Review of Nursing in the Community (RONIC)
UNISONScotland's concerns

Bridget Hunter, UNISON Scotland's Lead Officer for Nurses and Midwives identifies concerns over the new role of community health nurse replacing the time-honoured traditional roles of district nurse, health visitor, school nurse, public health nurse and family health nurse.

Visible, Accessible and Integrated Care, the Review of Nursing in the Community in Scotland was published on 14th November 2006. This review was an action point from Delivering for Health. Sponsored by Paul Martin, the then Chief Nursing Officer for Scotland, it was considered that the demographic changes and concern over workforce pressures meant that the future provision of nursing services in the community required to be updated.

The report proposed a generic community health nurse model and identified four development sites: NHS Borders, Highland, Lothian and Tayside, to test out the model over the two years. In April 2008, we moved to the implementation phase with the new role of Community Health Nurse (CHN) replacing the time-honoured traditional roles of district nurse, health visitor, school nurse, public health nurse and family health nurse which many consider to be the ‘Jack of all trades and master of none’.

Although the status of this project then reverted to pilots in all four sites, concern has been raised by the nurses and GP’s on the ground, not purely as a result of the impending changes but also because the impact will produce a reduction in the standard of service that is already available to the people of Scotland. Although an evaluation group was established to work up and submit a bid for external contractors to assess the impacts of the process, and although partnership involvement is in place in the four development sites, many staff side members are concerned that their fears are disregarded.

The main concerns are that:

• It will result in a diminution of the size and quality pool of Scottish community nursing skills
• It has made many nurses consider leaving their lifelong profession early
• It has resulted in a devaluation of the presently existing skills
• It will result in the fragmentation of the UK wide recognition of those skills.
• The short term vision of amalgamation for longer fusion of these designations is contrary to the conclusions in the other UK countries who recommend expansion, enhancement and strengthening of the present skills.
• It already has, and will continue to, cause skills inconsistency throughout Scotland in different health board areas.
• It has allowed the unencumbered and unevaluated mushrooming of schemes in the non-pilot sites.
• It is perceived by practitioners as having no clinical improvement in practices for the benefits of the patient.
• It is a one way street with no way of back tracking once implemented.
• There is no alternative strategy being tested to measure against.
• The baseline study identified that two thirds of community staff did not support the generic role of CHN
• The NMC have been noticeably hesitant at accepting CHN onto any specific part of the register for nursing
• The evaluation process is flawed as it can only measure short term indicators and only over a period of six months.
• These short term indicators (such as detection rates of post-natal depression, breast feeding or immunisation rates, or smoking cessation) will have other influences or variables which could contaminate the purity of outcome data.
• The evaluation process is flawed in that it can not measure long term indicators which are vital in the assessment of all community nursing.

The disenchantment so far has come purely from staff within the pilot sites who are anxious that they are 1)not skilled to perform across all of the other roles and, 2) did not choose to do these duties.

Staff are not reassured that the training on offer will fully skill them to raise their expertise to the level of the experienced staff who presently deliver these roles and equally they are not convinced that there will be sufficient funds to backfill replacement staff for them to undertake this level of training.

From the beginning one of the main concerns has been that the elements of public health and prevention will, as a matter of course, be relegated in priority against the pressing needs of acute health. This goes against the fundamental aims and objectives of the review and those stated in Better Health, Better Care for the war on ill health prevention, tackling health inequalities, substance misuse as well as the early years strategy.

Bridget Hunter
Lead Officer for Nurses and Midwives
UNISON Scotland
March 2009