The fall and rise of the polyclinic and its link to the role of the nurse Elizabeth Haidar Lord Darzi Healthcare delivery is subject to constant transformation and reform as the NHS seeks to provide effective health care under the scrutiny of service users. This can be especially difficult in times of recession. This article will consider the similarities between the development of a public healthcare system in the 20th and 21st centuries in Britain under Lords Dawson and Darzi respectively, and the impact these changes have had on discussions on the introduction of polyclinics and on nursing today. Key words: Healthcare reform ■ Nurses ■ Nurse’s role ■ Government
T
he NHS is under threat; it takes up one fifth of the UK’s national budget. NHS England Chief Executive Simon Stevens has said £20 billion of cuts will be needed in the next 5 years (Ham, 2014). Individual politicians and government policy have a large part to play in the development of healthcare services. This article looks at how, a century apart, two Lords have sought to influence policy.
Lord Dawson Health reform was pioneered in early 20th century Britain by royal doctor Lord Dawson (1864–1945). It has been reported that the death of King George in 1936 was hastened by Dawson and that this was noted by Dawson himself in his diary. As Chairman of the Consultative Council on Medical and Allied Services, he was commissioned to write report on health care in 1919 and he produced a report on the Future Provision of Medical and Allied Services in 1920 (Dawson, 1920). This report may have been significant in starting debates that prepared the ground for setting up the NHS in 1948. The Dawson Report, commissioned under the Ministry of Health Act 1919, declared: ‘Organisation of medicine has become insufficient, and because it fails to bring advantages of medical knowledge adequately within the reach of the people.’ (Dawson, 1920)
Elizabeth Haidar, Senior Lecturer, Middlesex University, London Accepted for publication: February 2014
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Lord Ara Darzi (born in 1960) is a Labour peer. He was appointed Parliamentary Under-Secretary of State at the Department of Health in 2007 by the then Prime Minister Gordon Brown, and he held this position until 2009. He reflected on NHS health care and said ‘there are stark inequalities in health outcome’ (NHS, 2007). He summarised his findings in A Framework for Action (NHS, 2007). He, much like Dawson, felt that services should be focused on the individual’s needs and choices and said ‘provision should, wherever possible, be tailored to the particular needs of each individual’ (NHS, 2007).
‘Mutual convenience’ Dawson favoured a healthcare service dependent upon the ‘mutual convenience’ of the patient and health professional, calling it ‘freedom of action for doctor and patient’ (Dawson, 1920). His views were that health centres, or polyclinics, should be either ‘primary’ or ‘secondary, ‘the former denoting a more simple, and the latter a more specialised service’ with a domiciliary service providing care to patients in their homes or inviting them to the closest primary health centre (Dawson, 1920). The focus was on integrated care and partnership working between health professionals, maximising the contribution of the entire workforce, which was not dissimilar to Darzi’s A Framework for Action report, which suggests ‘better communication and cooperation between the community and the hospital, between urgent and planned care and between health and social care’ (NHS, 2007:7).This was to prevent people from falling through the gaps. Dawson believed that doctors, instead of being isolated from one another, should be ‘brought together and in contact with consultants and specialists’ (Dawson, 1920).
Multidisciplinary care and the introduction of the polyclinic Darzi believed in localising care where possible and centralising it where necessary, suggesting routine health care should take place as close to home as possible. He identified that more complex care should be centralised to ensure it was carried out by the most skilled professionals. The Coalition Government also recognised the importance of decentralising power and giving power to the people, with an end to a ‘top-down’ government (Carswell and Hannan, 2011), although its actions of guiding choice and competition may not necessarily have been seen by some as giving power to the people. Dawson advised that the ‘general practitioner duties should embrace the work of communal as well as individual medicine’
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Abstract
British Journal of Nursing, 2015, Vol 24, No 3
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‘Would not give advice as regards treatment to sick persons, nor, knowing them to be sick, visit them in her capacity as health visitor unless with the consent and under the supervision of the doctor attending the case.’ (Dawson, 1920) Dawson advised that the domiciliary service be multiprofessional and cater for patients, whether in their own home with a preventative and curative service, in the doctor’s surgery or in the primary health centre. He discussed primary health centres having many facilities under one roof, such as medical, surgical and maternity beds, out-patient clinics, ambulance services, dispensary, radiography rooms, hydrotherapy, laboratory for simple investigations, and that they could be specific to the region (Dawson, 1920). Dawson continued that these primary health centres could be independent, or attached to secondary health services, adding they must cater for local need. Only 40% of GPs were in favour of these health centres after the NHS was introduced (Berridge, 2008); 28 centres were built between 1948 and 1967 and over 700 in the following decade (Berridge, 2008). Dawson’s polyclinics failed in early 20th century Britain for a number of reasons. First, there were cuts in the economy of the 1920s, known as the Geddes Axe, and the plans to implement polyclinics were expensive. Furthermore, doctors’ earnings came from private fees, insurance payments or a panel system (people who paid national insurance (first introduced in 1911) could access free but limited health care from a doctor who was on a local list or panel) and there was no desire by doctors to be salaried employees of the state (Berridge, 2008; 2009). Additionally, support dwindled as the Minister of Health changed from Christopher Addison to the less sympathetic Sir Alfred Mond in 1921. Moreover, the top civil servant involved, Sir Robert Morant (who was a great exponent of nurses) died prematurely (Fenwick, 1920). There was some interest from GPs who thought better health care would be provided with the introduction of polyclinics and there would be a chance to raise the status of GPs. However, the word ‘polyclinics’ was used as a derisive term by health campaigners Drs Innes Pearse and George Scott Williamson in the 1930s who were opposed to them as they themselves grouped together ad hoc services (Lewis and Brookes, 1983) in the ‘Peckham Experiment (1926–1950) (Pioneer Health Foundation, 2015).They believed an individual should shoulder responsibility for his or her own welfare and should not be
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robbed of this responsibility, as this would lead to societal degeneration (Lewis and Brookes, 1983). Darzi, to an extent, revived Dawson’s ideas. He believed that care should be multidisciplinary, bringing together the valuable contributions of practitioners from different disciplines. The NHS should be committed to working in partnership with other organisations, including local government and the voluntary and private sectors, Darzi said (NHS, 2007). He recommended models of healthcare provision based on services, not buildings or institutions, focusing on care taken to various settings, echoing Dawson’s plan to create a three-part system with at-home, primary and secondary healthcare centres. Darzi’s name became synonymous with the term ‘polyclinic’ as he announced the key to integrated better care is a service that provides all care under one roof. Lord Darzi advocated dealing with health should be a combined effort (NHS, 2007). He believed there should be universal services focused on individual needs and that these should include women’s social and medical needs.This was to reflect care from early pregnancy through to newborn care, as well as mental health services. Polyclinics will: ‘Provide the infrastructure (such as diagnostics and consulting rooms for outpatients) where the majority of urgent care centres will be located. They will provide the integrated one-stop-shop care that we want for people with long-term conditions. (NHS, 2007: 11) Darzi put together the Equitable Access Programme: Primary Medical Care services in 2008-9 (Department of Health, 2008) with the aim of improving access to primary medical care by placing services in deprived areas. These were to be commissioned by primary care trusts (PCTs) and were to provide open access for urgent or routine care from 8am to 8pm seven days a week. The Coalition Government was interested in keeping these services, which would provide yearly reports on their efficacy.
Health and Social Care Act 2012 The Coalition Government’s Health and Social Care Act 2012 builds on some of the work started by Darzi, and in fact Dawson before him, to embed quality into the public health system (today the NHS) and its outcomes (Russell, 2011). The dissolved strategic health authorities and PCTs removed a layer of management, which was replaced with commissioners with GP consortia not dissimilar to GP fundholding as the commissioning model. GP fund-holding was initially abandoned when Labour came to power in 1997 (The King’s Fund, 2010), although the full impact was not analysed owing to its short life. The initial proposal was to make GPs accountable for the health service, also giving nurses some input in commissioning groups, and removing responsibility from government (BBC News, 2013). There were various misconceptions about polyclinics but it was a suggestion for healthcare services and ‘not a panacea’ (NHS Confederation, 2008). The aim was to open 115 polyclinics before funding dropped by 2011/12 (Ireland, 2009). Today, under the Coalition Government, polyclinics are not being commissioned. Former Health Secretary Andrew Lansley
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(Dawson, 1920). He suggested services ought to be tailored to the needs of patients, which should be classified into those which are ‘domiciliary as distinct from those which are institutional and those which are individual as distinct from those which are communal’ (Dawson, 1920). However, Dawson maintained that health care should be a combined effort and not left to one person to attend to, with the best results achieved when comprehensive care takes place in the same institution (Dawson, 1920). His definition of domiciliary services included doctor, dentist, pharmacist, nurse, midwife, and health visitor. However, these professionals were not expected to work beyond the boundaries of their role. For example, in the Future Provision of Medical and Allied Services Dawson says that a health visitor:
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PROFESSIONAL ISSUES announced that ‘poly-systems’ were vastly overestimated in their ability to shift health care (Quinn, 2010). The Coalition Government said that polyclinics would leave a £1.4 billion black hole in public finances as extra funds would be required to set them up (Gaines et al, 2008). However, the Coalition Government plans under the Health and Social Care Act 2012 suggest that providers would be able to set up to supply NHS services. The inclusion criteria for these providers would be that they would have to be jointly licensed by the Care Quality Commission and Monitor, which signifies a shift from getting people the care they need, to looking at the outcome of the care they receive. Providers could include the private sector, where some procedures might be more cost-effective.
Development of the nurse’s role The nursing role is quite different to how it was in the 19th and early 20th centuries, with nurses today able to voice their opinions in relation to commissioning. For most of the 20th century, there were no opportunities for nurses to be independent practitioners, to consult with patients, examine, prescribe for or review them. It has taken three centuries for nurses to participate in these activities owing to the late acceptance of females in the workplace and their contribution to health care (Ehrenreich and English, 1973). Nurses’ roles have been under discussion for decades but it was in the 1960s when the major impetus to reconsider the nursing role arose from a shortage of physicians (Wilson, 2005) and the UK Government policies (Read, 1999) to restrict junior doctors’ working hours (Seymour et al, 2002). Political and financial drivers have seen nursing roles expand from a caring role to that of a provider of medical care, which has been shaped by population needs and transformed over time. The changes to the nursing role have been aided by the NHS Plan: a plan for investment, a plan for reform (NHS, 2000) that enhanced the nursing role, enabling nurses to provide more comprehensive care to patients, to help ensure that the patient received the right care in the right place at the right time. This was of great importance for many reasons and it helped solve the problem of there being few services in rural and remote areas (Chang et al, 1999), as well as staffing issues for new technological developments (Castledine, 2004).
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Pre-20th century nursing In 19th century Britain, Florence Nightingale described nursing as ‘little more than the administration of medicines and the application of poultices’ (Nightingale, 1860). She felt nursing should ‘signify fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet’ (Nightingale, 1860). This was part of her Notes on nursing discussing ‘What is is, and what it is not’ (Nightingale, 1860). Nightingale’s influence transformed nursing from a low-status occupation to a skilled profession. It was previously seen as a basic level of domestic service and was said to be fundamental to housekeeping for those from a working-class background (Dingwall et al, 1988). Nightingale believed that nurses ‘did not have the power of laying clearly and shortly before the doctor, the facts’ (Nightingale, 1860) and this was perhaps the reason why Dawson alluded to doctors, rather than nurses, because
British Journal of Nursing, 2015, Vol 24, No 3
of the limitations of the role of the nurse whereby he said care ‘would pass from the hands of their own doctors’ to ‘the care of the medical staff of that centre (Dawson,1920).
Nursing in the 21st century In 21st century Britain, nursing is a profession that prides itself on its autonomy and independence. Nurses have a choice to work as a practitioner or to move into management. It is important to emphasise how crucial their extended roles have become in the provision of continuous care when there have been shortages of other health professionals owing to a lack of doctors as a result of the European Working Time Directive (NHS Employers, 2009). The impact of these extended roles was evident after the NHS Plan (NHS, 2000) proposed new targets to reduce the time patients had to wait for treatment. Today, patients have the opportunity to see a nurse who could provide them with appropriate and effective treatment. In 2002, the Department of Health (DH) introduced independent sector treatment centres (ISTCs), which were new private healthcare providers who competed with the NHS and the DH believed this competition would drive up standards across the NHS (British Medical Association, 2015).The ISTCs were paid whether or not they actually carried out the work and provided a greater choice for patients as to where they could be treated. The Coalition Government’s Health and Social Care Act 2012 had GPs commissioning healthcare services, but this presented a conflict of interest and required a review to involve other health professionals. GPs were given guidance on not allowing interests to affect their prescribing, treating, referring decisions (British Medical Association, 2013). Following the report of the NHS Future Forum, it was agreed to allow nurses a formal place on clinical commissioning groups (CCGs), along with hospital doctors. This had resulted from nurses voicing their disappointment at being overlooked for a role on CCGs after initially being promised a larger role in healthcare commissioning (Timmins, 2011). Another conflicting issue under the Health and Social Care Act 2012 is the role of the financial regulator. The financial regulator focuses on competition, but concerns arose questioning the direction of this monitoring (Bevan Brittan, 2012). There is a fear that the Act will enable the NHS to be taken over by private companies as the then Health Secretary, Andrew Lansley, was seen as destabilising the NHS by cutting the specialist nurses’ jobs and giving private companies the chance to profit at the expense of the NHS (Randhawa, 2011). However, the impact of the standard of the services will be monitored under the NHS Mandate between the Government and NHS Commissioning Board (Nicholson, 2011). In 2013, the DH set out its proposals for the following 2 years which focused on patients’ quality of longer, healthier lives (DH, 2013). Patients would be given the power to access results of how well services had been delivered, provide feedback on their care through the Friends and Family Test and book their GP appointments and prescriptions online, as well as talk to their GP online (DH, 2013). If patients were dissatisfied with their care, health professionals had the freedom to shape services to meet patients’ need as the Government’s interest aligns with making the NHS more efficient (DH, 2013).
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n Healthcare
delivery is subject to constant transformation and reform
n There
are similarities in the development of healthcare provision in the 20th and 21st centuries in the UK
n The
role of the nurse has developed alongside the various changes in healthcare provision
n Polyclinics,
Lord Darzi’s idea of having services under one roof, is not a new idea and was spoken about in the 20th century by Lord Dawson
Now GPs are establishing their GP consortia to aid with effective commissioning of patient needs (National Association of Primary Care, 2010). Highly skilled nurses need to make the most of the opportunity to extend their roles and contribute in debating cost-effective and efficient ways of delivering services for patients. This is highlighted in the Willis Commission as it suggests the new cadre of graduate nurses are practising independently and making autonomous decisions and that employers must make use of the enhanced skill of these emerging nurses (Willis Commission, 2012). As nurses become advanced practitioners, revalidation becomes ever more important.The Government response to the Francis Report (Royal College of General Practitioners, 2013) emphasises the importance of regulation of health professionals and advises that all nurses be revalidated, which is also outlined in the document Liberating the NHS Legislative Framework and Next Steps, (DH, 2010b). This revalidation will see the public accessing health care from a nurse as a service provider. This may be from a nurse working independently or alongside other health professionals within the nursing profession for the safety of the patients. Professor Bonnie Sibbald supports the idea of nurses as frontline providers of primary care, suggesting that it makes sense for GPs to use their skills on the minority of the patients (Iacobucci, 2008).
Conclusion Nursing roles are becoming increasingly dynamic and attractive to the public and help to improve services even under the political or international financial crisis alongside rising unemployment. Politicians come and go but services need to be evaluated on a long-term basis to measure their effectiveness. Nurses need to take full advantage of these changes and opportunities to make themselves visible and vocal to provide a choice of an alternative safe and effective, independent provider of health care for the public. Recognition of their efficiency needs to be constantly audited and acknowledged locally, nationally and internationally, especially in times of crisis. There are surprising similarities between Lords Dawson and Darzi and their approach to health care in Britain. Many of the changes they pushed for have allowed the development of the nurse’s role in society to what it is today.This should bring great pride to the profession, highlighting the dynamic role nurses BJN play in health care. Conflict of interest: none Berridge V (2008) Polyclinics: haven’t we been there before? BMJ 336 (7654) 161-1162 doi: 10.1136/bmj.39583.414572.AD
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Berridge V (2009) History Extra. 15 September. http://tinyurl.com/lq7r9by (accessed 8 January 2015) Bevan Brittan (2012) Regulation and competition under the Health and Social Care Act 2012. http://tinyurl.com/ob2fuvl (accessed 19 January 2015) BBC News (2013) Q&A: The NHS Shake-up The government is overhauling the way the NHS in England works. 1 March. http://tinyurl.com/5vcqns3 (accessed 8 January2015) British Medical Association (2013) Conflicts of interest in the new commissioning system: doctors in commissioning roles. British Medical Association, London British Medical Association (2015) Understanding the NHS reforms. Choice and any qualified provider. http://tinyurl.com/mgczp8y (accessed 22 January 2015) Carswell D, Hannan D (2011) David Cameron must hand power to the people before its too late. The Telegraph (online). http://tinyurl.com/khklqao (accessed 8 January 2015) Castledine G (2004) New nursing roles: deciding the future for Scotland. The Scottish Government http://tinyurl.com/n8qk7mw (accessed 8 January 2015) Chang E, Daly J, Hawkins A et al (1999) An evaluation of the nurse practitioner role in a major rural emergency department. J AdvNurs 30(1) 260-8 Dawson B (1920) Interim Report on the Future Provision of Medical and Allied Services. http://tinyurl.com/kats2nq (accessed 19 December 2014) Department of Health (2008) Equitable Access to Primary Medical Care http:// tinyurl.com/lfodruk (accessed 2 February 2015) Department of Health (2010a) Commissioning for patients: Fact sheet http:// tinyurl.com/la8s79n (accessed 8 January 2015) Department of Health (2010b). Liberating the NHS: Legislative framework and next steps http://tinyurl.com/ly9n488 (accessed 8 January 2015) Department of Health (2012) Health and Social Care Act 2012: fact sheets http:// tinyurl.com/pj3j4v3 (accessed 11 January 2015) Department of Health (2013) The Mandate A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 http://tinyurl. com/kha2ll7 (accessed 8 January 2015) Dingwall R, Rafferty AM, Webster C (1988) An Introduction to the Social History of Nursing. Routledge, London: 10 Ehrenreich, B. English, D (1973) Witches, Midwives, and Nurses A History of Women Healers. New York http://tinyurl.com/orp5jas (accessed 8 January 2015) Fenwick (1920) Editorial: A Great Public Servant—a loss to the nation. The British Journal of Nursing with which is incorporated The Nursing Record 64(1668): 167–8 Gaines S, agencies (2008) NHS polyclinic plans will leave £1.4bn black hole, Tories claim. The Guardian. http://tinyurl.com/osdvf2p (accessed 8 January 2015) Iacobucci G (2008) Nurses to outnumber GPs three to one in Darzi centres. 10 September. http://tinyurl.com/osqxebv (accessed 26 January 2015) Ireland T (2009) London bid for 115 polyclinics by 2011. www.gponline.com. 23 April. http://tinyurl.com/k7n4fdo (accessed 8 January 2015) The King’s Fund (2010) Clinical Commissioning: what can we learn from previous commissioning models? http://tinyurl.com/ornljyj (accessed 8 January 2015) Lewis J, Brookes B (1983) The Peckham Health Centre,“PEP”, and the concept of general practice during the 1930s and 1940s Med Hist 27(2)151-61 National Association of Primary Care (2010) The Essential Guide to GP Commissioning. http://tinyurl.com/o9my5mj (accessed 19 January 2015) Nicholson D (2011) Developing the NHS Commissioning Board. http://tinyurl. com/l56dnke (accessed 19 January 2015) NHS (2000) NHS Plan: a plan for investment, a plan for reform. http://tinyurl.com/ cwuknoz (accessed 19 January 2015) NHS (2007) A framework for action. http://tinyurl.com/m5q8wct (accessed 8 January 2015) NHS Confederation (2008) Ideas from Darzi: polyclinics. http://tinyurl.com/ p67lqba. (accessed 8 January 2015) NHS Employers (2009) European Working Time Directive. European Court of Justice Ruling http://tinyurl.com/kgeajn4 (accessed 8 January 2015) Nightingale F (1860) Notes on Nursing What it is, and what it is not. http://tinyurl. com/2cfsk (accessed 8 January 2015) Pioneer Health Foundation (2015) The Peckham Experiment in the 21st Century. http://tinyurl.com/o6m4p6f (accessed 8 January 2015) Quinn I (2010) Lansley orders halt to all Darzi plans nationwide. Pulse. 21 May. http://tinyurl.com/kwpgfqg (accessed 18 January 2015) Randhawa K (2011) Health secretary retreats as nurses say he’s not up to the job . London Evening Standard. 13 April. http://tinyurl.com/ohlpflb (accessed 19 January 2015) Read SM (1999) Nurse-led care: The importance of management support J Res Nurs 4(6): 408-21. doi: 10.1177/136140969900400603. Rivett G (2015) The Development of the London Hospital System. http://tinyurl. com/muv8h7j (accessed 19 January 2015) Royal College of General Practitioners (2013) The Initial Government Reponse to the Francis Report March 2013. Royal College of General Practitioners http://tinyurl.com/k8krnua (accessed 8 January 2015) Russell N (2011) What are the policy issues for health professionals and people with MS in 2011? Way ahead 15(1):2–3. http://tinyurl.com/l5h3caz (accessed 3 February 2015) Seymour J, Clark D, Hughes P et al (2002) Clinical nurse specialists in palliative care. Part 3. Issues for the Macmillan Nurse role. Palliat Med 16(5): 386-94 Timmins N (2011) Lansley takes the nurses’ medicine. ft.com (online). April 13 http://tinyurl.com/lfc4h3u (accessed 12 January 2014) Willis Commission (2012) Quality with Compassion: the future of nursing education. http://tinyurl.com/cvugp8t (accessed 8 January 2015) Wilson K (2005) The evolution of the role of nurses: the history of nurse practitioners in pediatric oncology. J Pediatr Oncol Nurs. 22(5): 250-3
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KEY POINTS
British Journal of Nursing, 2015, Vol 24, No 3
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
T
he NHS is under threat; it takes up one fifth of the UK’s national budget. NHS England Chief Executive Simon Stevens has said £20 billion of cuts will be needed in the next 5 years (Ham, 2014). Individual politicians and government policy have a large part to play in the development of healthcare services. This article looks at how, a century apart, two Lords have sought to influence policy.
Lord Dawson Health reform was pioneered in early 20th century Britain by royal doctor Lord Dawson (1864–1945). It has been reported that the death of King George in 1936 was hastened by Dawson and that this was noted by Dawson himself in his diary. As Chairman of the Consultative Council on Medical and Allied Services, he was commissioned to write report on health care in 1919 and he produced a report on the Future Provision of Medical and Allied Services in 1920 (Dawson, 1920). This report may have been significant in starting debates that prepared the ground for setting up the NHS in 1948. The Dawson Report, commissioned under the Ministry of Health Act 1919, declared: ‘Organisation of medicine has become insufficient, and because it fails to bring advantages of medical knowledge adequately within the reach of the people.’ (Dawson, 1920)
Elizabeth Haidar, Senior Lecturer, Middlesex University, London Accepted for publication: February 2014
180
Lord Ara Darzi (born in 1960) is a Labour peer. He was appointed Parliamentary Under-Secretary of State at the Department of Health in 2007 by the then Prime Minister Gordon Brown, and he held this position until 2009. He reflected on NHS health care and said ‘there are stark inequalities in health outcome’ (NHS, 2007). He summarised his findings in A Framework for Action (NHS, 2007). He, much like Dawson, felt that services should be focused on the individual’s needs and choices and said ‘provision should, wherever possible, be tailored to the particular needs of each individual’ (NHS, 2007).
‘Mutual convenience’ Dawson favoured a healthcare service dependent upon the ‘mutual convenience’ of the patient and health professional, calling it ‘freedom of action for doctor and patient’ (Dawson, 1920). His views were that health centres, or polyclinics, should be either ‘primary’ or ‘secondary, ‘the former denoting a more simple, and the latter a more specialised service’ with a domiciliary service providing care to patients in their homes or inviting them to the closest primary health centre (Dawson, 1920). The focus was on integrated care and partnership working between health professionals, maximising the contribution of the entire workforce, which was not dissimilar to Darzi’s A Framework for Action report, which suggests ‘better communication and cooperation between the community and the hospital, between urgent and planned care and between health and social care’ (NHS, 2007:7).This was to prevent people from falling through the gaps. Dawson believed that doctors, instead of being isolated from one another, should be ‘brought together and in contact with consultants and specialists’ (Dawson, 1920).
Multidisciplinary care and the introduction of the polyclinic Darzi believed in localising care where possible and centralising it where necessary, suggesting routine health care should take place as close to home as possible. He identified that more complex care should be centralised to ensure it was carried out by the most skilled professionals. The Coalition Government also recognised the importance of decentralising power and giving power to the people, with an end to a ‘top-down’ government (Carswell and Hannan, 2011), although its actions of guiding choice and competition may not necessarily have been seen by some as giving power to the people. Dawson advised that the ‘general practitioner duties should embrace the work of communal as well as individual medicine’
© 2015 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2015, Vol 24, No 3
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
‘Would not give advice as regards treatment to sick persons, nor, knowing them to be sick, visit them in her capacity as health visitor unless with the consent and under the supervision of the doctor attending the case.’ (Dawson, 1920) Dawson advised that the domiciliary service be multiprofessional and cater for patients, whether in their own home with a preventative and curative service, in the doctor’s surgery or in the primary health centre. He discussed primary health centres having many facilities under one roof, such as medical, surgical and maternity beds, out-patient clinics, ambulance services, dispensary, radiography rooms, hydrotherapy, laboratory for simple investigations, and that they could be specific to the region (Dawson, 1920). Dawson continued that these primary health centres could be independent, or attached to secondary health services, adding they must cater for local need. Only 40% of GPs were in favour of these health centres after the NHS was introduced (Berridge, 2008); 28 centres were built between 1948 and 1967 and over 700 in the following decade (Berridge, 2008). Dawson’s polyclinics failed in early 20th century Britain for a number of reasons. First, there were cuts in the economy of the 1920s, known as the Geddes Axe, and the plans to implement polyclinics were expensive. Furthermore, doctors’ earnings came from private fees, insurance payments or a panel system (people who paid national insurance (first introduced in 1911) could access free but limited health care from a doctor who was on a local list or panel) and there was no desire by doctors to be salaried employees of the state (Berridge, 2008; 2009). Additionally, support dwindled as the Minister of Health changed from Christopher Addison to the less sympathetic Sir Alfred Mond in 1921. Moreover, the top civil servant involved, Sir Robert Morant (who was a great exponent of nurses) died prematurely (Fenwick, 1920). There was some interest from GPs who thought better health care would be provided with the introduction of polyclinics and there would be a chance to raise the status of GPs. However, the word ‘polyclinics’ was used as a derisive term by health campaigners Drs Innes Pearse and George Scott Williamson in the 1930s who were opposed to them as they themselves grouped together ad hoc services (Lewis and Brookes, 1983) in the ‘Peckham Experiment (1926–1950) (Pioneer Health Foundation, 2015).They believed an individual should shoulder responsibility for his or her own welfare and should not be
182
robbed of this responsibility, as this would lead to societal degeneration (Lewis and Brookes, 1983). Darzi, to an extent, revived Dawson’s ideas. He believed that care should be multidisciplinary, bringing together the valuable contributions of practitioners from different disciplines. The NHS should be committed to working in partnership with other organisations, including local government and the voluntary and private sectors, Darzi said (NHS, 2007). He recommended models of healthcare provision based on services, not buildings or institutions, focusing on care taken to various settings, echoing Dawson’s plan to create a three-part system with at-home, primary and secondary healthcare centres. Darzi’s name became synonymous with the term ‘polyclinic’ as he announced the key to integrated better care is a service that provides all care under one roof. Lord Darzi advocated dealing with health should be a combined effort (NHS, 2007). He believed there should be universal services focused on individual needs and that these should include women’s social and medical needs.This was to reflect care from early pregnancy through to newborn care, as well as mental health services. Polyclinics will: ‘Provide the infrastructure (such as diagnostics and consulting rooms for outpatients) where the majority of urgent care centres will be located. They will provide the integrated one-stop-shop care that we want for people with long-term conditions. (NHS, 2007: 11) Darzi put together the Equitable Access Programme: Primary Medical Care services in 2008-9 (Department of Health, 2008) with the aim of improving access to primary medical care by placing services in deprived areas. These were to be commissioned by primary care trusts (PCTs) and were to provide open access for urgent or routine care from 8am to 8pm seven days a week. The Coalition Government was interested in keeping these services, which would provide yearly reports on their efficacy.
Health and Social Care Act 2012 The Coalition Government’s Health and Social Care Act 2012 builds on some of the work started by Darzi, and in fact Dawson before him, to embed quality into the public health system (today the NHS) and its outcomes (Russell, 2011). The dissolved strategic health authorities and PCTs removed a layer of management, which was replaced with commissioners with GP consortia not dissimilar to GP fundholding as the commissioning model. GP fund-holding was initially abandoned when Labour came to power in 1997 (The King’s Fund, 2010), although the full impact was not analysed owing to its short life. The initial proposal was to make GPs accountable for the health service, also giving nurses some input in commissioning groups, and removing responsibility from government (BBC News, 2013). There were various misconceptions about polyclinics but it was a suggestion for healthcare services and ‘not a panacea’ (NHS Confederation, 2008). The aim was to open 115 polyclinics before funding dropped by 2011/12 (Ireland, 2009). Today, under the Coalition Government, polyclinics are not being commissioned. Former Health Secretary Andrew Lansley
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(Dawson, 1920). He suggested services ought to be tailored to the needs of patients, which should be classified into those which are ‘domiciliary as distinct from those which are institutional and those which are individual as distinct from those which are communal’ (Dawson, 1920). However, Dawson maintained that health care should be a combined effort and not left to one person to attend to, with the best results achieved when comprehensive care takes place in the same institution (Dawson, 1920). His definition of domiciliary services included doctor, dentist, pharmacist, nurse, midwife, and health visitor. However, these professionals were not expected to work beyond the boundaries of their role. For example, in the Future Provision of Medical and Allied Services Dawson says that a health visitor:
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PROFESSIONAL ISSUES announced that ‘poly-systems’ were vastly overestimated in their ability to shift health care (Quinn, 2010). The Coalition Government said that polyclinics would leave a £1.4 billion black hole in public finances as extra funds would be required to set them up (Gaines et al, 2008). However, the Coalition Government plans under the Health and Social Care Act 2012 suggest that providers would be able to set up to supply NHS services. The inclusion criteria for these providers would be that they would have to be jointly licensed by the Care Quality Commission and Monitor, which signifies a shift from getting people the care they need, to looking at the outcome of the care they receive. Providers could include the private sector, where some procedures might be more cost-effective.
Development of the nurse’s role The nursing role is quite different to how it was in the 19th and early 20th centuries, with nurses today able to voice their opinions in relation to commissioning. For most of the 20th century, there were no opportunities for nurses to be independent practitioners, to consult with patients, examine, prescribe for or review them. It has taken three centuries for nurses to participate in these activities owing to the late acceptance of females in the workplace and their contribution to health care (Ehrenreich and English, 1973). Nurses’ roles have been under discussion for decades but it was in the 1960s when the major impetus to reconsider the nursing role arose from a shortage of physicians (Wilson, 2005) and the UK Government policies (Read, 1999) to restrict junior doctors’ working hours (Seymour et al, 2002). Political and financial drivers have seen nursing roles expand from a caring role to that of a provider of medical care, which has been shaped by population needs and transformed over time. The changes to the nursing role have been aided by the NHS Plan: a plan for investment, a plan for reform (NHS, 2000) that enhanced the nursing role, enabling nurses to provide more comprehensive care to patients, to help ensure that the patient received the right care in the right place at the right time. This was of great importance for many reasons and it helped solve the problem of there being few services in rural and remote areas (Chang et al, 1999), as well as staffing issues for new technological developments (Castledine, 2004).
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Pre-20th century nursing In 19th century Britain, Florence Nightingale described nursing as ‘little more than the administration of medicines and the application of poultices’ (Nightingale, 1860). She felt nursing should ‘signify fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet’ (Nightingale, 1860). This was part of her Notes on nursing discussing ‘What is is, and what it is not’ (Nightingale, 1860). Nightingale’s influence transformed nursing from a low-status occupation to a skilled profession. It was previously seen as a basic level of domestic service and was said to be fundamental to housekeeping for those from a working-class background (Dingwall et al, 1988). Nightingale believed that nurses ‘did not have the power of laying clearly and shortly before the doctor, the facts’ (Nightingale, 1860) and this was perhaps the reason why Dawson alluded to doctors, rather than nurses, because
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of the limitations of the role of the nurse whereby he said care ‘would pass from the hands of their own doctors’ to ‘the care of the medical staff of that centre (Dawson,1920).
Nursing in the 21st century In 21st century Britain, nursing is a profession that prides itself on its autonomy and independence. Nurses have a choice to work as a practitioner or to move into management. It is important to emphasise how crucial their extended roles have become in the provision of continuous care when there have been shortages of other health professionals owing to a lack of doctors as a result of the European Working Time Directive (NHS Employers, 2009). The impact of these extended roles was evident after the NHS Plan (NHS, 2000) proposed new targets to reduce the time patients had to wait for treatment. Today, patients have the opportunity to see a nurse who could provide them with appropriate and effective treatment. In 2002, the Department of Health (DH) introduced independent sector treatment centres (ISTCs), which were new private healthcare providers who competed with the NHS and the DH believed this competition would drive up standards across the NHS (British Medical Association, 2015).The ISTCs were paid whether or not they actually carried out the work and provided a greater choice for patients as to where they could be treated. The Coalition Government’s Health and Social Care Act 2012 had GPs commissioning healthcare services, but this presented a conflict of interest and required a review to involve other health professionals. GPs were given guidance on not allowing interests to affect their prescribing, treating, referring decisions (British Medical Association, 2013). Following the report of the NHS Future Forum, it was agreed to allow nurses a formal place on clinical commissioning groups (CCGs), along with hospital doctors. This had resulted from nurses voicing their disappointment at being overlooked for a role on CCGs after initially being promised a larger role in healthcare commissioning (Timmins, 2011). Another conflicting issue under the Health and Social Care Act 2012 is the role of the financial regulator. The financial regulator focuses on competition, but concerns arose questioning the direction of this monitoring (Bevan Brittan, 2012). There is a fear that the Act will enable the NHS to be taken over by private companies as the then Health Secretary, Andrew Lansley, was seen as destabilising the NHS by cutting the specialist nurses’ jobs and giving private companies the chance to profit at the expense of the NHS (Randhawa, 2011). However, the impact of the standard of the services will be monitored under the NHS Mandate between the Government and NHS Commissioning Board (Nicholson, 2011). In 2013, the DH set out its proposals for the following 2 years which focused on patients’ quality of longer, healthier lives (DH, 2013). Patients would be given the power to access results of how well services had been delivered, provide feedback on their care through the Friends and Family Test and book their GP appointments and prescriptions online, as well as talk to their GP online (DH, 2013). If patients were dissatisfied with their care, health professionals had the freedom to shape services to meet patients’ need as the Government’s interest aligns with making the NHS more efficient (DH, 2013).
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n Healthcare
delivery is subject to constant transformation and reform
n There
are similarities in the development of healthcare provision in the 20th and 21st centuries in the UK
n The
role of the nurse has developed alongside the various changes in healthcare provision
n Polyclinics,
Lord Darzi’s idea of having services under one roof, is not a new idea and was spoken about in the 20th century by Lord Dawson
Now GPs are establishing their GP consortia to aid with effective commissioning of patient needs (National Association of Primary Care, 2010). Highly skilled nurses need to make the most of the opportunity to extend their roles and contribute in debating cost-effective and efficient ways of delivering services for patients. This is highlighted in the Willis Commission as it suggests the new cadre of graduate nurses are practising independently and making autonomous decisions and that employers must make use of the enhanced skill of these emerging nurses (Willis Commission, 2012). As nurses become advanced practitioners, revalidation becomes ever more important.The Government response to the Francis Report (Royal College of General Practitioners, 2013) emphasises the importance of regulation of health professionals and advises that all nurses be revalidated, which is also outlined in the document Liberating the NHS Legislative Framework and Next Steps, (DH, 2010b). This revalidation will see the public accessing health care from a nurse as a service provider. This may be from a nurse working independently or alongside other health professionals within the nursing profession for the safety of the patients. Professor Bonnie Sibbald supports the idea of nurses as frontline providers of primary care, suggesting that it makes sense for GPs to use their skills on the minority of the patients (Iacobucci, 2008).
Conclusion Nursing roles are becoming increasingly dynamic and attractive to the public and help to improve services even under the political or international financial crisis alongside rising unemployment. Politicians come and go but services need to be evaluated on a long-term basis to measure their effectiveness. Nurses need to take full advantage of these changes and opportunities to make themselves visible and vocal to provide a choice of an alternative safe and effective, independent provider of health care for the public. Recognition of their efficiency needs to be constantly audited and acknowledged locally, nationally and internationally, especially in times of crisis. There are surprising similarities between Lords Dawson and Darzi and their approach to health care in Britain. Many of the changes they pushed for have allowed the development of the nurse’s role in society to what it is today.This should bring great pride to the profession, highlighting the dynamic role nurses BJN play in health care. Conflict of interest: none Berridge V (2008) Polyclinics: haven’t we been there before? BMJ 336 (7654) 161-1162 doi: 10.1136/bmj.39583.414572.AD
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Berridge V (2009) History Extra. 15 September. http://tinyurl.com/lq7r9by (accessed 8 January 2015) Bevan Brittan (2012) Regulation and competition under the Health and Social Care Act 2012. http://tinyurl.com/ob2fuvl (accessed 19 January 2015) BBC News (2013) Q&A: The NHS Shake-up The government is overhauling the way the NHS in England works. 1 March. http://tinyurl.com/5vcqns3 (accessed 8 January2015) British Medical Association (2013) Conflicts of interest in the new commissioning system: doctors in commissioning roles. British Medical Association, London British Medical Association (2015) Understanding the NHS reforms. Choice and any qualified provider. http://tinyurl.com/mgczp8y (accessed 22 January 2015) Carswell D, Hannan D (2011) David Cameron must hand power to the people before its too late. The Telegraph (online). http://tinyurl.com/khklqao (accessed 8 January 2015) Castledine G (2004) New nursing roles: deciding the future for Scotland. The Scottish Government http://tinyurl.com/n8qk7mw (accessed 8 January 2015) Chang E, Daly J, Hawkins A et al (1999) An evaluation of the nurse practitioner role in a major rural emergency department. J AdvNurs 30(1) 260-8 Dawson B (1920) Interim Report on the Future Provision of Medical and Allied Services. http://tinyurl.com/kats2nq (accessed 19 December 2014) Department of Health (2008) Equitable Access to Primary Medical Care http:// tinyurl.com/lfodruk (accessed 2 February 2015) Department of Health (2010a) Commissioning for patients: Fact sheet http:// tinyurl.com/la8s79n (accessed 8 January 2015) Department of Health (2010b). Liberating the NHS: Legislative framework and next steps http://tinyurl.com/ly9n488 (accessed 8 January 2015) Department of Health (2012) Health and Social Care Act 2012: fact sheets http:// tinyurl.com/pj3j4v3 (accessed 11 January 2015) Department of Health (2013) The Mandate A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 http://tinyurl. com/kha2ll7 (accessed 8 January 2015) Dingwall R, Rafferty AM, Webster C (1988) An Introduction to the Social History of Nursing. Routledge, London: 10 Ehrenreich, B. English, D (1973) Witches, Midwives, and Nurses A History of Women Healers. New York http://tinyurl.com/orp5jas (accessed 8 January 2015) Fenwick (1920) Editorial: A Great Public Servant—a loss to the nation. The British Journal of Nursing with which is incorporated The Nursing Record 64(1668): 167–8 Gaines S, agencies (2008) NHS polyclinic plans will leave £1.4bn black hole, Tories claim. The Guardian. http://tinyurl.com/osdvf2p (accessed 8 January 2015) Iacobucci G (2008) Nurses to outnumber GPs three to one in Darzi centres. 10 September. http://tinyurl.com/osqxebv (accessed 26 January 2015) Ireland T (2009) London bid for 115 polyclinics by 2011. www.gponline.com. 23 April. http://tinyurl.com/k7n4fdo (accessed 8 January 2015) The King’s Fund (2010) Clinical Commissioning: what can we learn from previous commissioning models? http://tinyurl.com/ornljyj (accessed 8 January 2015) Lewis J, Brookes B (1983) The Peckham Health Centre,“PEP”, and the concept of general practice during the 1930s and 1940s Med Hist 27(2)151-61 National Association of Primary Care (2010) The Essential Guide to GP Commissioning. http://tinyurl.com/o9my5mj (accessed 19 January 2015) Nicholson D (2011) Developing the NHS Commissioning Board. http://tinyurl. com/l56dnke (accessed 19 January 2015) NHS (2000) NHS Plan: a plan for investment, a plan for reform. http://tinyurl.com/ cwuknoz (accessed 19 January 2015) NHS (2007) A framework for action. http://tinyurl.com/m5q8wct (accessed 8 January 2015) NHS Confederation (2008) Ideas from Darzi: polyclinics. http://tinyurl.com/ p67lqba. (accessed 8 January 2015) NHS Employers (2009) European Working Time Directive. European Court of Justice Ruling http://tinyurl.com/kgeajn4 (accessed 8 January 2015) Nightingale F (1860) Notes on Nursing What it is, and what it is not. http://tinyurl. com/2cfsk (accessed 8 January 2015) Pioneer Health Foundation (2015) The Peckham Experiment in the 21st Century. http://tinyurl.com/o6m4p6f (accessed 8 January 2015) Quinn I (2010) Lansley orders halt to all Darzi plans nationwide. Pulse. 21 May. http://tinyurl.com/kwpgfqg (accessed 18 January 2015) Randhawa K (2011) Health secretary retreats as nurses say he’s not up to the job . London Evening Standard. 13 April. http://tinyurl.com/ohlpflb (accessed 19 January 2015) Read SM (1999) Nurse-led care: The importance of management support J Res Nurs 4(6): 408-21. doi: 10.1177/136140969900400603. Rivett G (2015) The Development of the London Hospital System. http://tinyurl. com/muv8h7j (accessed 19 January 2015) Royal College of General Practitioners (2013) The Initial Government Reponse to the Francis Report March 2013. Royal College of General Practitioners http://tinyurl.com/k8krnua (accessed 8 January 2015) Russell N (2011) What are the policy issues for health professionals and people with MS in 2011? Way ahead 15(1):2–3. http://tinyurl.com/l5h3caz (accessed 3 February 2015) Seymour J, Clark D, Hughes P et al (2002) Clinical nurse specialists in palliative care. Part 3. Issues for the Macmillan Nurse role. Palliat Med 16(5): 386-94 Timmins N (2011) Lansley takes the nurses’ medicine. ft.com (online). April 13 http://tinyurl.com/lfc4h3u (accessed 12 January 2014) Willis Commission (2012) Quality with Compassion: the future of nursing education. http://tinyurl.com/cvugp8t (accessed 8 January 2015) Wilson K (2005) The evolution of the role of nurses: the history of nurse practitioners in pediatric oncology. J Pediatr Oncol Nurs. 22(5): 250-3
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KEY POINTS
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