III: Nursing in a community environment

FACTORS INFLUENCING THE DELIVERY OF COMMUNITY HEALTH CARE SERVICES

      Community nurses face many challenges within their evolving roles. The transition from working in an institutional setting to working in the community can be quite demanding at first. As a student on community placement or a newly employed staff nurse, it soon becomes apparent that there is a wide range of factors influencing the planning and delivery of community health care services. Within the home/community context, the issues that impact upon an individual’s health are more apparent.People are encountered in their natural habitats rather than being isolated within the hospital setting. Assessment is so much more complex in the community as the nurse must consider the interconnections between the various elements of a person’s lifestyle.

     Defining health is complex as it involves multiple factors. According to Blaxter (1990), health can be defined from four different perspectives: an absence of disease, fitness, ability to function and general wellbeing. The concept of health has many dimensions: physical, mental, emotional, social, spiritual and societal. All aspects of health are interdependentinanholisticapproach.Itisprudent toviewanindividualwithinthecontextoftheirwider socio-economic situation when considering issues relating to their health. There are acknowledged inequalities in health status between different people within society and major determinants include social class, culture, occupation, income, gender and geographical location. The Acheson report (1998), which informs the present national public health agenda, provides a fairly comprehensive review of the literature/research available on inequalities in health. DOH (1998a) summarises some of the factors influencing health as follows:

• Fixed: genes, sex.

•    Social and economic: poverty, employment and social exclusion.

•    Environmental: air quality, housing, water quality, social environment.

•    Lifestyle: diet, physical activity, smoking, alcohol, sexual behaviour and drugs.

• Access to services: education, NHS, Social Services, transport and leisure.

      These different categories of influences upon health can be particularly useful in providing prompts when considering the health status of a local population of people. Dahlgren and Whitehead (1991) present a comprehensive model consisting of four levels:

•    Level 1: General socio-economic, cultural and environmental conditions.

•    Level 2: Living and working conditions – housing, health care services, water and sanitation, unemployment, work environment, education, agriculture and food production.

•    Level 3: Social and community networks.

•    Level 4: Individual lifestyle factors.

      The authors state that all four levels impact upon the health status of the individual, for whom age, sex and hereditary factors are also significant. The increased emphasis lately on the development of a primary care-led NHS has come about in response to demographic, technological, political and financial influences amongst others. An increasing population of older people, shorter hospital stays, improvements in technology and patient preference have all contributed to the movement of resources from the acute to the primary care sector. The development of new competencies to provide services away from hospital settings (Thomas 2000) means that an increasing number of people with both acute and chronic conditions will eventually receive care at home or in a range of other locations within the community. It is envisaged that hospitals will mainly provide diagnostic and specialist services in the future.

HEALTH NEEDS ASSESSMENT

A quote from Community-oriented Primary Care summarises the principles underpinning a needs- led, as opposed to a demand-led, service:

               Needs assessment requires more than epidemiological data on geographically defined populations. To be responsive to users, it requires the involvement of front-line service providers, particularly those based in the community. These information sources are complementary, and both need to be integrated to plan and deliver appropriate health services. Linking rigorous needs assessment to service definition and the iterative cycle of service assessment and revision requires close collaboration between commissioners and providers. Primary care professionals are closer to service users than most other providers, and have a key role in identifying health care needs.             Primary health care teams (PHCTs) are being required to assess their practice populations’ needs to guide practice and to achieve targets in areas such as health promotion. Systematic approaches to these tasks are required.         Primary care organisations of the future will have to retain their capacity to provide quality personal care and develop a population orientation if they are to move from a demand- led service – however responsive – to needs-led practice, and a better integration of primary health care, secondary care, social services and the voluntary sector. (King’s Fund 1994: p.1) This approach to primary health care is just as relevant today, particularly as we are now providing services to defined populations within primary care trust (PCT) boundaries. It is clearly important that we consider the actual/potential needs of our given population – regardless of our discipline – if we are to provide services that are relevant and efficient.

         Bradshaw’s taxonomy of need (1972), which describes four types of need, provides a useful starting point when addressing this subject: (1) ‘normative’ need is need as defined by professionals; (2) ‘felt’ need is a want as perceived by the population; (3) an ‘expressed’ need is a demand for a felt need to be met; and (4) a comparative need is defined by comparing services provided to individuals/populations with similar characteristics. In order for services to target needs appropriately, they need to respond to felt and expressed needs rather than normative need. Providing ‘needs-led’ services can be somewhat challenging for community nurses as it may well involve a greater empowerment of the client and a willingness on the part of the community nurse to re- examine their own motives/reasons for providing the current service in the way they do. This may lead to a fairly major change in the organisation of the service for the future, which will require regular evaluations. In a review of the district nursing services across England and Wales, the Audit Commission (1999) recognised that at least one in ten referrals to district nurses (DNs) are inappropriate. It is recommended that DNs define more clearly the service they provide. One of the major reasons for inappropriate referrals appears to be a misunderstanding on the part of colleagues within the primary health care team regarding the role andtheresponsibilitiesofDNs.Inresponse,DNscould address this issue in a number of ways.

          Community nurses can identify the needs of their given population by conducting a health needs assessment, which is a process of gathering information from a variety of sources in order to assist the planning and development of services. As society is constantly changing, health needs assessment is not a static exercise. According to the extract from Community- oriented Primary Care (King’s Fund 1994) quoted above, data is required regarding disease patterns (epidemiology) and public health in a particular area (PCT or locality within PCT), as well as information regarding local environmental factors/resources (knowledge base/experience of community service providers). In other words, a combination of ‘hard’ (statistical/research-based/quantitative) data and ‘soft’ (experiential/anecdotal/qualitative)data.

           In capturing the ‘essence’ of a locality, the term ‘community profile’ is frequently used to describe an area in relation to its amenities, demography (characteristics of the population), public services, employment, transport and environment. Traditionally, health visitors, in particular, have been required to produce community profiles as a form of assessment during their training. Any attempt to analyse the series of complex processes that make up a living community without the participation of local residents/consumers is a fairly fruitless exercise. In gathering information from a large community population, a variety of methods may prove useful.An approach known as participatory rapid appraisal has been described elsewhere (Chilton and Barnes 1997) and involves community members in the collection of information and in decision making related to this information. Originally used in developing countries to assess need within poor rural populations, it has been employed in deprived urban areas (Cresswell 1992). A wide variety of data collection methods are used and participatory rapid appraisal involves local agencies and organisations working together. By working in partnership with local residents, action is taken by community members who have identified issues of local concern/interest and discussed potential solutions. Clearly, participatory rapid appraisal could be used to help tackle specific issues as well as large-scale assessments.

MEETING THE NEEDS OF THE LOCAL POPULATION

           Current government policy (DOH 1997, 2000a, 2001) stresses the importance of a localised approach to community health care service provision. Each PCT is different in terms of its characteristics, which might include its demography, geographical location, environment, amenities, transport systems, unemployment levels, deprivation scores, work opportunities and access to services, for example. As a result of these potential variations, it is important to interpret national guidelines according to local needs. Each PCT has its own individualised local targets for public health identified within a HIP and tailored to the specific requirements of the local population. Such targets are usually chosen following an examination of local information sources, such as epidemiological data collected by the public health department within the health authority, general practice (GP) profiles and caseload analysis data obtained from local health care practitioners. By systematically reviewing local information sources and working within government/professional guidelines, community specialist practitioners have an opportunity to develop practice and more collaborative ways of working.

               DOH (2001) highlights the importance of front- line staff taking responsibility for implementing many of the recent changes in the NHS. This will involve community nurses becoming more actively involved in health needs assessment. It has been recognised that there are populations whose health care needs are unmet (Latimer and Ashburner 1997), which presents community nurses with the challenge of redefining their services to more accurately respond to the needs of their particular patient group. Traditionally, many community nurses have responded to referrals, which are frequently inappropriate and often do not represent the most urgent needs of the population in terms of priority. Responding more appropriately is not any easy task, as many of these unmet needs often require seeking out and might exist within the more disadvantaged sectors of society. It is not unreasonable to assume that many community nurses will require a greater understanding of different cultural issues and social value systems before they are able to identify specific unmet needs. The inverse care law means that, ironically,themoreadvantagedpeopleinsocietytend to receive better health care services (Acheson report, 1998). Current NHS policy is attempting to rectify this anomaly and end the so-called ‘postcode lottery’, whichsuggeststhathealthstatuscanbedetermined on the basis of where a person lives. Although national service frameworks (NSFs) are national guidelines produced to encourage the dissemination of best practice in relation to particular conditions or client groups, it is the responsibility of front-line staff to implement them locally and interpret them according to local conditions.

            Ensuring that local NHS organisations work together with local authorities, especially with regard to social care, is fundamental to the new ways of working, and PCTs are in an ideal position to facilitate this collaborative approach. Clearly, there are differences between PCTs in terms of the locations in which community health care services are offered to patients. Provision will vary considerably between a rural and an urban PCT. For example, in a rural location, there might tend to be more community hospitals, providing accessible local services that are not of a specialist nature, whereas walk-in centres, for example, tend to be located in more densely populated locations, such as city centres and airports. In order to provide high-quality care to patients, community nurses need the necessary skills, knowledge and expertise and it is the responsibility of individual practitioners and their employing authority to ensure that the appropriate training is organised. Working alongside their local workforce confederation, PCTs or other employing authorities plan for the future recruitment and training of new staff and the continuing professional development of existing staff. PCTs will also develop and update policies and procedures in relation to the clinical responsibilities of community nurses and these should relate to the latest benchmarking criteria and government/professional guidelines. Under the present government, it is suggested that patients should have an influence on the provision of health care services. Patients’ views should therefore be considered by board members of the PCT, who are charged with the responsibility of ensuring patient participation.

COMMUNITY HEALTH CARE NURSING DISCIPLINES

         A new understanding of community care as ‘process’ rather than ‘context’ is proposed by Clarke (1999) to enable us to value community nursing as advanced specialist practice in its own right, rather than as institutional or acute care nursing in another setting. Eng et al. (1992) encourage an ‘understanding that a community is a ‘living’ organism with interactive webs of ties among organisations, neighbourhoods, families and friends’. Community nursing takes place in a wide variety of settings.

     Recent government reforms in terms of the structures and systems that form the NHS (e.g. DOH 1997, 2000a, 2001) have led to an acknowledgement by community specialist practitioners that their roles and responsibilities need to be examined and redefined in preparation for the new challenges ahead. Leadership, practice development and partnership working are key elements within the roles of all community specialist practitioners (DOH 2001). The Nursing and Midwifery Council (NMC) are currently attempting to redefine the role of the specialist practitioner. In the early 1990s, the UKCC conducted the PREP (post-registration education and practice) project to clarify the future training requirements for post-registration nurses. At the time, eight community specialist practice disciplines were identified: occupational health nursing, community paediatric nursing, community learning disability nursing, community mental health nursing, general practice nursing, school nursing, health visiting and district nursing. The UKCC (1994) proposed a common core- centred course for all specialities, which was to be at first degree level at least, and one year in length. According to the UKCC, the remit of community specialist practice embraces ‘clinical nursing care, risk identification, disease prevention, health promotion, needs assessment and a contribution to the development of public health services and policy’. It is perhaps particularly pertinent in the current context of partnership working that we embrace those common aspects of our practice as community specialist practitioners. In espousing the uniqueness of the individual disciplines, there is an acknowledged danger that nurses will miss out on opportunities to influence a primary care-led NHS (Quinney and Pearson 1996).

Occupational Health Nursing (OHN)

            OHN is a relatively new nursing discipline that has developed from its origins in ‘industrial nursing’ in the mid-19th century, when the role was mainly curative rather than preventative (Chorley 2001). Occupational health nurses work within the wider occupational health services and play a preventive role in advising employers, employees and their representatives on health and safety issues in the working environment, and the adaptation of the working environment to the capabilities of the employees (RCN 1991). The role of the OHN is concerned with preventing ill health which affects the ability to work, and ill health caused by employment, and also with promoting good health and developing health promotion strategies in the workplace. OHNs’ responsibilities are as varied as the industries/businesses in which they are employed. Chorley (2001) identifies five elements of the OHNroleasbeingprofessional,managerial,business, environmental and educational responsibilities. Many factors influence the future role of the OHN, including political, economic and public health care strategies. However, Chorley (2001) argues that OHNs can professionally influence key areas of their practice by assessing future health care trends through analysing research, reviewing epidemiological data and conducting needs assessment.

Community Children’s Nursing (CCN)

             According to the Royal College of Nursing (RCN 2002b), the past few decades have seen considerable growth and innovation for CCN services. In 1987, there was a total of 25 services in the UK; currently, there is a total of 150 CCN teams in England alone. There are very few areas (mainly rural) without a service. The development of the CCN services has been supported by a number of pertinent reports (DOH 1991; DOH/NHSE 1996, Audit Commission 1993). The Department of Health and the NHS Executive (1996) agree that ‘CCN services should be led, and predominantly staffed, by nurses who possess both registrations as a children’s nurse and experience of community nursing’. There are three key elements within the delivery of CCN services: (1) first contact/acute assessment, diagnoses, treatment and referral of children; (2) continuing care, chronic disease management and meeting the imperatives of the Children’s NSF; and (3) public health/health protection and promotion programmes – working with children and families to improve health and reduce the impact of illness and disability (DOH 2002).

Community Learning Disability Nursing (CLDN)

        According to Barr (2001), there was a recognition of the need for more community-based services to be provided for people with learning disabilities living at home and their families in the mid-1970s. Around this time, different models of service were developing around the notion of ‘normalisation’, which is the underlying philosophy of many of the services provided for people with learning disabilities. Normalisation may be defined as ‘a complex system which sets out to value positively devalued individuals and groups’ (Race 1999). Service principles for learning disability services should be based on an individual’s assessed needs; flexible and sensitive in service provision; equitable and integrated with an accessible range of services that offer priority to those in the greatest need; prompt, effective and comprehensive and evaluated by the degree to which they provide privacy, dignity, independence, rights and fulfilment for people with learning disabilities (DHSS 1995). CLDNs often work closely with other members of the multidisciplinary team. Bollard and Jukes (1999) stress the importance of CLDNs clarifying their working relationships with other community specialist practitioners and members of the primary health care team in order that people with learning disabilities do not fall between services or receive conflicting advice.

Community Mental Health Nursing (CMHN)

         The CMHN service has been well documented since its inception in the mid-1950s. The expertise of the CMHN lies in assessing the mental health of an individual within a family and social context. CMHNs may be located in health centres, GP practices, voluntary organisations and accident and emergency departments. They represent people with mental health needs and provide high quality therapeutic care (Long 2001). Four elements underpin the professional practice of CMHNs. First is a guiding paradigm, which involves respecting, valuing and facilitating the growth unique to each individual (Rogers 1990). Second, therapeutic presence is needed to restore clients’ dignity and worth as healthy, unique human beings. Third, the therapeutic encounter, which is essential for healing and growth. Finally, the principles of CMHN, which include the search for recognised and unrecognised mental health needs; the prevention of a disequilibrium in mental health; the facilitation of mental health-enhancing activities; therapeutic approaches to mental health care and influences on policies affecting mental health (Long 2001). Although several models are emerging in the organisation, delivery and evaluation of community mental health services, the guiding principles remain the same. Community profiling and collaborative working are considered by Long (2001) to be pivotal in promoting the mental health of the nation.

General Practice Nursing (GPN)

         Nurses have been working in general practice for more than 80 years (Hyde 1995). Since the early 1990s, the number of practice nurses has grown considerably in response to the demands of general practice. The service expanded from 1515 nurses in 1982 to 10198 in 1998 (RCGP 2000). At the same time, the range of services they provide has also developed rapidly. Practice nurses frequently fulfil the role of ‘gatekeeper’ and are relatively easily accessible and acceptable to patients as they are located within GP surgeries. The role of the practice nurse is wide- ranging and covers all age groups within the practice population (Saunders 2001). The types of service provided might include tasks such as ear syringing and venepuncture through to nurse-led chronic disease management programmes operated within agreed protocols. The expansion of nurse prescribing will enhance the provision of care for practice nurses working within clinics such as these (DOH 2000b). Chronic disease management and screening/secondary prevention programmes are areas of expertise for practice nurses, which could be further developed (Eve and Gerrish 2001). More recently, practice nurses have become involved in the implementation of NSF guidelines at a local level and often play a key role in establishing nurse- led clinics to tackle public health targets. For example, clinics for people with coronary heart disease.

School Nursing

          School nurses have been employed within the school health service for more than 100 years but have not been afforded, despite their importance, the same status as their community specialist practice colleagues, according to Thurtle (2001). DeBell and Jackson (2000) state that the assessment of the specific health-care needs of school age children in the community is essential in the development of the school nursing service. They also emphasise that ‘school nursing is committed to the health improvement of children and young people of school age’. In addition to delivering core health surveillance programmes within schools, school nurses consider themselves to have particular responsibility for promoting healthy lifestyles and healthy schools; for child and adolescent mental health; chronic and complex health needs; and for vulnerable children and adolescents (Obeid 2001). DOH (1999a, p.13) emphasises that school nurses are ‘playing a vital role in equipping young people with the knowledge to make healthy lifestyle choices’. Key aspects of the school nurse’s role include the assessment of health needs of children and school communities, agreement of individual and school plans and delivery of these through multi-disciplinary partnerships; playing a key role in immunisation and vaccination programmes; contributing to personal and health and social education and to citizenship training; working with parents to promote positive parenting; offering support and counselling, promoting positive mental health in young people and advising on and co-ordinating health care to children with medical needs. In addition to this the DOH (1999b) identifies school nurses as public health practitioners with a specific role in the healthy school programme, tackling teenage pregnancy and working with families.

Health Visiting (HV)

       The health visiting service has been in existence for more than 100 years and has its roots in public health and concern about poor health. The overall aim of the service is the promotion of health and the prevention of ill health. According to the Council for the Education and Training of Health Visitors (CETHV 1977), the four main elements of the health visitor’s role are the search for health needs; stimulation of awareness of health needs; influence on policies affecting health; and facilitation of health-enhancing activities. Although health visitors (HVs) will continue to maintain their public health role, they are also developing a much wider role in primary care. Traditionally, the focus of their work has been on monitoring the development of the under-fives. Several documents (Acheson 1998; DOH 1999a,1999b) have defined a new health agenda for the future, in which health visitors have a key role. A statement from Making a Difference (DOH 1999a, p. 132) reads: ‘we are encouraging [health visitors] to develop a family-centred public health role, working with individuals, families and communities to improve health and tackle health inequality’. Family health maintenance, child protection and community outreach with vulnerable groups are examples of the type of work HVs undertake. Appleby and Sayer (2001) stress the importance of health visitors finding new ways of measuring the effectiveness of their work, which tends to have long-term benefits for society but has always been notoriously difficult to quantify.

District Nursing (DN)

          District nurses can trace their roots back to the mid- 1800s at least and the historical development of the service is well recorded. District nurses used to work in relative isolation but are more likely nowadays to work within a team (Thomas 2000). The role of the district nurse has evolved over time in response to political influences and the changing needs of the populations served. Although it is acknowledged that the role of the district nursing service is not clearly defined, it involves the assessment, organisation and delivery of care to support people living in their own homes (Audit Commission 1999). The three major elements of the role are that of clinical expert, manager and teacher (Clarridge et al. 2001). District nurses care for people with acute and chronic illnesses as well as those requiring palliative care. The majority of people on the district nurse’s caseload tend to be from the older generation. According to the RCN (2002a), the value of the district nursing service comes from its holistic approach to patient need and its ability to implement a package (often complex) of treatment that transcends health and social care. District nursing work is complex and wide ranging. Intermediate care, rehabilitation, rapid response and prevention of admission teams are current initiatives within the modernisation programme. District nurses are playing key roles in developing many of these innovative services.

Integrated Nursing Teams

        Integrated nursing teams are ‘teams of community- based nurses from different disciplines, working together within a primary care setting pooling their skills, knowledge and ability in order to provide the most effective care for their patients within a practice and the community it covers’ (HVA 1996). According to the Department of Health (1999a), integrated nursing teams are beneficial as they promote greater understanding of each other’s roles, help to reduce duplication and allow for more targeted use of specialist skills. Considering the acknowledged importance of tailoring services to patient need, an approach that responds to and addresses nursing/health issues identified as part of an individual or population- based health needs assessment exercise is preferable.

       Beech (2002) explores the potential for integrated nursing teams in primary care settings and recognises that, at present, very little research-based evidence exists in relation to integrated nursing teams, particularly in terms of patient outcomes. She believes that all those people with a vested interest need to be consulted prior to the establishment of integrated teams and a structured approach is required for successful practice development.

GUARANTEEING A QUALITY SERVICE

        With the launch of their new manifesto for health in 1997, the Labour government stressed the importance of delivering quality standards within the NHS: Professional and statutory bodies have a vital role in setting and promoting standards but shifting the focus towards quality will also require practitioners to accept responsibility for developing and maintaining standards within their local NHS organisations. For this reason, the Government will require every NHS Trust to embrace the concept of ‘clinical governance’ so that quality is at the core, both of their responsibilities as organisations and of each of their staff as individual professionals. (DOH1997) The DOH (1998b) reinforces the importance of ensuring that the services provided by health care professionals are of a high quality. The present government have established a number of organisations and initiatives designed to support a culture of excellence in health care: the National Institute for Clinical Excellence (NICE), national service frameworks (NSFs), the Commission for Healthcare Audit and Inspection (CHAI), the National Performance Framework, a National Survey of Patient and User Experience, and clinical governance (CG). NICE provides advice on best practice with regard to existing treatments and evaluates new health interventions. In so doing, it encourages the use of the most appropriate treatments in terms of clinical and cost effectiveness. NSFs are evidence-based national guidelines issued in relation to the treatment of specific client groups or disease categories. They act to ensure that people receive integrated, safe and clinically effective care (RCN 2002c). Collaborative practice is a prerequisite for the successful implementation of the NSFs. NSFs include strategies to support their implementation and establish performance milestones against which progress, within an agreed timescale, can be measured. NSFs form one of a number of initiatives designed to raise quality and decrease variations in service. There are plans to publish only one new framework annually. An external reference group (ERG) consisting of health professionals, service users and carers, health service managers, partner agencies and other advocates assists in the development of the NSFs with the support and supervision of the DOH. Since its launch in April 1998, the NSF programme has embraced established frameworks on cancer and paediatric intensive care and developed the mental health NSF (September 1999), the coronary heart disease NSF (March 2000), the national cancer plan (September 2000), the older person NSF (March 2001), the diabetes NSF (2001) and the children’s NSF (2003). NSFs are being prepared for renal services and long-term neurological conditions. The Commission for Healthcare Audit and Inspection (CHAI) is due to replace the Commission for Health Improvement (CHI), the national body that supports and monitors the quality of clinical governance and of clinical services. CHAI will be a more powerful health inspectorate, responsible for both public and private sectors. CHAI’s other responsibilities will include conducting ‘value for money’ audits; determining star ratings for all NHS bodies and recommending special measures where necessary; validating performance assessment data, including waiting list information; reporting on NHS organisations’ performance; providing independent scrutiny of patient complaints and reporting annually to parliament on health care progress and the resources that have been used. There are plans to create a single Commission for Social Care Inspection at the same time as CHAI, with a legal obligation on the two bodies to co-operate. The National Performance Framework is designed to give a rounded picture of NHS performance and will address six areas: health improvement; fair access to services; effective delivery of appropriate healthcare; efficiency; patient/carer experience and health outcomes of NHS care. The National Survey of Patient and User Experience is conducted annually to elicit the opinions of people in relation to care provided by the NHS. The current government has proposed a 10-year modernisation programme for the NHS, which incorporates clear national standards, local delivery, statutory duty, life-long learning and professional self-regulation, monitoring of services through CHAI and the NHS Performance Framework and User survey. Clinical governance (CG) is the central concept that embraces all of these elements. It is a framework through which NHS organisations are accountable for continuously improving the quality of their services. According to Bennett and Robinson (2002), clinical governance is the vehicle for identifying not only excellence in care but also those aspects of practice that require further development. The RCN (2002c) describes three main elements within clinical governance: quality improvement, risk management and management of performance and systems for accountability and responsibility. Quality improvement includes standard setting, clinical audit and evidence-based practice. Standards are devised in line with national/local clinical guidelines and evidence-based best practice and then implemented. Clinical audit is conducted to evaluate whether care meets the required standards and, where necessary, improvements are made, implemented and re-audited. Risk management involves all of those activities designed to promote best practice and avoid detrimental events happening. Individual practitioners are encouraged to view critical incidents and patient complaints positively and to learn from experiences, supported by a ‘no blame’ culture. In the clinical area, this involves clinical supervision, continuing professional development and effective clinical leadership. Within the wider NHS organisation, risk management systems might include incident reporting procedures and strategies/protocols to prevent adverse events. Systems for accountability and responsibility place a statutory responsibility for care within all NHS organisations. PCTs, and more specifically the chief executive, are responsible for the quality of care provided within their organisations. A clinician is appointed within each NHS organisation with responsibility for the implementation and evaluation of the CG framework. A spirit of teamworking and commitment to high standards of care is essential if CG is to be effective.

        According to Zeh (2002), CG needs to be considered alongside professional self-regulation and continuing professional development. Increasingly, community specialist practitioners are being encouraged to develop their practice by discussing and sharing experiences with colleagues and regularly updating their skills, knowledge and expertise. In addition, there is a requirement to voice any concerns regarding compromised care and actively link into the wider organisational CG framework. Community nurses are accountable to the Nursing and Midwifery Council (NMC) and the public for the duties they perform. With CG, there are increased opportunities for patient involvement in decisions about care and more explicit mechanisms in place to make complaints and put forward their views.

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