Leading change

The Public Health Nursing Leads at Leicestershire Partnership NHS Trust led on the development and implementation of a new model of care for public health nursing, as well as the adoption of a new discharge support tool to empower and enable safe practice.

Where to look

The RCN (2019) outline the marked improvement in life expectancy over the last 100 years, whilst recognising there are huge inequalities across the population. Living longer doesn’t necessarily equate to living better or healthier. Yet, better housing and living conditions, alongside improved access to health care and vaccination has led to a significant reduction in infectious diseases.

The World Health Organisation identifies that public health refers to all organised measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Public health supports individuals, organisations, and society to tackle preventable disease, mortality and disability using:

• Prevention: reducing the incidence of ill health supporting healthier lifestyle;
• Protection: surveillance and monitoring of infectious disease, emergency response and immunisation; and,
• Promotion: health education and commissioning services to meet specific health needs.

Today it is non-communicable diseases, such as diabetes and respiratory conditions that are of increasing concern. The underlying causes of ill health are often attributable to unhealthy lifestyles, namely smoking, obesity and alcohol consumption. These are also associated with social inequalities.

Within Leicestershire and Rutland, nursing leads identified that health visitors and school nurses were increasingly delivering specialist interventions that are more complex and time consuming. This was reducing capacity to focus on prevention and early intervention – specific areas of their training. When the Trust were successfully awarded the three Local Authority public health contracts for Leicester, Leicestershire and Rutland to deliver the Healthy Child Programme 0-19, the nurse leads identified this as an opportunity to refresh practice, to address unwarranted variation and deliver this ambitious programme.

What to change

Prior to the change, health visitors and school nurses at Leicestershire Partnership NHS Trust were seeing families for a wealth of complex concerns whilst they awaited specialist services. Additionally, other services were signposting families back to health visitors and school nurses, as a universal service. The nursing leads identified an opportunity to provide local clarity on the role of public health nurses for staff, other health professionals and those using the service, in order to maximise the impact of the team by standardising practice.

How to change

The Healthy Child Programme (HCP, Department of Health, 2009) is used as guidance to underpin the work of Leicestershire’s Healthy Together programme, which reflects current evidence-based practice in child health and the growing health improvement agenda. The Healthy Child Programme ‘456 model’ details the public health nursing offer including 4 levels of service, health reviews and high impact areas (Public Health England).

To deliver the HCP locally, there needed to be clarity on how to standardise delivery and how to utilise the evidence base to implement this programme across public health nursing, with the support and understanding of all partners including GPs and health professionals. To support this, a guide on the number of contacts offered for all evidenced based packages of care (the 4 levels of service) was developed and cited in the services Standard Operating Guidance.

The time frame for these contacts would be dependent on the area of practice and flexible (including the number) to individual need. Public Health Nurses use their professional judgement and provide clear rationale and evidence around deviations to the offer.

At the end of the package of care:

• The GP should be informed if there are still concerns and the care plan documented;
• A referral may be made to another service;
• The child/parent discharged to universal services with the support of the team’s digital offer and information on advice clinics/drop ins;
• The contact is recorded on ‘SystmOne’ and step down back into universal service; and,
• The Discharge Support Tool on ‘SystmOne’ must be completed by all practitioners.

This new model was developed to define the boundaries of local Public Health Nursing to support the practitioners to offer the universal Healthy Child Programme and universal plus defined packages of care up to a maximum of 4 contacts.

The new service was launched across spring 2017 for the 3 areas. The team looked to build on well-established relationships in local neighbourhoods to continue providing local families with the care they need, including targeted support and early intervention where appropriate. This service delivers the Healthy Child Programme through home visits, health centres, children’s centres, schools and appropriate community settings.

Feedback from practitioners and evidence from local community profiles was explored to support the operational delivery of the programme. This highlighted a high number of safeguarding cases, increased interventions for families in emotional health and well-being, growth and continence. This feedback highlighted a need to build in a risk assessment ‘safe discharge support tool’. The nursing leads worked to design a tool to support practitioners in decision making about discharge to ensure safe, effective care and avoidable harm. The discharge support tool is a clinical tool based on a traffic light (RAG) system. It is not designed to replace professional clinical judgement but support safe, consistent decision making in practice.

The tool is designed to be completed at the end of a package of care for a child, young person, and family. It is available digitally in the electronic record keeping system and it is now a mandatory requirement. The tool asks practitioners 3 key questions:

• Are there any outstanding health needs that are not being met by another professional or organisation?
• Are there any unmet risks that may impact on the ability to discharge?
• Are there any ongoing concerns about the safety of the child or family members that are not being met by another professional or organisation?

Where all questions are answered no, the tool indicates that is it recommended to return the child to universal service provision to support the clinician’s decision-making process. Where discharge concerns are identified, the practitioner’s have a choice as to whether they identify the discharge as red/amber or green and are supported to access the right services for the child or family.

A roadshow was undertaken to support Public Health Nurses (health visitors, school nurses) and their teams to understand the changes in process, as well as the rationale for the discharge support tool. Further events were held with community paediatricians, speech and language therapists, dieticians, physiotherapists and children’s mental health services so they also had the opportunity to understand the changes, which may impact on their services. General Practitioners were made aware through the local Clinical Commissioning Groups.

Within health visiting and school nurse services, a rolling programme of education, training and support has been developed to assist staff to use the new systems. It has also been integrated into practitioner supervision and 1:1 sessions with managers. The tool had been piloted by a team of practitioners before wider application.

Adding value

Better outcomes – During 2018/19 (to January 2019), the tool has been used 10,840 times, supporting practitioners in decision making regarding children and their families’ care. The tool has also supported practitioners to work more effectively and collaboratively across services. This additional governance on discharge was particularly supportive to practice in the 1^st year of the new service offer, as the requirement to be clear on time limited interventions was crucial for the successful delivery of the service offer. To support safe care, the tool gives the organisation data on the families where the risk of discharge is high; for example, when a family have been referred but are on a waiting list or where no other service is involved. It identifies discontinuity of care, providing evidence to commissioner organisations to act upon.

Better experience – Anecdotal evidence from practitioners has highlighted that this tool has been well received across the workforce and by the families it supports, as decision making is clear and evidence based. Practitioners report feeling supported to make decisions and that the tools assist them with ensuring children access the right care at the right time.

Better use of resources – Anecdotally, the improved service design as well as implementation of the tool is reportedly supporting efficient practice within the health visiting and school nursing teams and supporting better relationships across services in Leicester.

Challenges and lessons learnt for implementation

Some areas of practice do not directly fit the criteria of ‘no more than 4 contacts’. In these instances, the discharge support forum discussed and supported decision making, demonstrating flexibility to ensure patient-centred care.

Within Leicestershire, there is also confidential one-to-one advice clinics for service users to access public health nurses if they have concerns, as well as a texting service and a website for service users to get advice and support.

For more information contact

Joanne Wilson
Lead Nurse
Leicestershire Partnership NHS Trust
Joanne.Wilson@leicspart.nhs.uk

Nicy Turney
Public Health Nursing Lead, Healthy Together
Leicestershire Partnership NHS Trust
Nicy.Turney@leicspart.nhs.uk

Sarah Fenwick
Service Lead
Healthy Together Leicestershire Partnership NHS Trust
Sarah.Fenwick@leicspart.nhs.uk