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Section 1: Context and culture

Context

People in Scotland are living longer. While this is something to be celebrated, it also presents challenges to health services.

The proportion of older people in Scotland is expected to rise to 1 in 4 over the next 25 years, with 1 in 12 being over 80. This means people are more likely to need hospitalisation for multiple episodes of care and will tend to have longer stays when in hospital. In addition, a falling birth rate and declining population raise implications for employing the health and social care professionals of the future. This combined picture shows how urgent is the need for change in our health care systems.

NHSScotland now, more than ever, needs to be flexible, creative and responsive. It needs to design services where patients want them, and deliver when they want them. This is the agenda pursued by Delivering for Health.

Delivering for Health builds on the rich policy and legislative context that has developed in Scotland in recent years in areas such as public health, mental health, children's health, cancer, CHD/stroke, diabetes, maternity services and in the structure and organisation of the NHS itself.

It takes this considerable momentum forward in calling for:

• a fundamental shift in the way the NHS works, from an acute, hospital-driven service to one that is community based
• a focus on meeting the twin challenges of an ageing population and the rising incidence of long-term conditions
• a concentration on preventing ill-health by equipping the health service to encourage and secure health improvement and 'wellness', rather than just treating illness
• a drive to treat people faster and closer to home
• a determination to develop services that are proactive, modern, safe and embedded in communities.

That is why it is so important now to identify how NMAHPs can contribute to the policy agenda by developing a new delivery action plan for NMAHPs explicitly driven by Delivering for Health.

Policy analysis is the central driver of the delivery action plan, ensuring alignment not only with Delivering for Health, but also with other important policies and initiatives. Policy was the starting point, and the action plan sets out how NMAHPs can contribute to taking policy forward in practice.

The action plan takes its place as one of a number of initiatives that should contribute to the delivery of the policy agenda, including the Review of Nursing in the Community, the Draft Rehabilitation Framework, Rights, Relationships and Recovery - the Review of Mental Health Nursing in Scotland ( SEHD, 2006a), Changing Lives: the 21st Century Social Work Review (Scottish Executive, 2006) and the Review of the Role of the Senior Charge Nurse/Midwife in Scotland. It also builds on established NMAHP national policy, including Caring for Scotland, Building on Success, Nursing for Health ( SEHD, 2001b), Choices and Challenges ( SEHD, 2002b) and the Allied Health Professionals' Research and Development Action Plan ( SEHD, 2004a).

NMAHPs across Scotland have been very active in recent years, responding creatively to the Scottish Executive's policy agenda and striving to meet service users' needs and demands.

Along with their multi-disciplinary, multi-agency team colleagues, they are driving the health service response to the challenges it faces across all fronts - in promoting healthy lifestyles and adopting a public health focus, in caring for older people, in meeting the needs of the acutely ill at home and in hospital, in working with people with long-term conditions as they learn to manage day-to-day living, and in delivering services in new and better ways.

Caring for Scotland presented a bold and ambitious vision for nursing and midwifery. It set out a series of recommendations covering areas such as role development, supporting vulnerable patient groups, improving services for people with long-term conditions and developing leadership that not only aimed to maximise the potential of the nursing and midwifery professions, but also complemented and supported the wider NHS agenda in Scotland.

Building on Success set out how AHPs, working from the strong foundation of a health promotion, public health focus and with a commitment to developing their contribution to the care of children, older adults and people of all ages who experience illness, disease and disability or have special needs, make particularly valuable contributions that bolster people's recovery and improve their quality of life. It recounted how AHPs were reducing waiting times through new ways of working, providing early interventions to help avoid hospital admissions and enabling individuals to live independently, reducing dependency on care services within the community.

Most significantly, Caring for Scotland and Building on Success put NMAHPs in the right direction of travel to enable the professions to play their full part in delivering the policy for NHSScotland that has been set out in Delivering for Health.

The introduction of Delivering for Health presents the opportunity for NMAHPs to build on traditional values and culture to develop services fit for 21st Century Scotland. To do this, NMAHPs need to take stock and respond appropriately.

Delivering Care, Enabling Health and its action plan have been developed within this context.

They will be central to the development of NMAHP services in Scotland across a range of areas, including public health, disease management, rehabilitation and research and development.

Each nurse, midwife and allied health professional, regardless of where they work and at what level they practice, must take personal responsibility for contributing to the exciting new policy agenda in Scotland. It is crucial that all of us play our part.

Culture - underpinning principles of nursing, midwifery and the allied health professions

The quality of patients' experiences of health care services is, to a large extent, dependent on how NMAHPs and other professionals relate to and engage with them on an individual basis. People who use services assume that all professionals' clinical skills and knowledge are up to date and fit for purpose. Their perception of the unique benefits individual practitioners bring to their care and treatment is consequently heavily influenced by their experience of how the individual practitioner relates to them. Approachability, kindness, courtesy, empathy and an obvious willingness to respect and listen to the person all score high among the qualities patients value most in health professionals. The importance of these qualities has been confirmed in numerous consultation events with people who use health services.

Consequently, the underpinning principles governing NMAHP practice must reflect what patients look for from health professionals.

A caring base for nursing and midwifery practice

Caring is fundamental to nursing and midwifery services and remains core to all nursing and midwifery functions. It can and should describe both the act of providing care and the way in which it is delivered. Individual nurses and midwives at all levels must acknowledge caring as the central essence of their practice and endeavour to ensure it is underpinned by a caring ethos.

It is important to emphasise that caring for someone doesn't necessarily mean doing for the person. There will always be a need for nurses and midwives to 'do' for people who are acutely ill or chronically disabled. But Delivering for Health places a strong emphasis on promoting self care and enabling people with long-term conditions to live as independently as possible in their communities, managing their conditions to the best of their ability and directing services in providing the support they need. Nurses and midwives have strong communication, facilitation and organisational skills that lend themselves well to helping people achieve these aims. Caring in a nursing and midwifery sense therefore has much to do with enabling.

Many exciting opportunities for nurses and midwives to extend and develop their functions are being introduced in NHSScotland through Delivering for Health across the whole spectrum of practice, with many opting to use the Knowledge and Skills Framework of Agenda for Change to develop their roles and competencies to meet patient and service need. Consultant-level posts are being developed and new nursing and midwifery posts are being created in specific areas.

All such opportunities are being, and must continue to be, underpinned by a caring approach that reflects nursing and midwifery's core values.

Role development and extension opportunities are to be welcomed. They are pushing the boundaries of nursing and midwifery practice to deliver modern, patient-focused services that meet defined needs. Delivering for Health particularly highlights the need for developed roles for nurses to support the delivery of actions on unscheduled care, long-term conditions, out-of-hours and emergency services, orthopaedic services and diagnostic waiting times.

But there are risks that people within and outwith the professions may assume that role development and extension signal an intention for nursing and midwifery to move away from traditional areas of practice (such as caring for older people, protecting the public and promoting health among the population) towards a 'high-tech' orientation. This assumption must be challenged, in word and deed.

Nurses' and midwives' engagement with role development opportunities that involve adopting a newer, technically-focused function will be supported by a strengthening of nursing and midwifery's traditional practice base.

Nursing and midwifery's fundamental core is about supporting, educating, enabling, comforting and encouraging people to live fulfilling, healthy lives. It is about ensuring hygienic and safe environments within which patients can receive safe and effective services, and about co-ordinating service delivery to meet individual and community needs. When illness strikes, nurses and midwives aim to help the person back to health as quickly as possible. If full recovery is not possible, they support the person in living a full and productive life with a long-term condition. For those patients with terminal illness, they strive to ensure a comfortable and dignified death, with full support for the person and his or her family and carers.

Skills previously the domain of other professions are welcome additions to the nursing and midwifery repertoire, but they are complementary to, and will not usurp or replace, traditional skills.

The reason for this is very straightforward. The changing health picture of Scotland set out in Delivering for Health, with older people comprising greater proportions of the population, will require the development of technical skills to offer short, focused, effective interventions. But there will also be an increasing need for the more traditional elements of the nursing and midwifery role, particularly in relation to helping people stay healthy and in supporting and enabling those with long-term conditions to live positive lives in their communities. This will call for core assessment, communication, relationship and leadership skills in nursing and midwifery to be promoted and sustained.

The family of nursing and midwifery is sufficiently wide to embrace new technically focused functions while sustaining and nurturing core fundamental skills and values. It is those skills and values that patients and the public most respect, and most cherish.

An enabling base for allied health professional practice

Enabling is fundamental to AHP services. It can and should describe the way in which service users are enabled to have rapid access to diagnostic, assessment or treatment interventions, and also reflect the caring way they are supported to achieve their full health or rehabilitation potential. In consultations, service users have consistently identified emotional support and empathy from practitioners as being essential ingredients of a positive, enabling health care experience.

AHPs support people of all ages in their recovery, helping them to regain movement or mobility, overcome visual problems, improve nutritional status, develop communication abilities and restore confidence in everyday living skills, consequently helping them to enjoy quality of life even when faced with life-limiting conditions. They work as key members of multi-disciplinary, multi-agency teams, bringing their rehabilitation focus and specialist expertise to the wider skills pool.

This is a strong foundation from which to achive the transformational change necessary to underpin an 'enabling' health system, one which encourages and supports individuals, wherever possible, to be self sufficient in managing their own condition, using professional and health intervention as a resource when needed.

As demand for AHP skills within health, social care and education teams grows, a vast array of opportunities has opened up to this varied group of professions in supporting service improvement and promoting public health, providing better access to the right health professional and, ultimately, securing improved health outcomes. Making the most of such opportunities requires AHPs to become enablers not just of patients, but also of other professionals, parents, carers and service providers in the voluntary and independent sectors.

Practitioners and managers of AHP services need to develop flexible and responsive services that enable early access to the right health care professional or support service. Such changes will require openness to the potential technology presents in advancing communication, patient information, self-managed care and evaluation. This may also mean enablement will be facilitated in new and varied ways in locations such as leisure centres and community pharmacies.

Treatment options will build on existing developments in drop-in services, self assessment, group interventions and expert patient support as well as traditional one-to-one interventions. These should be explored in partnership with patients and should be seen as being integral to our drive to improve services.

Key Message
Caring is the essence of nursing and midwifery practice, and enabling is at the heart of allied health professionals' practice.

A rights base for practice

A rights-based approach to care, as described in a plethora of health-related legislation and initiatives in Scotland, sits very well with traditional NMAHP values. It promotes people's rights to be respected and valued by services, and calls for:

• the provision of effective care and treatment
• promotion of social inclusion and a wider citizenship agenda, including the adoption of community development approaches that enable NMAHPs and communities to work and learn together
• respect for families and carers and the contribution they make to patient care
• non-discrimination
• equality
• respect for diversity
• access to appropriate sources of information and support to ensure patients' and carers' rights are respected.

A rights-based approach needs to be underpinned by a values base for practice. A values base must reflect what patients, families and carers are asking for, which is to:

• be treated with dignity and respect
• have their emotional, social, spiritual and physical welfare promoted and their safety assured
• have NMAHPs spend time with them and listen to them with empathy
• be considered as a partner in care and management and not as a passive recipient of services
• be provided with information that will help them reach informed, confident and safe decisions
• be cared for by professionals whose practice is competent, safe and effective, who care about them and who enable their recovery and self-care skills.

Respect for diversity is a key principle underpinning NMAHP practice. The focus on promoting equality in health was reinforced in Fair for All: Towards Culturally Competent Services (Scottish Executive, 2002). Following the publication of Fair for All, the National Resource Centre for Ethnic Minority Health ( NRCEMH) was established in 2002 to work with NHSScotland to promote the race equality agenda.

Recognising and respecting diversity, however, stretches beyond ethnic and racial boundaries. People also suffer discrimination and inadequate services as a result of prejudice based on age, gender, sexual orientation and social status. NMAHPs need to challenge negative attitudes and behaviours and promote a positive approach to diversity in their engagement with patients, families, carers, the public, and with colleagues.

Key Message
The core values of nursing, midwifery and the allied health professions must underpin the practice of every NMAHP and should drive models of care that promote positive and equitable engagement with patients, families and carers as the central focus for practice.

A team base for practice

Multi-disciplinary, multi-agency teams are a cornerstone of Delivering for Health, which states:

'The emphasis on integrating care will require multi-disciplinary team working. It will require collaboration and co-ordination between professionals and across organisational boundaries - in fact, a partnership approach at all levels to achieve continual improvements in quality and value for money.'

NMAHPs work as part of multi-disciplinary, multi-agency teams. Team-working is integral to the effective operation of services, and the multi-disciplinary, multi-agency team is at the core of service delivery. Good team-working is about harnessing what individual professionals do in common purpose. The contributions individual professions make to the team are therefore central to teams' overall performance.

The success of service redesign and the Delivering for Health agenda will to a large extent be determined by how effectively health care workers work together in teams - communicating with each other, planning jointly and adopting a teamwork ethos that places patients, families and carers at the centre of service planning, delivery and evaluation.

Patients, families and carers comprise a central component of this team-based approach to care. There are numerous areas of service in which patients and carers are playing key roles in delivering care and treatment. It is crucial that they are also involved in planning and evaluating care decisions, and that including patients and carers as a part of teams, to the extent to which they wish to be involved, becomes the norm in multi-disciplinary, multi-agency team practice.

NMAHPs work not only as members of multi-disciplinary, multi-agency teams, but also as members of their own uni-disciplinary teams. The foundation for contributing effectively to multi-disciplinary, multi-agency teams is a sense of valuing the unique contribution each profession makes to the team. Through this, responsibility for the welfare of fellow team members, including support workers and bank staff, develops and team spirit can grow. Working in effective teams gives team members the confidence to share skills and knowledge and work flexibly to meet defined patient needs.

Core elements of establishing cogent teams have been defined. They include:

• recognition of the contributions of all in the team
• acknowledgement of, and support for, the contribution of all who deliver services, including families, carers and volunteers
• recognition of the need for members to work in and across a wide range of teams.

The development of these core elements requires:

• clear working relationships and mutual respect within teams and with others who provide services
• support networks and learning opportunities
• development of team leadership qualities ( RCN, 2004).

Services in remote and rural areas of Scotland provide positive examples of models of team working that are worthy of consideration and adoption by more urban-based services.

Multi-disciplinary education is a strong underpinning element that supports the development of effective, capable teams, and the benefits of multi-disciplinary education and training are well recognised. NMAHPs should learn not only alongside fellow health professionals, but also with social services and local authority staff, people from the voluntary sector, service users, families and carers.

There will be occasions when uni-disciplinary education activity will be more appropriate for NMAHPs, but a strong focus on multi-disciplinary, multi-agency education should pervade education curricula and continuing professional development activities, with service users, families and carers also being involved more actively in educating NMAHPs in classroom and practice situations.

Key Message
Multi-disciplinary, multi-agency teams are a cornerstone of the new health policy agenda.

An education and research base for practice

The vision set out in Delivering for Health of effective, integrated, patient-focused services depends to a large extent on the delivery of evidence-based care. Education and research evidence provides the foundation from which safe and effective care is built.

Education at pre- and post-registration levels plays a major part in preparing NMAHPs to deliver safe and effective services. It is the gateway through which professionals can acquire positive attitudes and the competencies and proficiencies required for registration, then subsequently develop their knowledge and skills to improve performance, achieve personal aspirations and meet ongoing professional standards and requirements.

Professional self regulation is the means through which the public is assured that NMAHPs are competent and fit to practice in a safe and effective manner. Following the final report of the Shipman Inquiry (Cabinet Office, 2005), the Department of Health in England led reviews of both medical and non-medical professional regulation, the latter of which has explored the need for regulation of health care support workers.

The outcomes of both reviews will be considered by Scottish Ministers with a view to being implemented across the UK. Scotland, on behalf of the UK, will test the viability of a model for the regulation of health care support workers based on a system of national standards and a central list.

NMAHPs have a long history in practice development as a means of promoting increased effectiveness in the provision of safe, effective, evidence-based, patient-focused care. Activity in relation to practice development is now supported by the NHS Quality Improvement Scotland Practice Development Unit ( PDU) (Box 1.1).

Box 1.1 NHS Quality Improvement Scotland Practice Development Unit
The NHS Quality Improvement Scotland Practice Development Unit ( PDU) utilises a range of approaches to enable individuals, teams and organisations to improve the quality of health care and the patient experience in a modernising NHS. The PDU aims to influence the culture of practice by:

• promoting and facilitating knowledge transfer
• translating evidence into practice
• responding to national and local health care priorities
• ensuring best practice is recognised and shared across the country.

For further information, access: http://www.nhshealthquality.org

Practice development is the vehicle through which knowledge can be translated into practice to benefit patient outcomes. Collaboration and partnerships are essential to maximising the potential offered by the PDU and the enormous capacity of the NHSScotland e-library; working in tandem, these two valuable resources can make a significant impact on the practice of NMAHPs.

NMAHPs have a significant role to play not only in delivering evidence-based interventions, but also in generating the research from which effective interventions can be identified. They commonly focus their research efforts on issues that are important to patients - effective care for long-term conditions, palliative care interventions and research into quality issues in service delivery, for instance. Advancing NMAHP research therefore goes hand-in-hand with advancing a patient-led research agenda.

Supported by significant funding from the Scottish Executive, the Scottish Funding Council and NHS Education for Scotland, the national strategy for research and development in nursing and midwifery, Choices and Challenges, and the AHP Research and Development Action Plan have driven the creation of three regional research consortia in Scotland (see Box 1.2) to oversee and develop NMAHP research within a multi-disciplinary context. These consortia are building on the ethos adopted by the Nursing, Midwifery and Allied Health Professions Research Unit ( NMAHP Research Unit) (see Box 1.3) to encourage a programme-focused approach built on collaborative relationships to develop the evidence base to underpin NMAHP practice.

Box 1.2 Regional Research Consortia
Three regional research consortia have been set up to bring a multi-disciplinary focus to developing an evidence base that underpins interventions from nurses, midwives and allied health professionals.
The programme areas these consortia have taken as their foci sit well with the agenda set out in Delivering for Health. They are:

• children and young people; managing enduring conditions; maximising recovery from trauma and acute illness (East Consortium)
• decision making; function for living; gerontology (HealthQWest Consortium)
• enhancing self care (North East Consortium - the Alliance for Self-care Research).

Box 1.3 The Nursing, Midwifery and Allied Health Professions Research Unit ( NMAHP Research Unit)
The NMAHP Research Unit, co-hosted by Glasgow Caledonian and Stirling universities, is core funded by the Chief Scientist Office. It fulfils its national remit by operating at international levels of excellence in focusing on three programmes of research:

• stroke
• decision making
• urogenital disorders.

It aims to promote rigorous research to underpin NMAHP practice that reflects the needs of the people of Scotland and the NHS. The foundations for an extensive evidence base have already been established, mainly built on quantitative studies.
The unit has a strong focus on NMAHP-led research, with NMAHPs not only involved in research, but also leading projects. It has considerable experience in running NMAHP trials which promote the involvement of NMAHP staff in trial sites.
For further information, access: http://www.nris.gcal.ac.uk/index.html

Choices and Challenges and the AHP Research and Development Action Plan also strongly promoted the concept of the clinical collaborator, which was defined as:

'experienced individuals with clinical and/or management commitments who are able to secure and facilitate access to service users or staff. They may be involved in research at different levels, but do not necessarily have to be part of the research team.'

The clinical collaborator model enables practitioners to be engaged in the research agenda while continuing to be clinically active.

Key Message
NMAHPs, in collaboration with partners, are actively building an evidence base that will support the plan for the NHS set out in Delivering for Health. This must continue into the future.

A base for safe and effective practice

NHS Boards are responsible for delivering patient-focused care that is high quality, safe and effective. Patient safety is an increasing priority at the heart of clinical and non-clinical activity across NHSScotland. It calls for a commitment from all levels of service to develop an organisational patient-safety culture based on risk assessment and risk management and which is built on:

• strong leadership (managerial and clinical)
• organisational commitment to patient safety
• clinical data management systems
• openness to learning from patient safety issues
• engagement with clinicians.

Clinical quality measures - measures derived from routine data sets that relate to processes and outcomes of clinical care - can contribute to the achievement of this aim. Audit Scotland published Planning Ward Nursing - Legacy or Design? in December 2002 (Audit Scotland, 2002). It presented the results of a performance audit carried out on behalf of the Auditor General, recommending that:

• NHSScotland should develop and agree clinical quality measures that focus on continuous improvement
• NHS Boards should review the quality indicators regularly and take action when problems arise.

In response to the report, the Scottish Executive Health Department commissioned NHS Quality Improvement Scotland ( NHSQIS) to undertake a pilot study to investigate the feasibility of defining, developing and piloting clinical quality indicators for nursing and midwifery in NHSScotland. ²NHSQIS' final report from the project ( NHSQIS, 2005) stressed the necessity to progress work in this area. There is a need to:

• assure the public, patients, families and carers about the quality of care
• improve patients' experience in relation to the fundamental and essential elements of care that matter to them
• foster a culture that moves the professions from being perceived primarily as data collectors to a position where they are acknowledged as meaningful users of comparative clinical data
• promote and develop a culture of safe and effective care within the professions and in multi-disciplinary, multi-agency teams
• maximise opportunities presented to the professions by the eHealth agenda.

The NHSQIS project highlighted the substantial challenges posed to practitioners by the lack of routine systems for collecting clinical data. It nevertheless generated enthusiasm among leaders and practitioners to create a culture in which individuals have appropriate systems in place to support them to:

• take responsibility for patient safety and effectiveness
• be accountable for their actions in the delivery of improved patient experiences and outcomes.

To progress the recommendations in the NHSQIS report, the Chief Nursing Officer and NHS Board Nurse Directors have committed to developing and agreeing a core set of Clinical Quality Indicators ( CQIs) for nursing and midwifery in collaboration with NHSScotland and NHSQIS. The CQIs will:

• provide senior charge nurses/midwives with information to support the development of practice
• be integrated into national clinical data sets to assess and support the delivery of safe and effective practice
• provide NHS Board Nurse Directors with information that informs performance management and organisational governance.

The development of CQIs has been recognised as a need among AHPs, and a recommendation for action has been set out in Allied Health Professions Workload Measurement and Management ( SEHD, 2006b). Previous work carried out through the establishment of the AHP Clinical Effectiveness and Practice Development Network ( AHPCEPD Network) has positioned the AHPs to take forward CQI-related initiatives.

The AHPCEPD Network arose from a national project in 2001 which aimed to co-ordinate, implement and evaluate multi-professional AHP support mechanisms for the successful implementation of clinical effectiveness throughout the country. The final evaluation of the project (Holdsworth and Blair, 2004) highlighted significant success in building a clinical effectiveness, evidence-based culture among AHPs. Since completion of the project in March 2004, clinical effectiveness for AHPs has been supported by NHSQISPDU and has expanded to include all nine allied health professions in a single, national, clinical effectiveness and practice development network that will focus on a number of national topics that are care-group specific.

Key Message
Service users and the public are entitled to expect the care they receive to be safe, effective and assured.

An example of an area in which safe and effective practice is central is shown in Box 1.4.

Box 1.4 Safe and effective practice
A key element of providing safe and effective practice is protecting patients, families and carers from health care associated infections ( HAI). A broad estimate of the cost of HAI in Scotland is up to £180m per annum, or 380,000 bed days lost. Tackling HAI is a key priority for the Scottish Executive and NHSScotland. The Ministerial HAI Task Force has adopted a coherent national approach across a wide range of HAI issues, including surveillance, cleaning and hygiene, education and training and management, to develop a raft of national policies, guidance and best practice.
The key message across all these strands of work is that 'infection control is everybody's business.' We can only reduce the risk of HAI by ensuring that everyone working in, being treated by and visiting NHSScotland is aware of and follows best practice.
The HAI Task Force embarked upon a new phase of work in 2006 with the focus very much on implementation and monitoring of compliance with infection control measures to ensure they are firmly embedded into everyday practice across NHSScotland. NHS Boards and their staff will have a leading role to play in local implementation.

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