Ann Gavin-Daley and Chris Mullen MBE “Working Together Consultancy”

1. 10 years on – Evaluation of the Non Medical Consultants role in the North West – Part Two September 2010 Ann Gavin-Daley and Chris Mullen MBE “Working Together Consultancy” Working Together Consultancy

2. Part Two –The Aims Part two - Aims • To provide an overview of the impact findings • To review the influencing factors and sustainability • To share & discuss some of the recommendations for the future Working Together Consultancy

3. The NMC Interactive Impact Framework Areas explored in the NMC role were:- • Leadership & Consultancy • Partnership working • Expert clinical practice – direct & indirect • Service development • Education, Training & Development • Research, audit and evaluation The NMC Interactive Impact Framework Working Together Consultancy

4. Part Two -The Impact, 6 areas IMPACT Analysis used QIPP ie impact on Quality, Innovation, Productivity and Prevention • 1. Leadership & Consultancy – evidence of this found in all aspects of the framework • LQF qualities found included political astuteness, collaborative working, effective strategic influencing, empowering others, leading change through people and seizing the future • A key part of Leadership was promoting partnership and empowering others examined separately Working Together Consultancy

5. 2. Partnership Working • The NMC’s impact on partnership working was evident in the following areas: • Partnership working with clinical teams, • Education, training and development partnerships, • Health economy partnerships, • Regional and national partnerships Working Together Consultancy

6. Clinical Team Partnerships • 78% (n74) provided examples of the NMCs influence & impact on internal & external partnerships and cross boundary working • The Impact was:- • Increasing the engagement of users and carers in the management of their care • Increasing the involvement of users and carers in service review and development • Enhancing the autonomy and personal decision making of staff • Providing training and development to facilitate staff empowerment. • “Development of critical care outreach service has proved to develop improved partnership with the ICU/HD Units with regards to management of the acutely ill, recognition communication (at all levels) has ensured that pts are seen earlier and escalated appropriately, and post discharge care much improved to reduce the revolving door syndrome” • “Encouraging staff to look at pathway development with voluntary sector providers” Working Together Consultancy

7. Education, Training& Development Partnerships • The evidence demonstrates NMCs support staff involvement in cross boundary working through the provision of Education, Training and Development and or their partnership with education providers • “Lectured to undergraduate students and promoted breast services as a career choice, have succeeded in getting students to apply for jobs in an area where it is difficult to recruit” • “Developed cross boundary education programmes for local service providers” Working Together Consultancy

8. Health Economy Partnerships • NMCs were found to proactively promote increased staff involvement in working across the local wider health economy • “My role was brought in to facilitate redesign of the pathway for patients with musculoskeletal pathology to enhance quality and reduce waiting times. This led to the creation of the MCAS which has now been fully operational for 5 years. The MCAS is a triage and treatment service which has resulted in large scale reduction in waiting times to both orthopaedics and rheumatology and has helped achieve the 18 week referral to treatment target.” • “Linking in to primary care in prison” • “Have contributed to the work with non nhs and third sector providersto establish care pathway for client group” Working Together Consultancy

9. Regional and NationalPartnerships • There were a small number of examples of NMCs engagement in regional and or national activity that increased staff involvement in cross boundary working • “Working with Health Protection Agency developing secondment opportunities/joint working/joint posts”. • “Worked with the Kings Fund to help other Trusts to adopt national guidance and offer advice on how to bring about change related to this”. Working Together Consultancy

10. Networking and Sharing • The majority of NMCs were involved in networking however the level and amount of engagement was variable:- • 61% (n58) were involved in national groups • 90% (n85) had been or were involved in regional expert groups and or networks • 76% (n72) were or had participated in internal groups • 86%(n82) provided evidence of sharing their expertise through presenting at conferences and seminars • 62% presented nationally and 34% presented internationally • The impact of networking was identified as; sharing ideas and best practice , influencing service development, benchmarking, influencing policy and practice, educating others, and research/publication opportunities and personal support and enhancing own practice Working Together Consultancy

11. Partnerships WorkingEmpowering Others • EMPOWERING PATIENTS • “I am currently building a team to manage the non-invasive ventilation (NIV) service, helping others participate in the physiotherapy-led clinic, and developing a new weaning service. The NIV service and physio-led clinic have enabled many patients to return to work despite needing ventilatory support, and travel safely for holidays where previously they could not.” • “Provide extensive training to patients and families regarding the care and management of their feeding device. These empowered patients/carers adapt their lifestyles to cope with managing a feeding device, keep well and ultimately stay out of hospital.” • “Lead a patient involvement group who have carried out various projects and consultation nationally. They are often used by DOH for opinion, involved in research, conferences etc./ Latest project is being rolled out nationally by CAT” Working Together Consultancy

12. Partnerships WorkingEmpowering Others • EMPOWERING STAFF • What the sponsors said:- • “The NMC for Older People has had a huge impact on the knowledge and skills of staff in relation to their use of the Mental Capacity Act in decision-making” •  “The Physiotherapist NMC has had a huge impact on the diagnosis, management and treatment of back pain by staff in MSK services.” • Some examples • “The Safeguarding role within the organisation has been fully embraced throughout the organisation at all levels. ……Staff are empowered to raise concerns when things go wrong and also patients are empowered to challenge traditional systems.” • “Created opportunities to become involved in leading national projects e.g. National Prevalence of HealthCare Acquired Infections”. Working Together Consultancy

13. 3. Impact through Expert Practice • Guidance circulated by the DHdescribed the NMC as, a high level expert practitioner, expected to influence practice, policy and service delivery through others. • The NMCs demonstrated they were:- • Changing local clinical practice • Developing new standards and guidelines • Developing services • Sharing best practice & Enhancing own personal practice Working Together Consultancy

14. Local Practice Some examples • “Improvements in continence care leading to measurable improvements on wards as measured by Trust’s “Nursing Assessment and Accreditation” System” • “Development of Trust Medicines reconciliation policy reducing risk of errors and noncompliance” • “Development of Mattress replacement policy resulting in reduction in risk pressure sores and infections”. • “Trust wide Standardisation of tracheostomy care “ • “Changes in Trust wide wound management practice leading to reduction in discomfort for patients and reduced length of stay” • “Redesign existing respiratory pathways to provide better outcomes for patients and the health economy e.g. Care closer to home through oxygen therapy review with saving of over £100k, Sleep service review – streamline pathway resulted in reduced waiting time for treatment from 6months to 4 weeks”. Working Together Consultancy

15. Developing New Standardsand Guidelines • Evidence of impact on quality through developing standards & guidance • Large majority work where no precedents exist , The NMC role for a considerable number appears to play an important role in risk assessment, prevention, ensuring legal compliance, patient protection and risk reduction for organisations. • “Introduced Liquid based Cytology programme across …….. including GP practices, Practice Nurses and sexual health services. Developed and designed monitoring processes in conjunction with laboratory staff and practitioners. Standardised documentation across the practices and trust services and designed, organised and delivered training to all stakeholders”. • “Impacted nationally on practice in observation through published research Developed NIMHE toolkit for suicide prevention. Developed toolkit for self-injury”. Working Together Consultancy

16. 4. Impact on Service Development • 88% (n84) provided significant evidence of influencing service development • Many examples including NMC led clinics, demonstrated influencing at board level involving reconfigurations, new services and key organisational priorities • 14% (n13) described service impact through staff e.g. skill mix, devolvement, substitution, training and development of staff in support of QIPP agenda Working Together Consultancy

17. Impact on Service Development • “I have led the service redesign for community midwifery across four maternity units in……... Originally, there were four very different service models with varying degrees of progression. It has taken a considerable amount of time and partnership working with staff and stakeholders to achieve a new service but this is now in place. I have raised approximately £5 million pounds in external funding since coming into post which has enabled me to recruit additional staff to help us promote the public health agenda in midwifery……...” • “My role was brought in to facilitate redesign of the pathway for patients with musculoskeletal pathology to enhance quality and reduce waiting times. This led to the creation of the MCAS which has now been fully operational for 5 years. The MCAS is a triage and treatment service which has resulted in large scale reduction in waiting times to both orthopaedics and rheumatology and has helped achieve the 18 week referral to treatment target.” Working Together Consultancy

18. Sharing Best Practice • The NMC’s were impacting on a wider scale through the use of evidence based practice - locally, regionally and nationally • 3 examples of many of the national influence the NMC has had; • “We have late in 2009, won the Chief Nursing Officer Award … in relation to the work we have done with A/E in responding to the needs of domestic violence victims. This work was based on a strong evidence base” • “share evidence based practice via the health access and inequalities managed clinical network I run which is a leadership network for health facilitators working on reducing health inequalities for people with learning disabilities across Cheshire and Wirral” • “My work in developing new ways of working with mentally disordered offenders has significantly influenced the national agenda and is a central reference point for the Bradley Report 2009”. Working Together Consultancy

19. 5. Impact through Education, Training and Development • 90% (86) provided examples of how they have influenced the practice of others • 5 themes, with the highest frequency at the top emerged:- • influencing practice through their day to day practice with clinical staff, • influencing practice through links with education providers • influencing practice through specific focus on advanced practice/service development • influencing practice through internal programmes • influencing practice of patients/clients Working Together Consultancy

20. Influencing Practice through theirDay to Day Practice with Clinical Staff • The findings indicate the NMC uses education, training and development, in day to day practice influencing the current & future practice of others • This resulted in:- • Practitioners increased confidence and competency, • Consistent practice, • Improved patient safety and • Risk reduction. • “Delivered tracheotomy training and reduced number of clinical incidents relating to these patients”. • “Resuscitation/stabilisation of the sick child training to make nurses more confident. Venepuncture, cannulation PGD training to enhance staff nurse roles”. Working Together Consultancy

21. Influencing Practice through InternalProgrammes • 78% (84) delivered specialist session to own team • 71% (n67)delivered specialist session to multidisciplinary teams. • “Development and mentoring of a group of advanced practitioners in readiness for the unit and their on-going commitment to themselves as professionals and to the ideal of the unit”. • “Teach GPs how to inject joints. I have a GP trainee with me on a weekly basis. regularly have members of the wider team shadowing” • “Development of Diagnostic Nurse Endoscopists ,Therapeutic Nurse Endoscopist ,Assistant practitioner role” • Findings show the NMCs facilitate and support the development of new roles and new ways of working which supports the QIPP agenda Working Together Consultancy

22. Impact Though links with EducationProviders • 83% (79) had either formal or informal links with universities • Impact – supporting required current & future workforce development.. • 42% (40) provided advice on Masters Level programmes • 51% (48) provided advice on Degree Level programmes • 55% (52) provided advice on Post Registration programmes • 37% (35) provided advice on Pre-Registration programmes • Above may indicate under reporting of links • Lack of time sometimes limited external engagement Working Together Consultancy

23. Influencing Practice of Patients/Clients • Many examples of NMC acting as patients advocate to help them make informed decisions • 2 patient examples • “I provide training and education in all nutritional care and device management. This empowers the carer or patient and prevents complications related to the therapy and prevents readmission to hospital. By providing training and education carers feel confident and are competent in care management. • “Have and do provide training as part of the role for example - Clinical Risk Assessment, Formulation and Management to include The Start Risk Assessment - Working with service users who self-injure - Collaborative Problem and Goal Centred Planning. Working Together Consultancy

24. Education, Training and DevelopmentImpact – key points • Findings indicate NMCs are influencing future practice by their engagement in the development and delivery of formal education to meet service needs • A large number 25% (n24) of NMCs do not appear to be involved in the provision of expert advice which given the impact should be more actively promoted • To maximise the potential benefit of NMCs involvement in this area organisations should ensure there is adequate time for ETD for local staff (Recommendation 27) Working Together Consultancy

25. 6. Impact Through Research, Audit and Evaluation • 83% (n79) said they had undertaken some form of the above • Significant examples of changing / improving practice through audit & evaluation • Research grants were submitted by 32% (n30) NMCs and 15 were successful • One sponsor said ““The Tissue Viability Nurse attracts significant income from research trials-this is used to pay some of the salary costs of her team”. • “Have used research and audit to challenge DOH implementation of ‘Same Sex’ accommodation in teenage & young adult units. Audited to collect evidence and wrote further guidance for TYA care- now on DOH website for national use’. Working Together Consultancy

26. Research, Audit & Evaluation • ‘Need for further research/audit in relation to emergency hospital admissions for children and the benefits of care closer to home. The COAU reduced emergency admission rate from 69% to 35%’ • The use of local audit enabled me to get £300K capital two years ago to improve the environment we deliver our service within. • Those with formal links to universities made more research bids and were more successful than those who had informal links. Those with informal links made more applications and success than those with no links. • Higher % of successful grants from teaching & specialist Trusts • The findings showed how RAE can play a valuable role in changing practice Working Together Consultancy

27. Impact – key recommendations • The evidence expands considerably on previous information on the impact of the NMC role, however it is recognised that the detail is variable and in some cases brief • Recommendation 6 NMCs and organisations need to be supported to produce more sophisticated evidence for measuring and articulating the NMCs quantifiable impact on service. Sections 1.2/1.3/2.2/3.1 Key stakeholders: Organisations/NMC • Recommendation 7 It is recommended that further casework is commissioned to enable a cost effective assessment to be undertaken of the impact of the NMC. Sections 1.2/2.2/3.1 Key stakeholders: Organisations/NHS North West /Universities Working Together Consultancy

28. Influencing factors • How established the NMCs were:- • 84% (n80) scored above 6 – well established • How easy to become established - 46% (n44) scored below 5 indicating it was not easy for most • 33% (n31) took 2 years to become established • “Post has to be continually re-established every time there is a change in organisation or senior management” • “Opportunity to develop post only really took off in 2009 - 3 years after my appointment. This coincided with resolution of some issues which I inherited on appointment and the reduction in managerial workload”. (NMC appt 2006) Working Together Consultancy

29. Factors That Helped “Support from management to be creative and evidence based” “ Having complete freedom to act interpreting and setting up professional standards” Working Together Consultancy

30. Factors That Hindered “Each new regime tries to disestablish the post or make it difficult to fulfil the post criteria. The wish to make the post a management post is constantly evident and often leads to wider misunderstanding” “Lack of clear understandingof the value and worth of the role within organisations. Culture not being ready for changes in the way we work” Working Together Consultancy

31. Other Issues – lack of Understanding • NMCs described other issues such as budget restraints, staff shortages, heavy clinical demands, lack of access to some training e.g. supervision • NMCs described certain characteristics that helped them to ‘survive’ and succeed:- • Drive, determination, self belief, and passion most frequently stated • Above supported by high levels of motivation and commitment • Key point – The lack of support, understanding and or clarity of the role by others was highlighted by several NMCs as a frustrating and limiting actor Working Together Consultancy

32. Infrastructure • Accountability • Managerially • 55%(n52) were managed locally at Divisional/Directorate level • 21% (n20) were managed at corporate Director level • Professionally • 55% (n53) at corporate direct level • 36% (34) at Divisional/Directorate level • Administrative support • 33%(n31) had no administrative support • 67% (n64) had some form of support mostly shared and or part time Working Together Consultancy

33. Organisational Change and Role Change Changed to meet service needs - “It has grown - partly because I don’t stop looking for ways to improve! Also it has been influenced by NICE publications, which in particular have set out more direction for Outreach and ICU patient follow up for years to come, making look ahead now to models of outreach / medical emergency teams of the future”. Working Together Consultancy

34. Role Change Key Themes • Focus change - “The clinical element has become much clearer - the current political & economic climate has had a major influence - pathways of care & service redesign figure much more significantly” • Role development -‘Expanding outside of learning disabilities into adult / older people’s mental health and wider public health role for the organisation as well. Expansion into adult / older people’s mental health has been due to the success of the health facilitators I had been leading in learning disabilities and the board paper I wrote to expand this service into this field. Trust wide public health role again was taken on after the chief exec and medical director asked me to look at how we could introduce a public health strategy into the organisation” • Management Responsibility changes - “More recently there have been increasing demands on the post from the Trust for input of a managerial nature unrelated to the specialist nature of the post or the original intent of the post which is proving a challenge” Working Together Consultancy

35. Role Change - discussion • The findings indicated that the NMC roles did frequently change • It suggests that whilst the majority had influenced the changes a significant number reported they had not had any influence. • This lack of influencing did appear to impact on the NMC themselves as those who had the ‘change done to them’ were less satisfied with their role than those who had had direct influence and involvement with the role change. Working Together Consultancy

36. Organisational Support – Other Issues • Overall the NMCs have been well supported in development needs for HEI and leadership • 56% do not have access to supervision & 34% have neither supervision nor mentorship • This area was identified as needing more support including opportunities for 1 to 1 • There were benefits for the individual & service when supervision was undertaken Working Together Consultancy

37. Organisational Support - Summary • The importance factors critical to success are:- • A supportive culture • Director level accountability • Clarity of role, expectations and outcomes • Organisational understanding of role • Support from staff within the organisation • Adequate administrative support • One to one development and • Formal clinical supervision Working Together Consultancy

38. Sustainability – The Future • Intention to stay:- • 53% intend to stay 4-5 years • 36% (n34) intend to move on in next 4 years • 79% (n75) are either satisfied or very satisfied • Future career:- • 41% (n39) had no plans for moving on • 47% (n45) expressed some thoughts about ‘next moves’ e.g. Director /Assist Director posts (19%), consultancy role(11%), regional/national role(8%), education (5%) etc Working Together Consultancy

39. Sustainability – Career Pathway • The NW advanced practitioner programme has the potential to be a platform for future NMCs and form part of the development framework for the future • Dual posts could provide opportunities for NMCs to ‘test out’ future direction of travel • The NMC role is still keeping ‘expert practitioners’ in practice, however several are having thoughts about progressing onwards • Recommendation 21 It is recommended that further discussion on the development of an ‘associate NMC’ role is undertaken for potential future NMC post holders. Sections 2.1/2.3 Key stakeholders: NHS North West/Panel/ Organisations Working Together Consultancy

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41. CPD & Development Needs • 23% indicated service specific courses- prescribing, approved clinician etc • 18% identified leadership development courses • 18% are doing HEI courses – Masters and PHDs • 23% wanted more access to networks with other NMCs • 14% wanted more access to structured personal support/development • 15% wanted access to mentorship/supervision/coaching • 10% identified management development needs • Recommendation 24 – learning framework for transferable skill Working Together Consultancy

42. Sustainability – Workforce Planning Turnover is about 1-2 NMCs /year Very little evidence of succession planning Recommendation 2  It is recommended that in the development of local organisational workforce plans NMCs are explicitly included and appropriate succession plans are put in place. Sections 2.1/2.3 Key Stakeholders: Organisations Working Together Consultancy

43. Sustainability – the Future • Sponsors -“Opportunities for ensuring the role is a success is to look for gaps in current provision, e.g. shortages of medical consultants, difficulties in recruiting to specific areas of practice”. • Panel – ‘keeps us honest’ & one suggested a system for ‘licensed organisations’ to support future development Recommendation 30 a) Given the impending strategic organisational change across the NHS in the North West, the future of the process for overseeing NMC role development in the North West needs to be considered and agreed with stakeholders. b) Stakeholders should also consider strengthening and supporting the role of the panel to incorporate the monitoring of recruitment and retention trends and proactively sharing the impact of the role. Sections 1.1/1.2 Key Stakeholders: Organisations/NHS North West Working Together Consultancy

44. 30 Recommendations Grouped under 2 Themes • Workforce planning & Performance Management Recommendation 1   Although 70% of organisations in the North West currently have NMC roles there are 30% who have none. The evidence of the impact of the NMC role needs to be shared widely to assist organisations to determine their requirement for NMC role based on the needs of service and to enable sustainability. Sections 2.1/2.3 Key stakeholders: Organisations/ NMCs Recommendation 8 It is recommended that further case work is undertaken to identify potential benefits of role substitution and skill mix changes, by and through, the NMCs. Section 2.2 Key Stakeholders: NHS North West/Organisations (Casework)/NMC Working Together Consultancy

45. Recommendations Continued 2. Sustainability and the Future Recommendation 16 Organisations should ensure that there is a good level of knowledge and understanding of the NMC role throughout the organisation for current and future NMCs posts. Sections 2.1/2.3 Key stakeholders: Organisations/NMC Recommendation 19 Organisations need to ensure that NMCs have sufficient dedicated administrative support. Sections 2.1/2.3 Key stakeholders: Organisations/NMC Recommendation 22 A regional forum to support networking for NMCs (with links to education providers) should be established by the NHS North West. Sections 2.2/2.3 NHS Key stakeholders: NHS North West/Panel/ Organisations/ Working Together Consultancy

46. Any questions? Working Together Consultancy