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Section 1
Introduction by the Chief Nursing Officer
This Review of Nursing in the Community in Scotland has been taken forward by the Scottish Executive in partnership with a wide range of stakeholders representing the service, individuals, carers, families and communities.
Two project officers have worked alongside a National Steering Group ( Appendix 1), a Patient and Carer Group and a Practitioner Group (Appendix 2) to conduct the process of the Review and deliver its report. The Scottish School of Primary Care provided invaluable resources and support to enable the Review to progress. The literature review undertaken by staff from Napier University and Queen Margaret University College, Edinburgh, which can be accessed at: www.scotland.gov.uk/nursing, provided an essential foundational element to the Review.
The Review fulfils a commitment to action from Delivering for Health ( SEHD, 2005). Delivering for Health signals a transformational change in the NHS from a service that is primarily focused on providing care in hospitals to one where care is planned, delivered and evaluated close to people's homes.
Scotland is changing, and the NHS is changing with it. The demographic picture of our country is of an ageing population with reducing numbers of people of working age. Action is needed now to ensure the increased care demands produced by the former are not failed by insufficient numbers of health and social care professionals implied by the latter.
Delivering for Health sets out the policy that prepares the NHS to meet future challenges. It 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, coronary heart disease, stroke, diabetes, maternity services and in the structure and organisation of the NHS itself to call 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.
This fundamental shift in thinking about where and how health services are delivered means that all professional groups have to look anew at the way they work. They need to determine how they must change to contribute effectively to the new health policy agenda.
That is why we felt it was so important to identify the specific contribution nurses, midwives and allied health professionals ( AHPs) can make to the new NHS by developing Delivering Care, Enabling Health ( SEHD, 2006a). It sets out the nursing and midwifery response to Delivering for Health, looking in detail at the cultural, capability and capacity issues necessary to harness the considerable energy, enterprise and enthusiasm of these vital professions in taking the policy forward and providing the services patients want and need.
Delivering Care, Enabling Health leaves no stone unturned in its quest to create the environment in which nurses, midwives and AHPs - working from a cultural base embedded in caring, enablement, respect for diversity and promotion of a rights-based, values-based approach to care - can deliver for the people of Scotland. It challenges them to think afresh, to look at the way their professions are educated, how they work in teams with fellow professionals, and how well positioned they are to deliver on the priority areas for the people of Scotland and the NHS. It asks difficult questions and proposes challenging solutions.
This Review of Nursing in the Community emerges from and is central to the new environment in which nurses, midwives and AHPs will work and flourish in Scotland. It is crucial that the Review is read and understood in relation to Delivering Care, Enabling Health, which sets out a wide range of actions that will affect and be affected by nursing services in the community. The two documents are designed to complement each other, with the Review building on and adding to the national action plan for nursing, midwifery and the allied health professions described in Delivering Care, Enabling Health.
Nurses in the community are key players in delivering the new policy agenda. They are at the heart of health services in the community, working in partnership with individuals, carers, families, communities and professional services. The success of the fundamental shift in the way the NHS works will to a large extent depend on how nurses in the community - working as part of multi-disciplinary, multi-agency teams - adapt, adjust and advance in the new NHS milieu.
That is why it is so important to get nursing in the community right. The model proposed in this Review points the way ahead for nurses to provide proactive, modern and safe services embedded in communities and delivered close to people's homes.
But like Delivering Care, Enabling Health, the Review had to ask difficult questions and the solutions it proposes are undoubtedly challenging. It looked at nursing services in the round as they are delivered in Scotland's increasingly diverse communities in remote, rural and urban areas. It involved not only what some might consider the 'traditional' disciplines of nursing in the community, such as district nursing and health visiting, but also a wide range of community-based nursing services, including those for people with learning disabilities, people with mental health problems and people living with cancer.
Most importantly, it looked at how patients and carers see nursing services and asked them what they wanted and valued most. They told us they wanted:
- appropriate nursing services when they need them
- a nurse who helps them to co-ordinate care
- consistency in the advice offered to them by individual nurses
- nurses who identify carers early in their caring 'career' and signpost them to appropriate support
- care provided by competent and appropriate practitioners who know about them and the communities in which they live
- nurses who support them by working with them
- nurses with excellent communication and relationship skills.
The result of all this endeavour is a radical, exciting model for nursing in the community that reflects what patients and carers want and is designed to ensure nurses are fit for purpose in contributing to the new health policy.
It is a model that many people - patients, nurses and community-based health and social services professionals - will welcome and adopt with enthusiasm. We know this, because people had been asking for a model along these lines throughout the Review process and, in some cases, for many years before the Review was even launched.
But it is a model that will also raise concerns among some nurses in the community who have become accustomed to delivering particular services in particular ways. These nurses provide valuable services, and I acknowledge both the contribution they make and the anxieties they have about the changes proposed in the model. For some, who have been through a series of professional and policy changes over the last decade or so, the new model may even seem like 'a change too far'.
I want to assure these nurses that the model is not about devaluing the roles they perform or the tradition from which the roles emerge. Rather, it builds from those solid foundations to capture the essence of nursing in the community in 21st century Scotland. It describes a new nursing role that is modern, priority focused and fit for purpose. It defines nursing as a central player in delivering the new health policy agenda, with a strong focus on delivering services closer to home and addressing the twin challenges of an ageing population and a rising incidence of long-term conditions. And most importantly, it describes a role that will play a vital part in developing the community services patients and communities demand within a public health context.
Change is challenging, but change is necessary. The process of introducing the model into practice is bound to raise further questions, concerns and potential obstacles. That is why we have chosen to implement it initially in a small number of NHS Board areas ( see Section 3).
Experiences and learning from these Development Sites will not only teach us a great deal about the efficacy and effectiveness of the model, but also about the whole process of change management. I am confident that it will show us how change, which might appear threatening at the outset, can be transformed into a positive, inspiring experience. I look for, and expect, strong nursing leadership in the Development Sites to drive the process of change and ensure that lessons are learned and acted on.
I invite all nurses, regardless of their current role and place of work, to share in the exciting opportunities the model presents for individuals, carers, families and communities. I encourage them to embrace new ways of working and take full advantage of the future career options they offer. And I urge them to engage with the new agenda of community-based services, to work with their colleagues in all settings to design and deliver visible, accessible and integrated care, and to listen to what patients and carers are telling them. That is the process that underpinned the Review, and it is the process that will now govern the dawning of this new era for nursing in the community in Scotland.
Paul Martin
Chief Nursing Officer
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