psychotherapy service

History

It is now considered that approximately one third of all consultations with the GP are psychosocial in nature and involve psychosomatic complaints as a result of a personal crisis such as bereavement or marital stress (Papadopolous and Bor 1995). The doctors at Cuckfield understand that mental and physical health affect each other and have encouraged the development of an autonomous counselling and psychotherapy team, which comprises a part-time psychotherapist, the nurse practitioner who holds a diploma in counselling and the CPN (Community Psychiatric Nurse).

Current practice

John Davidson, psychotherapist has been trained in both cognitive and behavioural and psychodynamic psychotherapy as well as hypnotherapy and autogenic training.

Sue Davidson has undertaken an integrated training and is able to utilise different types of therapy tailored to the client's needs, as well as being trained in teaching stress management and assertiveness skills.

Reg Cook is a CPN of many years standing and is more involved with the seriously mentally ill patients at the practice. He has also undertaken autogenic training in the past.

During the past year Sue has had to decrease the number of clients she sees due to other commitments, which has had an impact on the other team members.

Conclusions

The team is therefore able to offer a comprehensive 'in-house' mental health service, which is both popular with clients and other health professionals alike. A recent audit revealed that 93% of clients were seen within 6 weeks of referral and over 80% found the counselling to be helpful/very helpful and would seek counselling again.

Recommendations

Each year referral rates rise and the team are now considering more group work in order to cope with the volume, particularly in the area of relaxation and stress management (50% of last years clients received autogenic training). This may also serve to relieve the pressure on John and Reg as it is not envisaged that Sue will be able to increase the numbers of clients seen.
Ref: Papadopolous, L. and Bor, R. (1995) Counselling Psychology in primary care: a review.
Counselling Psychology Quarterly 8 (4) 291 - 303

Asthma

History

Asthma is a common, chronic condition where there is long-term inflammation of the airways of the lung. The aim of asthma treatment is that patients should be free of symptoms day and night, to reduce the risk of severe attacks, to minimise absence from work or school, the restoration of normal or best possible long term airway function and to ensure the normal growth of children (Levy, M. et al. 1997).

Current practice

The number of asthmatics at the surgery totals approximately 280 patients representing 4.6% of the practice population.
Sue Davidson undertook a diploma in management of asthma last year and took over the asthma clinics last September.
Sheila Graysmark is currently studying for her diploma and is now beginning to see patients on a regular basis.
Together we hope to develop a centre of excellence for asthma care providing a more cohesive, evidence based service than before.
A mini audit recently carried out revealed that during the first 6 months of Sue taking over the clinics those clients who had experienced night-time symptoms improved by 54%, day time symptoms improved by 46% and compliance had generally improved resulting in a 90% compliance rate.
Following a time consuming survey of patients notes, Sue is now sending out appointments to all those who appear to be mis-using their medication or who have not been seen for over a year, a total of 72 patients. This will then be followed up by another audit. It is hoped that by this time every asthma patient will understand his/her diagnosis, will be able to use their inhalers properly, will have a peak flow meter at home, will be prescribed appropriate medication and will have a self-management plan.
Sue Davidson and Sue Cowdy also have plans to improve asthma care in the local schools, particularly in the areas of understanding and compliance, using audit in the first instance and then to develop a better liaison system between schools and general practice. It is hoped that this will be set up by June 1999.

Conclusions

We feel that we are beginning to improve the care offered to asthmatic patients. As 2 nurses are now trained in asthma care, there will no longer need to be a break in service for holidays as before.

Recommendations

We believe that by working in partnership with patients in the development of their self- management plans, acute asthma attacks, the use of nebulisers and hospital admissions will be minimised and more people will be able to lead a 'normal' symptom-free life.
A self-management document is in the process of being formatted and we are hoping to get sponsorship for printing it. We are developing a practice protocol for the management of asthma, which we hope, will be used by nurses and doctors alike.

Ref: Levy, M., Hilton, S. and Barnes, G. Asthma at your fingertips. (2nd edition) 1997

Osteoporosis

History

'Osteoporosis is a systemic skeletal disorder characterised by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility' (Hillier and Cooper, 1997).

1 in 3 women and 1 in 12 men are affected by osteoporosis, representing a major public health problem. Dual X-ray Absorptiometry (DXA) is the most reproducible method for measuring bone density and is the current best predictor of osteoporosis (National Osteoporosis Society, 1996).

Current

The surgery were very fortunate in being able to have the use of a forearm DXA scanner for a period of approximately 6 months.
711 women between the ages of 50 and 75 were invited for a scan of their forearm, which can help predict whether they are at risk of developing true osteoporosis, of which 495 took advantage.
The results have been very interesting and are as follows:

Twelve women under 50 were also scanned seven of whom had a normal result' with the remainder showing a degree of osteopaenia (demonstrating low bone mass below the young normal mean) and therefore at greater risk of going on to develop true osteoporosis.
All women with an abnormal result have been re-invited to discuss their condition with either Dr. M. Harvey or Sue Davidson and all have received lifestyle advice, information and explanation of their condition and appropriate medication.

Conclusions

This has been a time-consuming exercise, but those involved believe it to have been very worthwhile and trust that in the long-term these ladies will be able to avoid the pain and disability of osteoporosis and associated fractures, and also save the NHS millions of pounds in treatment.

Recommendations

It is recommended that those at osteoporotic risk will be re-scanned again in 3 - 5 years time in order to assess their progress and to evaluate whether their treatment has been effective.
Ref: Hillier, S and Cooper, C. (1997) The Epidemiology of Osteoporosis in Osteoporosis Illustrated.
Osteoporosis Resource Pack. (1996) National Osteoporosis Society.

Audit

History

"The aim of medical audit in general practice is to improve the quality of service provided to patients registered with the practice. It includes anything which contributes to the smooth running of the practice and the reduction of stress in the members of the primary health care team as well as purely clinical matters"
(W. Sussex MAAG).
It involves setting acceptable standards, systematically gathering data to find out what is actually happening and whether standards are being achieved and if not implementing changes and then reviewing.

Current

Sue Davidson who holds the certificate of clinical audit is the audit co-ordinator for Cuckfield Surgery and works alongside Dr. M. Harvey on many audits. Recent audit topics include counselling, epilepsy, asthma, alcohol, immunisation, eczema and myocardial infarction.

Conclusions

Clinical audit is an essential tool in evaluating clinical effectiveness. It is a process designed to improve patient care, which has become the accepted method by which professionals can measure their working practice as compared to what is believed to be good practice.

Recommendations

Sue Davidson and Sue Cowdy are undertaking further training in clinical audit in order to support and evaluate the clinical projects and changes being brought about by the introduction of the integrated nursing team and will act as a resource to other team members.

Ref: Medical Audit - A Purposeful Process. West Sussex Medical Audit Advisory Group


Integrated nursing

History

"A team of community-based nurses from different disciplines, working together within a primary care setting, pooling their skills, knowledge and abilities in order to provide the most effective care for the practice population and community it covers" (CPHVA Professional Briefing Paper - June 1997).
Integrated nursing teams are being introduced all over the country and the doctors and nurses at Cuckfield have all agreed to participate in a pilot project to develop the concept in Mid-Sussex.
The fundamental aim of integrated nursing is to provide high quality care to Practice patients by maximising the use of Community Nursing resources.

Current

The project has been up and running since January of this year and the team members have all participated in team-building days.
At Cuckfield it was decided that a GP (Dr. Barrie) and the Practice Manager would be involved so that enhanced communications would be maintained.
Although striving for autonomy the nursing team recognises that they are a team within a team and they did not wish to risk isolation and the creation of barriers. Training has been undertaken in areas such as budgeting, audit, recruitment and selection with a view to the team becoming potentially self-managed. The main priority has been the production of the Practice Profile so that the health needs within the community can be identified. The team will then decide who is most skilled to meet those needs and it is envisaged that this approach will prevent unnecessary and time-consuming role duplication.

Conclusions

Since its inception, the team has experienced the process of forming, storming, norming and performing, as described by Tuckman, 1965. There have many occasions when we all wanted to give up, when morale ran low and we questioned the whole concept.
However, we continue to meet and work together well as a team and maybe only now are we beginning to feel a sense of achievement as the practice profile reaches completion.

Recommendations

The project will be evaluated and monitored using qualitative and quantitative measures, which will be carried out by the Project Facilitator and the Clinical Effectiveness Manager from the Trust. They will receive external and therefore unbiased support and advice from Sussex University.
Very gradually the team will begin to take on more responsibility for itself, vital in light of the new Primary Care Groups to be established next April, 1999.
Nursing and nurses need to have a voice in the future of the new NHS and a 'team voice' is more powerful than an individual one.

Ref.
Tuckman, BW. & Jensen, MA. (1977). Stages of small group development in Journal of Nursing Administration (1993).
CPHVA Professional Briefing Paper - June 1977

CUCKFIELD POPULATION STUDY

Total live births (per thousand population)
OPCS 1992 VS1 statistics
England and Wales=13.4 Haywards Heath=11 - 12 Cuckfield=

Infant mortality rate per 1000 live births (1991)
OPCS VS1 statistics
England and Wales=7.3 Mid Downs=4.9 Cuckfield=

Stillbirth Rates 1991(deaths after 24 weeks gestation)
OPCS VS1
England and Wales=4.6 Mid Downs=4.4 Cuckfield=

Perinatal mortality rates 1991
OPCS VS1 (No. of stillbirths + deaths in first week of life)
England and Wales=8.0 Mid Downs=7.0 Cuckfield=
(Chichester 5.5 - why?)

Neonatal mortality rates 1991
OPCS VS1 (No of deaths in first 28 days of life)
England and Wales=4.4 Mid Downs=3.5 Cuckfield=
(Chichester=2.8 why?)

Post neonatal infant deaths 1991
OPCS VS1 (No. of deaths after 28 days but before end of first year of life) rate per thousand births over 4 years
England and Wales=6.6 Haywards Heath=<3 Cuckfield=

Teenage pregnancies ( age 15 - 17)
yearly average per 1000 females (1988 - 1993)
Haywards Heath 4.15 Cuckfield=
(compared with figures of 10.42 and 9.67 in other areas in W. Sussex)

Termination of pregnancy (age 15 - 19)
1992/93 OPCS Census 1991) per 1000 females
Haywards Heath - NHS=3, BPAS=19 Cuckfield -
(compared with figures of 8 and 1 and 59 and 13 using other areas as above)

Top 10 causes of death 1992
OPCS VS3

Ischaemic heart disease
England & Wales 145904 - 26%
Mid Downs 599 - 22.5%
Cuckfield

Stroke
England & Wales 66291 - 11.8%
Mid Downs 323 - 12%
Cuckfield

Ca Trachea, bronchus, lung
England & Wales 33662 - 6%
Mid Downs 128 - 4.5%
Cuckfield

COPD
England & Wales 28602 - 5%
Mid Downs 120 - 4.4%
Cuckfield

Pneumonia
England & Wales 26257 - 4.7%
Mid Downs 136 - 5%
Cuckfield

Ca female breast
England & Wales 13663 - 2.4%
Mid Downs 79 - 2.9%
Cuckfield

Ca colon
England & Wales 12781 - 2.2%
Mid Downs 61 - 2.2%
Cuckfield

Mental disorders
England & Wales 12950 - 2.3%
Mid Downs 61 - 2.2%
Cuckfield

Ca prostate
England & Wales 8735 - 1.5%
Mid Downs 46 - 1.7%
Cuckfield

Diabetes Mellitus
England & Wales 8067 - 1.4%
Mid Downs
Cuckfield

Ca of lymphatic and Haematopoietic tissue
England & Wales
Mid Downs 50 - 1.8%
Cuckfield


Top 10 causes - GP consultations

Data for asthma admission rates in H. Heath (1991)

Asthma

Cuckfield civil parish 1991

Population survey - W Sussex

Cuckfield Rural

Elderly population

In 1994, in the United Kingdom, 8,000 people (7,000 women and 1,000 men) were aged 100 and over. In 2031 it is estimated that 28,000 women and 6,000 men will be in this age group. In 1994 a man of 60 could be expected to live for another 19.7 years and a woman of the same age for 23.6 years. It is estimated that people over 75 years of age will have doubled by the middle of the next century whilst the oldest old, that is aged over 90 will have more than tripled (Age Concern 1997). This group presents a challenge to the primary health care team with a variety of unique problems associated with the physiological changes of ageing, chronic illness and declining social support.

Because of the wide variety of conditions and illnesses that they suffer, they are also likely to experience the adverse effects of multiple medications prescribed by health professionals. They are most susceptible to falls, incontinence and alteration of mental status and evaluation of their care must include their social, functional and medical status best carried out using a multi-disciplinary approach. (Roche R. 1996).

Many elderly live alone and many experience hardships associated with reduced finances, lack of transport and lack of basic facilities such as washing machines and central heating. Hypothermia and associated winter deaths contributed to a 19% above average death rate between 1991 and 1995, compared with rates for Germany and Scandinavia which were 4% and 7% respectively above average (Age Concern 1997). Carers take the burden of care from the State and in 1990 57% of carers had dependants (mostly female), over 75 years of age (Age Concern 1997). (See elsewhere for account of Carers in the Community).

Ref. Older People in the United Kingdom. Some basic facts. (September 1997). Age Concern Roche R. (1996) in Medicine - a primary care approach. W.B. Saunders Company. Sue Davidson's Work Profile 1.4.98 - 29.5.98 (20 working days)

Analysis from the graphs has revealed that nearly a quarter of my time is involved in surgery representing nearly half of the total number of patients seen. Consultations vary in length and content - minor childhood ailments, skin disorders, female complaints and contraception, stress related disorders to name but a few as well as those who come mainly for reassurance or to know whether they should see a GP. Although I do have specific time set aside for asthma and the menopause, patients often book in to normal surgery time for these appointments.

Asthma takes up a large percentage of my time (17%) and a quarter of all the patients I see are for asthma and COPD. During the assessed period the management of osteoporosis involved 10% of my time and 15% of the total number of patients seen. However, this will not be so in future as the scanning has now come to an end. I now need to consider how best to use the time that this will now offer. Although only 4% of my patients were seen for counselling, this represented 10% of my total time. It is not envisaged that I will increase the number of patients seen for counselling, as it is very time consuming and might be considered an expensive use of my time.

Appointments for management of the menopause have reduced considerably since the introduction of a specific clinic just over a year ago. As research continues to demonstrate the importance of hormone replacement therapy in the prevention of osteoporosis and cardiovascular disease, as well as alleviating the uncomfortable and sometimes debilitating symptoms of the menopause, I need to review and evaluate the service and consider how best to take it forward. Although I completed the Certificate of Family Planning in February of this year, I have not really had much opportunity to put it to good use. I believe this to be great shame as it is a waste of a skill, which is already gradually, being lost and a waste of time and money involved in the study time. I therefore need to seriously consider how best to use and update these skills so that the practice and its patients can benefit.

Cuckfield Nurses

The blood-taking service has now been in operation for one year and has become very popular with patients; in fact, almost a 'victim' of its own success. The allocated time for this drop-in service is often not sufficient to cope with the increasing demand, causing the nurses to then run behind with their pre-booked appointments. We have also begun to question whether this is a service that should be carried out by such highly qualified/paid nurses, when, in fact, it could quite easily be performed by a trained auxiliary nurse at 'B' grade. Over the past year it has been calculated that the cost of Sheila taking bloods has been approximately £499 and Libby, £421; a total of £920. A 'B' grade would cost £515 (1st level) for a similar number of hours. As we were considering this, it occurred to us that the nurses also carry out many non-nursing duties, often necessitating them working extra time, which they then have to take back. The whole situation has recently become very difficult with nurses under pressure to see more and more patients, working extra hours in order to do so, but then being absent whilst reclaiming time. (The cost of this time during the period January to August this year amounts to £746.93). This then set us thinking again about the possibility of employing an auxiliary who could not only carry out blood taking sessions, but also take over some of the administration duties, re-stocking of doctor's rooms and ordering of stock. This would then provide extra appointment time for the nurses who could then be using their skills more appropriately. For example, it has been estimated that if they were released from the blood-taking sessions, it would make available approximately 416 further appointments yearly!

DNA (Did not attend) APPOINTMENTS

Following review and analysis of nursing workloads, it has become apparent that a great deal of time has been wasted by patients not turning up for pre-booked appointments. The nurses involved include the Nurse Practitioner, Health Visitor and Practice Nurses. It has been estimated that over the past year this has cost a total of approximately £1,605! We have therefore identified this as an area which we need to address urgently. Dr. Harvey has started this initiative by producing the attached notice which is now displayed in the waiting room. Pnuemonia The nurses and doctors at Cuckfield have initiated a vaccination campaign this year to target all those who would benefit from receiving the pneumococcal vaccination in an effort to reduce the above figures in Mid Downs. The target population are those suffering with chronic conditions such as diabetes, heart and lung disease, kidney and liver disease and anyone who is considered to have a weakened immune system. Many of the patients who traditionally attend for their 'flu' jabs' are in this category and will be offered the vaccination at the same time. Ca Prostate During the past year at Cuckfield Medical Practice there have been eleven men diagnosed with cancer of the prostate, all of whom have received care and management from Dr. M. Harvey who specialises in urology. This represents 0.18% of the total practice population. We are fortunate that we are able to offer this service 'in-house' and that Dr. Harvey is able to carry out regular follow-ups and PSA testing. This has resulted in men's health having a high profile in the practice. The Practice nurses ensure that men are informed of the need for regular self-examination when they come for new patient medical checks and all practitioners remind their patients opportunistically in surgery. Main treatment is by Zoladex injection; one patient has had an orchidectomy and others have been treated by Cypterone, Flutamide and DXT

BLOOD TAKING SESSIONS

History

Rationale:

1. To provide a service to patients who would otherwise find it difficult to attend the blood-taking department at the Princess Royal Hospital.

2. To ensure fasting blood is taken as early as possible in the day for patient comfort

3. To maximise the number of patients that could be seen in one hour for blood taking - previously all patients were offered 10-minute appointments.

Process:

1. Drop in sessions run by Practice Nurse 08.30 - 09.00 every Monday and Thursday except for Bank Holidays.

2. Patients informed via notice in waiting room, written slips and verbally via receptionists, GPs and nurses.

Review of sessions to date

1. Well attended by patients, minimum attendance 2 patients, maximum 17!

2. Patients appreciate convenience of service, especially no appointment system, demonstrated by high numbers of attendance and verbal comments.

3. Costly approach to blood taking (see comments under Cuckfield Nurses)

Recommendations:

1. Blood taking sessions should continue as an example of working practice meeting patient care.

2. More cost-effective approach needs to be considered e.g. nursing auxiliary nurse with appropriate training. The Future Primary Care Groups With effect from April 1999 all GP Practices will be represented within a primary care group abolishing the Fund Holding System introduced by the previous government and effectively bringing the two-tier health system to an end. The purpose of primary care groups is: "…….to bring together GPs and community nurses in each area to work together to improve the health of local people"

The New NHS  - A Nursing viewpoint

The groups will also involve other personnel including social services, pharmacists and other health professionals who together will not only commission health services but will also aim to improve the care that they offer. However whilst change can often be exciting and challenging it can also bring disruption and uncertainty, and the introduction of primary care groups is no exception. It brings with it the potential to change an imperfect and unequal health care system but there will necessarily be casualties. At Cuckfield the standard of care currently being offered to patients is at grave risk of being adversely affected as staff members paid directly from fund-holding face the realisation that there may be no job for them come next April.

Nurse Practitioner

Unlike practice nurses, nurse practitioners work alongside GPs seeing patients with undifferentiated and undiagnosed problems, making a diagnosis and prescribing treatment and a total package of nursing care. In the USA it has been demonstrated that nurse practitioners are able to provide care equivalent to doctors at a lower cost (ANA Publications 1980 and Stone P. 1994). Sue Davidson runs regular surgeries from 9.00 - 11.00 each morning and 4.30 - 6.00 Monday evening and over the past year has seen a total of 2136 patients. She works within protocols developed by herself and the GPs during her training.

During the remainder of the time she carries out her counselling duties, administers medical audit for the practice, plans health promotion campaigns for the surgery, co-ordinates the nursing services and fulfils the role of team leader for the integrated nursing team. One of the major benefits of employing Sue has been the provision of extra appointments reducing the pressure on the GPs, particularly when they were on leave. After two years of practising in this role, there have been no complaints registered with the surgery with no reported incidences of mis-diagnosis or other problems. Indeed patients now tend to self-select whether to see Sue or the GP and Sue's surgeries are as full as the GPs.

Research confirms that nurse practitioners can deal with urgent and non-urgent medical problems safely and reliably (Marsh G. 1995 and Atkin K. 1993) and patients demonstrate a high level of satisfaction with the choice of a different style of consultation (Myers P. 1997).

With the introduction of primary care groups Cuckfield Medical Practice is at risk of losing this valuable service, going against the whole ethos of 'improved care' advocated by the government.

Counselling and psychotherapy service

This service has been operating in its present form for the past three years and is also a potential casualty of the new primary care groups. Sue Davidson' s role in counselling has already been mentioned but the majority of consultations are with John Davidson who works for the practice for up to eight hours weekly and is also paid out of fund holding. A recent audit revealed that the majority of patients seen by the counsellors Sue and John suffered from varying degrees of depression, anxiety and other stress related problems. If this service should therefore no longer be available, these patients will be left to develop more long-term, chronic conditions, as Reg, CPN continues to see only the seriously mentally ill. Yet again, hardly an improvement in patient care!

Ref: American Nurses Association (ANA), Nurse Practitioner: A Review of the Literature, 1965 - 1967. ANA Publications, 1980. NP - 62. 1-24 Atkin K., Lunt N., Parker G., Hirst M. (1993) Nurses Count - a National census of Practice Nurses. York: University of York. Marsh G. Dawes M. Establishing a Minor Illness Nurse in a busy General Practice (1995) British Medical Journal. 310: 778 - 780 Myers P., Lenci B., Sheldon M. (1997) A Nurse Practitioner as the first point of contact for urgent medical problems in a general medical setting. Family Practice. Vol. 14. No. 6 492 - 497 Stone P. (1994) Nurse Practitioners research review - Quality of care. Nurse Practitioner. 19: 17 - 27

Mental Health

History

Reg Cook, community psychiatric nurse is allocated 50% of his full time employment for Cuckfield Medical Practice and the other 50% for his administrative duties as Team Leader of Community Psychiatric Nurses at Linwood Community Mental Health Centre. His remit is to provide a service for the mentally ill in the community (with a priority for the seriously mentally ill), enabling them to retain their independence and autonomy.

Mental Health services are subject to change in the near future following a review by the West Sussex Health Authoriy and publication of the White Paper produced by the Government focusing of mental health provision.

Specialised services are available for those in the community suffering from conditions such as Alzheimer's disease and doctors and nurses can refer directly to the elderly mentally infirm team at Linwood Community Mental Health Centre.

Current

It will be seen from his workload figures that the majority of his time is spent with patients suffering from depression (33%) and psychosis (20%) and it is of concern to note that 21% of his time is taken up with waiting for patients who do not attend! The majority of his patients are seen in their own home and the remainder are seen either at the mental health centre or at the GP surgery. The figures presented also include those patients referred to him via the counselling team.

Recommendations

It has been noted elsewhere in this document that the counselling team at Cuckfield could become a casualty of the new PCGs. Reg is working to full capacity at present and therefore all those other patients would either not be seen, be put on a waiting list or would have to pay privately for their own counselling elsewhere. It would be appreciated if referring GPs could offer more information on their patients to enable appropriate allocation.

Community Nursing

The community nursing service visits people in their own homes when they are unable to attend the practice for treatment. They are part of the Primary Health Care Team working together to achieve a better standard of care and service for the practice population. Projected population figures for the Mid Downs area for people aged 65 years and over is shown to increase by approximately 4.5 thousand by the year 2001 and of these the over 75 age group will be increasing the most (W.S.H.R.Atlas 1994).

Breakdown of Cuckfield Medical Practice Elderly Population:

When looking at the various reasons for our visits the most common is the treatment of leg ulcers which totals 34% of all visits with most involving the over 65 age group.

The elderly also have multiple problems, which require thorough assessment and referrals to other agencies as necessary. The next largest group requiring visits is the terminally ill and accounts for 14% of all visits. They also receive input from hospices, the intensive home nursing service and Macmillan nurses who are available for the ongoing care and support of both patient and carer. Care of the diabetic patient accounts for 13% of all visits and involves patient education and monitoring of their condition for signs of deterioration and complications.

Conclusions

Nurses in the community need to be highly trained and regularly updated in the care and prevention of leg ulcers. They need up to date knowledge of the various agencies involved in the care and support of the elderly in the community. Working in partnership with the elderly, encouraging them to be independent and autonomous requires not only infinite patience but also teaching and counselling skills. Nurses should have this training provided enabling them to offer a consistently high standard of care. "Everyone needs to know more about the process of ageing and the difficulties it may bring. Ultimately, the quality of life of elderly people, especially the very old and frail, rests on the attitudes and perceptions of those younger than themselves" (DHSS, 1981).

Ref. West Sussex Health Reference Atlas, (1994/95) DHSS (1981) Growing Older. HMSO London

Nursing profile

This profile has been compiled by the members of the integrated nursing team of Cuckfield medical Practice as part of the integrated nursing team pilot project. All team members have been involved and have contributed their own valuable information and knowledge, often using their off-duty time to complete their research and write up results.

A practice profile involves the systematic gathering and analysis of data, the review and evaluation of the effectiveness of current practice and offers an opportunity for reassessing the health service provision and health promotion in the local area. A document of this kind is necessary to keep up to date with the changing health needs of the population together with the ever-changing demands and expectations of the general public. Part of the remit of Primary Care Groups (PCGs) is to prioritise and develop services to improve the health of their population (Dept. of Health 1998) and for this they will need Practice Profiles.

As the PCGs become established, replacing the current fund-holding status it is imperative that nurses, particularly in the areas of health promotion and prevention, are targeting and prioritising the greatest need of the practice population. We must demonstrate that our work is efficient and effective and have a voice that is heard within the PCGs to ensure that funding is available for the identified unmet needs of our patients. One of the ways in which the Government aims to modernise the National Health Service is through clinical governance, in which each clinician and manager is accountable for the quality of patient care. This may help decisions to be based on clinical judgement rather than cost alone, improving patient care and clinical standards.

By working as an Integrated Nursing Team, compiling the Practice Profile, analysing our work, drawing conclusions and recommendations and acting upon these for the benefit of our patients, we are taking an active role in clinical governance (Cook 1998, Harvey 1998)

Ref: Cook R. (1998) A first class service. Practice Nurse 16 (6) pp 343 - 347 Department of Health (1998) The New NHS Modern and Dependable - Establishing Primary Care Groups Harvey G. (1998) Protocols and Nursing Guidance for Good Practice. Issues in Nursing and Health No. 21 London:RCN References: Knight s. (1998) Population changes and challenges. Women's Health 3(3) pp 14 - 17 RCN (1993) Protocols and Nursing Guidance for Good Practice. Issues in Nursing and Health no. 21 London:RCN Ross B (1998) "Strengthening the nursing contribution to primary health care". Primary Health Care 8 (7) pp 10 - 13 Ca female breast

Action Plan for the future

Explore ways of decreasing differences in health between social classes e.g. childhood accidents

Continue active health promotion for stroke, pneumonia, cancer of the female breast, cancer of prostate

Possible budget management by integrated nursing team

Review of the menopause clinic - audit

Asthma audit

Set up family planning service

Development of practice nurse protocols

Review over 75's health check

Review blood taking service/non-nursing duties

Look into employment of nursing auxiliary

Follow up non-responders for adolescent immunisation clinic - possible setting up of clinic at Farney Close school

Revise over 75's assessment sheet

Identify and assess more carers

Annual screening invitation letter for carers to be devised

Audit carer's project

Step up DNA initiative

Establish parenting skills group

Establish health visiting clinic for older children

Establish evening immunisation clinic for working parents

Establish relaxation/stress management group at Cuckfield

Complete integrated nursing team project

Training

Libby

Diabetic Management, Chichester. Completion January 1999

Sue Cowdy

Diploma in Professional Practice, Brighton Diane Diabetic Management. Completion November 1998

Sheila

Diploma in Professional Practice, Brighton