Q. What are the key Messages from this policy?
A. Key messages are as follows:-
- The Community Health Nurse (CHN) model is being developed and tested in 4 NHS Boards until March 2009;
- Thereafter a report with recommendations will be made to the Scottish Government who will take a decision on the way forward;
- Other work groups have been established to look at:- education and training, workforce/workload and formal independent evaluation of the model;
- The Scottish Executive will liaise with the non development sites and a communication strategy is being developed;
- The timescales are as follows:-
a. April 2007 to March 2008 - planning in the development sites
b. April 2008 to March 2009 - implementation of new role in the development sites.
c. January 2009 to April 2009 - report and recommendations to the Scottish Executive.
Q. Why is this role only being shaped now?
A. There will be a serious shortage of nurses in the future and pressures are exerted on both demand and supply. Also, the population of Scotland is getting older and research tell us they will have more complex, multiple health needs. This role has been developed to address these issues.
Q. How will the role of the specialist nurse change?
A, The skill mix of each CHN team will vary according to the needs of the local community in which it is based. Specialist nurses may work in a particular clinical area and provide support and advice to CHNs. Alternatively, specialist nurses may opt to work as part of the CHN team if this is appropriate to the local circumstances.
Q. What are the timescales around the evaluation?
A. The evaluation is scheduled to be completed by March 2009.
Q. What about the continuing imbalance of resources between the acute sector and the community?
A. One of the key recommendations in Delivering for Health was to shift the balance of care for acute to community. Each health board area will develop their plans in line with these recommendations which will include looking at the resource implications of this.
Q. Are agenda for Change outcomes with variations across Scotland going to be addressed?
A. This is not within the remit of the development of the new service model.
Q. Are new baby visits to mothers and babies to continue?
A. Yes.
Q. How are non development sites going to be engaged by the Scottish Executive?
A. The Executive is compiling a communication strategy for the non- development sites which will be available of the website in due course.
Q. How do you demonstrate the accountabilities in "getting it right for every child (GIRFEC)"?
A. Over the next couple of months we will be engaging with the GIRFEC implementation team at SEHD . These discussions will inform the visioning in terms of the roles within the service model and feed into the capability framework.
Q. What nursing investment is each NHS Board putting into the policy drivers affecting nursing?
A. In relation to the new model for community nursing, the Scottish Executive is making available additional funds to the development sites to test the new model. Funds have also been made available to carry out the evaluation of the model and to NES to produce a capability framework and to scope out current training.
Q. What are the tangible measures that will be rolled out from the development sites? How will these be determined?
A. It is too early to know what outcomes will come from the development of the new model.
Q. Can we be assured of quality of care if we are developing advanced practitioner roles?
A. The development of all nursing roles within the service model will be in line with NMC standards.
Q. Healthcare assistant/support workers- if we are extending their role, what regulatory and accountability measures are being developed?
A. The role of healthcare assistants and support workers in the new model will be tested by the development sites. Any learning/ recommendations made will be considered by the Scottish Executive.
Q. Are there going to be changes to the traditional services provided by nurses?
A. This will be tested in the development sites.
Q. Can we have more information on how the public will be made aware of the proposed changes to the nursing service they will receive in future?
A. Public engagement is very important to the development sites as well as the Executive. It is envisaged that the public will have the opportunity to influence the shape of the new model. Each development site and the Executive is preparing a communication strategy which will include robust plans to engage with the public. The Scottish Executive's strategy is available on this website.
Q. Can the new model be adapted as the development sites progress?
A. Yes. The Executive deliberately didn't prescribe a "one type fits all" model in its report. The model is flexible to meet the needs of the local community and can be adapted as necessary.
Q. When will we get clarity on the various roles?
A. The development sites are currently running "A Day in the Life of a CHN" workshops to scope out the role. NES is developing a capability framework. The Executive is working on job descriptors. Once all these pieces of work are pulled together more information will be available.
Q. How are the development site practitioners feeling?
A. It is fair to say that there are mixed feelings about the new role.
Q. How will double duty increases fit into the new model?
A. The new service model incorporates the disciplines of District Nursing, Health Visiting, School Nursing and the Family Health Nurse role will be incorporated into the new discipline of Community Health Nurse.
Q. Career progression. If our staff can become advanced practitioners why would they take on the CHN role?
A. Not all nurses will wish to become advanced practitioners and may wish to remain as Community Health Nurses or progress their career in a different direction.
Q. How will current community nurses get the new skills needed for this CHN role?
A. The Review recognises that the educational needs of both new Community Health Nurses and current practitioners, who need to broaden their skills, are challenging. Skills for Health will have already done some of this work. Higher education institutes and NHS Education for Scotland will also be central to this process. NES are leading a project to look at the capabilities and competencies that current staff will need to acquire to take on the role.
Q. When will the current SPQ cease?
A. Work around transition planning for the education course is currently being undertaken by NES. When the outcome is known further information will be made available.
Q. Who is going to support the CHN in practice/clinical element of training?
A. Existing staff
Q. What are the implications for the pre-registration programmes?
A. This is currently being considered by the Executive.
Q. When will new CHNs start their education programmes?
A. The education programmes will be approved and students recruited by 2009.
Q. What if the development sites come up with different ideas for the capability framework?
A. All ideas wall be considered however, a final document will be submitted to the NMC by October 2007.
Q. Who is the GP on the national group so that local GPs can be informed about the new model?
A. The Executive acknowledges that the engagement of GPs is vital. The Royal College of General Practitioners (RCGP) is represented on the Programme Board which oversees the development of the new model, by Sheena MacDonald. She reports back to the chair if RCGP. Each development site also has a GP representative on their local steering groups. GPs have also attended workshops run by the development sites. GPs will have access the national website as well as the newsletters which are produced by the Executive and the development site.
Q. Will nurses be attached to GP practices or be geographically based?
A. The Development sites will address this issue for their own areas. It will be a matter for individual NHS Boards to determine whether group attached/aligned or geographically based services are selected for their areas. The size and skill mix within nursing teams will need to be responsive to local need and determined by local geographic, demographic and other health and social service configurations.
Q. Why are practice nurses not included in this model?
A. Practice Nurses are critical in the delivery of care to communities and will be important partners of those working within the new service model. It has not been possible to identify Practice Nurses in the model due to the particular nature of their employment circumstances. It is recommended that local systems embrace their skills and expertise and include them in team approaches to meet the health needs of local communities.
Q. How is this policy being communicated across the Executive - not just the health department?
A. The report of the review of nursing in the community, Visible, Accessible, Integrated care, is on the Scottish Executive website and was published via a news release which was available to all Scottish Executive Directorates. Preliminary discussions have been held with colleagues in the Education Directorate and Social work colleagues and these will continue as the model develops.
Q. How will the Community Health Nurse role fit with care management?
A. Work is ongoing at this stage to develop the vision around the Community Health Nurse role. Within these discussions care management has been highlighted. Once further discussion has been done with development sites and non development sites the information from these discussions and those of the capability framework will be reviewed. Thereafter, draft job descriptors will be shared with staff before we develop a job description in collaboration with staff side partnerships and human resources.
Q. IT facilities to facilitate new nursing processes and information sharing?
A. The Scottish Executive eHealth Strategy deals with these issues. Any other IT related issues raised by the development sites will be taken up with the eHealth leads.
Q. What are the proposed pay bands?
A. Information on pay bands will come from the testing being done in the development sites.
Q. How is it envisaged that jointly appointed roles (council/HIM) will fit into the CHN model?
A. Jointly appointed roles should fit very well into the model. This will be tested in the development sites.
Q. Why are you getting rid of District Nurses and Health Visitors?
A . We are not getting rid of the services District Nurses and Health Visitors provide. We are changing how Nurses and Health Visitors are organised and educated to help them to provide high quality services to meet the health needs of Scotland in the 21st Century. To mark this change, the new nurses will be called Community Health Nurses, which we feel reflects their role more accurately.
Q. With Scotland's poor health record, shouldn't we have more health visitors / public health nurses not less?
A. All nurses have a role to play in improving the health of Scotland. We need to harness the whole nursing resource, not just one element of it. We are not taking health visitors way from their public health role; we are adding all nurses to that resource.
Q. Thousands of Scottish families will lose out on the nursing specialists they need for a particular problem, because of the merging of community nursing disciplines. Why are you going ahead with this model?
A. No one in Scotland will lose out in this new model, indeed many families will gain because the nurse will bring a wider knowledge base and skills to assess, co-ordinate and deliver the care required. This care will be enhanced by the ability of the CHN to draw on a network of specialists. No nurse will be expected to operate outside their sphere of competence.
Q. Why introduce such a radical change when community nurses already feel demoralised?
A. During the early workshops, nurses talked about feeling that they had lost their sense of professional identity and needed to be given a clear direction. The model proposes to do that. Implementation will be phased over a period of time, ensuring that the lessons from the 4 Development Sites are taken on board before full implementation.
Q. The outcome of the Review was a foregone conclusion.
A. This is not correct. The review team based their conclusions on evidence from district nurse, health visitors, carers and patients, managers and other stakeholders. Patients and carers told us they wanted one nurse to contact. During the workshops, nurses talked about feeling that they had lost their sense of professional identity and wanted a clear direction.
Q. Did you look at alternative models?
A. Yes. International models were considered. Other models which were suggested were built on the current structure and would not successfully address the underlying issues. Many led to an increasingly fragmented service rather than a more joined up one. We felt a completely new model was necessary.
Q. The consultation was a sham and comments were not taken on board.
A. The consultation time frame reflects the constraints of the original deadline in Delivering for Health. Consultation with key stakeholders has been an integral part of the entire Review process. In light of comments received, the report was redrafted and more information was provided on the evidence collected. An additional 'core element' was added to the Practice Framework, however, the model was not changed as we believe it is the right way forward for patients, carers and nurses. The work done in the Development Sites will allow for a fuller testing of the implications of the model and highlight further work that needs to be done.
Q. Why has the Review been so rushed and the consultation period so short?
A. The consultation time frame reflects the constraints of the original deadline in Delivering for Health. Consultation with key stakeholders has been an integral part of the entire Review process. The work done in the Development Sites will allow for a fuller testing of the implications of the model and highlight further work to be done.
Q. There is a wealth of evidence to say that Health Visitors make a significant contribution to improving the health of communities. Why are you not developing their role?
A. We recognize the amount of effort Health Visitors have put into developing their Public Health Role. However the majority of Health Visiting practice in Scotland has continued to focus on families, and in particular young children within families. The limited research evidence available to the review questioned the impact Health Visitors have when working on Community Development Programmes and whether this would be the most appropriate application of nurses' knowledge and skills in the future. The Development sites will explore this issue further.
Q. There is evidence that Home Visiting by Nurses improves outcomes for children in many areas, such as fewer: unplanned pregnancies, time on benefits, admissions to A&E and anti-social behaviour. Why are you stopping this?
A. The longitudinal study carried out in the US by Olds et al, has demonstrated that home visiting targeted on socially excluded families has positive impacts on health and social outcomes for children. The Starting well Project in Glasgow also targeted socially disadvantaged communities in the first phase and families in the second. It is too early to identify whether there are any health and/or social benefits for children, but there is evidence that of improved confidence and self-esteem among the mothers. However both demonstrate the importance of providing these services in an integrated way, involving social and education services as well as health.
The Development sites will work closely with the exercise, soon to commence, to scope the nature and role of health professionals caring for children and young people in Scotland, to ensure that nurses' skills and knowledge are appropriately targeted.
Q. England announced that all Sure Start children's centres must visit every parent of a newborn baby in their area. Shouldn't Scotland be doing the same?
A. England launched an Action Plan on Social Exclusion in September 2006 - 'Reaching Out'. It includes "Health-led support from pre-birth to age 2, focused on the most at-risk, with 10 demonstration projects, up-skilling of key staff such as midwives and health visitors, and revised commissioning guidance nationally".
This is similar to the Starting Well Project which began in Glasgow in 2000. The exercise, soon to commence, will scope the nature and role of health professionals caring for children and young people in Scotland, to ensure that nurses' skills and knowledge are appropriately targeted. Staff will work with the development sites and ensure we take into consideration the lessons from the Project.
Q. Why are you moving away from the policy set out in Nursing for Health?
A. We are not moving away from the recommendations in Nursing for Health, rather we are building on it. The two overriding messages in Nursing for Health are that all nurses should base their practice on Public Health principles and specific programmes should target those in most need.
Q. A generalist role implies a loss of expertise
A. It is neither feasible nor desirable to continue with the current and increasing level of specialisation that exists within community nursing. There will be a serious shortage of nurses in the future as pressures are exerted on both demand and supply. The generalist/specialist interface is one of the key areas that will be explored in the Development Sites.
Q. Is it not inevitable that health promotion and illness prevention will always be given a lower priority to the needs of acutely ill patients on a caseload?
A. In a similar way to the Family Health Nurse, it is envisaged the Community Health Nurse would have a dual health improvement and disease management remit and would be delivered through an integrated team approach.
Q. How do you expect nurses be able to continue to provide a service when they are already stretched as well as get all this extra training they will need for this new role?
A. This will be one of the key areas that will be explored in the Development Sites. Boards will look at using their nursing and support resources creatively to allow staff to acquire the breadth of skills for the role. NHS Education for Scotland will be working closely with the Development Sites to provide learning opportunities for staff. They have recently advertised for a project officer to lead on this work.
Q. Many staff, especially part time staff, already struggle to complete their mandatory training, are we not going to be spending all our time on courses?
A. Community staff already have many of the pre-requisite skills for the Community Health Nurse role - it is a matter of adding to and building on these skills.
Q. Will there be new courses for staff nurses to become Community Health Nurses?
A. NES will be working with educational providers to look at developing programmes to support nurses to become CHNs. However, it may be that this will look different from the current courses and allow a more flexible way of learning.
Q. What about newly qualified staff; have they wasted time training to be District Nurses or Public Health nurses?
A. No. The educational preparation they receive will stand them in good stead for their future role. The new model is to be tested in 4 Health Boards over the next 2 years. Thereafter there will be another implementation period across other boards. During these phases we will need qualified staff to undertake community nursing duties.
Q. I usually arrange for around twelve staff to be supported to begin Public Health and District Nursing courses, on behalf our Board. Our Board is not one of the development sites, and I am planning to send twelve staff on the courses next year. Should I send them, or should I wait until the following year and send them on the new CHN courses?
A. The PH and DN courses will provide a solid and robust educational framework for nurses who will spend the majority of their careers working within the new model. NES will be working closely with Higher Educational Institutions to move towards providing the programmes of the future and transitional Programmes (what ever form they take) will be available for staff who hold PH/HV and DN qualifications. We will be supporting Boards to make decisions about which Programmes they should be commissioning in the transitional period.
Q. I am a Community Children's Nurse and I have a caseload of children with generic nursing needs? Will I now be considered a 'specialist'?
A. Many children with generic nursing needs will be cared for by CHNs, who will draw on the expertise of Children's nurses when appropriate. However, children with complex needs will be cared for by specialist childrens' nurses who will work along side the CHN team when the care required is beyond the scope of practice of the CHN. A review of the role of the children's nurse is proposed. It is proposed that this review would take place in parallel with the Development Sites.
Q. Is there a need to have more child health nurses working as part of the Community Health Nursing Team?
A. The skill mix of each CHN team will vary according to the needs of the local area in which it is based. Nurses working primarily with Children in the Community, will practice according to the generic practice framework, in common with all members of the team. A review of the role of the children's nurse is proposed. It is proposed that this review would take place in parallel with the Development Sites.
Q. I am a specialist children's nurse working from the hospital, where do I fit into this model?
A. Care provision needs to be increasingly flexible and be integrated between hospital and community settings. It may be that you act as a specialist in a particular clinical area and provide support and advice to CHNs who are providing care to a child in the community, at times this may mean that you provide the expert care directly. Alternatively, you may opt to work in the community and work as part of the CHN team or children's team.
Q. I am a parent of a child with complex health care needs, who will be my keyworker?
A. It is likely that much of the care will be provided by the CHN. However, s/he will refer to specialist children's nurses who are expert in a particular area of care when they need support and advice. It may be that the CHN arranges for some care to be given by a specialist childrens' nurses when it is outside their sphere of competence. A review of the role of the children's nurse is proposed. It is proposed that this review would take place in parallel with the Development Sites.
Q. Will all Community Health Nurses need to have the common competencies developed by NES to care for children?
A. Yes - NES will develop a competency framework for the CHN role which will be based on the CHN job description and will include care for the whole family.
Q. Is this model moving away from the policy of integrated teams?
A. The model is based on a team approach which should not be made up exclusively of nursing staff. For example, the team may include social work skills and independent sector colleagues as appropriate.
Q. How can this generic nurse have highly specialised skills that Health Visitors currently have to deal with child protection?
A. As a generic worker it is anticipated that the Community Health Nurse would be able to meet the health needs of the majority of children in the community. It is important however, that the role of the specialist children's nurse and how it interfaces with the new model is further explored. A review of the role of the children's nurse is therefore proposed. It is proposed that this review would take place in parallel with the proposed Development Sites.
Q. What is the evidence on which you have based the proposed model?
A. The review has based the model on evidence from:
- The workshops which explored what nurses working in the community are good at and their frustrations, as well as what they could do in the future in terms of Delivering for Health.
- Workshops with users and carers.
- A consideration of the current model of service delivery as well as other models of nursing roles, namely Family Health Nurse and Community Matrons.
- A consideration of the policy drivers of care provision.
- The literature review.
- The results from WHO Europe researchers who conducted a multi-national evaluation across all countries taking part in the Family health Nurse pilot.
- Two conferences involving a range of practitioners, nurses and other managers, educationalists and other stakeholders.
Q. Will Scottish community nurses be penalised if they want to work in other parts of the UK?
A. During the process of implementation, work will be undertaken with the Nursing and Midwifery Council and colleagues from across the UK to explore the issues of registration, building on lessons learnt from the Family Health Nurse project around registration. Increasingly employers are looking at skills and capabilities rather than formal qualifications.
Q. Why a capability framework rather than a competency framework?
A. Capability is associated with facilitating the continuing development of practitioners' ability and potential and is an essential element of lifelong learning and personal and professional development. It differs from competence in that:
- competence describes what individuals know or are able to do in terms of knowledge, skills and attitudes at a particular point in time.
- capability describes the extent to which and individual can apply, adapt and synthesise new knowledge from experience and continue to improve his or her performance (Fraser & Greenhalgh, 2001).
It has been argued, however, that competencies do not take into account complexity (Wilson & Holt, 2001) and that effective practitioners need more than a prescribed set of competencies to carry out their roles effectively (Sainsbury Centre for Mental Health, 2001). Health care is often complex and unpredictable, with a culture of constant and rapid change. Health care practitioners need to be responsive to change and to be adaptable in responding to the demands of different situations (Fraser & Greenhalgh, 2001). The ability to adapt incorporates professional judgement, decision-making skills and experiential knowledge gained from experience in many different (but similar) situations. The more expert the practitioner, the more likely he or she is able to adapt in unpredictable and unfamiliar circumstances (Benner, 1984).
Capability frameworks focus on:
- realising people's full potential
- developing the ability to adapt and apply knowledge and skills
- learning from experience
- envisaging the future and contributing to making it happen
These elements are congruent with continuing professional development, lifelong learning and personal development goals, each of which is a vital part of the make-up of current and future healthcare practitioners.
Capabilities incorporate several components (Sainsbury Centre for Mental Health, 2001):
- a performance component - identifies what people need to possess and what they need to achieve in the workplace;
- an ethical component - concerned with integrating knowledge of culture, values and social awareness into professional practice;
- a component that emphasises reflective practice in action;
- the capability to effectively implement evidence-based interventions in the changing context of health services;
- a commitment to working with new models of professional practice and accepting responsibly for lifelong learning.
Q. How will the implementation of the Community Health Nurse model affect child protection?
A. The CHN will take the lead in child protection in the new team structure and will delegate specific work to appropriately skilled members of the team who may or may not be nurses. This will depend on assessment of needs of each child and family. Most of these needs being met by universal services with the more complex cases managed through sharing care with specialist services or other agencies as required.
Q. How will risk to children be assessed without the Health Visitor visiting regularly?
A. All children and families will have a named person who will be their first point of contact however all the workforce should have the skills to identify children, young people and adults in need of support and/or protection. Advanced practitioners and consultant nurses will use their high level skills to provide specific care to complex cases.
Q. Who will work with the most vulnerable children, young people and adults who do not require protection measures?
A. The needs of the individuals concerned will be assessed at the earliest opportunity and a single agency health care plan agreed. A practitioners who has the right skills to meet those needs will be allocated to the case. This may or may not be a nurse. Whoever is the named person must be clear about their role and responsibility to the individual.
Q. Who will take part in child and adult protection conferences, initial referral discussions (strategy discussions) and children's hearings?
A. The named person for the individual will be responsible for submitting reports and contributing to any procedural meetings or discussions. They must be clear about their role and responsibility for assuring that the health care needs are met within a care plan that sets goals and timed measurable outcomes.
Q. Who will support practitioners working with the most vulnerable people?
A. In the case of children the child protection nurses and adviser will continue to be available to give support and advice when necessary as well as colleagues in social work and police. There will be clinical supervision systems established which will allow for practitioners to reflect and learn from their work experience.
Q. How will practitioners cope if there concerns are not taken seriously by other agencies?
A. When a practitioner is concerned about the care of a child or adult they should record their concerns and share them with colleagues and in discussion with the individual or family agree the best way forward to support or protect the individual. A referral is not handing over but sharing the care and providing the right person to meet the needs of the individual at the right time. If there is a disagreement or conflict between practitioners in different agencies the Community Health Nurse should be informed and the policy should be followed to support the management of such circumstances maintaining the best interests of the individual as the focus.