Re: FW: [pafsinterestgroup] FNP and HV roles

[Guest guest]

I too felt very sad about this. I recollect the early FNP pilots in

Scotland and all my concerns at that time have been justified.

First, it isn't a pukka NP role - the education required isn't up to

it and it doesn't sound like they're taking on an undifferentiated

caseload as primary care workers. Second, it's just not enough to

fit the bill for families with children. Perhaps it's got more to

offer adults living with chronic health problems - they could do with

a nurse offering secondary and tertiary preventative work and based

in their local communities. But even here, the training doesn't fit

the needs, especially in terms of mental health and substance abuse,

IMO.

Child development and parental support needs don't stop at age 2,

neither is there an integrated nationally available service for

parents with problems nor for children with disabilities. If you

look at the WHO data on children, the UK was a success in terms of

child health and child mortality. Compare this with the USA figures,

which are among the worst in the developed world, especially for

homicide and those categories of 'other violent deaths'. This is no

kind of model for a public health service or a caring society which

wants to look after its weaker members.

It's such a middle class thing to think that the problems are all

solved. Socially, our society is pretty divided by class and income,

but I'd hate to think that we'd go down the US route of simply

accepting a substantial health and educational underclass from birth

as natural and inevitable in a supposedly meritocratic society.

Humanity is either worth caring for as a whole society, or you'd be

kinder ending their struggles and removing their children before

everyone suffers too much. ly, this isn't what I came into

health visiting for.

When the dust dies down and the DH publicity caravan moves on, the

problems inherent to our society remain. is right about the

Hawthorne effect too. Consider the history of the First Parent

Visitor programme.

I don't think the FNP role fits the bill in terms of a primary

preventative role. GPs and Family Centres are all very well and the

articulate middle class users will always take advantage of this sort

of service better than those who're mistrustful and anxious about

such services, or feel unwelcome there. I'm committed to a model

based on unsolicited home visiting, not by sick nurses, but by health

visitors who want to work with people before things go pearshaped and

they need a referral.

The wretched thing is that we've partly contributed to this situation

by our own faith that the system was resilient enough to cope with a

wholse series of hairbrained government policies. Colleagues on

SENATE tried harder than anyone else to prevent our qualification and

registratration being undermined, but it was undermined and the

funding issues and targets in the NHS took PCT eyes off the ball in

terms of primary care services which were provided by NHS employees.

HV training budgets in my area were at a standstill for about 3 years

- how do we expect universities to cope with that? Unlike medical

staff, DH can't just import more HVs from the rest of the world when

they haven't trained enough here. But my fear is that they won't

even bother.

The UK has been one of the best and safest countries in the world for

a child to grow up in. I hate the idea that we could lose that, but

dismantling universal primary health and social care systems hasn't

done much for health outcomes in the post Soviet Eastern European and

Baltic states, has it? It's time DH looked at a wider range of

models because in respect of primary health care outcomes, the US

doesn't shine.

.

--------------------------------------------------

On 13 Jan 2008 at 12:18, Whittaker wrote:

From: pafsinterestgroup

[mailto:pafsinterestgroup ] On Behalf Of Cowley

Sent: 13 January 2008 11:20

pafsinterestgroup

Subject: Re: [pafsinterestgroup] FNP and HV roles

Dear

I felt very sadwhen I read this, but not surprised. I am so sorry to

have been so slow to respond, but felt it needed some explanation and

consideration. I will be really interested to know if anyone thinks

my analysis is inaccurate or if it resonates with their observations,

too.

When the idea of the Olds programme was first mooted for the UK in

2006, it was clear that it needed to be implemented by health

visitors or midwives; nurses were only mentioned because they don't

have health visitors or midwives in the US, and because of the title

of the programme. That did cause some ruffled feathers in the DH,

because they had spent a lot of time and energy trying to abolish

health visiting by removing them from statute and closing their

register; now here was the Social Exclusion Task Force promoting

health visiting as if it still existed and as if its practitioners

could do a good job. So, in the first instance, there was a lot of

discussion about how important it was to ensure this programme could,

once it was rolled out, be integrated into the overall health

visiting service. I recall meeting Kate Billingham just after her

first visit to the US, which was the cause of much merriment because

she said the nurses implementing the programme in the States were

exactly like health visitors; spoke, dressed (pearls and cardigans!)

and even sat like health visitors. Olds has been at pains to

point out the the nurses in the US 'are not just nurses, not like

ordinary nurses,' and he is reportedly extremely impressed with the

calibre of the health visitors implementing the programme here. I

understand there are around 2-3 midwives and 1 children's nurse (does

anyone have exact figures?), but the vast, vast majority of

practitioners implementing the pilots are health visitors.

Pause for two thoughts. First, any study or experience of

implementing new services and new roles shows that it always

generates enormous enthusiasm and excitement, because of

- the contrast to the absolute drudgery of everyday practice;

protection from much of the stress

- the joy of having sufficient time and funding,

- the stimulation of new education and training, demonstrating and

expanding participants' consciousness

- the interest shown by managers and others (Hawthorne effect?)

- those chosen to participate are usually selected as a result of

fierce competition, so they start out excellent and enthusiastic.

The FNP is no exception; it would be an absolute disaster if, having

had so much money, support and time spent on them, the practitioners

were not saying how exciting and different it all is, so that is what

they are saying. Also, given the antipathy by the DH nurses towards

health visiting, practitioners would be firmly disapproved of, if

they ever mentioned that they used their health visiting skills. It

has to be made clear to everyone that these are NURSING pilots, not

health visiting ones (someone emailed me about these recently, and

said she had initially typed 'FNP plots,' which seems more to the

point really)!

Second, over the last year, various other things have happened in

health visiting. The health visiting review singled out the FNP as

one of the two roles being promoted as appropriate for health

visitors. It also, without actually saying so, indicated that 'health

visiting services' as such would be disbanded. Although a universal

and expanded CHPP would continue to be available, delivered by a team

'led by a health visitor,' the review indicated that would be all

that needed commissioning, apart from the FNP. Although that shows a

stunning lack of knowledge of health needs and what health visitors

actually deliver on the ground, it is a view that has been promoted

fairly consistently by the DH nurses for some time now, and it is

always delivered through this 'professional titles don't matter'

mantra. 'Professional titles don't matter' is a code for 'don't

mention health visiting, only talk about nursing.' There has also

been a view that we should 'get away from caseloads' for health

visitors. In other words, only deliver the CHPP and referrals to the

FNP, either as part of general practice or in the children's centre;

then we won't have to pay for expensive professionals holding

undifferentiated caseloads and high levels of responsibility.

Also, the post-registration consultation for 'modernising nursing

careers' has proposed five career routes, of which 'child family and

public health' is one. There is (of course) no mention of health

visiting, except to point out that the health visiting review was

part of this initiative and that the third part of the NMC register

is a bit of a nuisance which spoils their neat model (well, it isn't

phrased so undiplomatically, I admit!) This dialogue has run

alongside a serous dip in both student health visitor numbers and

health visitors in post. This drop in capacity is being used to

promote these ideas as positive and manageable, whilst visions of a

universal service linked in with one that also meets needs identified

(even if not so severe as to merit the FNP) through universal

contacts, are promoted as old-fashioned, unnecessary, without an

evidence base and unhelpful to health inequalities. Again, that shows

considerable ignorance, but professional rivalry, and the need to

promote nursing at all costs, is clearly more important in some

quarters than the need to serve the community, reduce health

inequalities or meet the health needs of the youngest and most

vulnerable members of our population.

Back to the roll-out of the second round of FNP pilots. The fact that

this second tranche of money has been made available is a testimony

to their success; that is down to the health visitors implementing

the programme, and to those supporting them in their new role. It is

not down to nursing. However, if the DH acknowledges that it is

health visitors who have done this, they might have to start saying

positive things about health visiting. And if anything is positive,

they want nursing to own it. What is so depressing about this, is

that it is such a clear example of professional rivalry being the

source of damage to service provision. We really should be developing

services to meet needs (all needs, across the social gradient, not

just a tiny minority) not to meet a professional agenda, however

exciting this new role might seem.

There are two cheerful things, though. First, there do seem quite a

few places now talking about reinvesting in health visiting services,

after 2007 being such a disastrous year of cuts and cutbacks. Second,

the new health visiting programmes, developed as a result of changes

to the standards in 2002 and 2004, are far better than the old SPQ

(community nursing) programmes developed in the late 1990s, and they

appear far more consistent across the country. So, for once, it seems

that the PCTs might be leading the way more positively. I hope Maggie

will say, if her CPHVA antennae are picking up different things to

me, but perhaps we should focus on pushing on those open doors,

rather than fighting the old-school nursing hegemony, which is just

so destructive.

Thank you for bringing this news to the group, , and like you, I

will be pleased to hear of anyone else's experiences and views.

kind regards

On 10 Jan 2008, at 10:41, Whittaker wrote:

I wonder did anyone else go to one of the two presentations this week

about the Family Nurse Practitioner pilot. I was at the Manchester

one yesterday and whilst I came away feeling enthused about this

exciting role, I simultaneously felt quite sad about what was muted

about health visiting.

I asked about training in the future for these new roles and whether

if as nurses it would be expected that they would sit on the third

part of the register. The response was for a preference not to be.

I suggested might it be an opportunity for developing, say a 3-4

year, direct entry programme for this nurse and the response was well

that's a interesting idea and yes possibly.

When another question was asked about what will happen to the

families when the child is two and the FNP service ceases - will the

family go under the wing of the generic HV service? The answer was

well we don't even know whether we will have a HV service of that

nature by the time these children are 2yrs (in about 18mths time).

The FNP programme of course is dedicated to the title nurse - one of

the key presented opened with saying this is not about titles, but I

noted that reference throughout the day by the central team was to

nurses' skills and what nurses can offer and little if any reference

to skills brought from existing health visiting base.

I'd be interested to hear any other experiences from these days. Are

any of you in this group working as FNP?

Whittaker

Senior Lecturer

Dept of Nursing

Room 432 Brook Building

University of Central Lancashire

Preston PR1 2HE

Tel: 01772 893786

Kwhittaker1@ uclan.ac. uk

http://www.uclan. ac.uk/facs/ health/nursing/ research/

groups/children/ index.htm

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sarahcowley183btinternet (DOT) com

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12/01/2008 14:04

[Guest guest]

I have to admit that I am reeling from trying to take in the history, emotions,

expertise and wisdom that lie behind this discussion. I am completely unable

to come to terms increasingly with the huge levels of discombobulation now

applying in the UK - where the four-nation experience is also going to become

increasingly at variance. This at a time when populations across UK borders

and more importantly, internationally, are increasingly mobile. It seems that,

against a backdrop of general short-term party politicisation of health and social

care (the same would also apply to education and essential infrastructure) that

people are being pulled all over the place/merger-demerger/Foundation-non-Foundation/

to PBC or not to PBC/ongoing silo'd effort across Govt Depts/historical class agendas

(bacon butties vs 'steerage') and a rhetoric -reality gap of gigantic proportions.

We are losing the plot. And now we are going back to screening! We can't even intervene

early for people we know to be in need right now!

The talk is all about locality and 'empowerment'; the experience is Centrism.

The talk is all about skills to meet needs; the reality is still about trad job

descriptions/Colleges/professional self-interests and personal survival against a melee

of constant change. The talk is about choice and an informed public; the reality

is 'reality TV' and widespread ignorance amongst millions as to how they work; why they

end up in the predicaments they do and the need to be skilled for life and not just trained for jobs.

The more I read, the more I am convinced that not only is the DH not competent

to run Medical Training; it is also incompetent at anything that relies on ground-up

nurturing/coordination and enablement and stymied by the party political agenda

and the need for annual Profit and Loss accounting.

It has to be about evidence, principles and highest common factors - not whim,

ego and lowest common denominators. "Nothing is impossible if people do not

need to claim the credit for doing it" (Tim Smit).

As a GP, I met many highly competent mums under 19 and many highly psychotoxic middle

class parents substantially over that age driving their children to early breakdown and psychosis.

Desert Island Discs turns up quite a lot of such affected children - but perhaps the Middle Classes

think we should continue this way, so that there will always be enough disturbed people with grim

childhoods who can then write highly charged and readable accounts or novels that they

can then settle down to read over a good glass of wine? None of our needs are age specific and this

madness reiterates when the young person moves from CAMHS to adult services at 18 (why not

25) and the 'adult of working age' moves to elderly services at 65. It is heavily about tradition.

Many would love to change much of this inanity; WE are told to 'modernise' by people who still

cannot raise money for their own husting ethically, refer to each other as "honourable gentlemen"

whilst braying like donkeys and who have the attention spans of goldfish.

(M) @primhe.

From: [mailto: ] On Behalf Of hwood@...Sent: 13 January 2008 13:48 Subject: Re: FW: [pafsinterestgroup] FNP and HV roles

I too felt very sad about this. I recollect the early FNP pilots in Scotland and all my concerns at that time have been justified. First, it isn't a pukka NP role - the education required isn't up to it and it doesn't sound like they're taking on an undifferentiated caseload as primary care workers. Second, it's just not enough to fit the bill for families with children. Perhaps it's got more to offer adults living with chronic health problems - they could do with a nurse offering secondary and tertiary preventative work and based in their local communities. But even here, the training doesn't fit the needs, especially in terms of mental health and substance abuse, IMO.Child development and parental support needs don't stop at age 2, neither is there an integrated nationally available service for parents with problems nor for children with disabilities. If you look at the WHO data on children, the UK was a success in terms of child health and child mortality. Compare this with the USA figures, which are among the worst in the developed world, especially for homicide and those categories of 'other violent deaths'. This is no kind of model for a public health service or a caring society which wants to look after its weaker members.It's such a middle class thing to think that the problems are all solved. Socially, our society is pretty divided by class and income, but I'd hate to think that we'd go down the US route of simply accepting a substantial health and educational underclass from birth as natural and inevitable in a supposedly meritocratic society. Humanity is either worth caring for as a whole society, or you'd be kinder ending their struggles and removing their children before everyone suffers too much. ly, this isn't what I came into health visiting for.When the dust dies down and the DH publicity caravan moves on, the problems inherent to our society remain. is right about the Hawthorne effect too. Consider the history of the First Parent Visitor programme. I don't think the FNP role fits the bill in terms of a primary preventative role. GPs and Family Centres are all very well and the articulate middle class users will always take advantage of this sort of service better than those who're mistrustful and anxious about such services, or feel unwelcome there. I'm committed to a model based on unsolicited home visiting, not by sick nurses, but by health visitors who want to work with people before things go pearshaped and they need a referral. The wretched thing is that we've partly contributed to this situation by our own faith that the system was resilient enough to cope with a wholse series of hairbrained government policies. Colleagues on SENATE tried harder than anyone else to prevent our qualification and registratration being undermined, but it was undermined and the funding issues and targets in the NHS took PCT eyes off the ball in terms of primary care services which were provided by NHS employees. HV training budgets in my area were at a standstill for about 3 years - how do we expect universities to cope with that? Unlike medical staff, DH can't just import more HVs from the rest of the world when they haven't trained enough here. But my fear is that they won't even bother.The UK has been one of the best and safest countries in the world for a child to grow up in. I hate the idea that we could lose that, but dismantling universal primary health and social care systems hasn't done much for health outcomes in the post Soviet Eastern European and Baltic states, has it? It's time DH looked at a wider range of models because in respect of primary health care outcomes, the US doesn't shine..--------------------------------------------------On 13 Jan 2008 at 12:18, Whittaker wrote:From: pafsinterestgroup [mailto:pafsinterestgroup ] On Behalf Of CowleySent: 13 January 2008 11:20pafsinterestgroup Subject: Re: [pafsinterestgroup] FNP and HV rolesDear I felt very sadwhen I read this, but not surprised. I am so sorry to have been so slow to respond, but felt it needed some explanation and consideration. I will be really interested to know if anyone thinks my analysis is inaccurate or if it resonates with their observations, too. When the idea of the Olds programme was first mooted for the UK in 2006, it was clear that it needed to be implemented by health visitors or midwives; nurses were only mentioned because they don't have health visitors or midwives in the US, and because of the title of the programme. That did cause some ruffled feathers in the DH, because they had spent a lot of time and energy trying to abolish health visiting by removing them from statute and closing their register; now here was the Social Exclusion Task Force promoting health visiting as if it still existed and as if its practitioners could do a good job. So, in the first instance, there was a lot of discussion about how important it was to ensure this programme could, once it was rolled out, be integrated into the overall health visiting service. I recall meeting Kate Billingham just after her first visit to the US, which was the cause of much merriment because she said the nurses implementing the programme in the States were exactly like health visitors; spoke, dressed (pearls and cardigans!) and even sat like health visitors. Olds has been at pains to point out the the nurses in the US 'are not just nurses, not like ordinary nurses,' and he is reportedly extremely impressed with the calibre of the health visitors implementing the programme here. I understand there are around 2-3 midwives and 1 children's nurse (does anyone have exact figures?), but the vast, vast majority of practitioners implementing the pilots are health visitors. Pause for two thoughts. First, any study or experience of implementing new services and new roles shows that it always generates enormous enthusiasm and excitement, because of - the contrast to the absolute drudgery of everyday practice; protection from much of the stress - the joy of having sufficient time and funding, - the stimulation of new education and training, demonstrating and expanding participants' consciousness - the interest shown by managers and others (Hawthorne effect?) - those chosen to participate are usually selected as a result of fierce competition, so they start out excellent and enthusiastic. The FNP is no exception; it would be an absolute disaster if, having had so much money, support and time spent on them, the practitioners were not saying how exciting and different it all is, so that is what they are saying. Also, given the antipathy by the DH nurses towards health visiting, practitioners would be firmly disapproved of, if they ever mentioned that they used their health visiting skills. It has to be made clear to everyone that these are NURSING pilots, not health visiting ones (someone emailed me about these recently, and said she had initially typed 'FNP plots,' which seems more to the point really)! Second, over the last year, various other things have happened in health visiting. The health visiting review singled out the FNP as one of the two roles being promoted as appropriate for health visitors. It also, without actually saying so, indicated that 'health visiting services' as such would be disbanded. Although a universal and expanded CHPP would continue to be available, delivered by a team 'led by a health visitor,' the review indicated that would be all that needed commissioning, apart from the FNP. Although that shows a stunning lack of knowledge of health needs and what health visitors actually deliver on the ground, it is a view that has been promoted fairly consistently by the DH nurses for some time now, and it is always delivered through this 'professional titles don't matter' mantra. 'Professional titles don't matter' is a code for 'don't mention health visiting, only talk about nursing.' There has also been a view that we should 'get away from caseloads' for health visitors. In other words, only deliver the CHPP and referrals to the FNP, either as part of general practice or in the children's centre; then we won't have to pay for expensive professionals holding undifferentiated caseloads and high levels of responsibility. Also, the post-registration consultation for 'modernising nursing careers' has proposed five career routes, of which 'child family and public health' is one. There is (of course) no mention of health visiting, except to point out that the health visiting review was part of this initiative and that the third part of the NMC register is a bit of a nuisance which spoils their neat model (well, it isn't phrased so undiplomatically, I admit!) This dialogue has run alongside a serous dip in both student health visitor numbers and health visitors in post. This drop in capacity is being used to promote these ideas as positive and manageable, whilst visions of a universal service linked in with one that also meets needs identified (even if not so severe as to merit the FNP) through universal contacts, are promoted as old-fashioned, unnecessary, without an evidence base and unhelpful to health inequalities. Again, that shows considerable ignorance, but professional rivalry, and the need to promote nursing at all costs, is clearly more important in some quarters than the need to serve the community, reduce health inequalities or meet the health needs of the youngest and most vulnerable members of our population. Back to the roll-out of the second round of FNP pilots. The fact that this second tranche of money has been made available is a testimony to their success; that is down to the health visitors implementing the programme, and to those supporting them in their new role. It is not down to nursing. However, if the DH acknowledges that it is health visitors who have done this, they might have to start saying positive things about health visiting. And if anything is positive, they want nursing to own it. What is so depressing about this, is that it is such a clear example of professional rivalry being the source of damage to service provision. We really should be developing services to meet needs (all needs, across the social gradient, not just a tiny minority) not to meet a professional agenda, however exciting this new role might seem. There are two cheerful things, though. First, there do seem quite a few places now talking about reinvesting in health visiting services, after 2007 being such a disastrous year of cuts and cutbacks. Second, the new health visiting programmes, developed as a result of changes to the standards in 2002 and 2004, are far better than the old SPQ (community nursing) programmes developed in the late 1990s, and they appear far more consistent across the country. So, for once, it seems that the PCTs might be leading the way more positively. I hope Maggie will say, if her CPHVA antennae are picking up different things to me, but perhaps we should focus on pushing on those open doors, rather than fighting the old-school nursing hegemony, which is just so destructive. Thank you for bringing this news to the group, , and like you, I will be pleased to hear of anyone else's experiences and views. kind regards On 10 Jan 2008, at 10:41, Whittaker wrote: I wonder did anyone else go to one of the two presentations this week about the Family Nurse Practitioner pilot. I was at the Manchester one yesterday and whilst I came away feeling enthused about this exciting role, I simultaneously felt quite sad about what was muted about health visiting. I asked about training in the future for these new roles and whether if as nurses it would be expected that they would sit on the third part of the register. The response was for a preference not to be. I suggested might it be an opportunity for developing, say a 3-4 year, direct entry programme for this nurse and the response was well that's a interesting idea and yes possibly. When another question was asked about what will happen to the families when the child is two and the FNP service ceases - will the family go under the wing of the generic HV service? The answer was well we don't even know whether we will have a HV service of that nature by the time these children are 2yrs (in about 18mths time). The FNP programme of course is dedicated to the title nurse - one of the key presented opened with saying this is not about titles, but I noted that reference throughout the day by the central team was to nurses' skills and what nurses can offer and little if any reference to skills brought from existing health visiting base. I'd be interested to hear any other experiences from these days. Are any of you in this group working as FNP? WhittakerSenior LecturerDept of NursingRoom 432 Brook BuildingUniversity of Central LancashirePreston PR1 2HE Tel: 01772 893786Kwhittaker1@ uclan.ac. ukhttp://www.uclan. ac.uk/facs/ health/nursing/ research/ groups/children/ index.htm Any representations, views and/or opinions in this e-mail are those of the sender, and not necessarily of the University. The University's computer network (including its e-mail facility) is intended for educational purposes, and the University accepts no liability for, and shall not be bound by, the contents of any e-mail sent from its network which do not relate to those purposes or other business of the University.This e-mail is confidential to and for the sole use of its addressee(s). If you should not have received it, please notify the sender and permanently delete it: you may not print, copy, disclose, distribute or rely on it, or any part of it.E-mail transmission is not guaranteed to be secure or error-free and the University does not accept liability for any errors in or amendments to the contents of this message which arise in consequence of its transmission by e-mail. sarahcowley183btinternet (DOT) com http://myprofile.cos.com/S124021C On No virus found in this outgoing message.Checked by AVG Free Edition.Version: 7.5.516 / Virus Database: 269.19.2/1221 - Release Date: 12/01/2008 14:04

[Guest guest]

Hooray for the voice of sanity, thank you Chris!  On 13 Jan 2008, at 16:29, Manning wrote:I have to admit that I am reeling from trying to take in the history, emotions,expertise and wisdom that lie behind this discussion. I am completely unableto come to terms increasingly with the huge levels of discombobulation nowapplying in the UK - where the four-nation experience is also going to becomeincreasingly at variance. This at a time when populations across UK bordersand more importantly, internationally, are increasingly mobile. It seems that,against a backdrop of general short-term party politicisation of health and socialcare (the same would also apply to education and essential infrastructure) thatpeople are being pulled all over the place/merger-demerger/Foundation-non-Foundation/to PBC or not to PBC/ongoing silo'd effort across Govt Depts/historical class agendas(bacon butties vs 'steerage') and a rhetoric -reality gap of gigantic proportions.We are losing the plot. And now we are going back to screening! We can't even interveneearly for people we know to be in need right now! The talk is all about locality and 'empowerment'; the experience is Centrism.The talk is all about skills to meet needs; the reality is still about trad jobdescriptions/Colleges/professional self-interests and personal survival against a meleeof constant change. The talk is about choice and an informed public; the realityis 'reality TV' and widespread ignorance amongst millions as to how they work; why theyend up in the predicaments they do and the need to be skilled for life and not just trained for jobs. The more I read, the more I am convinced that not only is the DH not competentto run Medical Training; it is also incompetent at anything that relies on ground-upnurturing/coordination and enablement and stymied by the party political agendaand the need for annual Profit and Loss accounting. It has to be about evidence, principles and highest common factors - not whim,ego and lowest common denominators. "Nothing is impossible if people do notneed to claim the credit for doing it" (Tim Smit). As a GP, I met many highly competent mums under 19 and many highly psychotoxic middleclass parents substantially over that age driving their children to early breakdown and psychosis.Desert Island Discs turns up quite a lot of such affected children - but perhaps the Middle Classesthink we should continue this way, so that there will always be enough disturbed people with grimchildhoods who can then write highly charged and readable accounts or novels that theycan then settle down to read over a good glass of wine? None of our needs are age specific and thismadness reiterates when the young person moves from CAMHS to adult services at 18 (why not25) and the 'adult of working age' moves to elderly services at 65. It is heavily about tradition.Many would love to change much of this inanity; WE are told to 'modernise' by people who stillcannot raise money for their own husting ethically, refer to each other as "honourable gentlemen"whilst braying like donkeys and who have the attention spans of goldfish. (M) @primhe.From: [mailto: ] On Behalf Ofhwood@....co.ukSent: 13 January 2008 13:48 Subject: Re: FW: [pafsinterestgroup] FNP and HV rolesI too felt very sad about this. I recollect the early FNP pilots in Scotland and all my concerns at that time have been justified. First, it isn't a pukka NP role - the education required isn't up to it and it doesn't sound like they're taking on an undifferentiated caseload as primary care workers. Second, it's just not enough to fit the bill for families with children. Perhaps it's got more to offer adults living with chronic health problems - they could do with a nurse offering secondary and tertiary preventative work and based in their local communities. But even here, the training doesn't fit the needs, especially in terms of mental health and substance abuse, IMO.Child development and parental support needs don't stop at age 2, neither is there an integrated nationally available service for parents with problems nor for children with disabilities. If you look at the WHO data on children, the UK was a success in terms of child health and child mortality. Compare this with the USA figures, which are among the worst in the developed world, especially for homicide and those categories of 'other violent deaths'. This is no kind of model for a public health service or a caring society which wants to look after its weaker members.It's such a middle class thing to think that the problems are all solved. Socially, our society is pretty divided by class and income, but I'd hate to think that we'd go down the US route of simply accepting a substantial health and educational underclass from birth as natural and inevitable in a supposedly meritocratic society. Humanity is either worth caring for as a whole society, or you'd be kinder ending their struggles and removing their children before everyone suffers too much. ly, this isn't what I came into health visiting for.When the dust dies down and the DH publicity caravan moves on, the problems inherent to our society remain. is right about the Hawthorne effect too. Consider the history of the First Parent Visitor programme. I don't think the FNP role fits the bill in terms of a primary preventative role. GPs and Family Centres are all very well and the articulate middle class users will always take advantage of this sort of service better than those who're mistrustful and anxious about such services, or feel unwelcome there. I'm committed to a model based on unsolicited home visiting, not by sick nurses, but by health visitors who want to work with people before things go pearshaped and they need a referral. The wretched thing is that we've partly contributed to this situation by our own faith that the system was resilient enough to cope with a wholse series of hairbrained government policies. Colleagues on SENATE tried harder than anyone else to prevent our qualification and registratration being undermined, but it was undermined and the funding issues and targets in the NHS took PCT eyes off the ball in terms of primary care services which were provided by NHS employees. HV training budgets in my area were at a standstill for about 3 years - how do we expect universities to cope with that? Unlike medical staff, DH can't just import more HVs from the rest of the world when they haven't trained enough here. But my fear is that they won't even bother.The UK has been one of the best and safest countries in the world for a child to grow up in. I hate the idea that we could lose that, but dismantling universal primary health and social care systems hasn't done much for health outcomes in the post Soviet Eastern European and Baltic states, has it? It's time DH looked at a wider range of models because in respect of primary health care outcomes, the US doesn't shine..--------------------------------------------------On 13 Jan 2008 at 12:18, Whittaker wrote:From: pafsinterestgroup [mailto:pafsinterestgroup ] On Behalf Of CowleySent: 13 January 2008 11:20pafsinterestgroup Subject: Re: [pafsinterestgroup] FNP and HV rolesDear I felt very sadwhen I read this, but not surprised. I am so sorry to have been so slow to respond, but felt it needed some explanation and consideration. I will be really interested to know if anyone thinks my analysis is inaccurate or if it resonates with their observations, too. When the idea of the Olds programme was first mooted for the UK in 2006, it was clear that it needed to be implemented by health visitors or midwives; nurses were only mentioned because they don't have health visitors or midwives in the US, and because of the title of the programme. That did cause some ruffled feathers in the DH, because they had spent a lot of time and energy trying to abolish health visiting by removing them from statute and closing their register; now here was the Social Exclusion Task Force promoting health visiting as if it still existed and as if its practitioners could do a good job. So, in the first instance, there was a lot of discussion about how important it was to ensure this programme could, once it was rolled out, be integrated into the overall health visiting service. I recall meeting Kate Billingham just after her first visit to the US, which was the cause of much merriment because she said the nurses implementing the programme in the States were exactly like health visitors; spoke, dressed (pearls and cardigans!) and even sat like health visitors. Olds has been at pains to point out the the nurses in the US 'are not just nurses, not like ordinary nurses,' and he is reportedly extremely impressed with the calibre of the health visitors implementing the programme here. I understand there are around 2-3 midwives and 1 children's nurse (does anyone have exact figures?), but the vast, vast majority of practitioners implementing the pilots are health visitors. Pause for two thoughts. First, any study or experience of implementing new services and new roles shows that it always generates enormous enthusiasm and excitement, because of - the contrast to the absolute drudgery of everyday practice; protection from much of the stress - the joy of having sufficient time and funding, - the stimulation of new education and training, demonstrating and expanding participants' consciousness - the interest shown by managers and others (Hawthorne effect?) - those chosen to participate are usually selected as a result of fierce competition, so they start out excellent and enthusiastic. The FNP is no exception; it would be an absolute disaster if, having had so much money, support and time spent on them, the practitioners were not saying how exciting and different it all is, so that is what they are saying. Also, given the antipathy by the DH nurses towards health visiting, practitioners would be firmly disapproved of, if they ever mentioned that they used their health visiting skills. It has to be made clear to everyone that these are NURSING pilots, not health visiting ones (someone emailed me about these recently, and said she had initially typed 'FNP plots,' which seems more to the point really)! Second, over the last year, various other things have happened in health visiting. The health visiting review singled out the FNP as one of the two roles being promoted as appropriate for health visitors. It also, without actually saying so, indicated that 'health visiting services' as such would be disbanded. Although a universal and expanded CHPP would continue to be available, delivered by a team 'led by a health visitor,' the review indicated that would be all that needed commissioning, apart from the FNP. Although that shows a stunning lack of knowledge of health needs and what health visitors actually deliver on the ground, it is a view that has been promoted fairly consistently by the DH nurses for some time now, and it is always delivered through this 'professional titles don't matter' mantra. 'Professional titles don't matter' is a code for 'don't mention health visiting, only talk about nursing.' There has also been a view that we should 'get away from caseloads' for health visitors. In other words, only deliver the CHPP and referrals to the FNP, either as part of general practice or in the children's centre; then we won't have to pay for expensive professionals holding undifferentiated caseloads and high levels of responsibility. Also, the post-registration consultation for 'modernising nursing careers' has proposed five career routes, of which 'child family and public health' is one. There is (of course) no mention of health visiting, except to point out that the health visiting review was part of this initiative and that the third part of the NMC register is a bit of a nuisance which spoils their neat model (well, it isn't phrased so undiplomatically, I admit!) This dialogue has run alongside a serous dip in both student health visitor numbers and health visitors in post. This drop in capacity is being used to promote these ideas as positive and manageable, whilst visions of a universal service linked in with one that also meets needs identified (even if not so severe as to merit the FNP) through universal contacts, are promoted as old-fashioned, unnecessary, without an evidence base and unhelpful to health inequalities. Again, that shows considerable ignorance, but professional rivalry, and the need to promote nursing at all costs, is clearly more important in some quarters than the need to serve the community, reduce health inequalities or meet the health needs of the youngest and most vulnerable members of our population. Back to the roll-out of the second round of FNP pilots. The fact that this second tranche of money has been made available is a testimony to their success; that is down to the health visitors implementing the programme, and to those supporting them in their new role. It is not down to nursing. However, if the DH acknowledges that it is health visitors who have done this, they might have to start saying positive things about health visiting. And if anything is positive, they want nursing to own it. What is so depressing about this, is that it is such a clear example of professional rivalry being the source of damage to service provision. We really should be developing services to meet needs (all needs, across the social gradient, not just a tiny minority) not to meet a professional agenda, however exciting this new role might seem. There are two cheerful things, though. First, there do seem quite a few places now talking about reinvesting in health visiting services, after 2007 being such a disastrous year of cuts and cutbacks. Second, the new health visiting programmes, developed as a result of changes to the standards in 2002 and 2004, are far better than the old SPQ (community nursing) programmes developed in the late 1990s, and they appear far more consistent across the country. So, for once, it seems that the PCTs might be leading the way more positively. I hope Maggie will say, if her CPHVA antennae are picking up different things to me, but perhaps we should focus on pushing on those open doors, rather than fighting the old-school nursing hegemony, which is just so destructive. Thank you for bringing this news to the group, , and like you, I will be pleased to hear of anyone else's experiences and views. kind regards On 10 Jan 2008, at 10:41, Whittaker wrote: I wonder did anyone else go to one of the two presentations this week about the Family Nurse Practitioner pilot. I was at the Manchester one yesterday and whilst I came away feeling enthused about this exciting role, I simultaneously felt quite sad about what was muted about health visiting. I asked about training in the future for these new roles and whether if as nurses it would be expected that they would sit on the third part of the register. The response was for a preference not to be. I suggested might it be an opportunity for developing, say a 3-4 year, direct entry programme for this nurse and the response was well that's a interesting idea and yes possibly. When another question was asked about what will happen to the families when the child is two and the FNP service ceases - will the family go under the wing of the generic HV service? The answer was well we don't even know whether we will have a HV service of that nature by the time these children are 2yrs (in about 18mths time). The FNP programme of course is dedicated to the title nurse - one of the key presented opened with saying this is not about titles, but I noted that reference throughout the day by the central team was to nurses' skills and what nurses can offer and little if any reference to skills brought from existing health visiting base. I'd be interested to hear any other experiences from these days. Are any of you in this group working as FNP? WhittakerSenior LecturerDept of NursingRoom 432 Brook BuildingUniversity of Central LancashirePreston PR1 2HE Tel: 01772 893786Kwhittaker1@ uclan.ac. ukhttp://www.uclan. ac.uk/facs/ health/nursing/ research/ groups/children/ index.htm Any representations, views and/or opinions in this e-mail are those of the sender, and not necessarily of the University. The University's computer network (including its e-mail facility) is intended for educational purposes, and the University accepts no liability for, and shall not be bound by, the contents of any e-mail sent from its network which do not relate to those purposes or other business of the University.This e-mail is confidential to and for the sole use of its addressee(s). 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