Complications from medical cosmetic tourism result in costs to the NHS

June 22, 2018 Leave a comment

My Post (15)While many patients venture outside of the UK for cosmetic surgery, due to the significant cost of private care in the UK, there is also a lucrative business for non-invasive aesthetic treatments abroad. In the UK, botulinum toxin injections or dermal fillers cost about £150–£350 per session, depending on the amount of product used (NHS Choices, 2016a). Chemical peels cost about £60–£100 for mild peels, with deeper treatments often costing over £500 (NHS Choices, 2016a). The cost of cosmetic micropigmentation varies from £75 for a beauty spot to £500 for lip liner (NHS Choices, 2016a). Microdermabrasion costs £40–80 for a single session (NHS Choices, 2016a).

By contrast, costs for treatments abroad can be substantially cheaper. For example, prices for botulinum toxin can be as low as £40 in Thailand, £50 in the United Arab Emirates and £60 in the Czech Republic (MEDIGO, 2017a). Chemical peels start from £22 in Thailand, £44 in Turkey and £45 in Malaysia (MEDIGO, 2017b).

Complications of non-surgical cosmetic treatment

Complications arising from non-invasive cosmetic treatments are less common and often less severe than those from surgical procedures. However, there is still a notable element of risk involved.

The most common complications from botulinum toxin and soft-tissue filler injections are bruising, erythema and pain (Levy and Emer, 2012). Erythema is also not uncommon following chemical peels, as well as irritation and burning (Levy and Emer, 2012). These side effects are generally temporary and easy to treat. More serious complications include muscle paralysis from botulinum toxin, granuloma formation from soft-tissue filler placement, and scarring from chemical peels (Levy and Emer, 2017).

Issues regarding regulation

In 2013, Sir Bruce Keogh was asked to undertake a review into the regulation of cosmetic interventions in the UK. It revealed that non-surgical interventions were almost entirely unregulated, with no restrictions on who may perform procedures (Department of Health (DH), 2013). This poses a significant risk to patients, as without accredited training, practitioners are unlikely to recognise complications of the procedures, or be able to treat them. The review committee therefore recommended approved training schemes were introduced, as well as accredited qualifications, and associated registers for both surgical and non-surgical cosmetic procedures.

The DH (2014) provided a response to this review, largely accepting many of the recommendations, but did not believe a new regulated profession for those performing cosmetic procedures should be introduced, as many practitioners were already members of professional registers and so subject to regulation. In 2015, Health Education England (HEE) unveiled new qualifications to improve the safety of non-surgical cosmetic procedures (HEE, 2015), but again did not go as far as to establish legal requirements for the administration of non-surgical cosmetic interventions.

Issues concerning regulation for non-surgical cosmetic interventions also exist in other countries. Due to differences in standards and qualifications, it can be difficult to establish the suitability of a practitioner to carry out an intervention. In Europe, dermal fillers are regarded as medical devices requiring only Conformité Européenne certification (Hachach- Haram et al, 2013). It is only in the US that dermal fillers are seen as medicines and are therefore required to be approved by the US Food and Drug Administration (Hachach- Haram et al, 2013).

Whose responsibility is follow-up care?

Follow-up care is an important part of treatment, particularly in the case of cosmetic surgery. The NHS advises that when making enquiries about treatment abroad, it is important to know how complications would be handled, what would happen if revision surgery was needed after the original procedure, and how much it might cost (NHS Choices, 2016b). Unfortunately, all too often the expectation in the UK is that if something goes wrong, the NHS will sort it.

It is believed the cost to the NHS of fixing botched botulinum toxin injections could be as much as £1 million a year (Savage, 2016). However, because of a lack of data, it is difficult to accurately gauge the cost to the NHS of fixing cosmetic complications, or to establish the numbers of complications attributable to UK private care, treatment abroad or self-administration.

It has been questioned whether cases should be considered individually, whether guidelines and standards of treatment need to be outlined, or whether treatment by the NHS should be strictly limited to acute cases only (Hachach-Haram et al, 2013).

Additionally, there is limited knowledge of public attitudes towards the regulation and safety of treatment. People considering this type of treatment need to be aware of the risks and thoroughly research the practitioners who will be carrying out their treatment. Many websites offer holiday packages of treatment, travel and accommodation, but can be misleading in what it is they are providing.

It is clear that tighter rules regarding regulation are needed globally, along with clear outlines of practitioners’ aftercare responsibilities and improved education around the possible risks for prospective patients. Without this regulation, it is evident the NHS will continue to pick up the bill when things go wrong.

References

Department of Health. Review of the regulation of cosmetic interventions: final report. 2013. https://tinyurl.com/b8qq6ek (accessed 11 January 2018)

Department of Health. Government response to the review of the regulation of cosmetic interventions. 2014. https://tinyurl.com/nnjvlym (accessed 11 January 2018)

Hachach-Haram N, Gregori M, Kirkpatrick N, Young R, Collier J. Complications of facial fillers: resource implications for NHS hospitals. BMJ Case Rep. 2013; pii: bcr-2012-007141. https://doi.org/10.1136/bcr-2012-007141

Health Education England. Qualification requirements for delivery of cosmetic procedures: non-surgical cosmetic interventions and hair restoration surgery. 2015. https://tinyurl.com/z43cs8s (accessed 11 January 2018)

Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121– 132. https://doi.org/10.4103/0974-2077.99451

MEDIGO. Botox injections and wrinkle treatment at clinics and hospitals worldwide. 2017a. https://tinyurl.com/yd3xzu34 (accessed 11 January 2018)

MEDIGO. Chemical peel at clinics and hospitals worldwide. 2017b. https://tinyurl.com/ycwe3y72 (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures. 2016a. https://tinyurl.com/yae8sdyt (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures: Cosmetic surgery abroad. London: NHS Choices; 2016b. https://tinyurl.com/ydckt79p (accessed 18 January 2018)

Savage M. Up to £1m a year spent fixing bad Botox. 2016. https://tinyurl.com/y7dfn9jh (accessed 11 January 2018)

Taken from Journal of Aesthetic Nursing, published February 2018.

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Review of Mental Health Act must address excessive detention rates

April 17, 2018 Leave a comment

My Post (4)Theresa May’s speech at the Conservative Party Conference on Wednesday 4 October was one mired by illness, a prankster and a backdrop that fell apart, presenting journalists with countless opportunities for cheap metaphors. But while the gaffs of her mea culpa overshadowed the announcement of new policies, for those that could see past the cringe-induced spectacle there were a number of interesting points.

One of these announcements was how the Government would be carrying out an independent review of the Mental Health Act. Building on her Brexit speech in January, where she vowed to correct the ‘burning injustices’ in modern society, May explained how a particular priority for her was ‘tackling the injustice and stigma associated with mental health’ (May, 2017).

She emphasised her desire for parity between mental and physical health through reiterating the Government’s pledge of increased investment in mental health. Recent announcements of an additional £1.3 billion to transform mental health services by 2021 (Health Education England, (HEE), 2017) were met with mixed reactions from key health bodies. It was said the funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services (Department of Health, 2017). However, organisations such as the Royal College of Nursing said the Government’s proposals ‘appear not to add up’ (Royal College of Nursing, 2017). Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

The Mental Health Act

The Mental Health Act was passed in 1983 and is the main piece of legislation that sets out when and how a person can be detained and treated in relation to their mental illness. People detained under the Mental Health Act need urgent treatment for a mental health disorder and are deemed to be at risk of harm to themselves or others. In May’s speech she argued that the three decades old legislation is leading to ‘shortfalls in services and is open to misuse’ (May 2017). While the Mental Health Act was amended in 2007, it is felt by many that a more substantial revision is needed. This amendment was originally a proposed bill, but many felt it was ‘too draconian’ (BBC news, 2007).

The Five Year Forward View for Mental Health called for the Mental Health Act to be revised ‘to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will’ (Mental Health Taskforce, 2016).

Reducing detention rates

Current detention rates under the Mental Health Act are too high. The latest published figures show the number of detentions under the Act are rising annually, increasing by 9% to 63 622 in 2015–2016, compared to 58 399 detentions in 2014–2015 (NHS Digital, 2016). Over the last 10 years they have increased by almost 50%. Of those detentions, a disproportionate number are of people from black and minority ethnic populations — four times as many black people as white people are detained. It is unclear why there are disproportionate detention rates between different communities, but this must be identified to ensure equal access to earlier intervention and crisis care services.

While reviewing the Act will use changes in legislation to help reduce the rates of detention, the difficulty will come in figuring out how the delivery of care must be changed so that detention can be avoided in the first place (Wessely, 2017). Additional focus is needed on the provision of earlier support. By identifying vulnerable people and addressing their mental health needs early, they can receive the support and care they need before detention becomes an unavoidable necessity.

For those that are detained, there needs to be a review of the areas constituting a ‘place of safety’. Police custody is not an appropriate area of safety. Around half the deaths that take place in or following police custody involve detainees with some form of mental health problem (Independent Police Complaints Commission (IPCC), 2017). Although police custody is only used as a last resort, it can exacerbate a person’s mental state, and has the effect of criminalising people who are in need of medical attention (IPCC, 2017).

Undertaking the review

The review will be carried out by Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. He is the former President of the Royal College of Psychiatrists and current President of the Royal Society of Medicine. Wessely will produce an interim report in early 2018 and develop a final report containing detailed recommendations, by autumn 2018.

References

BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm

Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-theprevention-of-mental-health-problems/

Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf

Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody

May T. Theresa May’s Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservativeconference-speech-full-text/

Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016

NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016

Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq

Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain – Here’s Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simonwessely/mental-health-act_b_18192476.html

Taken from British Journal of Healthcare Management, published November 2017.

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Jeremy Hunt’s plans to reduce prescribing and medication errors

January 25, 2018 Leave a comment

Adobe Spark (2)A new initiative aimed at reducing prescribing and medication errors across the NHS has been announced by Health Secretary Jeremy Hunt.

Hunt said medication-related errors are responsible for 5–8% of hospital admissions. This is due to 1 in 12 prescriptions involving mistakes relating to dosage, course length or type of medication. With just under  150 prescriptions handed out in primary care every second, Hunt has called the potential for errors ‘huge’.

Writing in the Health Service Journal, he said:

‘Up to 1 in 12 prescriptions may include a mistake and whilst we’re lucky most don’t cause harm to patients, there is more we can do to tackle the problem and make the NHS safer…That’s why I’ve launched a new scheme working with the NHS to reduce these errors and protect patients.’

According to Hunt, the scheme will explore a number of areas where he believes the NHS ‘can do better’. This includes improving the way that technology, such as electronic prescribing, is used, to ensure prescriptions are processed more efficiently; re-evaluating the way that patients are informed and educated about their medicines, to look along the pathway from prescribing to administration and monitoring; supporting 7-day clinical pharmacy services, where possible, in acute hospitals; and providing pharmacist support for care homes and GPs.

Hunt also said the programme will look at how the transfer of information about medicines when patients move between care settings might be improved, as it is during these transition points when things can often go wrong.

According to the Department of Health, the programme is likely to be launched later this year or early next year. It is aimed at helping the NHS meet the World Health Organization’s global patient safety challenge, which hopes to reduce severe avoidable medication-related harm by 50% globally in the next 5 years. An expert group is being put together to help scope the programme and establish how to improve patient safety.

Speaking at the Royal Pharmaceutical Society Annual Conference, Steve Brine MP, Parliamentary Under Secretary of State (Public Health and Primary Care), confirmed how Jeremy Hunt will be working with the Chief Pharmaceutical Officer, Keith Ridge, to tackle the challenge of prescribing and medication errors:

‘Studies currently indicate that up to 8% of prescriptions have a mistake in dosage level, course length or medication type—a risk which the WHO identifies as a leading cause of injury and avoidable harm in healthcare systems across
the world.’

How might this affect nurses?

While the initiative is likely to predominantly affect GPs, it will also have an impact on the 70 000 qualified nurse and midwife prescribers. The Nursing and Midwifery Council (NMC) recently launched a consultation on proposals for nurses and midwives to prescribe earlier in their careers.

The proposals, if implemented, would enable nurses and midwives to gain prescribing practice experience as soon as they qualify. They would, therefore, do the prescribing training as part of their degree so that they have more of an understanding when they graduate.

It is unclear how this may affect patient safety or the number of medication errors carried out by nurses. Nurse Prescribing contacted the NMC, but as their proposals are only in the consultation phase, they said they were unable to comment at this time.

Deborah Robertson, Senior Lecturer and Programme Leader in Non-medical Prescribing at the University of Chester highlighted how nurse prescribers are very aware of the risk of prescription errors, and that best practice is needed to ensure errors are minimised:

‘Nurse prescribers are already very conscious of the risk of prescription errors and in prescribing education—we spend a good deal of time ensuring that they know the legalities of prescription writing as well as the need for best practice advice to ensure the minimisation of errors.’

‘We always reiterate the benefits of team working in prescribing practice and establishing good relationships between prescribers and dispensing pharmacists to ensure prescribing errors are picked up in a timely manner and how to avoid confrontation. This also highlights the need for ongoing continuing professional development in all areas of prescribing practice.’

Taken from Nurse Prescribing, published November 2017.

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New techniques at pilot sites to improve bereavement care for parents

November 26, 2017 Leave a comment

Adobe Spark (1)A new pathway has been launched to improve the quality of care for parents who have lost a baby. The National Bereavement Care Pathway (NBCP) seeks to offer individualised, safe and sensitive care for parents and families at all stages of pregnancy and baby loss up to 12 months.

Led by Sands, the stillbirth and neonatal death charity, it has been produced in collaboration with a core group of charities and professional bodies, comprising the Institute of Health Visiting, the Royal College of Midwives, NHS England, the Royal College of Obstetricians & Gynaecologists, the Royal College of Nurses, Neonatal Nurses Association, Bliss, Antenatal Results & Choices, The Lullaby Trust and Miscarriage Association. It also has the support of the Department of Health and the All-Party Parliamentary Group on Baby Loss.

The first wave of 11 pilot sites has been rolled out across the UK to coincide with Baby Loss Awareness Week and includes Wirral University Teaching Hospital NHS Foundation Trust, Liverpool Women’s NHS Foundation Trust, and Hull and East Yorkshire Hospitals NHS Trust. The sites were chosen to be ‘representative of geography, capacity and specialism’, and will trial the use of new materials, guidelines and training for professionals to help improve the care that bereaved parents receive.

The latest figures show that in 2015 there were over 2,500 infant deaths (that is, deaths under 1 year of age) in England and Wales, with stillbirths and deaths of infants under 7 days accounting for around 6.5 deaths per 1,000 total births (Office for National Statistics, 2017).

Clea Harmer, chair of the NBCP Core Group and CEO of Sands, comments: ‘I am delighted that we have so many enthusiastic partners across the country who want to work with us in improving bereavement care for parents when a baby dies.

‘As a collaboration, we were inundated with offers of support and I am excited by the potential impact that the pathway will have in these 11 sites, in the first instance. We  look forward to learning from their experiences before wave 2 begins and the wider rollout later next year.’

A spokesperson for the Institute of Health Visiting says: ‘The Institute is pleased to be one of the key partners in the project group working to deliver a National Bereavement Care Pathway for England, with the support of the Department of Health and All-Party Parliamentary Group for Baby Loss.

‘We are really keen to support the project group with identification of community health providers [which employ health visitors] that are willing to be included in the second pilot phase. This will ensure that the pathway offers clear, consistent guidance to health visitors and enable them to work confidently alongside parents, providing compassionate and parent-centred care to those affected through use of the pathway.’

Sue Cooper is the bereavement midwife at Hull and East Yorkshire Hospitals NHS Trust. She highlighted the important role that bereavement midwives play in providing support for parents who have lost a child:

‘Losing a child is an incredibly difficult experience and something that no parent should ever have to go through,’ Cooper says. ‘If they do, however, it’s important that we, as health professionals, are able to provide the right advice, information and support for bereaved parents.

‘The quality of care and the empathy shown to parents at a time when they are struggling with a whole range of different emotions is crucial, and our role in guiding bereaved parents through this difficult time is not to be underestimated. How we care for bereaved families when their baby dies can have long-lasting effects. Good care can’t remove parents’ pain and grief, but it can help them through a devastating experience.

Cooper is hoping bereavement care in Hull and East Yorkshire will improve as a result of being one of the pilot sites on the new pathway: ‘We’re really pleased to have been chosen to pilot the new care pathway,’ she says. ‘We’re not only hoping to improve the care we personally provide for bereaved parents, but it will mean a lot to know that what we do here in Hull and East Yorkshire will go on to shape and improve services provided for others right across the country.’

Since the project was initiated, it has engaged with over 200 professionals and 60 parents, completing a gap analysis of current pathways, guidance and research. A number of pregnancy and baby loss pathways have been created, with input from members of the NBCP Parental Advisory Group, which shared their stories to help inform the pathway.

Cathy Warwick, chief executive at the Royal College of Midwives, says: ‘This is important work because it is about giving bereaved families better care following the sad loss of a baby and we need to get it right. Learning from parents and the results of the work at the pilot sites will mean care can be better tailored to meet the needs of families.’

According to Carmel Bagness, Royal College of Nursing’s professional lead for midwifery and women’s health, it is the responsibility of healthcare staff to support bereaved parents: ‘The loss of a baby is an absolute tragedy and it is up to healthcare staff to provide the best care possible for bereaved parents and families,’ she says. ‘This pathway could really help to improve the care they receive during this difficult time. We hope this pilot is just the first step towards better care throughout the country for parents and families suffering from this terrible loss.’

Caroline Lee-Davey, Chief Executive of Bliss, adds: ‘Bliss is proud to be partnering on this project to improve bereavement care for pregnancy and infant loss. We know that being supported in the right way can help grieving parents and families at this heart-breakingly difficult time, and we look forward to working with the pilot sites to deliver consistent, high-quality and parent-centred care.’

A second wave of pilot sites is planned for April 2018, with a national rollout expected later in October.

References

Office for National Statistics. Childhood mortality in England and Wales: 2015. London: ONS; 2017.

Taken from Journal of Health Visiting, published November 2017.

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Not enough ‘safe care’ for maternity service users, warns NHS England

November 24, 2017 Leave a comment

Adobe Spark (8)The chair of the Maternity Transformation Programme in England has warned that not enough is being done to ensure safety within maternity services. Speaking at the NHS England Health and Care Innovation Expo, Professor Sarah-Jane Marsh, said:

‘There are too many families […] who have not had safe care, who we have let down, and we need to do better.

‘Safety has to be at the heart of everything that we do in our maternity services. We have got to get it right. We know how to get it right, [but] often we just don’t do that consistently.’

In Better Births (NHS England, 2016), NHS England emphasised the need for safer, personalised, professional, family-friendly maternity services, realised through Local Maternity Systems, the maternity element of Sustainability and Transformation Plans (STPs). Here, providers, commissioners and organisations work at a local level to oversee and develop health care issues.

While Marsh called the vision ‘clear’, she cautioned that it was not ‘what is being talked about in every maternity unit in the country at the moment.’

Since the Maternity Transformation Programme was launched in July, 44 Local Maternity Systems have been set up to plan the design and delivery of services to populations of 500 000–1 500 000 people. Marsh claimed that these are making headway, and are looking towards the future of maternity services ‘with a ruthless focus on safety and personalisation.’ Although services are becoming safer, she warns that performance, when benchmarked against maternity staff, ‘is not as it should be’.

Marsh also raised concerns that boards are not as focused on maternity services, saying:

‘We need to have people, at board level, who really understand maternity safety, who understand how to get it right as well as to investigate when things go wrong.’

Marsh stressed that, while visions and national programmes are important,

‘The change that really matters is that which is made by clinical teams on the ground, coming together to want to make a difference for the patients, the families, the women they care for. And the women and families themselves having every opportunity to be able to participate, feedback their experience and work with professionals to improve services.’

Marsh also highlighted the importance of multiprofessional working, saying,

‘We need to see ourselves as one big maternity team […] We have got to move away from the idea that maternity care is purely about the midwives and the obstetricians, because there is so much more to it than that. […] Those who work together and train together ultimately go on to do even more personal and safe care.’

This sentiment was also emphasised by Professor Jacqueline Dunkley-Bent, head of maternity, children and young people for NHS England, who said:

‘We are working really hard and we will continue to work hard to ensure that avoidable death is reduced in this country. We have a commitment at the moment on the table from the Department of Health: £8 million has been allocated to support education and training. This fund has been awarded to maternity services to help them develop multidisciplinary training.’

Matthew Tagney, director of the Maternity Transformation Programme, agreed that progress was being made, but warned that the NHS was still far from its target of halving stillbirths, maternal and neonatal deaths, and brain injuries during or soon after birth by 2030:

‘I think there is a tremendous amount happening both nationally and locally.We are on track for 2020 but there is a huge amount more to do.’

While progress is being made on the delivery of better maternity services, there is still a long way to go. This was accepted by Marsh, who apologised to the hundreds of families who had lost babies:

‘You have my commitment and the commitment from the team at NHS England that we will work tirelessly every day to do the things that we know work in patient safety, and to make sure there are no baby deaths in this country that are avoidable.’

References

NHS England. National Maternity Review: Better Births—Improving outcomes of maternity services in England—A Five Year Forward View for maternity care. Leeds, NHS England: 2016

Taken from British Journal of Midwifery, published November 2017.

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Ensuring the district nursing role does not die out

September 4, 2016 Leave a comment

Adobe Spark (2)Recent figures published by the Welsh Government have revealed a 42% reduction in the number of district nurses in Wales between 2009 and 2015 (BBC News, 2016). The number of district nurses has fallen from 712 in 2009 to 412 in 2015, with six of the seven health boards in Wales reporting a reduction.

This follows trends seen in England in recent years, which has reported a 47% reduction in the number of qualified district nursing staff in the past decade (Royal College of Nursing (RCN), 2014). Frequent figures such as these have resulted in a warning from the RCN that district nurses are ‘critically endangered’ and face possible extinction by the end of 2025 (RCN, 2014). Consequently, it has called on the Government to fulfil its commitment to increase the number of community staff to 10000 by 2020.

Origins of district nursing

The district nursing role originated in 1859, when a wealthy Liverpool merchant, William Rathbone, employed a private hospital-trained nurse to care for his dying wife. He was struck by ‘the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided.’ Following the death of his wife, Rathbone set up a training home in Liverpool to give nurses the skills necessary to treat patients in the home.

The title came from the fact that Liverpool was split into 18 districts based on the parish system, so the nurses became known as ‘district nurses’.

There is little research, but a publication from the Department of Health revealed that more than 2.6 million people receive care from district nurses each year, in England and Wales alone, according to statistics gathered nationally (Department of Health, 2004). It is anticipated that this number will only increase.

Due to the increasing elderly population and number of people with long-term conditions, district nurses make a notable contribution to the NHS. Having specially qualified staff who are trained to deliver care to patients in their own homes, should reduce pressures on GP surgeries and emergency departments. However, the shortage of district nurses means many feel they are being pushed to breaking point. Reports of regular additional hours, activities left undone due to lack of time and a desire to leave the job are not uncommon.

The RCN have said the reduced numbers of district nurses has placed extra pressure on GP surgeries and emergency departments. Increases in caseloads from 30 patients to up to 150 means contact time is kept to an absolute minimum. This results in patients not receiving the appropriate care they need and therefore feeling they require further consultation by their GP or at the emergency department.

The future vision of district nurses

In 2009, The Queen’s Nursing Institute (QNI) published its 2020 Vision of the future of district nursing (QNI, 2009). It marked the 150 year anniversary of district nurses and highlighted their role in health care. Fundamentally, the principles of district nursing have changed little in 150 years and consist of ‘better care, closer to home’, ‘patient choice’, ‘integrated care’, and ‘co-production’ (QNI, 2009). As a specialism, district nurses are ‘practitioners, partners and leaders’ of care in the home (QNI, 2009).

Some of the issues identified in the QNI report surrounding district nurses included: ‘loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education’ (QNI, 2009).

It is important to highlight that there is a notable difference between nursing found in clinics, surgeries and other areas of primary care; and that found in patients’ homes. It is for this reason that the district nursing role remains an important part of the NHS.

The British Journal of Community Nursing and the QNI carried out a survey in 2008, gathering information and views from district nurses in England, Wales and Northern Ireland about the state of their specialism. The survey found that 13% of respondents’ employing organisations no longer use the title ‘district nurse’ at all. It also revealed that in those organisations that still use the title, more than 30% do not limit its use to those with a district nurse qualification (QNI, 2009). In some cases, the title was given to team leaders or case managers, with or without the qualification. Additionally, the survey revealed that only 48% of employing organisations continue to require district nursing team leaders to have the district nursing specialist practitioner qualification. Another 19%, who did at the time the report was published, plan to discontinue this requirement.

A follow-up report from the QNI published 5 years after the 2020 Vision, revealed an increase in the level of confusion about job titles, qualifications and roles concerning district nurses (QNI, 2014). As a result, one of the key recommendations of the the report was for a renewed investment in the district nursing specialist practitioner qualification.

Focus surrounding qualifications for district nurses was raised at the most recent RCN Congress, which passed a resolution calling on RCN council to lobby for all district nurse caseload holders to have the relevant specialist practitioner qualification (Ford, 2016). This arose amid concerns over the future of the district nursing role and its protected title. The Forum called for a practitioner who is ‘equipped with skills to manage a role that is highly complex and requires skills in negotiating, coaching, teaching and effective team management’ (Ford, 2016).

The current climate

The situation surrounding the place and role of district nurses within the NHS has gradually changed over the years. For example, it is no longer the sole role to be found delivering nursing care in the home as there are now a multitude of community roles working at different levels. The issue with this is that the meaning attributed to the district nurses’ unique title has eroded somewhat. As mentioned, some employers are using the title without the accompanying specialist qualification, further muddying the waters. District nurses are excellently placed to offer leadership over other health professionals in the home. However, if they have not received adequate training they will struggle to have the strong leadership skills required.

Within Simon Stevens’ Five Year Forward View he called for the introduction of a new care model known as Multispecialty Community Providers. One of the benefits of this model is to allow for the expansion of primary care leadership to include nurses and other community-based professionals. This new way of delivering care and ability to offer a wider scope of services is made possible by allowing the formation of extended group practices as federations, networks or single organisations.

Conclusions

District nurses offer a much-valued service to the NHS through their ability to treat large numbers of people at home, allowing patients to avoid having to go to hospital if they receive the appropriate level of care first-time around. However, this is only possible if the number of district nurses does not continue to fall. The reality is that those still in the role are under increasing pressure, as they find their workloads ever-increasing. The Government must fulfil its commitment to increase the number of community staff, and in particular, the number of district nurses.

Now, more than ever, is the time to reinstate the district nurse.

References

BBC News (2016) Royal College of Nursing concern over fall in district nurses in Wales. BBC News. http://www.bbc.co.uk/news/uk-wales-36828072 (accessed 17 August 2016)

Department of Health (2004) Patient Care in the Community: NHS District Nursing Summary Information for 2003–04, England. The Stationery Office, London. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4092113.pdf (accessed 17 August 2016)

Ford S (2016) All district nurses ‘should have specialist qualification’. Nursing Times. http://www.nursingtimes.net/news/community/all-district-nurses-should-have-specialist-qualification/7005789.fullarticle (accessed 18 August2016)

Health Education England (2015) District Nursing and General Practice Nursing Service Education and Career Framework. HEE, London. https://hee.nhs.uk/sites/default/files/documents/District%20nursing%20and%20GP%20practice%20nursing%20framework_0.pdf (accessed 17 August 2016)

Royal College of Nursing (2014) District nurses face ‘extinction’ in 2025. RCN, London. https://www2.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025 (accessed 17 August 2016)

The Queen’s Nursing Institute (2009) 2020 Vision: Focusing on the Future of District Nursing. QNI, London. http://www.qni.org.uk/docs/2020_Vision.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute (2014) 2020 Vision Five Years On: Reassessing the Future of District Nursing. http://www.qni.org.uk/docs/2020_Vision_Five_Years_On_Web1.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute, NHS England (2014) Developing a National District Nursing Workforce Planning Framework: A Report Commissioned by NHS England. https://www.england.nhs.uk/wp-content/uploads/2014/05/dn-wfp-report-0414.pdf (accessed 15 August 2016)

Taken from British Journal of Community Nursing, published 2 September 2016.

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Ministerial approval for commencement of work on paramedic prescribing

November 10, 2015 Leave a comment

Ministerial approval has been received for the commencement of preparatory work to take paramedic independent prescribing proposals forward to public consultation.

The College of Paramedics have been campaigning for a number of years to review the current legislation around non-medical independent prescribing and the case for paramedic independent prescribers.

The Allied Health Professions (AHP) Medicines Project was set up as a joint initiative by NHS England and the Department of Health to extend prescribing, supply and administration of medicines to allied health professions.

The aim of the initiative is to facilitate service redesign; increase patient choice; improve access to medicines; and make best use of allied health professionals’ skills, while maintaining patient safety.

Independent prescribing for paramedics is among the key proposals that the NHS England AHP Medicines team are focusing on.

A case of need has been developed for this proposal based on improving quality of care for patients in relation to safety, clinical outcomes and experience, while also improving efficiency of service delivery and value for money.

The consultations and supporting documents will be developed over summer, with the aim of seeking ministerial approval to publish the consultations later in the year.

Following public consultation, there will be significant further work to be undertaken, including submission of consultation findings for consideration by the Commission on Human Medicines, who will make recommendations to ministers regarding any potential changes to medicines legislation.

Taken from Journal of Paramedic Practice, published 10 September 2014.

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Prescribing for paramedics?

September 5, 2014 Leave a comment

This month, the Journal of Paramedic Practice contains an article from the College of Paramedics on the recent ministerial approval for the commencement of preparatory work to take paramedic independent prescribing proposals forward to public consultation.

In it, it outlines the work of the Allied Health Professions (AHP) Medicines Project, a joint initiative by NHS England and the Department of Health, which aims to extend prescribing, supply and administration of medicines to allied health professions.

The concept of independent prescribing for paramedics is not a new one—the Department of Health’s (DH) ambulance review Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DH, 2005) recommended that prescribing for paramedics should be actively explored. Since then, the College of Paramedics have been actively campaigning to review the current legislation around non-medical independent prescribing and the case for paramedic independent prescribers.

Under current medicines legislation, paramedics are able to supply and administer a range of medicines, on their own initiative, as part of their normal professional practice for the immediate and necessary treatment of sick or injured persons (DH, 2010). However, it is not currently possible for paramedics to write a prescription for a patient. This is largely because in an emergency situation, it would be unlikely that paramedics would need to write a prescription. Instead, their priority would be to stabilise, treat and transport the patient as necessary. However, the need for paramedics to provide a broader range of treatment in both emergency and urgent (non-emergency) settings has become increasingly apparent.

Paramedics are treating more patients at their homes, thus avoiding the need for many patients to visit A&E. Additionally, paramedics who have undertaken further training, such as emergency care practitioners (ECPs), often work independently in these two types of settings.

The Department of Health’s vision for urgent and emergency care is that ‘patients are provided with 24/7 services which are integrated together, so that patients get the right care wherever they access the health system’ (DH, 2010). The ambulance service plays a key role in allowing for this integration due to the flexibility of the roles that are undertaken by ECPs and other advanced practitioners in delivering care to patients at home and in the community.

The benefit of prescribing for paramedics is clear: not only would it support better integration of urgent and emergency care services, it would enable patients to avoid having to make an additional visit to another healthcare provider. The work that the College of Paramedics is undertaking with NHS England, the Association of Ambulance Chief Executives and Health Education England, therefore, is integral if this is to become a reality.

References

Department of Health (2005) Taking Healthcare to the Patient: Transforming NHS Ambulance Services. DH, London

Department of Health (2010) Proposals to introduce prescribing responsibilities for paramedics: Stakeholder engagement. DH, London

Taken from Journal of Paramedic Practice, published 5 September 2014

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Street Triage Mental Health Scheme introduced to West Midlands

June 3, 2014 Leave a comment

A pilot ‘street triage’ scheme from the Department of Health has been launched in the West Midlands to ensure people with mental health issues are kept out of custody and receive the right treatment.

The scheme will see paramedics from West Midlands Ambulance Service NHS Foundation Trust and nurses from Birmingham and Solihull Mental Health NHS Foundation Trust join forces with West Midlands Police to attend incidents involving people who require immediate mental health support.

The pilot follows similar schemes that have taken place elsewhere in the country, which have shown a reduction in the demands on police and ambulance time.

Dr Andy Carson, medical director for West Midlands Ambulance Service, said: ‘This is a fantastic and exciting opportunity for the Trust to work alongside partners to ensure the highest quality of care is delivered to some of the most vulnerable people from within our community. We welcome this opportunity and firmly believe this will ensure mental health provision will be amongst the best in the country.’

Jon Short, chief executive at Birmingham and Solihull Mental Health NHS Foundation, said: ‘There’s been a huge fuss in recent years over how much front-line police work deals with mental health issues.
‘Lots of their call-outs are to disturbances in the street or domestic issues. Police have limited powers in these issues, so the outcome is often an arrest.

‘The triage will allow trained paramedics and mental health nurses to assess people more thoroughly and to make police aware of the range of options available to them, such as if the person involved needs counselling or other care.’

Taken from Journal of Paramedic Practice, published 27 January 2014.

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Antimicrobial resistance is a ‘ticking time bomb’

September 9, 2013 Leave a comment

The Chief Medical Officer Professor Dame Sally Davies has announced that global action is needed if we are to overcome the ‘catastrophic threat’ of antimicrobial resistance.

The warning, made in her second annual report, highlighted the lack of new antibiotics discovered in the past two decades.

Despite new infectious diseases being discovered on an almost yearly basis, very few new antibiotics have been developed.

This means that we have limited resources to manage the increasing number of infectious diseases that are ever evolving to become resistant to current drugs.

‘We need to work with everyone to ensure the apocalyptic scenario of widespread antimicrobial resistance does not become a reality,’ said Professor Davies. ‘This is a threat arguably as important as climate change for the world.’

The importance of preserving current antibiotics was also emphasized. Professor Davies argued that in order to retain the effectiveness of existing antibiotics, responsible prescribing must be adhered to.

‘All physicians who prescribe antibiotics have a responsibility to their patients (and public health) to prescribe optimally,’ she said.

To help meet the challenges set out by Professor Davies, the Department of Health is planning to publish a UK Antimicrobial Resistance Strategy.

This five-year strategy will focus on championing the responsible use of antibiotics by ensuring NHS staff have the necessary knowledge, skills and training to prescribe antibiotics effectively.

Professor Davies stressed that governments and organizations across the world, including the World Health Organization and G8, need to realize the seriousness of the problem.

‘If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics.’

Taken from Practice Nursing, published 19 Mar 2013.

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