to a new role, all had development needs. In order to meet those needs in a consistent way, PHIS organised a structured education and development programme. Each PHP attended a development centre, facilitated by a range of professionals with an interest in public health. The development centres were based on the Healthwork UK public health specialist standards deemed to be relevant to the role. They consisted of a variety of exercises designed to identify the strengths and development needs of each participant. Participants received constant feedback during the centres and a written report identifying agreed development needs.

From the development centre process, the collective development needs of the group were identified, falling into three broad categories:

• Leadership and personal effectiveness

• Working with communities

• Understanding and applying information and statistics

Programmes were then commissioned to meet their needs, with PHPs selecting appropriate modules to meet the needs identified in their development report. A learning network was also established with funding from Queens Nursing Institute Scotland and a national database of mentors has been developed to enable easy access to mentorship and coaching.

In addition, many NHS Boards have organised structured development opportunities for local PHPs.

In Lothian, a Board wide induction programme for PHPs was developed. This 10 week programme also incorporated colleagues from health promotion, local Authority Health Improvement posts and lead nurses. The programme is generalist in nature and relevant to anyone with a significant public health element in their role. The joint approach to training has helped to build bridges and establish effective team work.

Creating Public Health Career Pathways for Nurses

It was originally proposed to map career pathways in public health for nurses. However, developments in public health over the last two years have somewhat overtaken this proposal.

Nursing for Health and the Health Improvement Fund have created a whole new cohort of practitioners in public health, most notably the LHCC PHPs and the Health Improvement Officers in Local Authorities. Together with the emerging nurse consultant posts, these developments have created a career route into public health that didn't previously exist.

The development of standards for public health led initially by Healthwork UK and subsequently by Skills for Health is creating a framework that can be applied across a number of professional groupings. The first set of standards were developed for specialist practice and describe the competencies required to achieve the equivalent level of skill of a Consultant in Public Health Medicine. A second set of standards for public health practice is currently in development. These standards will provide a similar framework for practitioners in public health. Extensive work on piloting the standards in Scotland will be undertaken during 2003.

In time, the implementation of public health standards and the development of links between them will provide a multi-professional career route in public health.

The wide variety of activity around developing the public health workforce in Scotland is now being drawn together into a co-ordinated work plan. Early priorities include:

• Mapping the job to be done and the skills and resources available to deliver

• Developing a public health career framework building on the UK standards

• Developing multi-professional education

• Nurturing networks and organisational development

• Leadership at all levels

The Leadership Role of the Public Health Institute of Scotland

The Public Health Institute of Scotland was established in January 2001and has played a key role in developing and supporting work around the implementation of Nursing for Health. The Institute has a leading role in focusing and co-ordinating public health effort, particularly in building confidence, capacity and opportunity for professionals and linking training and education providers and employers. Nurses working at all levels and settings are seen as key members of the public health community and have benefited from both PHIS' multi-disciplinary work around public health and from focused efforts around the role and contribution of nurses.

In the specific context of Nursing for Health, PHIS continues to play a key role in relation to skills development. In addition to leading the development of the PHP role, current and future activity includes:

• focused development work with Universities and NHS Trusts to support the cultural and practice shift from health visiting and school nursing towards public health nursing.

• Supporting skills development for the wider workforce (which includes all nursing disciplines).

Directors of Public Health - Leading the Public Health Workforce

Nursing for Health recommended that Directors of Public Health should play a more direct role in providing leadership to front line staff, ensuring a more explicit connection between strategy and practice. The development of the Public Health Practitioner role has been a key driver in enabling this development. Directors of Public Health have been actively involved in the recruitment and development of these posts in many cases and have organised systems and processes to ensure a direct link via PHPs to practice.

In Lothian, the Director of Public Health is developing an overarching health improvement/inequalities strategy and intends to marry up the strategy with action on the ground via PHPs.

In Forth Valley, PHPs are formally recognised as honorary members of the public health department with access to all of the resources of the department and a "hot desk".

In Lanarkshire, a public health consultant provides a direct link with the PHPs, who are actively encouraged to participate in departmental meetings and receive individual and group mentorship support.

Where Next?

The development of career pathways will be led through a work programme focused on the development of a multi-disciplinary public health workforce for Scotland.

The firm foundations established by PHIS in providing national leadership for public health nursing will be taken forward in the development of NHS Health Scotland.

11. Directors of Public Health should work with LHCCs and other agencies to establish multi-disciplinary public health networks, in which nurses should play an active role. The LHCC public health practitioner will be a key link in such networks.

12. The Nursing and Midwifery Practice Development Unit will create a database of good practice in public health nursing.

13. The Public Health Institute of Scotland should ensure that nurses are actively involved in national public health networks.

National Networks

At a national level, PHIS has been active in developing a number of topic specific networks. Networks around each of the three public health demonstration projects are developing, each led by a national co-ordinator. Their function is not only to share the learning from the projects, but also to bring together knowledge and professionals with an interest in the three topic areas of early years, sexual health and coronary heart disease. PHIS also supports a range of other national networks including the Promoting Public Health in Nursing Network PHHiN and a national network of Public Health Practitioners. The PHHiN network will continue to explore the potential of nurses for improving health by incorporating public health approaches within their day to day work.

Public Health Practitioner Networks

At a local level, in all but the smallest of NHS Board areas, where relationships tend to be between a few individuals, networks have developed, linking PHPs with colleagues in Public Health Departments and in some cases Health Promotion departments.

In Argyll & Clyde, a PHP network is facilitated jointly by a Public Health Specialist, Consultant in Public Health Medicine, and senior project manager from Health Promotion. The network meets monthly and has a both an educational and a knowledge sharing function.

In Grampian, PHPs have their own network supported by computer chat room with links into local authority areas.

In Fife, there is a virtual public health team linked to each LHCC, consisting of PHP, a Consultant in Public Health Medicine and a Health Promotion Officer. This forms the basis of a virtual network, which is already improving communication and information sharing.

NHS Board Wide Networks

The development of more extensive networks integrating public health and primary care is very much at early stages in most places, although there are a number of significant developments underway.

In Grampian, focus groups and informal discussions have been used to scope work on the development of a public health network, building on existing connections and developing ownership. The new network will involve all PHPs as well as local authority Health Improvement posts and community planning co-ordinators, with a significant IT element, creating internal and external web links. The network will aimto achieve linkages at operational and strategic levels and engage the wider public health workforce, building on existing good practice.

In Tayside, the public health and primary care network is well established and was highlighted in Nursing for Health. It has been reviewed in the light of PHP development and seeks to take a more strategic role with PHPs having local networks below it. Opportunities to incorporate links with staff in the acute sector are also being explored.

LHCC Networks

Local networks, involving a range of professionals within an LHCC are also developing in some areas.

In Greater Glasgow, there are networks developing within each LHCC. The networks have a variety of formats, some involving voluntary sector and local authority staff. Examples of the work undertaken by the networks include:

• Using the network to produce public health plans

• Formal consultation on priorities - via an annual event

• Network conference bringing people together

• Linking with existing networks via health promotion and SIPs

In Lothian, local networks are developing within each LHCC, involving a range of professionals including Patient & Public Involvement Officers, Health Promotion, GPs, Health Visitors, School Nurses, Community Education and local health project workers. Lothian wide networks also exist for PHPs, Patient and Public Involvement Officers and other groups. These are to be joined up by creating a Lothian public health directory and a web- based discussion group.

Sharing Best Practice

The review process leading to the development of Nursing for Health's publication generated a huge amount of information on good practice. It was originally proposed that this should be made widely available via an NMPDU database. In practice this proved difficult for a number of reasons. The information gathered was not in any standard format. There was some disagreement around what constituted good practice and some of the information proved to be already out of date. What is clear is that further developments over the last two years have made the sharing of practice information ever more important. The creation of NHS Quality Improvement Scotland, NHS Health Scotland NHS Education for Scotland and the Centre for Change and Innovation provides a new environment within which the sharing and promotion of best practice can take place.

Where Next?

Further development of public health networks has been identified as a priority for developing the public health workforce.

Opportunities for sharing practice on public health nursing will be explored within the new framework of quality, public health and education bodies developed in Scotland.

14. NHS Boards should ensure that they have the necessary infrastructure in place to support nurse involvement in community development work.

15. LHCC public health practitioners should map the existing resources of communities, developing links with community projects, development workers and voluntary organisations active in the area.

16. LHCCs should, where appropriate in response to locally identified need, assign dedicated nursing time to work on community based activities.

17. LHCC Public health practitioners should act as a key contact point for the local community, acting as a source of advice, support and information to voluntary and community groups.

Education and Practice Development

Overall, there has been great progress in establishing a role for nurses in working with communities. Training in community development skills has been made more accessible to public health nurses, both in community nursing education programmes and in LHCCs with support from public health practitioners. For example, many NHS Boards have commissioned either the "Health Issues in the Community", or the "Community Development in Primary Care" training programmes to raise awareness and introduce basic community development skills to nurses working in primary care. As a result of training and support for community development and community-based activity, there are numerous examples around Scotland of public health nurses taking new approaches to working in communities. However, the development of skills raises new challenges at local levels in supporting and enabling community development approaches.

Public Health Practitioners - a Visible Contact

As Public Health Practitioners become more established in their LHCCs, they are regarded as a key contact point for agencies and networks in the local community.

In Fife, PHPs reported that until the creation of the role, local authority staff found it difficult to find the right person in LHCCs to talk to, but the creation of the PHP role had led to a flowering of effective partnership working.

In Lanarkshire, PHPs have raised the overall awareness of how LHCCs should be engaging with communities, encouraging public involvement and working towards real involvement so the public can influence service delivery.

Public health nurses often work closely with PHPs who are increasingly engaged in mapping exercises, identifying both need and existing resources in communities. As a result, some are identifying areas where more nursing time could be deployed for community based activities.

A health needs assessment on the island of Unst in Shetland identified that a reduction in the RAF station had led to unemployment and men's health as a big concern. By starting with looking at the health of women and young people in the area, men are gradually coming on board for future work. This work has highlighted the need to challenge existing culture in both the local population and in nursing in order to take health improvement work forward.

The first cohort of public health nurses entered practice in September 2002 and many of them were assigned directly to community-based activity alongside caseloads.

Where Next?

As the capacity of Public health Nurses to undertake community development approaches expands, it is important to review both the training available and the extent to which it has helped develop practice.

Health Improvement in Scotland: The Challenge will create a new opportunity for public health nurses to apply their skills in community development .

18. Health Boards and Local Authorities as public health organisations should remove organisational barriers to effective partnership at all levels of their organisations, as should NHS Trusts as employers.

19. LHCC public health practitioners should encourage the development of local partnership working, bringing together nurses from all backgrounds and organisations into a team addressing the needs of the local community.

20. Health Boards should ensure that school nursing services are part of Primary Care Trusts and play a full role in the work of LHCCs

Nursing for Health identified many examples of organisational barriers getting in the way of joined up working. Different organisational structures and cultures often made it difficult to communicate effectively or make meaningful decisions. Over the last few years there has been a consistent policy message of joint planning and service integration, which together with the continuing development of LHCCs and the recognition of their role in health improvement and local planning, has helped created a culture where unhelpful boundaries are being steadily eroded. The pace of progress is inevitably variable in such a complex area. Examples from across Scotland demonstrate the extent to which effective partnership working is making a difference.

In Ayrshire & Arran, the NHS Board has formed three Locality Teams that are the main link to each of its three local authority areas. The teams bring Public Health, Finance, Information and Planning Officers together with PHPs, local authority Health Improvement Officers and locality Health Promotion Specialists. The new 'virtual' teams ensure a strong connection between the centre and local practice as well as being a central part of the planning structure, particularly in relation to the Local Health Plan, Community Plans and Social Inclusion Partnerships . One year on, this new approach is starting to make progress, with positive evidence of partners' behaviour and enthusiasm.

In Highland, the NHS Board re-structured, creating several joint agency initiatives, including development of Integrated Childcare and Community Care posts, and Integrated Joint Futures Project.

In Tayside, there is a joint decision making process on committing the Health Improvement Fund in each LHCC area.

Whilst there is a lot of evidence of activity in partnership with other agencies and community groups, there is less reported activity around engaging other disciplines of nursing in improving health. In many areas it is acknowledged that the focus of implementing Nursing for Health has been on re-designing health visiting and school nursing, with the potential to engage other groups of nurses seen as a future priority. There are however some good examples of practice emerging:

In Lanarkshire, the development of specific Men's health services and lifestyle clinics, in a variety of forms, have occurred across LHCCs, focusing on the importance of lifestyle and behaviour and bringing together nurses from a range of backgrounds.

In Tayside, public health seminars are planned for nurses in the acute trust, with a view to developing their public health role. The outcome will support the further development of local public health networks.

In Forth Valley and Lanarkshire, Learning Disability Nurses will be undertaking the public health nursing programme, with a view to providing a specialist service to learning disabled people in the community.

In Greater Glasgow the Midwifery Consultant is leading development of a public health focus within the midwifery service, targeting the needs of vulnerable women and communities.

The importance of integrating school nurses within the developing public health activity of LHCCs was recognised by Nursing for Health. Across Scotland, there is evidence of those links being developed. Either with the LHCC taking management responsibility alongside the rest of the public health nursing team or with partnership arrangements to support development of effective practice. The requirement to integrate with LHCCs is further set out in the Scottish Framework for Nursing in Schools.

Where Next?

Further work, led by NHS Health Scotland and NHS Education for Scotland and based on the outcomes from the PPHiN conferences will take forward the discussion around how to engage more nurses in public health activity.

21. Primary Care Trusts and LHCCs should facilitate the development of effective integrated primary health care teams.

22. Primary health care teams should identify a named lead person on public health. This would be a key person in the local public health network.

23. The Scottish Executive will work with GP representatives to facilitate effective teamwork and health improvement activity around maternity care and child health through the GP contract.

Integrated Primary Health Care Teams

Nursing for Health identified a tension between a desire amongst health visitors to focus on health improvement, which is a long term and often population focused activity and the pressures within primary care to provide a reactive individual service. The result was that many health visitors saw a tension between their role and the objectives of the Primary Health Care Team, resulting in a view amongst some health visitors that the solution was to sever ties with the PHCT. The development of more effective integrated Primary Health Care Teams and the need for a focus on public health within them was seen as a potential solution.

The extent to which these recommendations have been taken forward has been highly variable. Many areas reported activity on integrated nursing teams, some incorporating practice nurses alongside community nurses, but there was little reported progress on integrated primary health care teams. However, there were some exceptions.

In Lothian, a structured approach to the development of integrated primary health care teams was taken, explicitly including GPs. The specific aims of the project were to identify core competencies for nurse team leaders in developing integrated working and to provide appropriate development opportunities and to promote the concept on integrated working within LHCCs. The project set out specific recommendations, which are now being addressed by the PCT.

The debate about attachment to Primary Health Care Teams for health visitors has opened up. It was one of many subjects discussed at the series of consensus conferences on the future of public health nursing in the summer of 2002. The general consensus was that severing ties with PHCTs would not be sensible or desirable, but that there were some other potential models of practice that could be explored.

In Dumfries, health visitors are retaining an alignment with GP practices, but working more as a team with a community focus.

In Forth Valley, there is a named public health link person in each practice in the North LHCC, forming a local network. An initial exploratory meeting with all links looked at the wider public health role and supporting the role through integrated teamwork.

In Grampian, LHCC public health nursing workshops have looked at the public health nursing agenda. In Aberdeen City LHCC, 3 working groups were set up to look at:

• Corporate caseloads and developing a neighbourhood focus

• Developing a skills register to make best use of skills

• Developing the wider public health agenda.

Original plans to discuss minor changes in the GP contract with a view to addressing perverse incentives around maternity care and child health were superseded by a more significant review of the contract at UK level. However, the proposed new structure for the GMS contract has the potential to reduce duplication and promote teamwork. Similarly, the expansion in PMS pilots has seen the development of alternative contracting arrangements, which can be much more focused on local need and effective teamwork.

Where Next?

The further work of the Primary Care Modernisation Group, particularly in the context of the new GMS contract and the further development of PMS pilots will create an opportunity to take forward discussion on public health and primary care.

24. The Scottish Executive, in partnership with relevant stakeholders, will lead a radical modernisation of the public health nursing workforce. In the short term, this will involve the development of a public health nurse role which incorporates the roles of health visitor and school nurse

25. The Scottish Executive will invest in the education of the existing school nurse workforce to ensure that team leaders have educational and grading parity with existing health visitor colleagues.

26. Trusts and LHCCs should make changes to skill mix as opportunities arise to ensure that effective use is made of the skills of specialist practitioners. These changes should be based on the needs of the service and its patients/clients. Particular attention should be given to the development of new roles such as early education and child care workers and to the potential of working with voluntary and community groups to meet identified needs

27. Trusts should ensure that more effective use is made of nurses with specialist expertise, for example infection control nurses, occupational health nurses or CPNs, by ensuring that they are linked into local public health networks and are able to act as a resource to the LHCC

Developing Public Health Nursing

The first public health nursing courses, which brought together health visiting and school nursing, finished in September 2002. The Scottish Executive directly funded 128 places including 48 for existing school nurses, who embarked on a programme with a written promise of grading parity on their return. As at December 2002, 172 public health nurses had successfully completed the programme and were back in practice. In order to stimulate debate around the future development of the public health nurse role, three consensus conferences were held. The outcome is summarised in annex A. In addition, many areas have undertaken local reviews, workshops and consultations to help further define action plans and strategies.

In Borders, local workshops facilitated by the PHP, with input from the LHCC, public health department and professional organisations as well as school nurses and health visitors, identified priorities for local development and a number of outstanding questions which were fed into the national consensus conferences. The workshops formed a basis for developing public health nursing.

In Forth Valley, a new model for public health nursing practice has been developed as a basis for re-designing the service. A senior nurse has been seconded to lead the development work, engaging practitioners in changing practice.

An extensive consultation process was carried out in Greater Glasgow to achieve local consensus on the public health nursing role. It found that there was support for carrying out more community-based activity, but with maintaining public health nurses links with primary health care teams. It also identified support for skill mix, more evidence-based practice and that all primary health care team members had a role to play in public health.

Making Best Use of Skills

There are many examples emerging of skill mix relating to local needs. For example some areas are employing nursery nurses to work with public health nurses in clinics and community based child health initiatives. Some LHCCs and primary care teams are employing youth workers and mental health workers to meet locally identified needs. In addition, there have been some efforts to bring other nurses with specialist skills into public health networks, although this is not consistent across the country.

In Greater Glasgow, the Starting Well Demonstration Project has piloted the use of lay support workers working with individual families to provide support and promote parenting skills.

In Fife, the Acorn Project provides access to a pool of skilled nursery nurses who are available to support families. Referrals are made by health visitors, social workers and the voluntary sector.

Where Next?

The consensus conferences provide a broad framework for public health nursing, which should be used to further develop and define public health nursing roles. A network of Nursing for Health leads will be established to promote shared learning

A competency framework for nursing in schools is being developed by NHS Education for Scotland (NES) to support the implementation of the Scottish Framework for Nursing in Schools. This will inform future skill mix in this field of rpactice.

As the role of LHCCs continues to develop, further opportunities need to be found to link other nurses with specialist skills into local public health networks. The emerging public health workforce development programme will provide a focus for this.

28. LHCCs and NHS Boards should ensure that the distribution of available skills and resource matches the pattern of identified need in communities

29. LHCCs and partner agencies should target resources to communities with the greatest need. This may involve developing community based approaches or linking with existing developments such as new community schools or sure start projects

30. Trusts should ensure that there is a system of supervision or peer review in place for all community practitioners, which promotes reflection.

Mapping Needs and Resources

Over the early months of their posts, most PHPs have been heavily engaged in undertaking local needs assessments and mapping available skills and resources. This will form a firm basis for future efforts to re-shape service delivery and target existing services to address priorities.

In Forth Valley, PHPs in the North LHCC are working with Health Promotion colleagues to undertake a public health training needs analysis with practice teams. They will then identify teams for further development work, hoping to respond to identified needs. They will focus on multi-agency work around physical activity in partnership with Stirling and Clackmannanshire Councils.

In Greater Glasgow, a practice profiling tool has been developed and tested within LHCCs as a basis for targeting developments.

In Lanarkshire, the Nursing for Health Strategy group commissioned a mapping exercise to identify Public Health activities taking place in LHCCs, thus providing baseline information. From this, planning and development will take place to increase the public health capacity of LHCCs to reshape services and address health inequality issues. Some areas are already considering adopting corporate HV caseloads as an alternative method of delivering health visiting services.

Targeting Vulnerable Groups

The fruits of this early assessment as well as the development of partnerships with community groups, Social Inclusion Partnerships and New Community Schools will form a strong foundation for future targeting. As a wider focus on health improvement develops, different approaches to practice are evolving across Scotland, targeting the needs of vulnerable groups.

In Argyll & Clyde, health visitors in Inverclyde LHCC, working with a community paediatrician, have set out to target the needs of the most vulnerable families: those with drug and alcohol problems, a history of domestic violence and broader social problems. Having mapped out the needs of the group they are seeking to link up with agencies to identify service gaps & developments. Examples of developments include:

• An early intervention drugs project for teenagers with drug problems or with parents who have drug problems.

• Working with needle exchanges to provide child health /healthy living input. Clients were very wary at first, but eventually they hope to offer positive parenting sessions.

• Working with the homeless unit they have found a flat to provide a local clinic.

In Dumfries & Galloway, concerns about the health and well being of agricultural workers, particularly in the context of the Foot & Mouth outbreak, led to the development of the Stewartry Farmers Health Information Project, run in conjunction with the mart.

In Tayside, a health visitor for homeless families is working in a team with a trainer and development worker to raise awareness, provide training and develop services for particularly vulnerable groups at risk of and suffering domestic abuse.

As services move away from universal models of provision towards addressing needs, the importance of effective supervision and support for practitioners will become ever more important. Developing effective clinical supervision was a high priority in Caring for Scotland. There is good evidence that supervision is becoming more readily available.

Where Next?

LHCCs will need to continue to build upon this early work and use the developing community planning mechanisms to develop effective targeting. The health inequality indicators set out in Health Improvement in Scotland: The Challenge will provide a framework to focus this activity.

31. The Scottish Executive will make widely available the systematic review of the literature accompanying this review in order to support the development of evidence based practice.

32. Practitioners should apply the model of effective public health nursing practice outlined above when planning new initiatives.

33. The Chief Scientist's Office, the Nursing Research Initiative for Scotland and the Public Health Institute of Scotland should develop a programme of research into effective public health practice based upon the findings of the systematic review of the literature.

34. The Public Health Institute of Scotland in association with directors of public health should ensure that support is available via local public health networks to implement evidence based practice in public health.

35. The Public Health Institute of Scotland will develop outcome and process indicators for public health nursing that are relevant to practice and which can be used to inform service planning and strategy. These will replace the counting of contacts as a measure of activity.

36. Primary Care Trusts should ensure that where practicable, nurses use GPASS or other local primary care systems to record their activity with patients/clients.

37. Trusts should ensure that all nurses working in primary care have access to a computer which networks with GPASS or other local system, local HB/PCT networks and the NHS Net. 3.5M is available in the current financial year to support implementation for current district nurses and health visitors.

38. Directors of Public Health, working with LHCC public health practitioners should ensure that local public health networks establish means to share and make use of the detailed local knowledge of nurses in developing plans and strategies.

Applying the Evidence of Effectiveness

The review process leading to the publication of Nursing for Health included an extensive literature review undertaken by Dundee University. This has been widely distributed as a resource tool for nurses with an interest in public health and is being used across the UK, with access via both the Scottish Executive and Health Development Agency web-sites.

A key element of PHIS' responsibilities is around developing and sharing information and evidence to inform public health practice. The PHIS web-site brings together a wide range of sources of information as well as giving opportunities to contribute to debate on emerging evidence. Much activity is also taking place at local levels:

In Argyll & Clyde, West Renfrewshire LHCC hold a monthly public health learning set. They started by reviewing Nursing for Health and are now coming together to learn from one another and look at developing practice. Future Plans include developing a web site to share information with parents, which could be particularly useful as a high proportion of women go back to work early.

In Ayrshire & Arran, South Ayrshire LHCCs have developed a falls prevention programme using the available evidence base to develop an 8 week programme for older people who might benefit from some preventative work.

In Tayside, a monthly public health development meeting involving PHPs and colleagues in the public health dept creates an opportunity for sharing evidence and good practice, with individuals presenting on key topics, prioritising and tying national and local agendas.

Research and Development

Choices and Challenges - The Strategy for R&D in Nursing and Midwifery in Scotland set out the twin aims of:

• developing the capacity, culture and infrastructure to enable nurses and midwives to deliver services that are based on sound evidence drawn from rigorously conducted research programmes

• enabling nurses and midwives to value the generation and utilisation of research

The strategy will have a key role in developing the capacity and infrastructure to support research and development in nursing and promote evidence based practice. The need for good quality evidence in the public health field has also been recognised by the Chief Scientist's Office, making health improvement one of its national priorities.

Information for Practice

Nursing for Health recognised that access to IT by nurses was highly variable. Even where nurses had access to a computer, it was often shared with a number of colleagues or wasn't in a convenient location. A second significant problem was that useful information about practice was very difficult to find. Most information collected related to counting contacts with patients. This produced little of value to inform either practice or strategy and there were significant gaps around the public health dimensions, most notably any work with groups or communities.

The e-CHIP project was established early in 2002, with the aim of developing electronic information on community health services that is of value to practitioners, strategists and policy makers.

The project has a number of key strands:

• Developing a nationally and locally representative sample of activity based on practice teams (Practice Team Information (PTI)). The PTI project involves recording all team activity into the practice information system and involves a nationally representative sample of practices. The national sample has now been identified and will be fully established by April 2003, with information available from 2004. The next phase of the work will involve establishing a locally representative sample in each NHS Board area. The richness and detail of the information produced means that it is of value locally to professionals and at national level in terms of developing policy.

• Because not all nurses will record directly into a GP practice system, a virtual electronic record will be developed bringing together information from different systems to create the same picture as in PTI.

• The current PTI system has evolved over time, so the dataset whilst useful does not necessarily reflect future practice. The Community Nursing Network have recently concluded a consultation on the dataset which will help inform future developments and ensure that meaningful information is developed.

• Nursing for Health reported that 3.5M had been made available to ensure access to IT for community nurses. This has made a significant difference, although there are still some gaps, further investment in IT in 2002/3 included funding to complete the roll out. An audit of progress will identify any remaining gaps as the basis for future development.

• As much public health focused activity can't be attributed to individual contacts, e-CHIP will also look at ways of gathering and using information about the needs of and services provided for groups and communities. This work, in partnership with PHIS, will help ensure a better picture of the impact of public health nursing on the health of communities and provide information to support decision making both locally and nationally.

Where Next?

Implementation of e-CHIP will continue, enabling the development of reliable, meaningful information to underpin practice.

PHIS' role in developing the information to inform public health practice will be taken forward in NHS Health Scotland's remit. Nurses will need to continue to participate in this development.

39. Universities and Trusts should work together to develop the LHCC as a focus for community placements rather than an individual practice. Placements should seek to give a broad variety of experiences including placements with voluntary and community groups that will give a more rounded perspective of public health practice.

40. Teaching on public health should be strengthened by the involvement of public health experts to consolidate evidence based theoretical elements of the programme.

41. Universities should ensure that link nurse lecturers, preferably with appropriate background in public health/community nursing enhance links with LHCCs to support students and mentors in providing high quality learning experiences for students and facilitating the development of public health competencies.

42. The Scottish Executive will commission the training of an additional 60 health visitors and support 30 existing school nurses to achieve specialist practice qualifications in the short term.

43. The Scottish Executive will pilot WHO Europe's Family Health Nurse concept.

44. The Scottish Executive, working with the National Board for Nursing, Midwifery and Health Visiting in Scotland, the Public Health Institute of Scotland and universities will develop a new public health nurse education programme, which will bring together the existing specialisms of health visiting and school nursing.

45. The Scottish Executive will review with all interested parties the outcomes of the new public health and family health nurse programmes with a view to having only two routes to community specialist practice - the Family Health Nurse and the Public Health Nurse.

46. The Scottish Executive will ask the UKCC and its successor the Nursing & Midwifery Council to review the outcomes for health visitor education in the light of current practice requirements.

47. The Scottish Executive will establish a mechanism for commissioning community nursing education to meet the needs of current and future practice.

48. Trusts should identify development needs of nurses in the light of the recommendations of this review and future project work arising from it, and work with the Scottish Executive, the National Board for Nursing, Midwifery and Health Visiting for Scotland and education providers to address them.

49. The Public Health Institute of Scotland will work alongside the National Board for Nursing, Midwifery and Health Visiting in Scotland to develop an advanced qualification in public health for nurses which incorporates a multi-disciplinary Masters Degree and the acquisition of clinical competencies.

Pre - Registration Education

The implementation of Fitness for Practice pre-registration programmes in Scotland in 2000/01 provided an excellent opportunity for universities and their service partners to reflect on how public health could be strengthened within the new programmes, in line with the Nursing for Health recommendations. This has resulted in many programmes having increased emphasis on subjects such as health promotion, epidemiology and infection control with lecturer practitioners and clinical experts contributing to teaching activities. The Universities are also developing new approaches for providing appropriate learning opportunities in practice.

At the University of Paisley, students are now allocated to an LHCC as a focus for community placement. This allows students to develop understanding of the differing roles of all members of the primary care team and others who contribute to health and social care across a community, including the local population. The students are facilitated to experience a broad range of activities across health and social care settings and to reflect on holistic models of health.

Public Health Practitioners and Nurse Consultants in Public Health across Scotland are now contributing their expertise to bring public health alive for students by providing teaching input to groups of students or working with university staff to identify appropriate areas and organisations for placements.

In Aberdeen, there is a joint appointee who works for Grampian Primary Care Trust as a Public Health Co-ordinator and also as a lecturer in the Robert Gordon University. This approach ensures credibility of teaching staff and demonstrates to students how the current agenda of addressing health inequalities is being addressed by nurses, working in partnership with a range of colleagues.

At the University of Dundee, the number of teaching staff in the School of Nursing and Midwifery with qualifications and research expertise in public health has been significantly increased, resulting in a greater capacity to prepare students with skills in public health and knowledge of the evidence base for practice.

Developing Public Health Nurses

A two year secondment of a Professional Officer from NBS/NES to PHIS has enabled close collaborative working to support capacity building in public health nursing. To fit with the existing UKCC regulations, NBS worked with the five university departments offering health visitor programmes in Scotland to modify the programmes into the new public health nursing programme, allowing for the achievement of competencies needed to undertake public health activities with individuals, families, and communities. The graduates from these programmes were able to register as health visitors on the professional register and are able to work in a flexible way across primary care, school and community settings.

Some challenges were experienced in the implementation of the modified programmes, especially in identifying appropriate learning opportunities in practice, which would enable new ways of working to be developed. In order to address these issues, PHIS funded and managed the appointment of a Practice Education Facilitator for one year to each programme. The Practice Education Facilitators have provided a vital link between practice and education, supporting the mentors of the new public health nurses and working with a range of local organisations to identify suitable placements.

In 2002, the NMC approved new Standards for Health Visitors which articulated a stronger public health role and fits well with ongoing developments in Scotland. Some universities in Scotland have already redesigned their programmes based on the new standards and others are due for review/revalidation this year. Proposed changes to the NMC Professional Register in late 2003 will have an impact on the future education and regulation of health visitors and public health nurses and this will need to be monitored carefully with regard to ongoing professional developments designed to meet health needs in Scotland.

Family Health Nursing

A two year pilot of the WHO Europe Family Health Nurse concept commenced in February 2001 . This new model of practice, which combines clinical nursing care with public health approaches, was piloted in remote and rural areas of Scotland. Stirling University delivered the formal education programme, utilising educational approaches specifically designed to support practitioners working in geographical isolation. Graduates of the programme register on the NMC professional register as specialist practitioners (Family Health Nursing). Under special arrangements agreed with the NMC, no other nurses will be able to use this title until the project has been fully evaluated.

In Orkney, Western Isles and Highland, the first 10 Family health Nurses are now well established in practice, with a further 21 completing their education at the end of December 2002. In Orkney, where the two nurses work as the sole nurse with island communities, they have brought a valuable public health dimension to the nursing role. In Western Isles and Highland, roles have evolved in a variety of ways in response to local needs, with Family Health Nurses bringing new and different skills to existing teams enabling the service to develop around the needs of individual communities

A full evaluation of the Pilot is being conducted by a team from the Robert Gordon University. The final report in spring 2003 will inform future decisions about the family health nurse role in Scotland.

Continuing Professional Development

In addition to changes in initial pre and post registration education programmes for nurses and midwives, developments in practice require significant personal and professional development of existing staff. In addition to funding 128 places on the first public health nursing programme, a further 2M was made available over 2002-4 to support further places on the programme and CPD for the existing public health nursing workforce. Particular areas identified for development included leadership, community development, partnership working and IT skills as well as health needs assessment and new ways of working with service users.

Significant work has been undertaken by many Trusts in the last two years to review and map current levels of skills and identify areas for further development.

Grampian Primary Care Trust, has developed a Skills Register which is used to facilitate the sharing of expertise between practitioners and provide support/expertise in specialist areas as required.

Individual needs are being identified in personal learning plans and trust wide reviews of health visiting and school nursing services are highlighting the need for greater investment in practice development activities to support service redesign.

Development needs are being addressed in different ways. Where possible, multi-disciplinary and multi-agency approaches are utilised. Some Trusts are working closely with local HEIs to commission specific modules in public health approaches and skills. Local Public Health Networks are also used to provide opportunities for CPD and share areas of interest and expertise with colleagues from other organisations.

In Argyll and Clyde, there has been strategic development of public health capacity in the LHCCs with workshops held with key staff to plan future activities. Currently development activities include community development training, values and attitude training and Walk the Talk Peer Education with youth health worker colleagues. In Argyll and Bute LHCC, away days were held for health visitors and school nurses to explore corporate caseloads and develop strategies to implement Hall 4 agenda and in Lomond LHCC a practice facilitator has been appointed to support role development and new ways of working.

In Forth Valley, a senior nurse is being seconded to undertake an assessment of development needs of public health nurses based on health needs within localities.

Advanced Qualification in Public Health Practice

An NBS officer was seconded to PHIS in 2001 to lead work on the development of a new programme. A Discussion Paper was distributed from PHIS in the summer of 2002 which described a possible model for a Scottish Masters in Public Health Practice which had been developed following discussions with many key individuals and organisations with interest in public health and health improvement.

The model consisted of core modules related to key public health activities and knowledge base and a menu of optional modules which would give participants the opportunity to follow pathways relevant to specific areas of practice. It is anticipated that academic departments would form a consortium with partners from other academic disciplines and with public health organisations to provide a flexible programme incorporating the opportunity to develop competencies in public health practice as defined by Skills for Health. The programme could provide an opportunity for participants from a different sectors to learn together, developing a shared language in public health and supporting future partnership working. It is also expected that many practitioners involved in aspects of public health would dip into the programme to meet identified CPD needs.

There has been significant interest from academic departments and other organisations in participation in this development and NES and PHIS are now exploring the support mechanisms needed to take the initiative forward.

Where Next?

NHS Education for Scotland will continue the development of the Scottish Masters in Public Health Practice.

Universities need to continue to build upon partnerships to strengthen the public health components of education programmes for nurses and midwives, especially with the challenges raised by greater numbers of students requiring high quality clinical learning placements.

Workforce planning for the public health nursing workforce will be developed by the new Regional Workforce Centres working in partnership with NHS Education for Scotland, informed by discussion around the development of a multi-disciplinary public health workforce.

The outcomes of the Family Health Nurse evaluation will be shared and debate about the future implications for education and practice initiated.

PREGNANCY AND CHILDBIRTH

50. Midwives and public health nurses need to work closely together to ensure a seamless transition for parents.

Good progress has been made across the country to link midwives and public health nurses including bringing some into alignment with or even enabling them to become fully integrated into the LHCC. At the PPHiN seminars, midwives identified themselves as being committed to further developing their roles in public health. They are already involved in a variety of health promotion initiatives and multi-agency collaboration for health improvement, and in some areas are developing services targeted at marginalised population groups.

In Tayside, the post of Public Health Midwifery Consultant has been developed. The post holder, when appointed, will work closely with the existing Public Health Nurse Consultant to lead local service developments.

In Grampian, midwives and health visitors recognised that they were giving different advice. They have standardised a common set of routine information and are going on to consider a multi-disciplinary approach to positive parenting.

Midwives at the PPHiN seminars identified that they aspire to linking into wider public health activity by increasing their evidence-based practice for both health and social needs, having more influence on health policies and to work beyond individual patients to work across communities and populations.

Where Next?

Involving midwives in local public health networks and developing strong links with PHPs will help ensure that their unique opportunity for health improvement is fully exploited.

51. The Scottish Executive will lead the development and implementation of a new model of practice for Public Health Nurses working with young children and their families.

52. Primary Care Trusts and LHCCs should critically review the value of child health clinics and seek more relevant methods of service delivery to meet local need.

53. Public health nurses should make more effective use of peer support groups and networks to support parents.

54. NHS Boards and LHCCs should work closely with local social work services to ensure the delivery of an effective service to support vulnerable families, building on the findings of the forthcoming report on the review of services to support vulnerable families.

Nursing for Health recommended that a new model of practice be developed, with a core programme and targeting according to assessed need, using a Family Health Plan to set goals. Many strands of work are now coming together at national and local levels, which will enable this:

• Starting Well has tested out intensive models of visiting and have tested out structured goal setting and the use of a Family Health Plan.

• HEBS have undertaken extensive research on the potential for Family Health Plans.

• A consensus conference on the Health for All Children IV report has been held to agree consistent national approach to the core programme.

All of these pieces of work come together into Health Improvement in Scotland: The Challenge, with its priority of improving the health of children through a good start in life. Consultation on an early years strategy will follow this, setting future models of practice. The emphasis on targeting services to support the most vulnerable groups will reflect the findings of Growing Support and It's Everyone's Job to Make Sure I'm Alright.

In the meantime, much good work is taking place across Scotland on developing the role. In particular:

• Child health clinics have been reviewed in many areas, resulting in significant changes in practice.

• Models of peer support for parents have been developed

• Community development approaches to supporting families are being explored.

In Argyll & Clyde, Inverclyde LHCC, 10 parents were trained alongside 10 professionals (including health visitors, New Community School staff and family support workers) as trainers in child behaviour management. Pairs of professional and parent then run a handling children's behaviour course for groups of 10-20 parents.

In Borders, work on developing integrated children's services has created the opportunity to develop public health nursing within a managed clinical network, with public health nurses developing within a matrix connecting primary care, specialist paediatrics and communities.

In Dumfries & Galloway, child health clinics have been reviewed and are being re-developed into a baby club model, using peer support.

In Greater Glasgow, PHPs have led local reviews of child health clinics using a common assessment process, with a view to building on positive elements of the service

Where Next?

Future development will be informed by the forthcoming Early Years Strategy, which will draw together the strands of development so far into a consistent approach to improving health and well being for all children and families.

55. The Scottish Executive will lead the development and implementation of a new model of public health nursing practice within schools. Significant investment will be made in educating and preparing the new public health nurses to fulfil this role.

56. NHS Boards should ensure that school health services are fully integrated with LHCCs and work closely with schools and other key local agencies

57. NHS Boards should review the resourcing of local school health services to ensure that they can develop to meet local need.

58. LHCCs working in partnership with other local partners should develop accessible, approachable, confidential and anonymous health information and advice services for young people. Nurses should play an active role in the development of services that meet these needs in partnership with other disciplines and agencies.

Nursing for Health identified school nursing as an area in need of significant development. This was further reinforced by a commitment in Our National Health to revolutionise the service. The introduction of the first public health nurses, newly returned from their educational programme, has provided the impetus in many areas to re-focus the service.

In Greater Glasgow, a school health development group, bringing together the NHS Board, Yorkhill Trust and the Primary Care Trust are leading work on development of the service. This has included re-aligning school nursing teams with New Community School clusters and LHCCs as well as an independent consultation on potential developments with a wide range of stakeholders including parents.

In Borders, at the Burnfoot New Community School, the benefits of developing the school nursing role within an integrated approach can be seen in terms of the self esteem and mental health of children entering high school.

In Highland, the school nursing service has been the subject of a re-design project. A workshop, with 70 delegates from health and education considered the child's journey from 3-18, identifying core principles and recommendations for developing the service.

In Shetland, the service has been re-designed to have a core team of public health nurse and staff nurse, but with input from local nurses across the islands to ensure local continuity.

However a more structured approach was necessary in the light of the roll out of the New Community Schools approach across the country. Over the last year work has been underway, led by a multi-agency steering group, to develop a framework for nursing in schools. The Scottish Framework for Nursing in Schools was jointly launched by Mr Chisholm, Minister for Health & Community Care and Ms Jamieson, Minister for Education & Young People on 3 ^rd March 2003. The framework sets out the future direction of nursing in schools using a set of standards as the basis for future delivery of the service. The importance of the framework is emphasised by reference to it in the Revenue Resource Allocations for 2003/4, which will help ensure that investment in developing the service is made. Progress with implementation of locally agreed action plans will be the subject of future performance management.

Walk the Talk

Across Scotland there has been significant development of young people's health services. The Walk the Talk framework of funding via HIF, resource pack and local training in response to identified need has been helpful in supporting a wide variety of projects.

In Argyll & Clyde, West Renfrewshire LHCC, the Youth Hang Out has targeted boys particularly, seeking to address behaviour and to reach young people with particular problems. One boy has gone on to be on an interview panel for the group, to present to public health nurse students and now chairs the community forum as well as securing permanent employment.

In Dumfries & Galloway, a young people's service operates in Newton Stewart at lunch times from a community hall near to the school. As well as offering health advice and access to services, the clinic also acts as a lunch club, offering a healthy lunch to students attending. The lunch time session is particularly important for young people travelling to school by bus.

In Lanarkshire, the PCT has established an Integrated Youth Health Service to work in meaningful partnership with NHS and non-NHS staff and young people to support and promote youth health issues, improve integrated planning and service delivery to young people and prevent social exclusion

Where Next?

The final phase of Walk the Talk will aim to incorporate developments to date in young people's health services and integrate them into routine practice, through developing networks, ensuring education on working with young people is incorporated into professional education and developing a toolkit of resources and approaches.

The Scottish Framework for Nursing in Schools will be implemented, including national work to support networking and developing a profiling tool and competency framework

59. All nurses providing sexual health and family planning services should exploit the opportunity to give general health advice to their clients. In particular, nurses need to be well prepared to help women make informed health choices in the early stages of pregnancy.

60. Family planning and sexual health nurses should work with others to ensure that the sexual health needs of men are adequately addressed.

61. Family planning and sexual health nurses should provide targeted support to particularly vulnerable groups.

62. Occupational health nurses should fully exploit their valuable role in promoting health and well being with a sector of society that has little other contact with the health service.

63. Nurses should take a consistent approach to improving health, working on a multi-disciplinary, multi-agency approach where possible and using the best available evidence or guidelines.

64. Nurses working in prison should be supported to exploit their unique opportunity to improve the health of prisoners.

65. NHS Boards should support and encourage links with prisons to ensure that released prisoners have continuity of support and service in the community. This may involve the development of services that in-reach into prisons where appropriate.

66. Public health departments should give consideration to the health needs of prisoners, recognising that they will return to their community at some point.

67. Public health nurses should liaise with their prison counterparts to provide particular support to the families of prisoners.

Sexual Health

Some progress has been made in developing sexual health services. In many areas, services are delivered primarily through primary care, so reported developments tend to centre around the larger services in cities. However there were some good examples of services using their contact with women to promote health, targeting men's health and addressing particular needs.

In Tayside, a community learning disability nurse is running a weekly well women clinic in partnership with family planning services for women with learning disabilities. The clinic includes a full contraceptive service, breast awareness, cervical screening and menopause support. The service also includes a video sent to clients to help prepare them for visit and a health awareness pack.

In Argyll & Clyde, Genito-Urinary Medicine services are providing an outreach service in Greenock prison and at a local women's refuge.

In Greater Glasgow, family planning nurses are using a general health screening tool with all clients and using this as a means of addressing identified health needs. They are also targeting men, with a dedicated worker for men who have sex with men, general health screening at GUM clinics and a weekly young men's health clinic.

Working Aged Adults

The importance of the health of working age people has been recognised in the priorities set out in Health Improvement in Scotland: The Challenge. Occupational Health Nurses have a potentially very significant role to play in helping deliver that challenge. While there has been little evidence reported of developments around implementing Nursing for Health, there were some good examples of the potential of engaging in this agenda.

In Lanarkshire, two health visitors are working with Getting Ready for Work Centres, run by Skillseekers for 16-18 year old socially excluded clients. Priorities arising from a needs assessment included; substance misuse, mental health, physical activity and sexual health. A screening tool is used confidentially with each client and referrals made where necessary to other services.

In Forth Valley, PHPs plan to use a focus on staff health as one means of getting public health on LHCC agenda.

In Orkney, the health visitor and GP in a rural practice sent out formal invitations to all adult men to attend a well men's session. The formal invitations produced a good response in an area where male practice attendances tend to be poor, providing an opportunity to identify problems and promote health.

Prison Health

The new Health Promotion Framework for Scottish Prison Service will help ensure that the importance of health improvement with such a vulnerable population is raised. There is evidence of some involvement of public health nurses in promoting health in prisons and there is considerable potential for creating stronger linkages and support from local public health networks.

In Argyll & Clyde, health visitors in Inverclyde LHCC provide a concise health education/promotion programme to groups of prisoners (male and female) and prison staff. They also deliver health education/promotion sessions for vulnerable community groups that provide alternatives to prison and young offenders institutions. They also focus on vulnerable teenage groups within the community who are at risk of offending.

PHIS is facilitating a multi-disciplinary network, with representatives including the Scottish Prison Service, health promotion and social work. The network is aiming in the first instance to identify health improvement initiatives for prisoners while they are in prison as well as when they are released, and nursing developments will inform the processes of the network.

It is clear that nurses in many fields of work are taking new approaches to improving the health of the adult population, working with other disciplines and agencies and through networks.

Where Next?

Work being led by PHIS to develop a sexual health strategy will help inform future development and the sexual health network, established as part of the health demonstration projects will provide a forum for developing best practice.

Health Improvement in Scotland: The Challenge will provide a new impetus to developments with the working population.

PHIS' Prison Health Network will provide a basis for health improvement work with this vulnerable group.

68. Nurses should play a key role in the development of integrated services that promote continued independence for older people. In doing so they will need to work closely with colleagues in social work and other agencies.

There is a lot of evidence of activity in both assessment of need and service delivery for older people. In particular, the Joint Future agenda is creating the opportunity for nurses to play an active role in holistic assessment of needs and the development of targeted services.

In Grampian, one LHCC, following a public questionnaire on the role of the health visitor, has restructured over 75 screening to a quarterly health fair, bringing in community pharmacist and others to provide advice. Over 70 people attended the most recent event.

In Shetland, there is a dedicated health visitor for older people, who has developed workshops for older people with a focus on keeping active, with input of reminiscence therapy, music and exercise.

In Argyll and Clyde, a district nurse is seconded to work with a PHP one day a week to develop public health role of district nurses. Particular developments with older people include; group health education in day centres - focusing particularly on reducing laxative prescribing; re-designing the over 75 assessment based on Activities of Daily Living and developing pathways for continence management.

In Fife, Glenrothes LHCC identified levels of depression in the over 75 age group to be double the UK average. A study involving the PHP, Clinical Psychology and District Nurses is investigating local circumstances and any links to depression levels within the community.

Where Next?

There is a need to raise the profile of health improvement activity with older people alongside the development of integrated services. Actions within the workforce and community streams of Health Improvement in Scotland: The Challenge will provide support and direction for this activity.

69. Nurses working with people with severe and enduring mental illness should take opportunities to improve their general health and minimise risk taking behaviours

70. CPNs should develop their role in supporting and advising others in primary care on the prevention of mental health problems. They should have clearly established links with LHCCs and local public health networks.

71. CPNs working in child and adolescent mental health should provide support and consultancy to schools and the school health service on dealing with minor mental health issues.

72. Community learning disability nurses should develop an advisory and support role to primary care, to support mainstream services in meeting the health needs of people with learning disability.

73. NHS Boards should ensure that relevant, accessible health information and advice is available for adults with a learning disability and their carers.

74. Trusts should use the Health Promoting Health Services framework developed by HEBS to provide a framework to support the health improvement contribution of acute sector nurses.

75. Specialist nurses should exploit their expertise in their chosen field to inform needs assessment and planning processes.

76. Specialist nurses should ensure that secondary and tertiary prevention are an important aspect of their role.

77. Public Health Infection Control Nurses should play an active role in the development of Health Boards as Public Health Organisations.

Mental Health

Many areas reported that they saw considerable potential for involving mental health and learning disability nurses in public health, but had focused as a first priority on developing public health nursing. However there are some good examples of service development and significant potential for further development.

In Greater Glasgow, all staff in community mental health services have a health promotion emphasis in their objectives. A number of activities have been developed in partnership with LHCCs. Particular developments include a CMHT 5 a side football league, promoting physical activity among young men with mental health problems and mental health awareness in local schools. In the in-patient services patient activity co-ordinators have a role that includes work on exercise, stress, smoking, alcohol and domestic violence.

The SNAP Child and Adolescent Mental Health needs assessment has stimulated NHS Highland to employ 9 Primary Mental Health Workers. They come from a mix of backgrounds, mainly nursing and provide both direct support to children and young people and support and supervision to other professionals in managing mental health problems.

In Tayside, the Nursing for health agenda has been linked into mental health services, in particular, bringing a mental health dimension into wider health improvement discussions. This approach has led to multi-agency approaches in two LHCCs for postnatal depression and bereavement and for raising awareness of mental health as a public health issue.

In Fife, within the New Community Schools project, an approach is being developed to increase teacher awareness of depression in young people. This will be considered for further local implementation.

Learning Disabilities

The review of the contribution of all nurses and midwives to the care and support of people with learning disabilities took the recommendations of Nursing for Health as one of it's starting points. The report of the review, Promoting Health, Supporting Inclusion, set out recommendations to further developed the role of nurses working with people with learning disabilities in improving their health and well being, ensuring their effective integration into LHCCs.

In Greater Glasgow, the recommendations from Nursing for Health that related to learning disability nurses were identified. All nurses in the learning disability partnership (which includes some independent providers) were involved in identifying priorities for development, which included support and supervision, sexual health and information for people with learning disability.

In Highland, a workshop looked at the health elements of The Same as you, based on a philosophy of promoting health across the continuum. The output informed the development of the local health plan.

Infection Control

The important contribution that specialist nurses in infection control make to the public health function was acknowledged in Nursing for Health. It has become apparent since then that there is a need for greater numbers of nurses with specialist skills as well as for all nurses to have increased awareness of infection control related issues. In the last year extra funding has been made available to increase the numbers of Specialist Nurses in Infection Control.

Acute Sector Nurses

Nurses working in the acute sector and nurses with specialist roles, including infection control nurses, demonstrated in the PPHiN seminars that they were committed to further development of their public health skills. They wanted their current skills acknowledged and felt that there could be more opportunity for them to participate in health improvement activity in the future.

Where Next?

The PPHiN seminars provided the first opportunity for many nurses and midwives from the wider nursing workforce to discuss their potential public health roles. They identified areas for further exploration as follows:

• How can nurses and midwives be most effective in improving the health of vulnerable population groups?

• How do nurses and midwives contribute to multidisciplinary and multi-agency planning for health improvement?

• What additional skills do nurses and midwives need to achieve their vision for a public health role?

• How best can nurses and midwives be supported in further developing their public health roles?

Further work led by NHS Health Scotland and NHS Education for Scotland will take forward discussion on these key questions.

The national programme to improve the mental health and well being of the Scottish population provides a new driver to ensure that mental health is part of the business of all health professionals and health improvement is part of the business of mental health professionals.

The development of health improvement activities focussed on the needs of people with a learning disability will be further supported through implementation of " Promoting Health, Supporting Inclusion".

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