Specialist Nursing and Care Fund: report

How NHS boards have used the additional investment

The following examples provide a snapshot of how NHS boards across Scotland have used the additional investment to develop and expand specialist nursing services. ^[1] The enhanced clinical nurse specialist posts cover a range of conditions across the life spectrum and operate across hospital and community settings.

Brief stories are provided to give an insight into the impact the additional roles are having in different settings.

NHS Ayrshire & Arran has used the additional investment to create three new clinical nurse specialist roles.

The specialist role in tissue viability supports patients in the community, driving improvements and providing education for community and social care colleagues. The role in renal services increases the number of patients able to access home haemodialysis, a cost-effective and patient-centred choice. Supporting the existing home haemodialysis specialist nurse, the post-holder works to heighten staff awareness of self-care and the benefits home haemodialysis brings.

The new post in lung cancer support, jointly funded by the board and Macmillan Cancer Support, increases the number of patients seen by a specialist nurse at their first diagnosis appointment and enables more patients to benefit from ongoing support. Nurse-led clinics providing holistic assessments are being established.

NHS Borders has prioritised the appointment of two liaison clinical nurse specialists for older people, with the specific intention of reducing patients' stays in elderly care hospital wards and ensuring safe and appropriate discharge back to the community.

Similarly, NHS Dumfries & Galloway has recruited two nursing specialists in care of older people who, while based in community settings, also cross over to acute care to support older people.

NHS Fife is working collaboratively with regional neurological services based in NHS Forth Valley and NHS Tayside to ensure provision of services for those living with MND in Fife. The board has also used the additional investment to create new specialist nursing posts in adult epilepsy, Parkinson's disease and multiple sclerosis ( MS) services, with agreement being reached on shared care protocols across the care sectors.

The board has worked closely with the Quarriers' epilepsy field worker and has created an honorary contract for the service with social care. The epilepsy specialist nurse post focuses on enabling reductions in rates of depression and the incidence of suicide in people with epilepsy through early psychological screening. Suicide is three times higher in people with epilepsy than in the general population.

Among the responsibilities of the specialist nurse in Parkinson's disease is provision of education for staff in care homes.

NHS Forth Valley is working with NHS Fife to ensure specialist nursing provision for people living with MND. An additional specialist nursing resource has been created to support people with MND in both board areas, working two days with each board and supported by the NHS Lothian regional centre.

The board has also created new specialist posts in perinatal mental health (which is having a positive impact on patient safety while demonstrating ongoing commitment to women and their families), and epilepsy and learning disability, enhancing quality of care by providing an important link between learning disability teams and neurological services.

Perinatal mental health in NHS Forth Valley

Perinatal mental health is something of a silent problem, but one that is now raising its voice.

'It's been under the radar for quite a while, but affects a significant number of women,' says Angela Denholm, clinical nurse specialist in perinatal mental health in NHS Forth Valley. 'Our focus is early intervention and preventing mental illness from escalating during the perinatal period.'

Angela is a mental health nurse with experience in acute ward settings and the intensive home treatment team ( IHTT). It was during her time in the IHTT that she encountered women experiencing mental health problems around pregnancy, which fired her interest.

'I wanted to find out more about the effects of perinatal mental illness and options available, so undertook further education at Master's level,' she says. 'I was fortunate to be able to shadow the perinatal mental health advanced nurse practitioner in all aspects of her job, and take follow-up clinics on my own.'

Angela took up her clinical nurse specialist in perinatal mental health role in August 2016 and works closely with the advanced nurse practitioner, who has been in post since 2013.

'We offer assessments to women who develop, or are at risk of developing a mental health problem during pregnancy and postnatally, or who have a personal or family history,' she says. 'We do a full assessment using a comprehensive adult mental health assessment proforma with additional questions around perinatal mental health issues. From that, we come to a joint decision with the woman on how we progress and make a plan to address any issues. If we have concerns, we can refer to the IHTT or community colleagues.'

The waiting time for routine referrals for women has reduced since Angela came into post.

'That's not all down to the clinical nurse specialist post,' she explains, 'as there has also been a slight increase in the number of medical clinics. But the new post has certainly helped in the reduction.'

NHS Grampian is a neurology regional centre that has used the additional investment to take action and enhance care across four specialties:

• creating a full-time clinical nurse specialist for MS
• increasing the hours for three Parkinson's disease specialist nurses to the equivalent of one WTE
• appointing a paediatric allergy clinical specialist and clinical nurse specialist for rheumatology
• employing a clinical nurse specialist for MND who also provides support to NHS Orkney and NHS Shetland as part of a regional remit; administrative support for the MND specialists has also been increased, freeing up clinical time.

NHS Greater Glasgow & Clyde is also a neurology regional centre, providing support across the four boards in the west of Scotland ( NHS Ayrshire & Arran, NHS Dumfries & Galloway, NHS Greater Glasgow & Clyde and NHS Lanarkshire). Additional posts have been created to halve the caseload of existing clinical nurse specialists, minimise travel to increase time spent on direct clinical care and improve continuity for patients.

The board has appointed two additional MND specialist nurses, doubling the current resource to cover NHS Greater Glasgow & Clyde, NHS Lanarkshire and NHS Western Isles. Collaborative working across boards and with MND Scotland will ensure equity of access to patient-centred care provision. Two MS specialist nurses have also been appointed to support services across the west of Scotland, and over three full-time posts in palliative care have been created across the board area.

Some funding has been used to support the development of an interface project between the Institute of Neurological Sciences and forensic psychiatry services to progress improvement work in the management of patients with stressed and distressed behaviours. The board has also invested in its communication skills training group, a collaboration involving two hospices, acute and palliative care practice development staff, a consultant in palliative medicine and the learning and education department.

NHS Highland's review of specialist nursing services included feedback from third sector organisations. Following this, a full-time clinical nurse specialist in lymphoedema commenced in May 2016, and three 0.4 WTE-equivalent posts recruited for respiratory care. Two MND posts have also been recruited (1.2 WTE).

Two additional nurse specialists have been employed in perinatal mental health in NHS Lanarkshire, alongside two specialists in long-term conditions in the community and older people's services. The board has also self-funded two WTE nurse specialists for the North Lanarkshire Early Years Collaborative (until March 2018).

Motor neurone disease in NHS Grampian

Susan Stewart, clinical nurse specialist in MND, took up her role in August 2016 through the additional investment, joining a clinical specialist with an occupational therapy background who was already in post.

She and her colleague provide specialist support for patients and their families from diagnosis to death, and beyond. They are there at point of diagnosis, then arrange to assess patients at home within a week.

'When you see patients at home you can find out what's important to them in their own environment,' Susan says. 'It provides a very solid foundation for the subsequent relationship'.

Susan has prepared a reflective narrative about what she feels has strengthened in the service since her appointment.

'I wrote about how we are able to see patients at point of diagnosis and be more reactive,' she says. 'Before my post was created, longer times between seeing patients meant that some red flags were being missed. Now we're seeing them more regularly, so we can develop really good relationships, pick up changes and put interventions in place.'

Susan has established links with third-sector organisations, such as Sue Ryder and carers' groups locally and MND Scotland nationally, and will complete the European Certificate of Excellence in Palliative Care in June 2017.

She has linked into Robert Gordon University, delivering teaching sessions and providing bespoke clinical experiences for student nurses, and is using a national proforma to supply audit and research information to support efforts to bring a clinical drug trial to Scotland.

These are all important initiatives that have grown since she was appointed to the new post. But Susan has also found that more mundane matters can sometimes help in ensuring MND is on the map.

'Moving the location of the office I share with my colleague has helped raise awareness of the MND service among our peer group,' she explains. 'We were stuck in a dingy office far away from everyone else before, but now we're right in the heart of things - we're saying MND is here and we're important!'

Multiple sclerosis in NHS Grampian

Mairi Maguire, a clinical nurse specialist for MS, has been supported by her colleague Julie Robertson since January 2016. Julie's clinical nurse specialist post is funded by the additional investment, and she takes her place as part of a three-person nursing team.

'We offer advice and support to all patients with MS in Grampian,' Mairi explains. 'We see all patients newly diagnosed and follow them up throughout their MS journey.'

From Julie's appointment to mid-April 2017, 84 new patients had been diagnosed in Grampian. 'We had contact with all of them within 10 days, and that would have been almost impossible before the new post was established,' Mairi says. 'In fact, we almost always contact patients on either the same day or the next day after referral.'

The nurses run a clinic at Aberdeen Royal Infirmary, but also have an open-access telephone line and email service.

'We're able to see on average a minimum of an extra 20 patients per month at the clinic since Julie has joined us,' Mairi says. 'People use the open-access service for advice and support, or to arrange a visit to the MS relapse clinic we coordinate. When patients need advice, they need it quick. Since Julie arrived, I'd say 99% of the time we are now getting back to patients on the same day.'

An increase in disease-modifying therapy options means there is greater demand for monitoring blood results and general responses. One of the new treatments, natalizumab, is a monthly infusion administered via a central line. Patients receive the treatment at the MS nurse clinic, and having the extra clinical nurse specialist has improved the efficiency with which this can happen.

'We now always have two nurses at the clinic, which makes a huge difference,' Mairi says. 'Patients who postponed their infusion used to face big problems in trying to reschedule, but not now.'

NHS Lothian has used the additional investment to engage two WTE MND nurse specialists to cover Lothian and NHS Borders. Full-time clinical nurse specialists for child and adolescent health services and tissue viability have also been appointed, as has a Lead Nurse for Advanced Practice developed to provide leadership, advice and guidance to NHS Lothian across primary and secondary care services in relation to the development of advancing nursing and healthcare support worker roles. The role will also be pivotal in leading the implementation and ongoing support of advancing roles, ensuring there is a framework of service needs, planning, governance support and evaluation.

The role complements and reflects Scottish Government work towards a national approach to advanced practice, including a commitment to train 500 additional advanced nurse practitioners by 2021. Key short-term priorities for the lead nurse role in NHS Lothian have been to:

• implement relevant recommendations from the Role of the Advanced Nurse Practitioner Across all Scottish Health & Care Settings report, ^[2] published in June 2016
• coordinate and take responsibility for completion of an advanced nursing practice service needs and education needs analysis in the board area.

The Lead Nurse for Advanced Practice post-holder was appointed in May 2017.

NHS Orkney has worked closely with Alzheimer Scotland in developing a specialist nurse for dementia post and has jointly funded a full-time post to support frail elderly people. The board has also used its additional investment allocation to support education and professional development for staff through, for example, an advanced clinical examination skills programme delivered locally in conjunction with Robert Gordon University and NHS Education for Scotland, and senior charge nurse and team leader development days.

As part of its review of specialist nursing, NHS Orkney identified a need to increase the provision of specialist nursing for general neurology and MS: these developments have been funded internally, further enhancing services for patients. The regional funding for MND has been included to enhance local specialist MND input to the shared pathway with NHS Grampian.

Following a review of the demand for cardiac tests and rehabilitation services, and working with its managed clinical network (which includes representatives from the third sector), NHS Shetland is focusing its additional specialist nursing investment on increasing the capacity available to support existing cardiac services. It has been used to provide the cardiac service with extra nursing support through the appointment of a part-time nurse, which has freed the existing cardiac nurse specialist to focus on specific parts of the service requiring specialist input.

The funding for MND has been allocated at regional level and the board has been working closely with NHS Grampian and NHS Orkney to look at appropriate enhanced models of care. In addition to the regional service, the board has recently agreed a shared pathway and recruited a 0.2 WTE specialist nurse to support patients with MND: NHS Shetland has resourced this increase in specialist nursing input to enable the development of the local MND service while a regional model is being formalised. On average, five patients in Shetland are affected by MND: they are supported through a combination of local and specialist service input.

Cardiac services in NHS Shetland

Cardiac nurse specialist in NHS Shetland Marie Hurson has been in post since 2005. Her unique job has many facets, which allows her to lead and influence the strategic development of cardiac services across NHS Shetland at regional and local levels.

The additional investment in NHS Shetland has been used to provide a part-time nurse to support Marie and her colleagues in delivering local services. This has freed Marie from some of her day-to-day/routine duties to develop other parts of the service.

'The additional nursing input is helping with the cardiac rehabilitation service while supporting patient reviews in the community,' she says. 'The role includes local audit and fulfilling general management duties.'

The appointment has enabled Marie to focus on challenging issues, such as improving wait times for routine treadmill testing.

'I've been able to provide extra non-doctor clinics for the lower-risk patients who are waiting for a treadmill test, enabling their test to be delivered in a timelier way,' she says. 'I can then report back to the consultant and the GP in a much shorter time.'

With succession planning in mind, Marie also sees the new post as providing a great opportunity for professional development of junior staff.

'The post has given us an opportunity to develop the nurse while improving local services,' she says. 'She's had many development opportunities locally, including completing her non-medical prescribing, and we're now looking nationally for appropriate education options.'

Nurses in remote and rural areas often wear a number of different 'hats'. In addition to working with Marie in the cardiac service, the nurse is also a staff nurse in the emergency department.

'This means she's taking new knowledge and skills she's developed as part of her cardiac role back to the emergency department,' Marie says, 'which is a great benefit to that service too.'

NHS Tayside, one of the regional neurological centres, has increased the contracted hours of existing specialist nurses for people with Parkinson's disease to enable more people in Dundee to access the service. It has also appointed an oncology outpatients specialist nurse to increase capacity to accommodate treatment plans for patients undergoing combined chemotherapy at home.

Other collaborative initiatives designed to produce innovative solutions to existing challenges in NHS Tayside include developing a specialist nurse role to support patients with chronic respiratory disease to manage their conditions at home (the equivalent of 1.2 WTE) and increasing MND specialist nursing provision from one to two WTEs. The board has discussed all such developments with the third sector.

NHS Western Isles has appointed a general neurology specialist nurse with a special interest in epilepsy. Staff at the neurology centre in Glasgow will support this post-holder with education and training. MND clinical nurse specialist support is also being supplied by NHS Greater Glasgow & Clyde: patients with MND who live on the islands will also be supported by the newly recruited general neurology specialist nurse.

Activity has also been taken forward in NHS Scotland's special boards:

• The Golden Jubilee National Hospital has utilised funding to improve awareness of palliative and end of life care through joint working with St Margaret's Hospice.
• NHS 24 has used the additional investment to create a cardiac specialist nurse post.
• NHS National Services Scotland has used the funding to establish an advanced nurse practitioner for paediatric stem cell transplantation in NHS Greater Glasgow & Clyde.
• The State Hospital has invested in training to enhance nurses' competences in relation to physical health care of patients in the forensic mental health service.
• NHS Education for Scotland is considering education preparation for clinical nurse specialists within wider work on post-registration education being taken forward to ensure flexibility and sustainability.