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Leeds Community Healthcare NHS Trust, Professor Bob Lewin

Clinical Articles, News & Views

Call for more specialist nurses in HF and arrhythmia

The Leeds Community Healthcare NHS Trust Heart Failure Service has received funding from the British Heart Foundation (BHF) to set up a community intravenous (IV) diuretic service for patients with heart failure (HF).

The service will initially be led and developed by HF nurses Paula Smith and Caroline Senior, whose role also includes supporting and training others to ultimately deliver the service as well as engaging service users and other key stakeholders.

The service will aim to:

  • enhance patient care through better symptom control
  • reduce the distress caused by unplanned hospital admissions
  • deliver care at home in a timely manner
  • offer patients more participation and choice about where they will be cared for especially in the end stages of their condition when oral diuretics are failing to provide effective symptomatic relief
  • provide a safe cost effective service that is strongly focused on the needs of service users.

Lewin Photo April 2011 reduced copy

Professor Bob Lewin (University of York)

Professor Bob Lewin (University of York) spoke to BJC Arrhythmia Watch on why the NHS should appoint more Clinical Nurse Specialists:

“Chapter 8 of the coronary heart disease National Service Framework recommended that all patients should have an arrhythmia care coordinator who would guide them through diagnosis, treatment and, in complex cases, provide support for as long as required. In the main this role is performed by nurses, and until that aim is achieved I think there will continue to be a need to appoint more”.

“Cost pressures mean we should increase the spend on specialist nursing services, not reduce it.”

“There is a need to

  • improve the patient pathway by liaising between the patient, his or her family and different groups of medical staff
  • educate and encourage patients seen in secondary care in the better self-management of their condition
  • relieve doctors of routine clinical work
  • educate generalist staff in the hospital or across the secondary/primary care barrier about patients with complex care needs
  • a popular solution is to create a specialist nursing service.”

Do Nurse Specialists solve these problems?

“Over the last 10 years our research group, at the university of York, has evaluated the introduction of cardiac specialist nursing services including: Paediatric Cardiac Liaison Nurses, Adult Congenital Heart Disease Nurses, Arrhythmia Specialist Nurses and a collaboration between BHF Specialist Heart Failure Nurses and Marie Currie Cancer Nurses. The expectations placed on these new roles were not just fulfilled: they were often exceeded.”

“The birth of these new services was not always easy. The nurse/s generally had to win the, sometimes grudging, trust of medical staff, other nurses, managers and GPs.  Eventually, in most cases, within a couple of years, the battle was won. Some specialist nurses were empowered by their consultants or managers to develop their service even further, reshaping the clinical service in ways not envisaged in the original job description.”

“Patients and their carers valued the nurses highly, especially those who had experienced secondary care before the new service. Typically expressed benefits were: having a single person I can rely on to know the answer or to find out for me, someone I can talk to without feeling stupid and that I can understand when they talk to me, having someone who is kind and seems to care about me, I don’t feel like a number in a machine anymore, I know if I need help I can just phone her and she’ll tell me what to do, someone who knows about me instead of a having to explain to a new person every time!”

Why are Specialist Nurse services often first in the firing line?

“So when there are cost pressures, why are specialist nursing roles often the first to be threatened? Why, according to a survey carried out by the RCN in 2005/6, were 45% being asked to work outside their specialty to cover staff shortages? Why did 25% fear they were to be made redundant?  The answer is that when frontline acute services are under pressure these posts are often seen as providing a “Rolls Royce” service: an expensive luxury that is an easy target when money is needed to cover the cost of keeping people alive.  By 2004 it had become obvious to us that however many benefits the nurses provided they would be at threat unless we could show that they were not an expensive luxury. So, whenever possible, in our evaluations we collected economic data alongside the clinical outcomes.”

The financial case for CNS

“We were conducting pragmatic evaluations not randomised controlled trials and in most cases the best we could do was to compare admissions to hospital before the nurses were appointed and then afterwards. In some evaluations we were able to compare hospitals that had the nurses we were studying with similar hospitals that didn’t. What did we find? How much more did the service cost?”

“The evaluation of 76 community based Heart Failure Specialist Nurses showed that after they were appointed readmissions for CHF reduced by 35%. After the costs of salary and support for the nurse were accounted for each patient in the nurses caseload there was a saving of £1,826. (Pattenden, J. 2008).”

“The evaluation of Arrhythmia Specialist Nurses showed that after deducting the cost of the nurse and her support the estimated saving was £29,357 per nurse per year.”

“The Better Together initiative, where BHF Heart Failure Specialist Nurses and Marie Currie nurses worked together to meet the palliative care needs of the people with CHF significantly reduced costs in one site, and reduced the pressure on beds by allowing the majority of patients to die in the place of their choice, which usually was their own home in both sites. With both sites put together the many benefits to patients and their family were at no cost.”

“Remarkable as these findings were it is probably that the full cost-benefit is greater. For example, when interviewing consultants it was clear that without the nurse, further expensive medical posts would have been required. Nurses often prevented unnecessary primary care consultations, helped patients use their medication correctly reducing waste and so on, unfortunately we didn’t have the resources to capture all these additional savings.”

“From this year (2012) preventing early readmission is financially important for Hospital Trusts because the Department of Health intend to fine hospitals, by withholding payment, for every unplanned readmission within 30 days of discharge.”

Why we need more specialist nurse services

“The two main cost pressures on the NHS are hospital admissions and the growing number of people with chronic illnesses. Poorly educated, confused, scared patient who don’t know where to turn for effective advice and support, who don’t know how to use their medications effectively, who have frightened or overwhelmed carers add to NHS cost pressures because these are the main causes of unnecessary admissions. As medical treatments become more complex, admission times shorter, the number of patient to diagnose and treat greater, face-to-face time with patients less all these pressures are going to get worse and without some action so will unplanned re-admissions.”

“Identifying and managing the factors leading to unnecessary re-admission, improving communication and the efficiency of the patients’ treatment and pathway are what most specialist nurses do. In most cases this saves money that can be used to support the more basic acute provision. That’s why, in these times of budgetary stress, we need more of them.”

Published on: October 19, 2012

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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