Memorandum by the Royal College of Nursing
(RCN) (WP 38)
SUMMARY
— The RCN considers the measures outlined
in the White Paper as insufficient to address current health inequalities.
A greater focus on specifically targeted services is required
as well as greater recognition of the role of the health service
itself in reducing inequalities. The RCN also urges caution over
the presumption that choice is a matter purely for the individual.
— For the White Paper to be successful
the public need to be fully engaged in their own health. However
the proposals are relatively weak on the need for public and community
engagement in public health issues.
— The RCN welcomes many of the specific
interventions outlined in the White Paper, but feels that there
are still some areas for improvement, in particular around smoking,
obesity, sexual health and school nursing.
— The White Paper has significant implications
for workforce planning and underlines the need for greater investment
in recruitment and retention of the nursing workforce, as well
as the need for a significant change in the culture of the NHS
as a whole.
1. INTRODUCTION
The nursing workforce is a key resource in the
improvement of public health with nurses providing 80% of all
patient care. Nurses work in a variety of settings such as schools,
communities, general practice, the workplace, hospitals and care
homes. Each role encompasses a health promotion aspect and for
this reason maximising the contribution of nursing staff in public
health will be key to ensuring the successful implementation of
the public health White Paper.
With a membership of over 370,000 registered
nurses, midwives, health visitors, nursing students, health care
assistants and nurse cadets, the Royal College of Nursing (RCN)
is the voice of nursing across the UK and the largest professional
union of nursing staff in the world. The RCN promotes patient
and nursing interests on a wide range of issues by working closely
with Government, the UK parliaments and other national and European
political institutions, trade unions, professional bodies and
voluntary organisations.
The RCN welcomes much of what is proposed in
the public health White Paper, as it marks a turning point for
health service delivery by emphasising the responsibility of local
populations in health improvement. However we retain some specific
concerns, which are outlined below.
2. WILL THE
PROPOSALS ENABLE
THE GOVERNMENT
TO ACHIEVE
ITS PUBLIC
HEALTH GOALS
2.1 The RCN considers the measures outlined
in the public health White Paper insufficient to address the health
inequalities which currently present the greatest challenge to
the nation's public health. The link between health inequalities
and social inequalities is well known and accepted, with a marked
difference in life expectancy and morbidity between socio-economic
groups 1 and 5.[79]
We recognise that whilst the health service alone cannot completely
ameliorate health inequalities, it can make a significant contribution
to health improvement by tailoring services to those in greatest
need. However the principles behind the public health White Paper
need to be strengthened if the health inequality gap is to be
significantly reduced. The RCN believes there are a number of
ways in which this could be achieved.
2.2 Targeting the health of disadvantaged
groups is key to reducing health inequalities. Doing so can both
assist in equalising access to services and equalising outcomes
from health. care interventions. The RCN strongly believes in
redesigning health services so that they focus on those most in
need in order to compensate for poorer health status. However
the public health White Paper places insufficient focus on the
need for specifically targeted health services.
2.3 If a reduction in health inequality
is to be achieved, the role of children and families will be crucial.
There is evidence to suggest that early years experiences can
be a protective factor against social disadvantage in later life.
For example, research has demonstrated significant improvement
to the birth weight of babies born to low income mothers who received
tailored support from midwives during pregnancy.[80]
Clearly pregnancy and the early years are a crucial period in
which attention must be paid to supporting parents to nurture
the physical and emotional wellbeing of their children. Educating
and investing in families is the most effective way of empowering
people to take control of their own health, and both midwives
and health visitors are the professionals best placed to provide
such support. However there is a shortfall of midwives and health
visitors across the UK and those who are practicing face workload
and time pressures which means that in practice they have little
time to devote to children and families for this purpose.
2.4 Whilst the RCN acknowledges that a key
principle underpinning the White Paper is the enablement of individuals
to take personal responsibility for their own health, we urge
caution over the presumption that choice in public health is a
matter simply for the individual. Adult behaviours are shaped
by social and environmental circumstances as well as the individual's
will. Therefore changing health behaviour is much more than merely
providing information on healthy and unhealthy lifestyles. Similarly,
there needs to be a balance struck between individual choice.
and action taken in the interest of the public good. The ability
to express a choice may be hampered if it is to be determined
that the public interest will be served by a particular course
of action—eg water flouridation.
2.5 The health service itself can make a
significant contribution to reducing health inequalities as it
is the largest single employer in the UK[81],
a fact which merits greater attention. The potential impact the
health service can have on improving local employment and therefore
the local economy is considerable, with the subsequent knock on
effect of improving health inequalities within the local population.
There are serious shortages of staff in the NHS workforce, yet
the local population is often not considered as a source of candidates
for health service jobs. The RCN believes that the public health
White Paper should emphasise investment of NHS funds in pre-employment
training, "access" courses to professional education
and local recruitment as a means of developing the local workforce
and, in the long term, reducing health inequalities.
3. WHETHER THE
PROPOSALS ARE
APPROPRIATE, WILL
BE EFFECTIVE
AND WHETHER
THEY REPRESENT
VALUE FOR
MONEY
3.1 The RCN believes that if the public
are to be "fully engaged" in health matters as envisaged
in the Wanless review, and if true value for money is to be achieved,
the overriding aim of the White Paper should be to create a demand
for health, rather than merely a demand for health care. The extent
to which the public are engaged in their own health will be a
measure of the effectiveness of the proposals in the White Paper.
Yet it is relatively weak on the need for public and community
engagement in public health issues, even though evidence suggests
that community participation which focuses on building social
cohesion can impact on health outcomes.[82]
3.2 Whilst the RCN welcomes many of the
proposals set out in the White Paper there are a number of specific
areas of intervention outlined which need to be strengthened:
3.3 Smoking
Whilst the RCN warmly welcomes the measures
on smoking cessation, we feel the proposal to exempt some licensed
hostelries from a ban on smoking does not go far enough. The RCN
believes that a ban on smoking in all enclosed places should be
introduced. Nurses see the devastating effects of smoking on patients
every day. At RCN Congress in May 2004, RCN members voted in favour
of a resolution to campaign for a ban on smoking in public places.
We believe that only a complete ban will help to protect people
from second-hand smoke, encourage people to give up and ultimately
act as a deterrent.
Towards this objective, the RCN is working with
the Department of Health on a campaign targeting nurses who want
to give up smoking. The RCN firmly believes the health of the
nursing workforce is of paramount importance, and staff will be
provided with support and guidance in smoking cessation as part
of the Government objective of a smoke free NHS:
3.4 Obesity and Diet
Whilst the RCN welcomes the "Healthy Start"
proposal to provide vouchers to be exchanged for fresh fruit and
vegetables, the RCN believes that there is a need for stronger
measures to ensure school meals are nutritious and healthy. This
is a particular concern given the dependence of a substantial
number of children on these as their main meal of the day. The
White Paper outlines that the Government will consider introducing
nutrient based standards for school meals and vending machines.
However the RCN recommends that this should be a concrete commitment
to ensure food provided in schools is as healthy as possible.
3.5 Sexual Health
The RCN welcomes the proposed national roll
out of clamydia screening by 2007, however we feel strongly that
new and imaginative ways of working need to be found in order
to ensure this can be achieved. Similarly, the proposal to reduce
waiting times for both clinic appointments for sexually transmitted
infections to 48 hours, and termination of pregnancy before 10
weeks gestation is a positive development. However measures need
to be put in place to ensure this can be implemented. Current
specialized sexual health services are stretched to the limit,
but primary care services are ideally placed to work in partnership
with them to reach these targets.
However education in sexual health at pre-registration
level in both medicine and nursing is insufficient and needs to
be increased. Improving skills in sexual health for current and
future practitioners is a priority so that primary care services
and general practices within them are fully equipped to offer
a full range of sexual health services. The RCN therefore recommends
that funding for sexual health treatment and promotion services
should be ring fenced rather than, as is often the case, diverted
to other services within a Primary Care Trust.
3.6 School Nursing
The RCN warmly welcomes the target set in the
White Paper for one full time school nurse within one secondary
school and the associated cluster of primary schools by 2010.
The role of the school nurse is integral to the health and well
being of children, fulfilling functions such as immunisation,
providing health education, tackling bullying and promoting children's
emotional wellbeing. However there is currently a shortfall in
the number of school nurses and wider problems about recruitment
and retention of the nursing workforce generally. The RCN's most
recent labour market review, Fragile Future[83]
revealed that more than a quarter of the profession are now over
50 and there is an increasing reliance on bank and agency nurses.
The RCN believe the proposal outlined in the White Paper should
be accompanied by a recruitment campaign to highlight school nursing
as a career option.
In addition we are also aware of significant
problems in access to specialist school nurse post registration
education courses, as some higher education institutions no longer
run these. In light of this we feel it would be appropriate for
the Department to undertake specific workforce planning around
the school nursing workforce to identify future projections of
staff numbers and the level of need for training.
4. WHETHER THE
NECESSARY PUBLIC
HEALTH INFRASTRUCTURE
AND MECHANISMS
EXIST TO
ENSURE THAT
PROPOSALS WILL
BE IMPLEMENTED
AND GOALS
ACHIEVED
4.1 Given the prevalence of the role of
nursing in public health at all levels, the White Paper has significant
implications for workforce planning. Community nurses, health
visitors and midwives already undertake a substantial proportion
of face to face contact with patients and communities, and have
the potential to contribute further to make a real impact on public
health. However workload pressures and time constraints prevent
this. If the White Paper is to be implemented successfully investment
in recruitment and retention of the nursing workforce is crucial.
4.2 The proposals outlined in the White
Paper also have significant implications for the working culture
of the NHS as a whole. As outlined in the RCN's response to the
Health Select Committee's inquiry into public health in 2000[84],
a notable cultural shift is required if improvements in public
health are to be achieved. The culture of the NHS does not lend
itself well to broader public health. This is largely because
the core business of the NHS is seen by both the professionals
who work within it, and by the public, to be about delivering
services to care for or cure individuals who are ill. The RCN
believes that in order to achieve such a cultural shift, public
health should be part of a whole systems approach to healthcare
rather than treated in isolation. Organisational performance management
is needed which integrates both planning and delivery of public
health. The RCN believes that public health performance management
and assessment is required in all health trusts so that public
health becomes a mainstream activity alongside healthcare and
treatment.
4.3 There is a pressing need to foster multi-disciplinary,
multi-agency teamwork in public health. At present different agencies
and disciplines meet at strategic level to consider public health
issues. However there is no national mechanism to bring together
those who practice in the front line of public health, and the
RCN recommends that teamwork should be developed in public health
practice in every locality. Doing do will ensure that public health
is everyone's business by creating an infrastructure that supports
practitioners and local people working together to identify issues
and seek local solutions.
January 2005
79 Marmot, M (2004) Status Syndrome: How Your Social
Standing Directly Affects Your Health Bloomsbury: London. Back
80
Oakley, A et al (1990) "Social Support and Pregnancy
Outcome" British Journal of Obstetrics and Gynaecology,
97. Back
81
Coote, A (2002) Claiming the Health Dividend: Unlocking the
Benefits of NHS Spending Kings Fund: London. Back
82
Social Capital, A Discussion Paper, Performance and Innovation
Unit, Cabinet Office 2002. Back
83
Fragile Future? A review of the UK nursing labour market
in 2003, RCN November 2004. Back
84
RCN response to the Health Select Committee inquiry into public
health, 2000. Back
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