Editorial. Nursing and the primary healthcare agenda

‘The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components (Ottawa Charter, World Health Organization 1986)’. Aspirational statements such as this provide a political mandate for the development of national health services to address broader primary care and public health issues. Public health and health promotion have always featured in healthcare systems but became more prominent in Europe in the early 1970s (Freeman 2000). In the UK this was characterized by the abolition of Hospital Boards, which were replaced by Area and District Health Authorities with a remit for providing locality- or population-based health care (Abel-Smith 1994). More recently Foundation Trusts have been established in the NHS. Foundation Trusts are a new type of NHS Trust in England and have been created to devolve decision-making from central Government control to local organizations and communities so that they are more responsive to the needs and wishes of their local people (Department of Health 2005). Improvements in health technology, diagnostics and treatment mean that the role of hospitals is increasingly confined to short-term technical intervention (Newson-Davis & Weatherall 1994). Shortened lengths of hospital stay, day surgery and treatment centres mean that recovery for many patients takes place at home. As a result, hospital nursing care is increasingly provided as a consequence of a need for medical technology rather than as a consequence of human frailty (McKee et al. 1998). More recently, government policies in many Western countries are concerned to reduce hospital admissions for patients with long-term conditions by improving the patient and family ability for self-care (Glasgow et al. 2001, Department of Health 2004a). The combination of reduced length of stay and hospital avoidance policies means that many activities, traditionally associated with hospital nursing such as looking after patients when they are ill and helping them towards a full recovery, have relocated from the hospital to the community. Community nursing has a long tradition of providing these services to patients at home (Kelly & Symonds 2003). However, it too has to adapt to increasing medical specialization and the expertise required by new healthcare technologies (Bryar & Griffiths 2003). Moreover, access to community nursing by patients is variable and not necessarily linked to local hospital early discharge or hospital avoidance strategies. Much of the additional demand for community nursing is being met by an increasing number of specialist nurses and advanced nurse practitioners working within a community setting (Helvie 1998, Drennan et al. 2005). In the UK, practice nurses based in general practice surgeries are making a major contribution to chronic disease management and healthcare assessment (Hampson 2002). Added to this, attention is increasingly being focused on health promotion (Department of Health 2004b, Kinect Australia for the Lifescripts Consortium, 2005). This has traditionally been seen as a key aspect of health visiting or public health nursing which, in the UK, has predominantly focused on mothers and small children. Recent reforms in the UK consolidate the emphasis on population health and potentially extend the public health nursing role to a much broader population (Department of Health 2006). However, as McKee and Raine (2005) point out, health promotion and public health still sits uncomfortably in health policy straddling as does the individual liberty and choice and the role of health services in influencing individual behaviour. Despite these philosophical difficulties it is likely that future targets and government policies will focus on reducing overall levels of morbidity and mortality within defined population groups (Wanless 2003). The shift to community and primary care, therefore, presents a number of ongoing challenges to nurse managers. These include: identifying and scoping population requirements for nursing services across community, primary and hospital care; integrating care provided by an increasingly diverse number of agencies including hospital, community and primary care and independent providers; and identifying how nursing contributes to the overall health gains of the local population. The papers in this issue of the Journal illustrate how some nurses are rising to these challenges. The first paper by Kihlgren and colleagues looks at the managerial support required by community nurses referring older adults to Emergency Departments in Sweden. The paper highlights the high level of clinical responsibility which characterised the work of the community nurses in the study. It is likely that this level of clinical responsibility will become a feature of community nursing practice in the future. Scoping demand for community nursing services forms the focus of two papers in this issue by Gobnait Byrne and colleagues and by Linda Thomas and Tracy Reynolds. Both papers describe the development of tools to measure community nursing workload. Gobnait Byrne and colleagues use quantitative methods to develop a tool for predicting the needs of new and existing clients for public health nursing services. This study found that the elderly and child health groups accounted for the majority of nurses’ direct and indirect time. Linda Thomas, Tracy Reynolds and Loretta O'Brien allied the development of their tool for measuring demand for district nursing services with action research. This approach highlighted the unpredictability of the daily workload of district nurses confirming their reported difficulties in proactively managing their workload. The strengths of the current district nursing service are identified and the impact of new reforms on this service is discussed. The paper by Hasseler and colleagues describes a study designed to classify different levels of home-based-nursing and nursing-home care for groups with differing care needs in Northern Germany. This study used the Delphi technique to identify prospective needs for care as identified by a group of experts. The authors found that it was considered by the experts to be insufficient to implement only low threshold services like neighbourhood care and voluntary help. Instead, to cover the care needs of each group of patients and ensure high quality nursing, it requires a mixture of professional and informal services within well coordinated and networked services which cross the primary and secondary care interface. The paper by Brenda Leese and colleagues describes the role of Primary Care Cancer Lead Clinicians in developing local cancer networks. The study evaluates the impact of the lead clinician role in meeting national service improvement targets. The national survey indicated that this role has been undertaken by either GPs or nurses. A wide range of community-based nurses undertook this role including district nurses, palliative care nurses, practice nurses, a health visitor and nurse managers. Clinical credibility was key to the success of the role. Lead community-based clinicians responsible for coordinating services locally for a defined patient population may be a model that could be emulated with other services as one approach for integrating care provided by a diverse range of agencies. Governments are increasingly focusing attention on health promotion policies and working to identify the specific role of health services in implementing health promotion strategies. Two papers in this issue address the role of nursing in relation to health promotion. Drawing on the organization of the public health nursing service in Ireland, Sinead Hanafin and Sarah Cowley's paper develops a model of service quality for health promoting services. They highlight the difficulties with outcome-driven approaches in producing evidence when dealing with multidimensional issues in health care such as health promotion. Instead they develop a process model which clearly delineates indicators of quality for each stage in the model. Kyoko Yoshioka-Maeda and colleagues describe the development of the Japanese Purpose-Focused Public Health Nursing Model which identifies key aspects of public health nursing practice in Japan. It is interesting to note that both these papers derive their evidence base from nurses whose activities are geographically or population based, rather than GP or hospital attached. Both are client focused and scope public health nursing practice in relation to addressing specific client initiated needs within a specific locality. These papers indicate the importance of good quality information systems in developing community services to meet local population health needs. Finland has developed STAKE (National Research and Development Centre for Welfare and Health: http://www.stakes.fi). Internationally, this is one of the most advanced population-based health information systems yet developed. Sirpa Luukkainen describes how nurses have been able to utilize the information routinely collected by STAKE to develop and evaluate local inter-agency healthcare policy and practice. The difficulties faced by nurses and other health professionals in addressing key health policies may in part arise from the lack of an integrated information system such as the one described here. Language difficulties prevented Sirpa from expanding her article, however, her short description does provide an indicator of what could be achieved if a similar information strategy was developed elsewhere. Nurse managers are well placed to consider the strengths and limitations of the system described in this article and to decide whether it is something that should be emulated. Finally, Kay Price has produced a polemical and thought-provoking article on the role of health professionals and nurses in the health promotion ‘marketplace’. Based on the work of Zygmunt Bauman she describes the theoretical and philosophical challenges facing nurses and other health professionals implementing health promotion strategies within an individualized clinical care environment. The articles by Linda Thomas, Tracy Reynolds and Loretta O'Brein, Kyoko Yoshioka-Maeda and colleagues. Sirpa Luukkainen and Kay Price were originally presented at the 3rd International Conference on Community Health Nursing Research held in Tokyo in September 2005 (ICCHNR 2005). Taken together with the three other papers in this issue, this collection of papers highlights both the challenges and opportunities facing nursing and nurse managers in the delivery of contemporary healthcare policy. As hospitals specialize, the historical separation between community and hospital nursing is gradually dissolving with more technical and specialist care being provided in the community. This has implications for nursing where rigid role boundaries between hospital and community nursing have tended to highlight role differences rather than identify areas of common interest and shared care based on an analysis of population and client need. Community and public health nursing has many strengths as described in this issue of the Journal. As more care shifts into the community, the strengths of community and public health nursing need to be harnessed and integrated with the specialist skills of hospital nurses so that nursing can take a leading role in shaping future healthcare policy and practice.

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