motivational interviewing child › sites › ...individual (rest of world) of motivational £145...
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The real cost of eating disorders
EDUCATIONAL SUPPLEMENT – Relieving Children’s Earaches, sponsored by Nurofen for Children
CHILD IMMUNISATIONA project to improve uptake in north-east London
MOTIVATIONAL INTERVIEWINGA concept analysis for the community practitioner
Dying to be thin
CPHVA
Awards 2013
HOW TO GET INVOLVED
to live life their way**however that might be
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when entering or leaving the bath. Avoid contact with the eyes. Side Effects: (Refer to the SmPC for full list) very rarely, mild allergic skin reactions including rash and erythema have been observed, in which case the product should be discontinued. Marketing Authorisation Numbers: Cetraben Emollient Cream: PL 06831/0259 Cetraben Emollient Bath Additive: PL 06831/0260 Basic NHS Price: Cream – 50g pump dispenser £1.40, 150g pump dispenser £3.98, 500g pump dispenser £5.99, 1050g pump dispenser £11.62. Bath Additive - 500ml plastic bottle £5.75. Legal Category: GSL. Date of Preparation July 2012. Further Information is available from: Genus Pharmaceuticals Ltd, Park View House, 65 London Road, Newbury, Berkshire, RG14 1JN, UK. Cetraben® is a registered trademark. CET.API.V13
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Existing Unite/CPHVA members with queries relating to their membership should contact: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for further details.
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Non-member subscription rates: Individual (UK) £125 Individual (rest of world) £145 Institution (UK) £145 Institution (rest of world) £195
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© 2012 Community Practitioners’ and Health Visitors’ Association
ISSN 1462-2815
The views expressed do not necessarily represent those of the editor nor of Unite/CPHVA. Paid advertisements in the journal do not imply endorsement of the products or services advertised.
Community Practitioner journal
CommunityPraCtitioner
October 2012 Volume 85 Number 10 Community Practitioner | 1
34
CONTENTS
CommunityPraCtitionerThe journal of the Community Practitioners’ and Health Visitors’ Association (Unite/CPHVA)
CoVer Story:DyinG to Be tHin: tHe real CoSt of eatinG DiSorDerS
CO
VER
IMA
GE:
TH
INK
STO
CK
3 Editorial Your opportunity to effect change By Gavin Fergie
4 News round-up The latest in policy and practice
10 Association Unite welcomes new professional officer; training details
11 Antenna Quality first: are we expecting too much from the regulator? Book review; Research evidence
14 News feature The real cost of eating disorders By Chloe Harries
17 150 years
20 Professional and research A concept analysis of motivational interviewing for the community practitioner Debbie Chittenden
24 Diabetes screening as part of a vascular disease risk management programme Sara Bartram, David Rigby
30 Practice: peer reviewed The recognition and management of isolated cleft palate By Jennifer Williams
34 Preventing type 2 diabetes: a role for every practitioner By Jill Hill
38 Features A project to improve uptake of immunisation in north-east London By Catherine Sekwalor
42 Can a ‘sign-off’ experience with the health visiting service benefit students? By Kate Brown
48 Diary & Noticeboard
October 2012 Volume 85 Number 10 Community Practitioner | 3
Your opportunity to effect changeOne of the energising elements of the
Unite Professional Officer role is meeting with members, listening, reflecting with them and sharing news and views from colleagues elsewhere on our travels.
These occasions are often tinged with the harsh reality and the uncertainties of practice as colleagues share their experiences; but they also empower the Professional Team with emotion, opinion and energy we can focus on your behalf.
At a recent meeting, when the dialogue once again echoed the all-too common tale of uncertainty, dissatisfaction and plain old mental and physical fatigue, I challenged the audience by stating that is was ‘their fault’ that the situation was where it was. This was not targeted at those colleagues sitting in the room but at society as a whole, who have allowed the attacks on the NHS and other institutions that we hold dear. Someone must have voted for the present government, although I seldom meet anyone who admits to such an act.
At Unite we have been not been silent, we have been actively challenging the issues on your behalf and will continue to do so.
In this period of time, mid-electoral cycle, it is easy to think that influencing change will be the ‘thing’ to do in 2015. Certainly, opportunities do exist now to lend your voice and strength to campaigning in a way that many colleagues have done over the last 150 years. Those who have gone before had many challenges to contend with; sometimes they lost and sometimes they won but their principles carried them through. It is easy to forget now that the CPHVA colours – purple (symbolising dignity), white (purity) and green (hope) – were worn by supporters of the suffragette cause. Many words and deeds were undertaken to effect change for the better. Does that same spirit exist today?
There is a chance for you to continue this tradition during the protest events
EDITORIAL
CommunityPraCtitioner
Editorial Advisory BoardGaynor Kershaw (Chair) – Health Visitor, Heywood, Middleton and Rochdale PCT
Obi Amadi – Unite/CPHVA Lead Professional Officer
Maggie Breen – Macmillan Clinical Nurse Specialist – Children and Young People, The Royal Marsden Hospital NHS Foundation Trust
Toity Deave – Senior Research Fellow, Centre for Child and Adolescent Health, University of the West of England, Bristol
Barbara Evans – Community Nursery Nurse, Leicestershire Partnership NHS Trust
Gavin Fergie – Unite/CPHVA Professional Officer for Scotland and Northern Ireland
Margaret Haughton-James – School Nurse Team Leader and Practice Nurse, Guy’s and St Thomas’ Hospital
Catherine Mackereth – Public Health Lead, South Tyneside Primary Care Trust
Brenda Poulton – Emerita Professor of Public Health Nursing, University of Ulster
Editorial TeamPolly Moffat – Editor [email protected]
Jane Appleton – Professional Editor [email protected]
Chloe Harries – Assistant Editor [email protected]
Tel: 020 7878 2404
Naveed Khokhar – Designer [email protected]
Unite/CPHVA Honorary OfficersLord Victor Adebowale – President
Elizabeth Anionwu – Vice-President
Alison Higley – Chair
Unite Health Sector OfficersTel: 020 3371 2006
Obi Amadi – Lead Professional Officer
Rachael Maskell – Head of Health
Gavin Fergie – Professional Officer for Scotland and Northern Ireland
Rosalind Godson – Professional Officer for School Health and Public Health
Dave Munday – Professional Officer
Shaun Noble – Communications Officer [email protected]
Fiona Farmer – National Officer
Barrie Brown – National Officer
James Lazou – Research Officer
organised for 20 October 2012 where you can join like-minded individuals who believe in a fairer, more equitable society. That sounds very similar to why many of us ventured into public health nursing practice in the first place.
A more personal and no less effective opportunity to channel your energies will be in Brighton at our UK conference on 7 and 8 November. Some of the architects who have brought us to where we are will be there; and whether they like it or not you can put your opinion directly to them.
I believe it is better to articulate my dissatisfaction than to sit and moan to my dogs; although they are good listeners there is little to be achieved from this. In October, November and beyond, the opportunities are there for you to become active and articulate your view. It is empowering to feel you may be part of societal change – and the dog might just appreciate the rest.
Gavin FergieProfessional Officer, Unite/CPHVA
4 | Community Practitioner October 2012 Volume 85 Number 10
NEWS ROUND-UP
Unite has said that the removal of
Andrew Lansley from the post of
Health Secretary has given the government
an opportunity to ‘rethink’ the future
direction of the NHS.
Lansley has been removed from his post
at the Department of Health and will be
replaced by Jeremy Hunt, former leader of
the Department for Culture, Media and
Sport. Hunt’s career only narrowly survived
the Levinson enquiry earlier this year after
his handling of the Murdoch bid for BSkyB
was widely criticised. He has described his
new appointment as ‘the greatest privilege of
my life’.
Responding to the reshuffle, Rachael
Maskell, Unite Head of Health, said: ‘The
NHS has been pushed to the brink of
destruction by Andrew Lansley – a minister
who simply would not listen either to the
patients or the professionals.
‘Andrew Lansley must rank as one of
the worst health secretaries since the NHS
was formed in 1948. He presided over
deeply unpopular bungled reforms which
heralded rising waiting lists, £20billion
cuts to services, job losses to thousands of
nurses and other health workers, installed
an expensive, needless bureaucracy and
announced an open sesame to the private
firms which put profit before patient care.’
She added: ‘He was also responsible for
dramatic cuts to pay and pensions, as well
as long-established terms and conditions.
NHS staff have had their morale crushed
by Lansley’s unlistening and steamroller
mindset.
‘Jeremy Hunt must reflect deep and hard
on the errors of his predecessor and seek
immediate dialogue with the NHS team and
their unions. He has the power to slam the
door on the increasing privatisation of
the NHS’.
Anne Milton has also suffered at the hands
of the reshuffle, being removed from her
role as Public Health Minister after having
served as Parliamentary Undersecretary
of State for Health in 2010. The former
nurse had faced some controversies, most
notably around the issue of abortion, where
she instigated a review of the counselling
services offered to women pre-termination.
Her replacement, former journalist Anna
Soubry, was an outspoken critic of the
proposals from Conservative MP Nadine
Dorries to toughen abortion laws. It is
hoped her approach will balance Hunt’s
harder stance on the issue, having voted to
reduce the abortion time limit to 12 weeks
in 2008.
Scottish Health Secretary, Nicola Sturgeon,
who is Scotland’s Deputy First Minister, has
also been replaced. Taking over as Health
Minister will be former Infrastructure,
Investment and Cities Secretary Alex Neil.
Health ministers Paul Burstow and Simon
Burns were also replaced by Norman Lamb
and Daniel Poulter.
Chairman of the BMA Scotland, Dr Brian
Keighly, commented: ‘There are escalating
challenges for the Scottish NHS as it
struggles to cope with growing financial
pressures, which will have an adverse
impact on many patient services and
create additional pressures on the already
hard-pressed NHS workforce’.
Lansley and Milton out ... andHunt to be new health secretary
In: Jeremy Hunt becomes new Health Secretary, despite past near-misses with scandal
Out: Anne Milton is to leave her post Out: Andrew Lansley loses Health Sec role
October 2012 Volume 85 Number 1 Community Practitioner | 5
NEWS ROUND-UP
Cot death rates continue to fallThe number of unexplained infant deaths in
England and Wales has reached an all-time
low. Figures released by the Office for National
Statistics (ONS) show that there were 279 deaths
from sudden infant death syndrome (SIDS) in
2009, which dropped to 254 deaths in 2010, a
rate of 0.35 per 1 000 live births.
Although the drop between this period is
not statistically significant, there has been a
substantial drop since 2005, when the SIDS rate
was 0.5 deaths per 1 000 live births.
The rate has continued to drop since the
largest recorded peak in 1995 (when records
began); but there are some regions that have
much higher rates than the average of 0.35 per
1 000. The wost affected of these areas is north-
west England, which has 0.53 deaths per 1 000.
Chief Executive of the Foundation for the
Study of Infant Deaths (FSID), Francine Bates
OBE, has called for more to be done to reduce
cot deaths in this region in particular. She
said: ‘Although we have seen a small reduction
in the number of deaths across England and
Wales the figure for the north-west is extremely
concerning. The region has had the highest rate
for the last seven years.
‘We know that smoking is a major risk factor
for sudden, unexplained infant death and the
smoking rate in London is the lowest in the
UK; but the rate for the north-west is above the
national average.’
FSID hopes that with the help of public health
agencies, their ‘Reduce the Risk’ campaign may
become more high profile and reach a wider
audience.
Ms Bates said: ‘FSID has pledged to halve the
numbers of unexplained infant deaths by 2020
and public health agencies in the north-west
and also in Wales, which has the second-highest
rate, can help us achieve our goal by ensuring
that ‘Reduce the Risk’ campaigns, with a focus
on the dangers of smoking, are an ongoing local
priority.’
Unite/CPHVA Professional Officer, Dave
Munday, said: ‘The FSID and health visitors
should be proud of the huge impact that they
have had on reducing the risk of cot death. It’s
important to remember, however, that there
is still work to be done to further reduce the
numbers of cot deaths. FSID have sensibly
refocused their efforts on the big public health
issues that have the greatest impact (as they
did with their ‘Back to Sleep’ campaign). I’m
sure our members will continue to engage in
their work as positively and successfully as they
already have in the past’.
Statistics also show that cot death rates
among unmarried mothers are 1.18 per 1 000
and that along with the north west other
areas with higher than average cot death rates
include Wales with 0.50 per 1 000 and the West
Midlands with 0.46 per 1 000.
London had the lowest rates, with 0.21 per
1 000, followed by the East Midlands with 0.25
per 1 000 and the south east at 0.27 per 1 000.
A new online service has been
introduced that will enable
people to monitor and manage
their diabetes. The launch comes
at a critical time for diabetes
figures in Scotland, as the annual
Scottish Diabetes Survey has
shown that nearly 5% of Scots
have the condition – an increase
of around 10 000 people a year.
The results show that nearly
a quarter of a million people
(247 278) have diabetes. Of these,
the majority (217 500) have
type 2 diabetes, which is largely
preventable and is often caused
by an unhealthy lifestyle.
It is hoped that the website
‘My Diabetes, My Way’, run in
partnership with Diabetes UK,
will encourage those with the
condition to self-manage their
condition and ultimately to lead
longer, healthier lives.
Public Health Minister, Michael
Matheson, said: ‘Diabetes is a
growing problem for Scotland –
around £300million of hospital
expenditure relates to diabetes
treatment and the management
of its complications. Now
everyone living with diabetes in
Scotland has the opportunity to
view their own clinical diabetes
data online, and by having access
to the right information, people
can be supported to self-manage
and radically reduce the risk of
developing complications and
serious health problems’.
Chief Medical Officer, Sir
Harry Burns, added: ‘We also
need to maintain focus on
preventing diabetes by tackling
the underlying risk factors.
Stopping smoking, eating better
and taking regular exercise is
something we can all do to make
sure we are as healthy
as possible’.
Jane-Claire Judson, Director
of Diabetes UK, said: ‘Even with
the pressures of ever-increasing
numbers, as indicated in the
new Scottish Diabetes Survey,
everyone diagnosed with
diabetes is entitled to the best
diabetes care possible. Diabetes
UK Scotland has developed a
set of 15 healthcare essentials
that all those living with the
condition should receive. Making
sure everyone with diabetes has
access to these key services and
support systems in place is vital
for all those diagnosed’.
Visit:
www.mydiabetesmyway.scot.nhs.uk
Scottish diabetes self-monitoring website launched
6 | Community Practitioner October 2012 Volume 85 Number 10
NEWS ROUND-UP
CQC chair resigns as consultation for the future is launched
Measles outbreak almost doubles cases one year on
The Chair of the Care Quality Commission
(CQC), the body that regulates health and
social care in England, has resigned from the
‘demanding and complex’ role.
Dame Jo Williams, who has been Chair since
2010, announced her resignation shortly after
the CQC launched a consultation paper for their
2013 to 2016 strategy, setting out proposals for
what the regulator believes it should focus on.
She said: ‘It has been a privilege to hold this
important role, but now I believe it is time to
step aside for a new Chair to lead the CQC into
the next stage. But there is now clear evidence
that our regulation is beginning to have an
impact on the care that people receive, and it
feels as if the organsation is moving into the
next stage of its development’.
She added: ‘This week, we have published a
consultation document setting out proposals
for CQC’s strategic direction for the next three
years. I am delighted that that I have been able
to appoint David Behan as CQC’s new Chief
Executive – I am confident that he will continue
to build on the progress that we have made in
promoting and protecting the health and safety
of people who use services.’
Speaking at the launch of the CQC
consultation, Chief Executive David Behan said:
‘For [the]CQC, being successful means that
more health and care services meet quality and
safety standards – and improve quickly if they
don’t. I want people to know that together with
Healthwatch as the consumer champion we will
According to Health Protection Agency
(HPA) figures, there were nearly twice the
number of measles cases in England and
Wales from January to June 2012, compared
to the same period in 2011. The figure shows
a rise from 497 to 964.
The HPA is encouraging parents to ensure
that children are up to date with their MMR
jabs before returning to school.
Dr Mary Ramsay, Head of Immunisation at
the HPA, explained:
‘Measles can be very serious and parents
should understand the risks associated with
the infection, which, in severe cases, can
result in death. Although the update of the
MMR has improved in recent years, some
children do not get vaccinated on time and
some older children, who missed out when
uptake was lower, have not had a chance to
catch up.’
Unite/CPHVA Professional Officer, Gavin
Fergie, said: ‘Unite/CPHVA members work
tremendously hard to ensure the public are
aware of the crucial role that immunisations
have in reducing the incidence of these
diseases, the disturbing issue is that many
of these cases could have been preventable,
Unite/CPHVA continue to support and
promote this essential function of public
health practice’.
listen to them and use their experiences to help
inform the judgements we make about services
and I want to ensure providers of services
understand what good looks like and what is
unacceptable so they can improve the services
they provide.
‘The CQC is now in its fourth year. As we
enter the next stage of our development I am
clear that our role is to check that health and
care services meet national standards and in
that way drive improvements in the quality and
safety of services’.
The consultation paper asks for people’s views
on seven specific questions about the proposed
approach. These cover how the CQC regulates
services, how it manages its independence,
its relationship with the public and with
organisations that provide care, its role in the
complaints system, its responsibilities in relation
to mental health services and on how it can
measure its own impact.
Mr Behan said: ‘Perhaps the most significant
of our proposed changes is that we’ll tailor the
way we regulate different types of organisations
based on what has the most impact on driving
improvement. We will put people’s views at the
centre of what we do.
‘We also recognise we need to work more
effectively with others. We have a common
goal with other organisations to improve the
quality of health and care services. By sharing
information and acting together we will be
more effective in driving improvement’.
The consultation, which will run until
6 December, states that over the next three years
the commission will aim to improve the way
it uses information to find and address poor
care faster.
For full details of the proposals and how to
respond visit the CQC website:
www.cqc.org.uk/thenextphase
October 2012 Volume 85 Number 10 Community Practitioner | 7
NEWS ROUND-UP ADVERTISEMENT
Spending cuts strikes on the horizon
The General Secretary of Unite, Len McCluskey, has warned that government spending cuts may lead to co-ordinated strike action
by the end of this year and also in the run-up to the general election in 2015:
‘I think it is inevitable, as workers get more and more angry and frustrated as to the pressures on them, both in the private and the public sector, that there will be a demand for them to take industrial action. I see the issue of strikes and continuing protests actually increasing as we move closer and closer towards a general election.’
At September’s TUC conference McCluskey called for a £1 rise to the minimum wage to £7.19. He said: ‘There will be a huge injection of funds into the economy. We are talking about low-paid workers. If they get an additional £40 a week, they will be spending £40 per week, not putting any of it in the Cayman Islands’.
Unite was part of the co-ordinated protests on 30 November last year, and earlier this year in response to reforms to public sector pensions.
An overwhelming response to consultations launched by health unions on the subject of the hike in registration fees,
as proposed by the Nursing and Midwifery Council (NMC), has shown that a rise would be universally unpopular. Responding to Unite’s consultation, a staggering 98% were against the plans, which would see the current yearly fees increase from £76 to £120.
Unite/CPHVA Professional Officer, Dave Munday, said that the fees should not increase to above £86 per year, in line with inflation. He commented: ‘Our members have overwhelmingly rejected the enormous fee hike – which is basically a tax on nurses who have already suffered from two years of government imposed pay freeze.
‘To regain its credibility, the NMC needs to be more realistic in its financial demands – and we think increases in line with inflation, which is already running at 2.6% would be more realistic in future years’.
NMC fee hike consultation response
8 | Community Practitioner October 2012 Volume 85 Number 10
According to the 2012 Lansinoh Breastfeeding Survey of 1 200 mothers,
one in five claim that they were only given basic information on breastfeeding from midwives and health visitors.
Lansinoh Health Professional Liaison Director, Diane Emery, said: ‘We can see from the results that mums feel they aren’t receiving enough information and encouragement. It is imperative that mums know where they can go to find information about breastfeeding if they have any concerns’.
Reflecting on the results of the survey, Anna Burbridge of pro-breastfeeding group La Leche League GB said that there were ‘many reasons’ that could contribute to a reluctance to breastfeed, but added that having time with a healthcare professional can have a ‘positive effect’ on breastfeeding. She said: ‘If women receive accurate and positive information, and are supported, especially when difficulties arise, breastfeeding offers many benefits for both mother and baby.’
Unite/CPHVA Professional Officer, Dave Munday, said: ‘This survey reinforces what we already knew and have been raising with health organisations and the government. Parents want support from well-trained
and well-resourced health visitors who can have a huge impact on breastfeeding rates in communities. I would hope that with the increased number of health visitors via the “Call to Action” in England we will see improvements in parents’ experiences over the next few years. It is not surprising that they haven’t seen this yet.’
Other reasons given by mothers for not breastfeeding include a fear of pain and embarrassment, and fear of breastfeeding in public. Around one-quarter of respondents stated that it was ‘wrong and embarrassing’ to breastfeed in public.
Health professionals blamed for low breastfeeding rates
NEWS ROUND-UP
NewsiNbriefreport shows scots drinking lessA new NHS report analysing the sales of alcohol sold in Scotland has fallen by 4% between 2010 and 2011. The downward trend was apparent in all forms of alcoholic drink, apart from cider. Scotland’s former Health Secretary, Nicola Sturgeon, said: ‘I welcome the drop in sales of alcohol in 2011; however, sales are still at an unacceptably high level and are still around a fifth higher than in England and Wales’. Earlier this year MSPs voted to introduce minimum drink pricing, making Scotland the first place in the UK to do so.
Prenatal smoking linked to child obesityAccording to research published in the Archives of General Psychiatry, children of mothers who smoked during pregnancy are at an increased risk of becoming obese when they reach adolescence. The study, which took place on a cohort of Canadian adolescents, showed that children whose mothers smoked had higher body fat and a higher fat intake than those whose parents had not smoked.
Changes to NMC PiN cards From the end of September the Nursing and Midwifery Council (NMC) stopped issuing PIN cards. Members’ PINs will remain the same. You will receive a statement of entry letter when you first register, change your name or add qualifications. According to the NMC, the cards have been removed as they only show registration status on the day they are issued. No longer producing the cards will allow the NMC to divert £105,000 per year to spend on its core regulatory functions, including fitness to practise.It is members’ responsibility to ensure that the NMC have their correct name and address. To change your name or address visit: www.nmc-uk.org/Registration/Staying-on-the-register/Updating-your-details/ You can find out more information about the withdrawal of PIN cards on the website at: www.nmc-uk.org/Registration/Changes-to-NMC-Pins-cards/
NEWS ROUND-UP
NI extends flu jab to all children Northern Ireland’s Health Minister,
Edwin Poots, has announced that the
flu vaccine will be given to all children
aged between two and 17, free of charge,
following a recommendation from the
Joint Committee on Vaccination and
Immunisation (JCVI).
Mr Poots said: ‘Children in at-risk
groups, such as those with asthma, heart
conditions or cerebral palsy, are already
eligible to receive the flu vaccine from their
own GP. Following a recommendation
from the JCVI, and advice from my
officials, I have decided to extend the
vaccine to all children aged between two
to 17 years, free of charge. The target
date is autumn 2014 and the programme
will use a nasal spray vaccine. There will
be significant challenges to delivering an
extended programme that will require
up to 400 000 children to be vaccinated
during a six-week period and we will
look at the recommendations in detail to
decide how best to develop and deliver the
programme.’
Chief Medical Officer, Dr Michael
McBride, said: ‘Seasonal flu can be a very
serious illness, particularly for those in the
at-risk groups, which is why we already
offer vaccinations to these people.
‘We accept the advice of the JCVI that
rolling out a wider programme could
protect children and help to further protect
our most vulnerable members of society.
In the meantime, for the forthcoming flu
season, our priority remains to ensure a
high uptake rate is achieved in the at-risk
groups including pregnant women.’
C L I N I C A L LY- P R O V E N S C A R C A R E
PIP codes: 325-7474; 328-7356; 365-6931; 325-7466
References: 1. Sepehrmanesh M. Komp Dermatologie 2006; 1:30-32. 2. Sebastien G Komp Dermatologie 2006; 1:30-32. 2. Sebastien G Komp Dermatologie et al. Akt Dermatol 2004; 30:450.et al. Akt Dermatol 2004; 30:450.et al. Akt Dermatol
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ASSOCIATION
10 | Community Practitioner October 2012 Volume 85 Number 10
Happy Birthday to You! A health visiting 150thUnite/CPHVA provides online
training free to members. You
can find details about future sessions
and book your place on the CPHVA
website (see below).
In this new session, taking place
on Thursday 18 October, Unite
Professional Officer, Dave Munday,
will be talking about the 150th
anniversary of health visiting.
The session will include information about
the development of the profession, the
changes in society over that period
and how CPHVA has changed over
the years to ensure its members
have the support needed to
improve and develop. It will also
include some of the photos that
we’ve found while researching the
anniversary event.
For more information about the training session, and to
book your free place visit: http://tinyurl.com/8oynkcd
Professional Advisory Committeemember vacancy
The CPHVA Education and Development Trust’s (Trust)
Professional Advisory Committee (PAC) is seeking to recruit a new member as from November 2012.
This voluntary group supports the Trust by administering its two annual awards, namely the MacQueen Award and the Travel Bursary.
The position is open to all CPHVA members. We would particularly welcome expressions of interest from school nurse members to complement PAC’s skills set. Applications should be made by sending a brief CV (no more than one side of A4) and a supporting statement of no more than 300 words to detail what you would bring to PAC.
The annual time committment is in the region of four days. PAC members are supported to attend the CPHVA annual professional conference.
The deadline for applications is Thursday 1 November 2012.For further information contact the PAC’s chair Kitty Lamb.Email: [email protected] Tel 01904 551760
Unite welcomes new professional officer Jane Beach is commencing with Unite as
the Professional Officer for Regulation on
1 October 2012.
Jane is a registered nurse and Specialist
Community Public Health Nursing
(SCPHN) health visitor, with a first-class
honours degree in Health Studies and a
Master’s in Public Health. She has significant
experience of working in the health service
in nursing, midwifery and health visiting,
within provider, commissioner and health
care regulation organisations.
Jane worked as a health visitor in
Birmingham for 15 years before moving
into the health improvement team within
a PCT public health directorate. Here, her
roles included clinical leadership of the PCT
stop smoking service and nurse consultant
in public health. Her varied public health
portfolio included child and adult obesity,
health visiting and school nursing, family
nurse partnership, quality and safety, falls
prevention and research.
In September 2011 Jane joined the NMC
as Health Visitor Adviser where she had
particular responsibility for leading a project
for a review of the SCPHN part of the
register. Following a change of focus within
the organisation she took on responsibility
for developing revalidation standards and
public health regulation, including being a
member of the UK Public Health Register
(UKPHR) Board.
Jane is looking forward to a new challenge
and to working with members and health
care regulators on the current issues
affecting practice. She aims to provide
relevant advice and support, and to share
her knowledge and experience of regulation
to ensure that professional standards are
maintained at the highest levels for the
protection of the public.
Obi Amadi, Lead Professional Officer, said:
‘We are delighted that Jane will be joining
our team. The skills and knowledge she will
bring will complement and build on the
services we provide to our membership’.
You can find Community Practitioner on Twitter: @CommPracand on Facebook:www.facebook/com/CommPrac
Join the discussion ...
October 2012 Volume 85 Number 10 Community Practitioner | 11
ANTENNA
Quality first: are we expecting too much from the regulator?
T his meeting was the third in a King’s
Fund series ‘After the Act: what next?’
examining the challenges facing the
NHS now that the Health and Social Care Bill
has been passed.
The two previous events looked at the likely
impact the reforms will have on providers
and commissioners as they face the challenge
of ensuring high quality care for all patients
within the current financial squeeze.
The topic for this event was the role of
regulators in assuring quality in the NHS.
The title, ‘Quality first: are we expecting
too much from the regulator?’ hints at
the conclusions drawn at the meeting.
An invited audience of around 120 heard
presentations from eminent experts in health
policy, followed by a question-and-answer
discussion session.
TransparencyAnna Dixon, Director of Policy at the
King’s Fund, opened the meeting outlining
key points from the evidence gathered in
a recent paper on quality assurance in the
NHS (Preparing for the Francis Report: How
to Assure Quality in the NHS) (Dixon et al,
2012). This asserts that frontline clinical and
managerial staff are the first line of defence
in preventing serious quality failure in
provider organisations.
Second in line are boards whose main role
in quality assurance is to create a culture
of openness that supports staff to identify
and solve problems. Such a culture includes
openness with patients and carers regarding
any complaints and concerns. The role of
external regulators is seen as third in the
line of defence, often acting only long after
patients have suffered significant harm.
Cynthia Bower, former Chief Executive of
the Care Quality Commission, described
lessons learned from the Mid Staffs Inquiry
(Francis, 2010); for example, that the content
of patient complaints is far more revealing
about trusts’ commitment to quality care
than the overall number of complaints.
Confusion persists about how trusts deal
with and give redress for complaints,
and some trusts sadly don’t see patient
complaints as a key informative part of
quality enhancement. She acknowledged that
quality drivers in the past, such as meeting
A&E targets, may have detracted from good
patient care.
Meeting expectationsThe last speaker, Elizabeth Buggins is Chair
of an NHS Foundation Trust (among other
strategic roles), has 35 years’ experience with
the NHS and is inspirational for nurses. She
has seen many boards devoting too much
attention to meeting the expectations of
regulators at the expense of safe and effective
patient care.
She feels that having a more ‘critical friend’
relationship between boards and regulators
would reduce the current delay between
frontline staff highlighting concerns and
regulators finding poor performance long
afterwards. Revalidation of doctors is seen to
be another important regulatory driver for
future quality.
The final discussion elicited some wider
experiences and issues such as the untoward
effects which press reporting can have
on trusts’ reputations when their CQC
inspections are less than perfect on all
aspects of care.
Public perception may prefer that
‘heads roll’ but the true driver of quality
improvement is for boards to keep their core
purpose of good quality care for all patients
at the top of the agenda. All agreed that an
open culture is the key to trusts’ ability to
deliver safe and effective care. Regulators
have an important part to play as a vital
safeguard to deal with trusts that fail to
address poor-quality care.
Open culture
With the responsibility firmly on the
shoulders of all frontline staff, what can
individuals do to follow the aspiration of
Elizabeth Buggins to ‘make health services
more responsive to patients and more
satisfying for staff ’?
Suggested actions for frontline staff include:l Read the King’s Fund paper on the Francis
Report (Dixon et al, 2012)l Read your local trust board minutes
(publicly available online to assess data on
performance)l Check key performance indicators such
as levels of staff having annual appraisals,
pressure ulcer rates, patients’ experience –
percentage who would recommend the trust
to othersl Use other sources of patients’ experiences
such as Local Involvement Networks
(LINKs) to add depth of understanding of
the patient journey in the NHS – especially
for minority and hard to reach groupsl Observe a board meeting if you have
time – it may highlight gaps between
verbal impressions of good care but with
indicators showing otherwisel Check how boards deal with patient
concerns and complaints – numbers alone
are meaningless.
References Francis R. (2010) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust 2005–2009. London: The Stationery Office.
Dixon A, Foot C, Harrison T (2012). Preparing for the Francis report: How to assure quality in the NHS. London: King’s Fund. Available from: http://www.kingsfund.org.uk/publications/articles/francis_report.html [Accessed September 2012].
Catherine Gleeson MPhil RGN RSCN RCNT SNCert DipAC DipCOPD
Independent Consultant Nurse in School HealthPart-time Respiratory Practice Nurse, West Yorkshire
the true driver of quality improvement is for boards to keep their core purpose of good quality care for patients at the top of the agenda
ANTENNA
12 | Community Practitioner October 2012 Volume 85 Number 10
Research evidence
Infant siblings and the investigation of autism risk factors Infant sibling studies have been at
the vanguard of autism spectrum
disorders (ASD) research over the
past decade, providing important
new knowledge about the earliest
emerging signs of ASD and
expanding our understanding of
the developmental course of this
complex disorder. A traditional
sibling study, which already
incorporates close developmental
follow-up of at-risk infants through
the third year of life, is essentially
reconfigured as an enriched-risk
pregnancy cohort study. This
review considers the enriched-
risk pregnancy cohort approach
of studying infant siblings in the
context of current thinking on
ASD etiologic mechanisms. It
provides a description of the design
and implementation strategy of
one major ASD enriched-risk
pregnancy cohort study: the
Early Autism Risk Longitudinal
Investigation.
J Neurodev Disord 2012 18(1): 7
Anxiety and smoking cessation outcomes in alcohol-dependent smokersAnxiety-related characteristics,
including anxiety sensitivity
and trait anxiety, are elevated
in individuals with alcohol
and nicotine dependence, and
associated with greater difficulties
with quitting smoking. However,
little is known about how
anxiety-related characteristics
are related to smoking cessation
outcomes in alcohol-dependent
smokers. Higher levels of trait
anxiety were associated with more
smoking urges due to positive
reinforcement and anticipation
of relief of negative affect at quit
date. These results indicate that
for alcohol-dependent smokers,
levels of anxiety sensitivity and trait
anxiety are important to consider
in the assessment and treatment of
nicotine dependence.
Nicotine Tob Res 2012
Decision-making for mothers with cancerThe objective of this study was to
explore the process of decision-
making in mothers with cancer
when they are mothering young
children. The conditions of the
mothers’ lives created a context
in which mothers made meaning
of decisions. Mothers aimed to
maintain their bonds with their
children in the decision-making
process and used various coping
strategies as a consequence to
distress from decisional situations.
The results have implications for
future decision-making research in
cancer care.
Eur J Oncol Nurs 2012
New resourcesReconnecting young people with their fathersThe Fatherhood Institute (FI) is developing a pilot ‘Father-finding’ project to support young people who do not see their fathers, to address issues arising from this experience, and to reconnect (where desired, possible and safe) with their father and/or with paternal relatives. For further information email Fiona Harrison: [email protected]
New suicide strategy and £1.5 million into prevention researchA new Suicide Prevention Strategy will focus on supporting bereaved families and preventing suicide among at-risk groups. The call for research proposals to support the implementation of the national suicide prevention strategy is already underway and can be found at: http://prp.dh.gov.uk/2012/05/22/policy-research-programme-call-for-applications/
Book review: Childhood and societyChildhood and SocietyMichael Wyness2nd Edition (2012)Palgrave MacmillanISBN 978-0-230-24182-4
This book takes an
in-depth look at
childhood from a number of
different perspectives. What
is childhood, both now and
historically? How is childhood
perceived within different
countries and cultures? What
issues influence the types of childhood
experiences? It looks at the social meaning of
childhood, children in the context of family
and state. In short, the book
has a wealth of information
for anyone wishing to delve
into sociological debates about
childhood.
This second edition takes into
account the most up-to-date
research and how it impacts on
childhood today. I was intrigued
by the chapter ‘Childhood in
Crisis’, in which the authors
challenge some common
assumptions around this subject.
Case studies, including child
soldiers and child carers, depict not so much
a crisis of childhood caused by children, but
one that is inflicted upon them; and some
misconceptions are debated and challenged.
The book is of interest to many
professionals working with children, but it
is evidently a publication of such standing
that academics may need to ensure they have
included it in their scope of reading. The
style and language require the reader to have,
at the least, a good understanding of theories
of the sociological aspects of childhood.
However, it does provide an introduction
for those without this, providing they take
the time to understand the context of the
language. This is, of course, completely in
keeping with the authors’ extensive expertise
in the field.
Barbara Evans, Community Nursery Nurse
14 | Community Practitioner October 2012 Volume 85 Number 10
THE REAL COSTof eating disorders
Chloe HarriesAssistant Editor
It is estimated that around 310 000 young people aged 10 to 24 in England suffer from an eating disorder that has a significant impact on their lives. What should we be doing to address the problem and provide a more efficient, cost-effective service?
eating disorder it is not just their health that is at
risk – education, employment prospects, family
life and more, can all be blighted. We know that
treatment for eating disorders can be lengthy,
expensive and difficult to access. Now, for the
first time we have some researched, robust
and reliable data that back this up, and make a
powerful case for earlier, less costly interventions’.
David Collins, Projects Manager for Child
and Adolescent Mental Health Services Solent
NHS Trust (West), feels that we need to be more
creative with our ideas about using funds that
may be available. ‘[The report] is very valuable
as it further emphasises how important early
intervention strategies are to reduce the impact
of long-term illness on already stretched services.
‘The one thing it doesn’t do is inform the
government of how much potential new
funding has to alleviate the problem. It isn’t
purely about “throwing” money at the issues,
but being smarter with current resources and
using appropriately trained and experienced
healthcare professionals in the right areas’.
Unite/CPHVA Professional Officer for School
Nursing and Public Health, Ros Godson,
agrees: ‘It’s a good attempt to quantify the
problem in monetary terms, as everything in
healthcare nowadays has to have a price tag’.
Money mattersThe report produced some staggering figures.
The overall cost of eating disorders to the
NHS is estimated at £80 to £100million.
NHS Information Centre data showed
that there were 2 579 hospital admissions for
eating disorders from July 2009 to June 2010,
compared to 2 316 in the previous 12 months
– an increase of 11%.
Around 90% of these admissions were
female, and the average duration of one
episode in hospital was 38 days. This would
make the total number of inpatient days
98 000 in England each year.
The average specialist inpatient cost of eating
disorders per day for adults is £426 (2009/10)
– approximately £450 in 2011/12 prices.
Children’s specialist inpatient services per day
cost approximately £586 (2009/10) or £620 in
2011/12 prices. This makes the average cost
across both services for eating disorders £510
per bed, per day.
There are around 4.7/100 000 (population
per year) new diagnoses of anorexia nervosa
each year, and around 6.6/100 000 new
diagnoses of bulimia nervosa, resulting
in a total of 11.3 new diagnoses of eating
disorders per 100 000 population. With
the total English population coming in
at around 52.5 million this results in
around 6 000 new cases of eating disorders
diagnosed each year.
However, Beat believes that the prevalence
of eating disorders could be higher than this;
at around 28 per 100 000 population for
an anorexia diagnosis per year, and 40 per
100 000 population for bulimia nervosa.
A ccording to a recent report
commissioned by eating disorder
charity Beat, studies into the
economic impact of eating disorders in the
UK have been limited. The report’s authors
hoped that providing a breakdown of the cost
of eating disorders would strengthen the case
for more research and earlier intervention to
help sufferers.
The report, Costs of eating disorders in
England: economic impact of anorexia
nervosa, bulimia nervosa and other disorders
focussing on young people, was carried out by
Department of Health (DH) economist John
Henderson, on behalf of Beat and Pro Bono
Economics (a group that brings together
economists and charities), in the hope that
publishing economic analysis can benefit the
third sector (Beat, 2012).
Sue Holloway, Pro Bono Economics
Director, explained: ‘This is the first serious
attempt to quantify comprehensively the
costs of eating disorders in England; and the
resulting estimate shows the significant scale
of the problem. We hope this will support Beat
to achieve its vision that eating disorders can
be beaten’.
Economic impactChief Executive of Beat, Susan Ringwood,
cited the importance of the study. ‘The report
is the first time the economic impact of eating
disorders has been properly calculated. We know
that if people become chronically ill with an
NEWS FEATURE
THE SOONER SOMEONE GETS THE TREATMENT THEY NEED, THE MORE LIKELY THEY ARE TO MAKE A FULL RECOVERY
October 2012 Volume 85 Number 10 Community Practitioner | 15
NEWS FEATURE
16 | Community Practitioner October 2012 Volume 85 Number 10
Ms Ringwood notes the limitations of the
report: ‘We know this data only captures some
of the picture – it only focuses on England,
young people and doesn’t include private health
care, but it is a big step in the right direction.
Many people with eating disorders are not in
treatment and 40% of people who are in touch
with Beat have not even been to the doctors, so
these people will not show up in the data’.
Mr Collins explains how the care and
treatment of eating disorders is, in many cases,
a long and costly process. ‘We often work with
a young person for up to five years before any
visible evidence of improvement is found.
‘We therefore are fully aware of the cost
to services and the impact on other areas of
heath care. Resources are finite and where
complex disorders such as anorexia take the
majority of the cost for the smallest amount of
patients, there is an impact on the rest of the
budget for the service.’
Other costsCompared to other mental health disorders,
those suffering from eating disorders have the
highest mortality ratios – more than five times
that of their peers (Curtis, 2010).
Eating disorders also have a significant
impact in terms of education and employment
prospects and work output in general.
Ms Ringwood emphasises the importance
of early intervention. ‘Eating disorders have
the highest mortality rate of all mental health
disorders. It is vital that the individual is able
to access the right specialist treatment as early
as possible and Beat has long campaigned for
early intervention.
‘Young lives are being disrupted at crucial
stages in their development, with loss of
education, hindering career prospects
and premature death. This report clearly
demonstrates that healthcare costs would
be better spent earlier to stop the effects on
sufferers, their family and the community.’
Taking into account all of the statistics for
hospital care, loss of earnings, reduced mortality
and morbidity, primary care costs and future
disease burden, the (approximate) breakdown is:l £80million for healthcare treatmentl £230million for the present value of reduced
GDPl £950million for the value of reduced length
of life and health.
This makes a total cost of more than
£1.26billion per year for England alone.
More effective spendingMr Collins believes that the government needs
to reduce waiting times and make inpatient
services more accessible: ‘Educational input to
schools and colleges and use of media would
be a sound resource to highlight the need and
what services are available. More education
on how to refer at primary care level would be
useful and better interagency working could
be beneficial but there are blocks in systems
due to funding streams being cut so services
have to “rationalise” what service they give.
Some extra early intervention strategies have
been reduced due to fusing cuts in the NHS.’
Ms Ringwood agrees: ‘Our view is that those
millions could be better spent if more of it was
used to identify cases early, intervene quickly
and prevent eating disorders becoming
very serious, difficult to treat and all too
often deadly. We will be using this report to
highlight this important issue, sharing it with
policy and decision makers and showing them
how prompt action saves lives and money.’
A DH spokesperson said: ‘We know early
intervention is essential to help people with
eating disorders. The local NHS must ensure
that patients can access good care – including
emergency and intensive hospital treatment
for the most serious cases. We want to improve
everyone’s mental health; that’s why we are
investing more than £400million to expand
psychological therapies. These therapies can
help people – adults and young people – with
eating disorders’.
How school nurses can helpRos Godson feels strongly that school nurses
can be pivotal in terms of identification and
early intervention in cases of eating disorders.
‘Care for those with emotional and psychiatric
problems such as eating disorders is a
specialised area and the earlier such patients
get help, the better. School nurses must
encourage and enable young people (or their
friends) to come forward and ask for help,
then they must be able to refer appropriately
to the Child and Adolescent Mental Health
Service (CAMHS).
‘The other thing the school nurse service
could do is to stop carrying out the National
Child Measurement Programme (NCMP), as
this is concentrating on one problem; obesity,
and the children are all weighed at the same
time, leading to stress and embarrassment.
However, the correct public health approach
would be to deal with each child or young
person in a holistic manner about a range of
issues.’ Further tips for school nurses can be
found in Box 1.
School nurses have a key role to play in
the early recognition of eating disorders, and
subsequent interventions. Mr Collins believes
this needs to be emphasised and the school
nurse given greater responsibility to help
provide help and support to young people with
eating disorders: ‘More support from services
needs to be given to this group of health
care professionals than is currently available
through supervision and training as their own
training is not specific enough. We also need
better links with statutory services for eating
disorders need to be made in some areas.
‘I would advise school nurses to make links
with your local CAMHS service and seek
out extra training or shadowing to better
understand the socio-economic breakdown
of families and to better understand the
wider “systemic” issues that contribute
to the development of an eating disorder.
Interagency working can reduce the
communication difficulties and replication of
roles where multiprofessionals are involved.’
References Beat. (2012) Costs of eating disorders in England: Economic impacts of anorexia nervosa, bulimia nervosa and other disorders, focussing on young people. London: Beat.
Curtis L. (2010) Unit Costs of Health and Social Care 2009/10. PSSRU; University of Kent.
Paul McCrone et al (2008) Paying the Price: The cost of mental health care in England. London: The Kings Fund.
NEWS FEATURE
l Keep up-to-date with research evidencel Understand that this is a mental health conditionl Eating disorders affect girls and boys, and can be present in primary school-aged
childrenl The child may not look either too fat or too thinl Be aware of dental hygiene (as those who make themselves sick may have bad teeth
because of the regurgitated stomach acid)l Never mention any child’s size unless it is totally relevant to the subject in hand and there is a treatment that can be offered
Box 1. Tips for school nurses on dealing with eating disorders
Timeline
In the late 2000’s the health visiting profession began to experience the tide of change. The Department of Health began to take a greater
interest in the much-neglected practice, starting in February 2009 with the publication of the Child Health Strategy (Healthy Lives – Brighter Futures) a new government vision for the future of the health of children and young people, building on the idea of providing world-class outcomes and working to lessen health inequalities.
A few weeks later, the profession had further focus heaped upon it, with the launch of the Action on Health Visiting programme. This was followed by May’s joint CPHVA and DH Health Visiting Summit, promoting reinvestment in the profession and explaining the key roles of the health visitor.
By 2010, the DH began to produce a series of white papers, including the Public Health White Paper and the Public Health Outcomes Framework, both of which have gone on to shape the almost universally unpopular Health and Social Care Bill that was passed earlier this year.
The Department of Health releases the Child Health Strategy (Healthy Lives – Brighter Futures). The strategy presented the government’s vision for children and young people’s health and wellbeing. Setting out how to build on progress through world-class outcomes; high quality services; excellent experience in using those services; and minimising health inequalities.
Feb 2009
In March the Action on Health Visiting programme launched. The programme clearly stated the key roles of the health visitor, its purpose was to ‘articulate clearly the key roles of the health visitor and to take measures to promote reinvestment in the profession.’
Unite/CPHVA worked with Chief Nursing Officer Dame Christine Beasley and the DH, producing Getting it Right for Children and Families, maximising the contribution of the health visiting team. The strategy developed the five key roles for the health visitor associated with the Healthy Child Programme (HCP – formerly known as the
Child Health Promotion Programme (CHPP)):
● leading and delivering the universal HCP ● being the named health visitor in Sure Start
Children’s Centres ● supporting vulnerable families
● defining the specialist skills in protecting children
● creating and developing effective teams.
Mar 2009
Series of NHS white papers included the Public Health White Paper and Public Health Outcomes Framework.
2010
of public health
Health Visiting
October 2012 Volume 85 Number 10 Community Practitioner | 17
Department of Health and CPHVA joint-hosted the Health Visiting Summit with Skills for Health to build on existing programmes to ensure the work was grounded in service and professional development.
Healthy lives, Healthy People: Our Strategy for Public Health in England : ‘The White Paper sets out the government’s long-term vision for the future of public health in England. The aim is to create a ‘wellness’ service (Public Health England) and to strengthen both national and local leadership.’
Unite respond with concerns: ‘Unite is concerned that this consultation is taking place in parallel to the Health and Social Care Bill’s passage through Parliament. This makes it extremely difficult to answer and comment on sections in the Healthy Lives, Healthy People document, which depend upon the final version of the Health and Social Care Bill.’ Continuing: ‘The Healthy Lives, Healthy People document is rooted in wanting to change individual lifestyle choices, yet this is frequently removed from the wider social context in which those individual choices are made. Further, departments across government are pursuing policies that will severely undermine the stated public health agenda.’
May 2009
Nov 2010
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20 | Community Practitioner October 2012 Volume 85 Number 10
PROFESSIONAL AND RESEARCH: PEER REVIEWED
Debbie Chittenden MSc BSc Grad Dip Psy RN RHV Teacher FHEASenior Lecturer in Public Health Nursing NMC Stage 3 Practice Teacher Preparation Staffordshire University
Correspondence to: [email protected]
AbstractThis article will be of interest to school nurses, health visitors, student health visitors and their practice teachers. An opportunity is taken to explore the concept of motivational interviewing for community practitioners, to demystify the technique. Guided by Walker and Avant’s framework for concept analysis, the article explores if practitioners are already using a motivational interviewing approach, how this way of working can be effective and how to develop this useful communication skill to evoke and strengthen personal motivation for change. Key terms such as ‘agenda matching’ and ‘change talk’ are applied to case scenarios to add meaning to the exploration. Details of further resources are also provided.
Key words Motivational interviewing, agenda matching, communication skills, change talk, behaviour change
Community Practitioner, 2012; 85(10): 20–23.
No potential competing interests declared
A concept analysis of motivational interviewing for the community practitioner
IntroductionThe Healthy Child Programme (Department
of Health (DH), 2009a; 2009b) recommends a
partnership approach for effective working with
parents. It identifies motivational interviewing
(MI) as a useful, emerging method to support
partnership working. Such emergence has come
into view in the e-healthy child programme,
where it is incorporated in the last module
about the health visiting model of practice. This
does not appear to be the result of a reported
investigation in relation to school nursing or
health visiting; rather, it seems to have evolved
from success in the Family Nurse Partnership
(FNP), where it is reported that family nurses
are successful because of their ‘positive attitude
toward the client, based on agenda-matching,
strengths-based approaches and motivational
interviewing’ (DH, 2011a: 52).
Some community practitioners may argue
that family nurses have more time to deliver
their messages with a motivational interviewing
style and others may dispute that community
practitioners already practise in the spirit of MI
because their practice is informed by Rogers’
(1951) client-centred theory and they are
trained as specialist practitioners to use higher
levels of communication skills.
This article will explore where there is a match
with MI, where there is difference and what can
be learned.
Newly trained health visitors are being
educated about MI (DH, 2011b) and their
practice teachers are expected to role model
and critically discuss such nuances as
‘agenda matching, exploration, analysing and
recognising patterns’ (DH, 2011b: 11) to help
the students develop. However, it is hard to
locate guidance in this area for community
practitioners and clarity is needed. For this
reason, Walker and Avant’s (1988) eight-step
concept analysis methodology will be used to
explore MI in relation to its use by community
practitioners. This methodology is chosen in
preference to other similar frameworks because
it leads towards case construction, which, in
turn, illustrates aspects of MI. The process
follows eight steps.
Concept analysisSelect a conceptMI was developed by psychologists Miller and
Rollnick, who have researched and developed
the technique over the last 30 years. MI is a
powerful approach to facilitate change and,
historically, has been used with clients who have
challenges with substance misuse (Burke et al,
2003). People with addictive behaviours report
that they want to change, but at the same time
do not want to change; this tension has been
termed ambivalence.
MI has been defined by its authors as ‘a
client-centred, directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence’ (Miller and Rollnick,
2002: 25). This definition refers to a respectful,
collaborative conversation with a client about
change. The key principle is to express empathy
and to support self-efficacy by eliciting, through
curiosity, the client’s story. It is the client’s task
to articulate and resolve ambivalence, and the
practitioner’s task to facilitate expression of
both sides of the ambivalence impasse.
The spirit of MI can be expressed as
collaboration with compassion, evocation and
autonomy (Miller and Rollnick, 2010). Without
compassion it may be confused with a marketing
strategy for natural selling. Miller and Rollnick’s
third edition Motivational Interviewing is due
out in November 2012; they have researched
and refined the technique and present a new
four-process model to guide practice. This is:
engaging, focusing, evoking and planning. l The engaging stage incorporates counselling
skills, such as using simple reflections,
open-ended questions, providing
affirmations (a statement of the client’s
strengths, competencies, characteristics or
past successes) and summarising; and most
importantly, reflecting back what the client
has said. This helps the client to hear their
own words l Focusing is to do with agenda matching;
for the community practitioner this means
creating a balance between satisfying the
needs and expectations of the client and the
health professional’s agenda
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l By the evoking stage the client will have
come to a point in his or her ambivalence
when change talk may be detected. The
practitioner will respond to this talk to evoke
hope and confidence l The last stage of planning is the bridge to
change – to strengthen commitment and to
support change.
Critics of MI have stated that it is limited to the
client’s own view of the world; however, this can
be helpful. For example, sensitivity is needed for
a client who is living in a home with domestic
violence. Hohman (2012: 55) states: ‘If we impose
leaving as the desired behaviour/outcome, we
can inadvertently replicate the same controlling
behaviours that survivors experience with their
abusive partners’. Appropriate health promotion
is to discuss actions that the client can control
and behaviours they want to change. At the
same time, the safety of any child is paramount.
This example illustrates the complexity of
professional practice and the need for each
practitioner to make a careful choice about what
they say and how they say it.
Aims of analysisPublic health is well known to be both an
art and science of promoting and protecting
health. It can be argued that MI is a method of
communication rather than a technique and is
an art more than a science of nursing (Shinitzky
and Kub, 2001). The aim of this analysis is
to examine MI for its effectiveness in health
visiting teams (including nursery nurses) and
school nursing.
MI is not easy to learn (Hohman, 2012) and
training varies from a few hours to a few days.
There is not an official qualification, although
training should be provided by a member of the
Motivational Interviewing Network of Trainers
(MINT) (www.motivationalinterviewing.org),
an organisation that also regulates practice.
MI has been adapted by non-specialists in a
number of situations and the efficacy of the
intervention has been high (Miller and Rollnick,
2002). Community practitioners use counselling
skills but are not counsellors; MI is a counselling
style. It appears reasonable for community
practitioners to integrate MI techniques when
supporting a client in increasing readiness for
change. Understanding the stages of change
model (DiClemente and Prochaska, 1982) can
address this dilemma (see Figure 1).
In the second edition of Miller and Rollnick’s
(2002) text, MI was considered to be delivered
in two phases. While it is acknowledged that the
new four-process model supersedes the phase
distinction, it is worthwhile considering how
the principles of health visiting can be applied
(CETHV, 1977). Phase 1 could be considered
to incorporate the stimulation of awareness
of health needs and phase 2 the facilitation of
health-enhancing activities. Information-giving
would not be provided in phase 1; rather, the
practitioner’s goal is to elicit change talk.
The search for health needs could be in the areas
of alcohol intake, smoking cessation, choice of
feeding antenatally, appropriate weaning, and the
management of obesity or parenting skills. The
community practitioner may need to influence
local policy to ensure time is provided for
clinical supervision in developing this technique
to support professional development.
Determine defining attributesThe relationship between the core values of
the community practitioner and aspects of
MI are highlighted in Table 1. Both values of
the community practitioner and the therapist
trained in MI include the humanistic model
with a client-centred approach to support
self-efficacy by higher levels of communication
and partnership working.
There are subtle differences in how Rogers’
(1951) theory is used. In MI, empathy and
collaboration are emphasised along with being
non-judgemental, while the therapist has a goal
for behaviour change in mind. MI would not be
used in a listening visit for postnatal depression
as the client may identify her own agenda and
the health visitor supports the client to achieve
the goal the client sets. The difference in MI is
that the practitioner also has an agenda. Agenda
matching creates a balance between satisfying
the needs and expectations of the client and
the health professional. MI could be used with
listening visits when combined with cognitive
behavioural therapy (CBT) (Hohman, 2012).
For a practitioner engaging in health
promotion, the desire to uphold the ethical
principle of autonomy will inform decision-
making (Beauchamp and Childress, 2001), yet
there could be other theories common to MI
that could also help the practitioner ‘resist the
righting reflex’ and jump in with advice before
the client is ready. According to Festinger (1957),
people experience cognitive dissonance when
they engage in behaviours that are in conflict
with their internalised values. The practitioner
can use this state to develop discrepancy by
helping the client weigh up the pros and cons
of continuing the behaviour and consider a
decisional balance. If the client does not want
to change, their own words could sustain this
stance. The practitioner’s ability to respond to
client sustain talk and resistance (or discord)
in a manner that reflects and respects without
reinforcing the behaviour is termed ‘rolling with
resistance’. To ‘roll with’ rather than oppose is to
support self-determination (Vansteenkiste and
Sheldon, 2006) and again supports autonomy.
According to self-perception theory, people
perceive themselves as they articulate their
thoughts in social interactions (Bem, 1972). As
practitioners listen actively with reflections and
summaries about what the client says, the client
Figure 1. Aspects of motivational interviewing applied to the Stages of Change model (adapted from DiClemente and Prochaska, 1982 and Miller and Rollnick, 2002)
Phase 1: Stimulation of awareness of health needs
Recognising change talk in the client
Affirmations
Agenda matching
Resist the righting reflex
Roll with resistance
Contem-plation
Pre-contem-plation
Relapse Maintenance
Action
At all times exercise the spirit of MI: Collaboration, Evocation and Autonomy
Phase 2: Facilitation of health enhancing activities
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Core values of the community practitioner (NMC, 2004; Skills for Health, 2004)
Based on the humanistic model of client-centred theory (Rogers, 1951) and Bandura’s (1999) theory of self-efficacy
Collaborative working for health and wellbeing
Higher level communication skills
Ethically managing self, people and resources to improve health and wellbeing
Aspects of motivational interviewing (Miller and Rollnick, 2002)
Based on the humanistic model of client-centred theory (Rogers, 1951) the principles of MI are to express empathy, develop discrepancy, roll with resistance and support self-efficacy. Bandura’s (1999) self-efficacy theory is supported by agenda matching
The spirit of MI values collaboration, evocation and autonomy
The skills of MI can be outlined mnemonically with ‘OARS’:• Open-ended questions• Affirmations• Reflections• Summaries
Informed by theories from social psychology such as dissonance theory (Festinger, 1957), self-determination theory (Vansteenkiste and Sheldon, 2006) or self-perception theory (Bem, 1972), experienced practitioners will modify their MI for clients with serious mental illness, such as avoiding reflections of disturbing or despairing statements (Hohman, 2012)
Table 1. The relationship between the core values of the community practitioner and aspects of motivational interviewing
Example dialogue Identifying MI
HV There are a few things that I need to talk about and Collaboration and there will be a few things you probably want to ask; agenda matching where would you like to start?
Client I can’t think of any questions now Autonomy
HV Well I would like to talk about feeding baby, what are your plans about feeding baby?
Client I had wanted to breastfeed but my friend has put me off because she had a breast abscess and was in pain
HV Your friend did not succeed in breastfeeding and was in pain, you want to succeed but do not want an abscess or Reflecting pain
Client Too right. I may as well bottle feed from the start then baby will be used to it and won’t know the difference, I don’t want him to get muddled up
HV You want to breastfeed and you want baby to keep feeding in the same method so he doesn’t get muddled up Evocation
Client Yeah, but I’d like to breastfeed really Change talk
Table 2. A health visitor visits a pregnant mother antenatally
can ‘hear’ themselves and develop a different
perspective on their situation (Hohman, 2012);
they may begin articulating change talk or
speech that favours movement in the direction
of change. For example, words like ‘I need to
change’ or ‘I could ...’
Develop model cases The case study in Table 2 can be described
as motivational because there is a primary
intentional focus on increasing readiness for
change. Practitioners often have to communicate
serious messages, such as around safeguarding
issues. It is still possible to practise with the
spirit of MI at this time by using the Elicit-
Provide-Elicit (EPE) technique. First, permission
is sought to talk about the sensitive issue, once
this has been gained, the information can be
provided, followed by another eliciting question,
asking clients what they think of this or asking
if they want any other information. In this way
the practitioner can maintain equipoise while
being honest and helping parents think about
sensitive issues (see Table 3).
Construct additional cases The case study in Table 3 could have had a
different outcome if the school nurse had been
judgemental and just provided information.
Open questions can be used as a tool to gain
accurate understanding, which helps form
constructive conversations.
Identify antecedents and consequencesMI was developed in response to the less effective
confrontational method of health promotion
in the 1970s and 1980s. It is acknowledged
that people usually know the answer to their
problems and are better persuaded by their
own arguments for change rather than those
of others.
The aim is to identify and mobilise clients’
intrinsic values and goals to stimulate behaviour
change; the practitioner is directive about
pursuing the goal of examining and resolving
ambivalence, not directing advice (Faulkner et
al, 2009). MI in its pure form is quite different
from the brief, solution-focused approach (De
Shazer, 1985), where some MI aspects are used
in a structured format for screening and brief
intervention. The solution-focused approach is,
the name suggests, solution focused.
MI could be considered useful at the
beginning of a conversation on an area of
health promotion, where it is used to elicit
change talk. The solution-focused approach
can serve to move the consultation forward.
This could be ‘adapted MI’; an amalgamation
that has been expertly developed into guidance
for practitioners to be effective in their health
promotion messages (Field, 2012). This effective
initiative is called ‘Making Every Contact
Count’ (MECC) and can be learned in two free
e-learning modules for NHS workers (http://
learning.nhslocal.nhs.uk/courses/areas-care/
health-management-resources/making-every-
contact-count).
Miller and colleagues (2010) outline that MI
can be learned in three easy steps:l First, to practice a guiding rather than a
directing stylel Second, to develop strategies to elicit the
client’s own motivation to changel Third, to refine listening skills and to respond
by encouraging change talk from the client.
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PROFESSIONAL AND RESEARCH: PEER REVIEWED
Example dialogue Identifying MI
SN We were in a meeting last week with the social worker Elicit who said some pretty heavy stuff; do you want to talk about that?
Parent Yeah, what I want to know is, where he got the idea that I emotionally abuse my children from, I love my children
SN There has been some research that sheds light on the matter, would it be OK to share this information with you?
Parent Yes
SN It has been found that even when a child is in a different Provide room when there is arguing between parents, then the child can be affected emotionally, it could be an underlying reason why your child is bed-wetting and refusing to go to school
Parent I didn’t realise that
SN Is there anything I can help you with? Elicit
Table 3. A school nurse talks with a parent about domestic violence
Based on this, the technique appears usable by
community practitioners. The consequences
of using an adapted form of MI can equally
lead to improved outcomes, as long as the
strengths-based approach is maintained where
the practitioner listens to the client’s viewpoints
and concerns with empathy (Traux and Mitchell,
1971).
Define empirical referentsThere have been over 200 randomised,
controlled trials in MI (Miller and Rollnick,
2010). The efficacy of MI has been confirmed
(Burke et al, 2003) and a number of NICE
guidelines have incorporated the technique;
for example, smoking cessation. Midwives have
found MI to be effective in this area (Tappin et
al, 2005). More recently, Hohman (2012) has
outlined how social workers have applied MI
in areas such as domestic violence, child welfare
and work with adolescents in school settings.
ConclusionCommunity practitioners practice in a
strengths-based manner with their clients in an
atmosphere of acceptance and compassion, as
their colleagues who practice MI as a therapy do.
It is becoming increasingly clear that different
professionals (such as family nurses, mental
health nurses, social workers and community
practitioners) need to work in collaboration
with one another, not only to provide a role
model to clients but also to foster successful and
rewarding professional relationships.
Understanding the theoretical evidence-base of
MI can improve the effectiveness of MI practice,
and support the community practitioner to
use an adapted form of MI in conversations to
increase the possibility of change with clients
in health promotion topics, safeguarding issues
and listening visits. It is possible to develop
professionally through reading about MI, using
this communication style and reflecting on
practice with an experienced practitioner in
MI.
References Bandura A. (1999) Self-efficacy: towards a unifying theory of behavioural change. New York: Psychological Press.
Beauchamp T, Childress J. (2001) Principles of Biomedical Ethics (5th edn). Oxford: Oxford University Press.
Bem DJ. (1972) Self-perception theory. In: Berkowitz L (ed). Advances in Experimental Social Psychology. New York: Academic Press.
Burke B, Arkowitz H, Menchola M. (2003) The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. J Consult Clin Psychol 71(5): 843–61.
Council for the Education and Training of Health Visitors (CETHV). (1977) An Investigation to the Principles of Health Visiting. London: CETHV.
Department of Health (DH). (2009a) Healthy Child Programme. Pregnancy and the first five years of life.
London: DH.
DH. (2009b) Healthy Child Programme From 5–19 years old. London: DH.
DH. (2011a) The FNP in England. Wave 1 implementation in toddlerhood and a comparison between waves 1&2 of implementation in pregnancy and infancy. Available from: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123366.pdf [Accessed July 2012].
DH. (2011b) Educating Health Visitors for a Transformed Service. A suggested approach for education commissioners and higher education institutions and lecturers to aligning education with the new service vision for health visiting. London: DH.
De Shazer S. (1985) Keys to Solutions in Brief Therapy. New York: WW Norton.
DiClemente C, Prochaska J. (1982) Self-change and therapy change of smoking behaviour: a comparison of processes of change in cessation and maintenance. Addict Behav 7(2): 133–42.
Faulkner N, McCambridge J, Slym R, Rollnick S. (2009) It ain’t what you do, it’s the way you do it: a qualitative study of advice for young cannabis users. Drug Alcohol Rev 28: 129–34.
Festinger L. (1957) A Theory of Cognitive Dissonance. Evanston IL: Row & Peterson.
Field S. (2012) NHS Future Forum summary report second phase. Available from: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_132085.pdf [Accessed July 2012].
Hohman M. (2012) Motivational Interviewing in Social Work Practice. London: The Guilford Press.
Miller RM, Rollnick S. (2002) Motivational Interviewing. Preparing people for change (2nd edn). London: The Guilford Press.
Miller RM, Rollnick S. (2010) What’s new since MI-2? Second International Conference on Motivational Interviewing in Stockholm, Sweden. Available from: www.motivationalinterview.org/Documents/Miller-and-Rollnick-june6-pre-conference-workshop.pdf [Accessed September 2012].
Nursing and Midwifery Council (NMC). (2004) Standards of proficiency for specialist community public health nurses. London: NMC.
Rogers CR. (1951) Client-centred therapy. Boston: Houghton-Mifflin.
Shinitzky HE, Kub J. (2001) The art of motivating behavior change: the use of motivational interviewing to promote health. Public Health Nurs 18(3): 178–85.
Skills for Health. (2004) National occupational standards for the practice of public health guide. Bristol: Skills for Health.
Tappin DM, Lumsden MA, Gilmour WH, Crawford F. (2005) Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down. BMJ 331(7513): 373–78.
Traux CB, Mitchell KM. (1971) Research on certain therapist interpersonal skills in relation to process and outcome. In: Bergin AE, Garfield SL (eds). Handbook of Psychotherapy and Behavior Change: An Empirical Analysis. New York: Wiley: 299–344.
Vansteenkiste M, Sheldon KM. (2006) There’s nothing more practical than a good theory: integrating motivational interviewing and self-determination theory. Br J Clin Psychol 45: 62–82.
Walker LO, Avant KC. (1988) Strategies for Theory Construction in Nursing. Norwalk, Connecticut: Appleton and Lange.
l AMI is relevant to all community practitioners, all the time. By using the Elicit, Provide, Elicit (EPE) technique it empowers the client and provides appropriate partnershipl Agenda matching is a component of partnership working with familiesl It is recommended that practitioners reflect on their practice and seek support from an
experienced supervisor in order to develop effective collaborative conversations
Key points
24 | Community Practitioner October 2012 Volume 85 Number 10
Sara Bartram MPH BSc(Hons) RGN RSCN RHV RSNPublic Health PractitionerCommunity Health and Social Care PartnershipNHS Western Isles
David Rigby Mb ChB GPSI (Cardiology) GP Langabhat Medical Practice Leurbost Surgery, LochsIsle of Lewis
Correspondence to: [email protected]
AbstractType 2 diabetes mellitus is a growing public health concern worldwide. There is the potential to prevent type 2 diabetes mellitus by lifestyle interventions including increased physical activity, dietary modification and weight reduction in the obese therefore screening for diabetes can be beneficial. This case study discusses two methods used for diabetes screening as part of a population wide vascular risk management programme in an island community off the west coast of Scotland. The programme was delivered to individuals aged 40 to 79 years who met the inclusion criteria using a combined service delivery model including a multifunctional mobile unit across a remote and rural location. The change from using random plasma glucose to using the haemoglobin A1C (HbA1C) assay improved recommended follow rates for patients with a positive screen and reduced the burden on primary care and the hospital laboratory.
Key wordsDiabetes screening, HbA1C, cardiovascular disease risk management
Community Practitioner, 2012; 85(10): 24–27.
No potential competing interests declared
Diabetes screening as part of a vascular disease risk management programme
IntroductionDiabetes mellitus is a chronic and progressive
condition with potentially devastating
consequences for health, which increases
the risk of cardiovascular disease (CVD)
and other health problems (World Health
Organization (WHO), 2011).
Type 1 diabetes often starts at a young age
and is caused by a lack of insulin. It accounts
for 10–15% of all cases of diabetes (12% in
Scotland in 2010) (Oosterhoorn et al, 2011).
Type 2 diabetes mellitus (T2DM) starts
with resistance to the action of insulin and
is associated with older age, overweight and
obesity. T2DM is often asymptomatic in its
early stages, can remain undiagnosed for
many years, and is a growing public health
concern worldwide (Alberti et al, 2007).
Between 2007 and 2010 the crude prevalence
of diabetes in Scotland increased from 4.1%
to 4.6% (Oosterhoorn et al, 2011).
Clinical trials have demonstrated the
potential to prevent T2DM through lifestyle
interventions, including increased physical
activity, dietary modification and weight
reduction in the obese. These benefits can
have a long-lasting effect on risk factors
and diabetes incidence (Tuomilheto et al,
2011). This indicates there would be benefits
in identifying apparently healthy people
who may be at increased risk of developing
diabetes eg, through screening. Individuals
who have been screened for a condition
and found to be at risk of developing the
condition can be offered information, further
tests and appropriate treatment to reduce
their risk and/or any complications arising
from the disease or condition (UK National
Screening Committee (NSC), 2012).
The NSC assessed whole population
diabetes screening against the NSC criteria
for a screening programme. Diabetes
screening does not meet a number of the
criteria, so general population screening was
PROFESSIONAL AND RESEARCH: PEER REVIEWED
not recommended (NSC, 2006). However,
the NSC identified the need for a Vascular
Disease Risk Management Programme
(VDRMP) for adults over the age of 40, which
includes diabetes screening. The Scottish
Intercollegiate Guidelines Network (SIGN)
set out its recommendations for a VDRMP in
SIGN 97 Risk estimation and the prevention of
cardiovascular disease (SIGN, 2007), taking a
combined approach using both a ‘high risk’
and a population approach.
The guidelines recommend an assessment
of cardiovascular risk at least once every
five years for all adults aged 40 or above
who are not assumed to be at high CVD risk
based on clinical history, and individuals at
any age with a first-degree relative who has
premature atherosclerotic CVD or familial
dyslipidaemia. This assessment includes a
screen for diabetes. This paper compares
using random plasma glucose (RPG) and the
haemoglobin A1C
assay (HbA1C
) to screen for
diabetes as part of a population wide vascular
risk management programme.
BackgroundThe North of Scotland Public Health
Network (NOSPHN) invited remote and
rural areas across the north of Scotland to
become part of a consortium to develop a bid
for funding from the Scottish government
to pilot anticipatory care in remote and
rural areas. This provided the opportunity
to develop a service that would support the
Scottish government’s strategy for health and
wellbeing, Better Health, Better Care (Scottish
Government, 2007), through enhancing the
provision of anticipatory care in the local area
by developing a mobile multifunctional unit
that would deliver a VDRMP and lifestyle
coaching across the Health Board area in line
with SIGN 97 (2007).
Equally Well (Scottish Government, 2008)
proposed that, during 2009 to 2011, Health
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PROFESSIONAL AND RESEARCH: PEER REVIEWED
Boards should target high CVD risk primary
prevention as part of normal services
offered by the NHS. However, identifying
deprivation and inequalities within remote
and rural communities is more difficult than
in concentrated urban areas. Populations are
more heterogeneous and deprivation often
occurs at an individual household level rather
than an area level. Methodology proposed
by the Chief Statistician’s Office identifies
the 200 most deprived rural datazones
in Scotland based on income, access and
employment domains and overall Scottish
Index of Multiple Deprivation (SIMD) scores
for 2009. This provided new evidence that
the local area has considerable deprivation
compared to other rural areas in Scotland
with approximately 60% of the population
living within the datazones (Scottish
Government, 2010).
The Kerr report (National Framework
Advisory Group, 2005) suggested redesign
of services in the community could play an
important role in reducing health inequalities.
The development of strong primary and
community health systems can have a
significant effect on health, particularly with
deprived groups. Population-based health
care interventions are effective, but people
living in deprived areas have less access to
those interventions; this is exacerbated when
living in rural areas with limited transport
networks.
One way to make an impact on health
inequalities is to enhance access to care for
the most deprived sectors of the population.
This can be achieved through a collaborative
approach between primary care services
and community-based service provision.
Combining working on a mobile health
unit, service delivery in community venues,
inequalities-targeted services delivered by
third-sector partners and opportunistic
screening at a GP practice a VDRMP can
be delivered at a time and venue that is
convenient for service users.
Screening methodologyThere is no single accepted way of identifying
people who are at risk of diabetes or who
have existing undiagnosed diabetes, and
discussions are ongoing internationally
(NHS Health Check Programme, 2009).
The recommended methods include
fasting plasma glucose, two-hour plasma
glucose following an oral glucose tolerance
test (OGTT) and RPG in individuals with
symptoms of hyperglycaemia. The NSC
recommends using a random or preferably
a fasting blood sample to screen for T2DM.
SIGN 97 (2007) recommends, when screening
for diabetes, impaired glucose tolerance or
insulin resistance should be measured from
a random (non-fasting) sample of blood.
A value of ≤6.0 mmol/l indicates a normal
level. A value of ≥6.1mmol/l but ≤7.0mmol/l
requires a repeat measurement on a fasting
blood sample. If the value is ≥7.0mmol/l
an OGTT should be performed. Using a
non-fasting sample increases the opportunity
to provide population based screening as it is
more convenient for patients.
More recently, an alternative method has
been identified for diabetes screening – the
HbA1C
. This has traditionally been used as a
measure of control in established diabetics
as it measures how high the blood glucose
has been on average over the last eight to
12 weeks. Problems of standardisation and
validation had meant that it had not found an
approved position as a diagnostic tool (SIGN,
2010). However, over the last few years there
have been significant developments in the
standardisation of HbA1C
analysis as well as
information regarding outcome measures
when HbA1C
levels are used as a diagnostic
tool in comparison to the traditional fasting
glucose and OGTT measurement.
In 2009 the International Expert Committee
Report on the Role of the A1C
Assay in the
Diagnosis of Diabetes (Nathan et al, 2009)
made a recommendation that A1C
testing
is an appropriate means of diagnosing
diabetes with several advantages over current
methods. The big advantage of such an
approach is the ability to use this method
in non-fasted patients, which would reduce
the number of patients who need to return
to their own GP for a second appointment.
The WHO held an expert consultation
reviewing the evidence in March 2009, which
concluded that HbA1C
can be used as a
diagnostic test for diabetes provided that
stringent quality assurance tests are in place
and assays are standardised to criteria aligned
to the international reference values (WHO,
2011). From April 2009 the Department of
Random venous sample taken for HbA1C
HbA1C 42–47 mmol/mol
HbA1C ≥48 mmol/mol
HbA1C
<42 mmol/mol
Intensive lifestyle support. GP informed that HbA1C level borderline raised –
consider monitoring
Possible diabetes, need further testing at GP
practice. Advise attend for fasting sample*
Lifestyle advice alone
* Diagnosis to be made as per World Health Organization (WHO) criteria as shown below:l Random plasma venous glucose concentration >= 11.1 mmol/l or l Fasting plasma venous glucose concentration >= 7.0 mmol/l or l Plasma venous glucose concentration >11.1 mmol/l (2 hr sample in OGTT) l Diabetes should not be diagnosed on the finding of glycosuria, raised glucose on a
finger-prick sample or a raised HbA1C (screening only)(One reading sufficient if symptomatic; two diagnostic readings on separate days required if asymptomatic)
Current advice suggests that patients with an HbA1C between 42 and 47 mmol/mol should be classed as having ‘Non Diabetic Hyperglycaemia (NDH)’ and be monitored annually. NDH should be considered equivalent to Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT
Figure 1. Local algorithm for using HbA1c as a screening tool
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PROFESSIONAL AND RESEARCH: PEER REVIEWED
Health adopted HbA1C
as a screening and,
in some cases, a diagnostic, tool for their
cardiovascular screening programme (NHS
Health Check Programme, 2009). In the
local area all patients accessing the VDRMP
are offered diabetes screening; therefore, the
algorithm needed to be adapted for local use
(see Figure 1).
Service deliveryThe cohort for the VDRMP included all
individuals aged 40 to 79 years resident
within the Health Board area who met the
criteria for screening outlined in the SIGN
guidance (SIGN, 2007). Since April 2012
the age range has been reduced to 40–64
years, in line with Scottish government
policy for mainstreaming VDRMPs. All
individuals who attend the programme
undergo a comprehensive assessment with
an anticipatory care nurse specialist and then
spend some time discussing lifestyle issues
with a lifestyle adviser. If indicated, additional
targeted assessments eg, spirometry, are
also performed.
Initially, screening for T2DM was
undertaken using a random sample of blood.
This methodology as recommended by SIGN
(2007) was used over a two-year period from
May 2008 until June 2010, during which
time 3 898 individuals were screened and
offered generic lifestyle advice. Following
the decision to use HbA1C
as the screening
tool for diabetes in the NHS Health Check
in 2009 the local screening methodology
was reviewed.
During the review a move to using point
of care testing (POCT) was considered
for the whole VDRMP. This would enable
service users to receive all their results at the
time of assessment and to be provided with
individualised, targeted lifestyle advice. The
DCA Vantage HbA1C
analyser from Siemens
showed good correlation with the laboratory
method and acceptable precision. A proposal
was submitted to the Diabetes Managed
Clinical Network recommending introducing
this methodology for screening purposes. As
this methodology was not included in any
UK guidelines at the time discussions also
took place at a national level. The proposal
was accepted and in July 2010 the programme
moved to screening using HbA1C
.
All patients with a positive screen were
referred to their general practice for follow-
up. Results for RPG were issued to patients
within two weeks of the screen. Results for
HbA1c
screening were provided to patients
at the time of the assessment. Practices have
instant access to both sets of results once
processed by the laboratory electronically via
SCI-Store information repository. Follow-up
appointments were attended from one week
up to over three months following the initial
assessment for both screening methods.
Patients recalled by their GP within one
week of screening using RPG may have been
called before they had received their results.
For both screening methods over 50% of
patients requiring further assessment were
seen within 28 days.
ResultsThe mobile unit, supported by a Local
Enhanced Service (LES) agreement which
all general practices in the area signed up to,
and partnership working with third-sector
organisations enabled the service to reach
over 80% of the estimated target population
of 8 200 individuals.
Of the 3 464 individuals screened using
RPG, a cut-off level of glucose ≥6.1mmol/l
triggered a fasting appointment to identify
those with diabetes. Using such a level had
excellent sensitivity but poor specificity. In
addition, this generated a significant amount
of work for primary care and the laboratory,
with 12% of all those screened requiring a
follow-up test. A glucose value ≥7.0mmol/l
indicated an OGTT should be performed, 133
individuals met this criteria. Six individuals
were referred to their general practice because
blood samples were not obtained during
the screening assessment. Being referred for
further assessment could result in anxiety for
a large number of patients who may not have
diabetes until their results are known.
The implementation of screening using
the HbA1c
assay reduced the number of
referrals for fasting blood glucose to less
than 2%. Of the 3 201 individuals screened to
date 50 obtained an HbA1C ≥48mmol/mol
indicating possible diabetes. This equates
to 1.56% of the total number seen and 170
(5.3%) of those screened the HbA1C
reported
was 42–47mmol/mol indicating non-diabetic
hyperglycaemia (NDH). This figure is
Table 1. Outcome data
HbA1C Random plasma glucose
Number tested
Number positive at screening
% positive at screen
Number followed up to date
% followed up as recommended*
% confirmed diabetic at follow-up
% confirmed non-diabetic hyperglycaemia^ at
follow-up
3201
50
1.56%
44
94%
53%
26%
3464
133
3.83%
100
75%
20%
15%
Table 2. % of patients with HbA1C ≥48 mmol/mol
Age Percentage HbA1C ≥48 mmol/mol
Total screened
40–49
50–59
60–69
70–79
80–89
0.36
1.79
2.56
2.86
3.58
4
16
16
8
1
1118
898
627
280
28
*47 HbA1C eligible, 133 RPG eligible for follow-up ^Non Diabetic Hyerglycaemia (NDH) includes: Impaired Fasting Glucose (Fasting Glucose 6.1-6.9), Impaired Glucose Tolerance (2hr OGTT values 7.8-11.1) and NDH (HbA1C 42-47mmol/mol)
October 2012 Volume 85 Number 10 Community Practitioner | 27
PROFESSIONAL AND RESEARCH: PEER REVIEWED
significant in informing the future planning
of services. NDH is often associated with a
cluster of inter-related cardiovascular risk
factors – hypertension, dyslipidaemia (with
raised triglycerides and low HDL) and central
obesity – and carries a high risk of progressing
to T2DM. All individuals in this category are
provided with appropriate lifestyle advice,
increased physical activity, maintaining
a healthy weight and following a healthy
balanced diet can reduce insulin resistance.
The GP is informed so a programme of
annual monitoring can commence.
OutcomesOutcome data in relation to diabetes
follow-up is available for 6 665 of the
patients screened to date. Table 1 outlines
the outcomes of patients found to have a
positive screen defined as those screened
using the HbA1C
with a value ≥48mmol/mol
and for those screened using RPG with a
value ≥7.0mmol/l.
The figures show the yield from screening
using RPG to be low, with only 20% of those
with a positive screen confirmed at follow-up
as T2DM, which was consistent with the
findings of Ealovega et al (2004). In addition,
the false positive rate of RPG testing is
significantly reduced when HbA1C
testing
is employed. At 94% the follow-up rate for
HbA1C
is high; this may be a benefit of POCT,
as patients are provided with their results and
an opportunity to discuss their implications
at the assessment.
A total of 53% of individuals with a positive
HbA1C
were confirmed at follow-up as having
T2DM and a further 26% with NDH. The
latter group requires closer follow-up due to
the known association with the development
of type 2 diabetes over time.
The Scottish Diabetes Survey (Oosterhoorn
et al, 2011) estimates the proportion of the
population undiagnosed with diabetes within
the local area as 2.7%; higher than the 0.68%
identified within the programme. Further
examination of the programme data relating
to HbA1c
screening demonstrates an expected
increase in percentage of positive screens
with age (Table 2). The reduced number of
positive screens identified in the programme
is probably due to the upper age cut-off for
the VDRMP.
Introducing POCT and changing the
methodology for diabetes screening to the
HbA1C
assay has improved patient care.
Patients no longer have the anxiety of waiting
for their results, the provision of targeted
lifestyle advice enables patients to become
partners in the decision-making process
regarding follow-up care improving patient
experience:
‘The real key difference with this service
compared to others is the fact that the blood
tests are processed then and there so you get the
results and can discuss what you need to rather
than talking about generalities and don’t have
to go back’.
The burden on primary care and the
laboratory has been reduced with the
improved specificity compared to RPG and
the identification of patients with NDH
informs diabetes service planning.
Recommendations and conclusionsUsing RPG as a screening tool for diabetes
did not prove to be effective. Poor specificity
resulted in unnecessary burden being
placed on primary care having to provide
follow-up assessments and increased
anxiety for patients while they waited for
results. Introducing POCT and changing
the methodology for diabetes screening to
the HbA1C
assay improves patient care and
experience. Having access to patients’ results
during the assessment facilitates an informed
conversation about the care pathway, ensures
patient-centred care and promotes lifestyle
change reducing the numbers of individuals
opting for medication as the only means to
reduce their risk factors.
With the roll-out of VDRMPs across
Scotland and the UK, further consideration
should be given to recommending the use
of HbA1C
as the method of choice when
screening for diabetes.
References Alberti KGMM, Zimmet P, Shaw J. (2007) International Diabetes Federation: a consensus on type 2 diabetes prevention. Diabetic Medicine 24(5): 451–63.
Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. (2004) Opportunistic screening for diabetes in routine clinical practice. Diabetes Care 27(1): 9–12.
Nathan DM, Balkau B, Bonora E. (2009) International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. Diabetes Care 32(7): 1327–34.
NHS Health Check Programme. (2009) Putting Prevention First – NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance. London: Department of Health.
National Framework Advisory Group (2005) A National Framework for Service Change in the NHS in Scotland: Building a Health Service Fit for the Future. Edinburgh: Scottish Executive.
Oosterhoorn E, Scott M, McAlpine R et al. (2011) Scottish Diabetes Survey 2010. Available from: www.diabetesinscotland.org.uk/Publications/SDS%202010.pdf [Accessed February 2012].
Scottish Government. (2007) Better Health, Better Care: Action Plan. Edinburgh: Scottish Government.
Scottish Government. (2008) Equally Well. Edinburgh: Scottish Government.
Scottish Government. (2010) Relative Poverty Across Scottish Local Authorities. Available from: www.scotland.gov.uk/Resource/Doc/322580/0103786.pdf [Accessed February 2012].
Scottish Intercollegiate Guidelines Network (SIGN). (2007) Risk estimation and the prevention of cardiovascular disease: A national clinical guideline 97. Edinburgh: SIGN.
SIGN. (2010) Management of Diabetes; A national clinical guideline 116. Available from: www.sign.ac.uk/pdf/sign116.pdf [Accessed July 2012].
Tuomilehto J, Schwarz P, Lindstrom J. (2011) Long-term benefits from lifestyle interventions for Type 2 Diabetes prevention; time to expand the efforts. Diabetes Care 34(Sup.2): S210–14.
UK National Screening Committee (NSC). (2006) The UK NSC policy on Diabetes screening in adults. Available from: www.screening.nhs.uk/diabetes [Accessed February 2012].
UK National Screening Committee (NSC). (2012) UK Screening Portal. Available from: www.screening.nhs.uk/screening [Accessed February 2012].
World Health Organization (WHO). (2012) Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a WHO Consultation. Geneva: WHO.
l Type 2 diabetes is a preventable, growing public health concern worldwide that can remain undiagnosed for many years
l The UK NSC recommends a VDRMP for adults over the age of 40 years, which includes diabetes screening. However, there is no single accepted way of identifying people who are at risk of diabetes or who have existing undiagnosed diabetes
l Using the HbA1c assay has a higher yield and a lower false positive rate than random plasma glucose l Using validated point of care testing patients can be provided with targeted lifestyle advice enabling them to become partners in the decision making process regarding follow-up care
Key points
28 | Community Practitioner October 2012 Volume 85 Number 10
Jennifer Williams RGN RSCN RHV Dip HE BSc MScClinical Nurse Specialist (Cleft Lip and Palate)North West, Isle of Man and North Wales Cleft NetworkSecretary, National SIG for Cleft Nurses
Correspondence to: [email protected]
AbstractCleft palate in the absence of a cleft lip (i.e. isolated cleft palate) causes upset for parents whenever it is diagnosed; however, delayed diagnosis at over 24 hours of age can cause increased distress due to feeding difficulties and fear of what else could have been missed. One third of cleft palates are not recognised within 24 hours of delivery. Considerable effort is being made to ensure early diagnosis following delivery, by raising awareness of midwives, neonatologists and paediatricians of the need to visualise the whole palate including the uvula, and through changes to the Newborn Screening Programme. Community practitioners including health visitors and school nurses are ideally placed to recognise key feeding and speech features associated with cleft palate, and then to refer to one of the nine regional cleft teams (England and Wales). There is a managed clinical network in Scotland, and there are also centres in Northern Ireland and Eire. Multidisciplinary cleft care commences in conjunction with local health services following referral to the regional specialist team.
Key wordsCleft palate, delayed diagnosis, feeding and speech difficulties, referral, multidisciplinary team management
Community Practitioner, 2012; 85(10): 28–31.
No potential competing interests declared
The recognition and management of isolated cleft palate
IntroductionThe foetal face forms during early pregnancy,
with the lips formed by eight weeks gestation and
the palate by 10–12 weeks gestation (Watson,
2001). The anterior palate is hard and bony,
and the posterior palate is soft and comprises a
muscular sling; this lifts to meet the back of the
pharynx to close off the nose from the mouth for
feeding and speech. Sometimes there is a failure
of fusion, resulting in a gap (cleft) of the upper
lip and/or palate.
A cleft of the lip and/or palate is the most com-
mon facial abnormality, with an incidence of one
in 700 live births in the UK (Cleft Lip and Palate
Association (CLAPA), 2009). Approximately
1 000 children are born each year in England,
Wales and Northern Ireland with a cleft of the
lip and/or palate; of these, approximately 50%
of children born with a cleft will have an iso-
lated cleft palate, ie, not involving the lip (Crane
Project Team, 2011).
Where there is a cleft of the palate the muscles
do not meet in the midline and the palate is un-
able to function properly. Isolated clefts of the
palate are not always detected at birth (Butcher,
2007; Habel et al, 2006), causing problems with
feeding and growth, or even speech. Approxi-
mately 50% of children with cleft palate will
have other anomalies, and cleft palate may arise
as part of a recognised syndrome (Stoll et al,
2000).
Antenatal/postnatal diagnosisClefts of the lip and alveolus are frequently de-
tected at the 20-week anomaly scan, but cleft pal-
ate is rarely visible at this scan (Martin and Rose,
2004). Babies are examined following delivery
by the midwife and again by the paediatrician
or midwife before discharge (Lumsden, 2012).
The NICE clinical guideline regarding newborn
postnatal care states that a ‘full examination
needs to be done within 72 hours and repeated
at the end of the postnatal period. This should
include the head (including fontanelles), face,
nose, mouth including palate’ (National Insti-
tute for Health and Clinical Excellence (NICE),
2006). Traditionally, this was done by a finger
sweep; however, this does not allow full exami-
nation of the palate. The neonate’s tongue occu-
pies most of the oral cavity, making it difficult
to view the posterior soft palate and uvula. The
only reliable way to detect a posterior cleft pal-
ate is by using a torch and depressing the tongue
(eg, with a tongue depressor, laryngoscope, 1 ml
syringe or small dental mirror) to prevent the
tongue obstructing the palate view.
A cleft of the lip is obvious when a baby is
born, but isolated cleft palate can be missed. Up
to a third of clefts of the palate are not detected
in the first 24 hours following delivery (Butcher
and Cleft Nurses’ Special Interest Group (SIG),
2010).
Late diagnosisThe Cleft Nurses’ SIG group have undertaken
two national audits of the timing of diagnosis of
cleft palate. Of 963 babies born with a cleft in
2005, 472 had an isolated cleft palate (Butcher,
2007). A total of 105 (22%) were not picked up
within 24 hours, with smaller clefts of the soft
palate more likely to be missed. The SIG repeated
the audit in 2009, anticipating an improvement
in speed of diagnosis following interventions to
raise awareness. Of 1 026 babies born with a cleft
in 2009, 435 had cleft palate only; and 130 (30%)
were not picked up within 24 hours, showing
PRACTICE: PEER REVIEWED
Figure 1. Normal palate with uvula pulled up
October 2012 Volume 85 Number 10 Community Practitioner | 29
ing and speech. The muscles of the soft palate
wrap around the Eustachian tube that links the
middle ear with the back of the pharynx. Mis-
alignment of the palate muscles affects their
function, and this can interfere with the usual
flow of air and mucous along the Eustachian
tube. Fluid may build up in the middle ear and
cause otitis media with effusion (glue ear), creat-
ing a conductive hearing loss. This in turn can
lead to problems with speech development.
If the palate is not able to function properly,
then this can affect the articulation of the oral
pressure sounds, such as b, p, d, and g. Speech
may sound nasal, sometimes making speech al-
most unintelligible to strangers. This can lead to
communication difficulty, frustration, potential
behavioural problems, and issues with confi-
dence and self esteem.
Occasionally there may be no obvious cleft, but
a bifid uvula and a pale translucent area in the
midline where the muscles within the soft pal-
ate have not come together; this is a sub-mucous
cleft palate. The child may only present later
with poor speech articulation. These children
often have a history of early feeding problems,
including nasal regurgitation of feed (Moss et al,
1990).
Management of cleft palate by the regional cleft teamCleft services were re-organised into specialised
regional multidisciplinary teams following the
Clinical Standards Advisory Group (CSAG) re-
port to provide expert care (CSAG, 1998). Fol-
lowing the diagnosis of a cleft, the family should
be referred within 24 hours to the regional cleft
lip and palate team for management and sup-
port.
Early care The family is first seen by the CNS within 24
hours of referral, to confirm diagnosis and un-
dertake an assessment of feeding skills. The CNS
offers information, counselling and support
with feeding and managing their baby, both in
hospital and at home.
The CNS assesses the impact of any upper air-
way obstruction associated with cleft palate, as-
sisting paediatricians in managing the airway. It
is recommended that babies with cleft palate be
nursed in a lateral position, to stop the tongue
dropping back into the airway. Eight babies with
cleft palate died of SIDS between 2005 and 2009;
families of seven of these were advised to lay
their babies in supine (Bannister, 2011). Lateral
positioning is not usually recommended accord-
ing to cot death advice; however this is a special
PRACTICE: PEER REVIEWED
worsening detection rates. Cleft teams still regu-
larly receive referrals for babies diagnosed late.
Although NICE recommends examination of
the palate within 72 hours of birth, parents and
professionals tell us of the difficulties faced dur-
ing the time from birth if a cleft palate is not de-
tected and managed. Therefore, the Cleft Nurses’
SIG set their postnatal standards as follows: l Standard one: all babies born with a cleft lip
and/or palate are to be diagnosed at birthl Standard two: all babies are to be referred by
relevant professionals to the cleft team within
24 hours of diagnosisl Standard three: the clinical nurse specialist
(CNS) should visit within 24 hours of receiv-
ing referral.
Implications of a cleft palate (possible signs and symptoms) If the cleft is not diagnosed while in the mater-
nity unit then community staff are well placed
to recognise the possible signs of a cleft palate,
including feeding, breathing, growth or speech
problems. Sometimes parents recognise that
their child’s palate looks different from other
children’s, and may seek reassurance or help in
accessing treatment.
FeedingThe palate is important for stabilising the nip-
ple or teat, and for creating suction for effective
feeding. Therefore, babies with cleft palate will
often have a history of feeding difficulties which
may include: l Difficulty latching onto the breastl Fast suck (2/second) with irregular swallow
patternl Ineffective sucking l A clicking sound when feedingl Lengthy feed times of over an hour’s durationl Small volumes of feed takenl Frequent small feedsl Nasal regurgitation of feed, either during a
feed or when vomitingl Difficulty holding a dummy inl Poor growth.
Parents and professionals often report that
the baby is sucking and sucking, but the milk
is not going down. The baby demonstrates a
non-nutritive sucking action, where the suck is
ineffective due to an inability to create sufficient
negative intra-oral pressure to draw milk from
the breast/teat.
Infants with undiagnosed cleft palate often
take time to regain their birth weight, and the
baby may present with faltering growth. In se-
vere cases an infant may present with dehydra-
tion. Historically, even when a diagnosis of cleft
palate had been made, babies would struggle to
thrive, where there was no CNS service (Jones,
1988; Lee et al, 1997). Difficulty feeding can lead
to exhausted parents who may struggle to bond
with their baby.
BreathingSome babies with cleft palate may also have noisy
breathing, secondary to a small bottom jaw (mi-
crognathia). A posteriorly placed tongue (glos-
soptosis) results in upper airway obstruction,
most noticeable in a supine position. These are
features consistent with Pierre Robin Sequence.
Most babies with cleft palate can be placed on
a continuum, exhibiting from mild to severe
functional effects, including airway obstruction
(Bannister, 2001).
Hearing and speechCleft palate can cause problems with hear-
Figure 2. Small posterior cleft palate seen with aid of tongue depressor
Figure 3. Cleft extending into hard pal-ate, showing nasal septum
30 | Community Practitioner October 2012 Volume 85 Number 10
group of babies for whom their airway is put
at risk by supine positioning (American Acad-
emy of Pediatrics (AAP) Taskforce, 1992; Habel,
2001).
The cleft CNS emphasises the need for vigilance
in all other aspects of cot death advice, especially
with regard to smoking, as this can exacerbate
any airway problems the infant is experiencing.
The CNS provides a specialist feeding assess-
ment, provides equipment, and demonstrates
how to assist the baby’s feeding if safe and ap-
propriate (Shaw et al, 1999). The CNS service
continually re-assesses feeding skills, adapting
equipment, technique, and feed type as required
and monitoring growth on a regular basis.
Failure to thrive is a well recognised potential
effect of cleft palate, but this can be ameliorated
by the expert support from the specialist nursing
service (Pandya and Boorman, 2001; Beaumont,
2008). The CNS counsels the parents and helps
them to accept and adapt to the different needs of
their new baby. Information and advice is offered
regarding weaning to reduce nasal regurgitation
of food.
Management An appointment will be made for the family
to meet the multidisciplinary cleft team within
four to six weeks of birth as appropriate. Pri-
mary surgery to repair the cleft in the palate is
usually performed at around six to 12 months
of age. The surgery will take place at a special-
ist children’s surgical unit within one of the nine
regional cleft centres, and the CNS offers peri-
operative assessment and ongoing support.
The child will require monitoring of speech in
order to assess the function of the palate. Some
children will require local speech therapy to as-
sist the development of the oral pressure sounds.
Some children may require speech investigations
such as videofluoroscopy or nasendoscopy to as-
sess the need for further surgery (re-repair) to
improve the length or movement of the soft pal-
ate, or pharyngoplasty to build up the back of
the pharynx, so that the palate does not need to
move as far to obtain closure.
Hearing, speech and dentition, are monitored
until late teenagehood. Some children will also
need the further support of clinical psychology,
and other families may benefit from genetic as-
sessment, especially if there is a known family
history, or other anomalies are present.
DiscussionDetection of cleft palate following delivery is
being addressed in various ways, including dis-
cussion by lead cleft nurses with organisers of
the Newborn Screening Programme, Royal Col-
lege of Midwives video teaching examination of
the newborn (McDonald and Lynn, 2011) and
general teaching. While NICE states that the
examination of the newborn check should be
performed within 72 hours of birth, cleft nurses
regard this as too late to prevent early feeding
problems and distress.
As identified by the SIG audit, a significant
number of cleft palates are still missed at this ex-
amination, and it then falls to community staff
to be observant for signs of cleft palate.
Late diagnosis causes distress to the infant
and parents, who are often angry or upset. They
may wonder if something else has been missed;
this could lead to complaint or consideration of
litigation. It is in everyone’s interests to pick up
signs of this easily detectable condition.
ConclusionCommunity health visitors, nursery nurses, and
school nurses are well placed to look for signs of
cleft palate, and to make appropriate referral to
the regional cleft team. Although it may be chal-
lenging for the community nurse to make this
diagnosis and inform parents, families are grate-
ful that someone has listened to their anxieties,
and that the cause of their baby’s difficulties has
been identified. They then feel able to under-
PRACTICE: PEER REVIEWED
T iming of diagnos is (2009 audit)
305
130
0
50
100
150
200
250
300
350
Cleft palate detected within 24hours of birth
Cleft palate detected after 24 hoursof birth
Number of babies with cleft palate
Num
ber
of b
abie
s w
ith c
left
pal
ate
T iming of diagnos is of c left palate (2009)
305
43
19
2419 8 13
<24 hours
24-72 hours
72hrs-7 days
7 days-1 month
1-3 months
3-12 months
> 12months
Figure 4a. Timing of diagnosis (2009 audit)
Figure 4b. Timing of diagnosis (2009 audit)
October 2012 Volume 85 Number 10 Community Practitioner | 31
stand their baby’s behaviour and begin to adjust
to their baby’s condition with the support of the
community and specialist nursing teams.
Acknowledgements The author would like to acknowledge the
support of cleft CNSs throughout the country,
who have been involved in the gathering of data
for the national SIG audits.
ReferencesAmerican Academy of Pediatrics (AAP) Taskforce on Infant Positioning and SIDS. (1992) Positioning and SIDS. Pediatrics 89(6): 1119–126.
Bannister RP. (2001) Early feeding management. In: Watson ACH, Sell DA, Grunwell P. Management of Cleft Lip and Palate. London: Whurr.
Bannister RP. (2011) A dilemma: is side-lying an acceptable option in the management of infants born with an islolated cleft palate. A 5 year audit of infants, sleep position and death
rates. Craniofacial Society of Great Britain and Ireland Annual Scientific Conference, University of York.
Beaumont D. (2008) A study into weight gain in infants with cleft lip/palate. Paediatr Nurs 20(6): 20–3.
Butcher S. (2007) Cleft palate: the value of early diagnosis. Midwives 10(8): 382–83.
Butcher S, Cleft Nurses’ Special Interest Group. (2010) Late diagnosis of cleft palate. Craniofacial Society of Great Britain and Ireland Annual Scientific Conference. Liverpool.
Cleft Lip and Palate Association (CLAPA). (2009) Understanding Cleft Lip and Palate. London: CLAPA.
Clinical Standards Advisory Group (CSAG). (1998) Cleft Lip and/or Palate. Report of a CSAG Commitee. London: The Stationery Office.
Crane Project Team. (2011) Crane Database Progress Report. London: RCSENG.
Habel A, Elhadi N, Sommerlad B, Powell J. (2006) Delayed detection of cleft palate: an audit of newborn examination. Arch Dis Child 91(3): 238–40.
Habel A. (2001) The role of the paediatrician. In: Watson ACH, Sell DA, Grunwell P. Management of Cleft Lip and
Palate. London: Whurr.
Jones WB. (1988) Weight gain and feeding in the neonate with cleft: a three-centre study. Cleft Palate J 25(4): 379–84.
Lee J, Nunn J, Wright C. (1997). Height and weight achievement in cleft lip and palate. Arch Dis Child 76(1): 70–2.
Lumsden H. (2012) Core strength. Midwives 1: 42–3.
Martin V, Rose DH. (2004) Prenatal diagnosis of cleft lip. In: Martin V, Bannister RP. Cleft care: A practical guide for health professionals on cleft lip and/or palate. Salisbury: APS.
McDonald S, Lynn B. (2011) Examination of the newborn: online. Available from: www.rcm.org.uk/midwives/reviews/examination-of-the-newborn-online [Accessed September 2012].
Moss AL, Jones K, Piggott RW. (1990) Submucous cleft palate in the differential diagnosis of feeding difficulties. Arch Dis Child 65: 182–4.
National Institute for Health and Clinical Excellence (NICE). (2006) NICE Clinical Guideline 37: Routine postnatal care of women and their babies. London: NICE.
Pandya AN, Boorman JG. (2001) Failure to thrive in babies with cleft lip and palate. Br J Plast Surg 54(6): 471–5.
Shaw WC, Bannister RP, Roberts CT. (1999) Assisted feeding is more reliable for infants with clefts - a randomised trial. Cleft Palate-Craniofacial Journal 36(3): 262–8.
Stoll C, Alembik Y et al. (2000) Associated malformations in cases with oral clefts. Cleft Palate Craniofac J 37(1): 41–7.
Watson ACH. (2001). Embryology, Aetiology and Incidence. In: Watson ACH, Sell DA, Grunwell P. Management of Cleft Lip and Palate. London: Whurr.Whurr.
PRACTICE: PEER REVIEWED
l Cleft palate cannot be detected antenatally by routine ultrasound scan l A third of babies with cleft palate are not diagnosed within 24 hours of birthl Babies with cleft palate often demonstrate ineffective feeding, and have a history of nasal
regurgitation of feed. Older children may have nasal sounding speechl Community practitioners are well placed to recognise signs of cleft palate from the
history offered by parents and carersl Community practitioners are advised to contact their regional cleft team for advice, and
to refer children with suspected cleft palate to their regional team for multidisciplinary cleft management
Key points
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Professional Officer Health Sector Full-time (Education) £41,195 plus £3,105.00 London Allowance (where appropriate)
Unite/CPHVA vacancy
Nursing in the community faces challenges across the UK: the importance of a good start for the infant in the family; the implementation of the Health Visitors’ Plan in England; the shift of public health finance to local government; the growth of the extended school day and the shift to academies; the transfer of community nursing services to Foundation Trusts, Community Trusts and Social Enterprises.
For leaders and practitioners this is the UK conference to keep up with the best practice in the four countries, find solutions to your problems and celebrate the the difference that health visitors, school nurses and community practitioners make to children and their life chances.
This conference and exhibition will:
Breakfast Briefings
Sponsored by:
Keynote speakers:
Len McCluskey General Secretary, Unite the Union
GROUP BOOKING DISCOUNT AVAILABLE NOW – CALL 020 7324 4330 FOR DETAILS
For further details and bookings call: 020 7324 4334Or register online today at: www.neilstewartassociates.com/cphva
Professor Viv Bennett Department of Health’s Director of Nursing and the Government’s Principal Advisor on Public Health Nursing
Jackie Smith Acting Chief Executive and Registrar, The Nursing and Midwifery Council
Dame Elizabeth Fradd Chair, Health Visitors’ Taskforce; Independent Health Service Advisor
Cont
ribut
e to your PREP requirem
ent • Contribute to your PREP requirem
ent
•
AN NIV ERSARY
ANANANIV ERERE SRSR ASAS
RARA
YRYRYPublic Health Nursing Practice
in HEAL TH
Nursing in the community faces challenges across the UK: the importance of a good start for the infant in the family; the implementation of the Health Visitors’ Plan in England; the shift of public health finance to local government; the growth of the extended school day and the shift to academies; the transfer of community nursing services to Foundation Trusts, Community Trusts and Social Enterprises.
For leaders and practitioners this is the UK conference to keep up with the best practice in the four countries, find solutions to your problems and celebrate the the difference that health visitors, school nurses and community practitioners make to children and their life chances.
This conference and exhibition will:
Bring you up to date with policy developments that will affect practice in the coming year
Highlight the best innovations and working practices from around the UK
Provide an update on the Implementation Plan for Health Visiting and the Development Plan for School Nurses
Review the new employment destinations of nurses after the closure of PCTs
Look at the safeguarding of children and the rules and practices needed
Help understand the impact of information technology on the work of nurses across the community
Look at the risks social networking media creates for children and professionals
Breakfast Briefings
Sponsored by:
FOR DETAILS
Department of Health’s Director of Nursing and the Government’s Principal Advisor on Public Health Nursing
GALA DINNER & PARTY Includes... PRE-DINNER DRINKS RECEPTION3 COURSE (SILVER SERVICE) DINNER– WITH WINE ENTERTAINMENT DANCING INTO THE EARLY HOURSVISCOUNT ROOM HILTON BRIGHTON METROPOLE WEDNESDAY 7 NOVEMBER 2012 AT 8PM
TICKETS: £18.00 (Incl VAT) We couldn’t let the 150th anniversary pass without celebrating in style and so we are pleased to announce the Unite/CPHVA Gala Dinner and Party in the Viscount Room at the Hilton Brighton Metropole on Wednesday 7 November 2012 at 8pm. For this year only, Unite/CPHVA with the support of Ten Alps Publishing, will be sponsoring this fantastic gala event and we hope that, in this anniversary year, as many of you as possible will come along and celebrate with us.
Places are limited, so please book early to avoid disappointment.
Confirmed exhibitors
Unite/CPHVA Nursing and Midwifery Council Newlife Foundation for Disabled Children World Cancer Research Fund (WCRF UK) Foundation for the Study of Infant Death (FSID) NCT Bliss HeadSmart NSPCC Solihull Approach Baby D (KoRa Healthcare) South East Coast Strategic Health Authority Aptamil Pfizer Nutrition (SMA) A2 Milk UK British Journal of School Nursing Wirral NHS Trust The London Orthotic Consultancy Ltd Calpol Johnson’s Baby Feeding for Life Foundation Journal of Family Healthcare Genus Pharmaceuticals ChiMat One Plus One Lansinoh Nurofen for Children Institute of Health Nursing Department of Health Cow & Gate Mothercare Sudocrem - Forest Tosara Ltd CPHVA Charitable Trust Harlow Printing Ltd
r PREP requirement • Contribute to your PR
34 | Community Practitioner October 2012 Volume 85 Number 10
Jill Hill RGN BSc(Hons) Specialty Trainee Year 5 in PaediatricsDiabetes Nurse Consultant, Birmingham Community Healthcare NHS Trust, and member of the NICE Programme Development Group
AbstractType 2 diabetes accounts for approximately 90% of the three million people who have diabetes in the UK, and it presents a significant challenge to the NHS. The number of people developing the condition is rapidly increasing, and it is estimated that five million people will have diabetes by 2025. Diabetes can lead to the development of a number of disabling and costly complications including blindness, kidney failure, heart disease, stroke and amputation. Type 2 diabetes is treated by improvements in lifestyle, losing weight, treatment with a number of oral medications and, eventually, injection therapy including insulin. The increasing number of people with diabetes means it is a significant consumer of NHS resources. The development of type 2 diabetes is associated with a number of risk factors. There is strong and consistent evidence which shows that early detection of people at high risk followed by changes in lifestyle can reduce the incidence of type 2 diabetes and its complications, eg: diabetes. New guidance from the National Institute for Health and Clinical Excellence (NICE) on identifying people at high risk of developing type 2 diabetes and the provision of clinically and cost effective interventions to prevent or delay the onset of the condition has recently been published. This article summarises the guidance and particularly focuses on the role of nurses working in primary and community care settings.
Key wordsType 2 diabetes, blood glucose, prevention, risk factors, lifestyle modification
Preventing type 2 diabetes: a role for every practitioner
IntroductionThere are approximately 3 million people with
diabetes in the UK, of whom 90% have type
2 diabetes. Type 1 diabetes typically occurs
in children and young people, and usually
presents with a dramatic onset of weight loss,
polyuria and thirst. The insulin-producing
beta cells are destroyed by an auto-immune
process and individuals with this condition are
totally dependent on insulin injections for the
rest of their lives.
Type 2 diabetes is caused by insufficient
production of insulin and resistance to insulin.
It is strongly associated with obesity and
commonly occurs in middle-aged and older
people; although some children and people
in their 20s are now developing the condition.
There may not be any noticeable signs or
symptoms. It is a progressive condition, and
although may initially respond to lifestyle
modification, it may need a variety of oral
medications and, eventually, injection therapy
including insulin to normalise glycaemia.
Both types of diabetes can lead to the
development of a number of distressing,
costly complications. These include the micro-
vascular problems of retinopathy (which can
lead to blindness), nephropathy (leading to end
stage renal failure) and neuropathy (which can
manifest in a variety of ways such as erectile
dysfunction, gastro-paresis, and painful feet).
Myocardial infarction, angina, stroke and
peripheral vascular disease are examples of
macro-vascular diabetes complications.
The numbers of people developing type 2
diabetes are increasing significantly in the UK
and worldwide. It is estimated that by 2025,
there will be approximately five million people
in the UK with diabetes, most of whom will
have type 2 diabetes.
Apart from the personal costs of living with
the condition and its complications, this diabetes
epidemic has huge consequences for future NHS
resources. Diabetes consumes about 10% of the
annual NHS budget at £10billion, which equates
to about one million pounds per hour (Diabetes
UK, 2012). Less than a quarter of that cost relates
to the treatment and ongoing management
of diabetes, most costs arise from treating the
complications of diabetes (Hex et al, 2012).
However, there are a number of large trials
across the world, including Finland, USA, China
and India that demonstrate that type 2 diabetes
can be prevented or delayed in individuals
at risk. Relatively simple improvements in
lifestyle behaviour can significantly reduce
risk. The evidence from these interventions
contributed to the development of the recently
published guidance from NICE (NICE, 2012),
which complements earlier guidance aimed at
reducing risk at the population and community
level (NICE, 2011).
Identifying people at high riskThere are a number of risk factors associated
with the development of type 2 diabetes, some
of which are modifiable. These are listed in in
Table 1.
Certain medical conditions can also increase
the risk of developing type 2 diabetes. These
include cardiovascular disease, hypertension,
polycystic ovary syndrome, mental health
problems, learning difficulties, and previous
gestational diabetes.
PRACTICE: PEER REVIEWED
Table 1. Factors associated with high risk of developing type 2 diabetes
Non-modifiable
l Increasing age
l Ethnicity (South Asian, African–Caribbean, Chinese or black–African descent)
l Having a first-degree relative with type 2 diabetes
l Having had a low birth weight
Modifiable
l Being overweight
l Sedentary lifestyle
l Diet
October 2012 Volume 85 Number 10 Community Practitioner | 35
l Assess their risk of type 2 diabetes using
a validated self-assessment questionnaire
(paper based or online; an example is the
Diabetes UK online diabetes risk score at
(www.diabetes.org.uk/Riskscore/). The risk
assessment tool for health professionals
is available (www.diabetes.org.uk/
Professionals/Risk-score-assessment-tool/)
or GP practices can use a computerised risk
score based on information contained in
patient records l If they are assessed as high risk, to contact
their GP surgery or practice nurse for a blood
test, either the fasting blood glucose or the
HbA1c
test to confirm their level of risk and
discuss how to reduce it, or whether they
already have type 2 diabetesl Practice nurses in particular will be involved
in using the practice-based assessment tool.
However, all nurses should encourage adults
to complete a risk assessment. Indeed, some
nurses who may feel they have very little input
to diabetes care, may be working with people
at particular risk (learning difficulties, mental
health and other hard-to-reach groups).
What advice should nurses give?People using the risk score will be categorised
into either low/intermediate or high risk of
developing type 2 diabetes. Nurses may be asked
to interpret results and give follow-up advice.
NICE guidance recommends that people with
a low or intermediate risk score should be given
brief advice on the risks of developing diabetes,
the benefits of adopting a healthy lifestyle, and
should be signposted to areas that can support
the modification of risk factors (eg, local
walking groups to support increasing physical
activity levels). Nurses should advise people in
this category to re-assess (or be re-assessed)
their risk at least every five years.
People with a high risk score should be
offered a blood test to eliminate undiagnosed
diabetes or categorise risk further, which can
either be a venous fasting blood glucose (FBG)
or glycated haemoglobin (HbA1c
). The latter
test was, until recently, just used to monitor
glycaemic control in people with established
diabetes. However, in 2011 the World Health
Organization (WHO) recommended that
HbA1c
could be used to help diagnose diabetes
in most situations (other than pregnancy, in
children/young people with symptoms, in
anyone of any age with symptoms suggesting
type 1 diabetes, in anyone taking medication
that may cause a rapid glucose rise, and in
those with acute pancreatic damage) and if
PRACTICE: PEER REVIEWED
High-risk scoreLow or intermediate risk score
Reassess risk at least every 5 years
>75 yearsUse risk assessment tools
and questionnaires
40 to 74 years• Use validated risk assessment took or validated self-assessment questionnaire• Follow NHS Health Check process and protocols where possible
High-risk groups• People aged 25 to 39 years of South Asian, Chinese, African–Caribbean, black African and other high-risk black and minority ethnic groups• People with conditions that increase the risk of type 2 diabetesUse risk assessment tools and questionnaires
Consider a blood test for South Asian and Chinese people aged 25 and over
with BMI >23 kg/m2
Offer brief advice on:• The risk of developing diabetes• The benefits of a healthy lifestyle• Modifying risk factors
Offer a blood testChoose either FPG or HBA1c – use as appropriate and according to national quality specifications
Moderate risk
FPG <5. mmol/l or HbA1c <42 mmol/mol
(6.0%)Offer a brief intervention to:• Discuss the risks of developing diabetes• Help modify individual risk factors• Offer tailored support services
High risk
FPG 5.5–6.9 mmol/l or HbA1c 42–47 mmol/mol
(6.0–6.4%)Offer an intensive lifestyle change programme to:• Increase physical activity• Achieve and maintain weight loss• Increase dietary fibre, reduce fat intake, particularly saturated fat
Possible type 2 diabetes
FPG ≥7.0 mmol/l or HbA1c ≥48 mmol/mol
(6.5%)Carry out a further blood test if asymp-tomatic, according to national quality specifica-tions, to confirm or reject the presence of diabetes
Reassess risk at least every 3 years
Reassess weight and BMI and offer a blood test at least
once a year
No diabetesOffer an intensive lifestyle change
programme
DiabetesEnter diabetes management
pathway
Stag
e o
neSt
age
two
FPG = fasting plasma glucose HBA1c = glycated haemoglobin
The new NICE guidance can be used
alongside the NHS Health Check programme,
the national vascular risk assessment and
management programme for people aged
40 to 74 years.
The new recommendations focus on two
major activities:l Identifying people at risk of developing type 2
diabetes using a staged (or stepped) approach.
This involves a validated risk-assessment score
and a blood test – either the fasting blood
glucose or the HbA1c
test to confirm high riskl Providing those at high risk with a quality-
assured, evidence-based, intensive lifestyle-
change programme to prevent or delay the
onset of type 2 diabetes.
Recommendations include encouraging
adults to:
Figure 1. Pathways for identification and management of risk (NICE, 2012)
36 | Community Practitioner October 2012 Volume 85 Number 10
certain criteria are met (for example, normal
haemoglobin HbA1c
levels of 48 mmol/mol
(6.5%) or above indicate that someone has
type 2 diabetes.
A report from a UK expert group on the
implementation of the WHO guidance
recommends using HbA1c
values between 42
and 47 mmol/mol (6.0 to 6.4%) to indicate that
a person is at high risk of type 2 diabetes (John
et al, 2012).
If the FBG is 7 mmol/L or greater, or the
HbA1c
is 48 mmol/mol (6.5%) or greater, then
this falls in the diabetes diagnostic range. If the
individual has no symptoms, the test should
be repeated and if positive again, diabetes is
confirmed and the person should be supported
along the usual diabetes pathway.
If the FBG is less than 5.5 mmol/L or the
HbA1c
is less than 42 mmol/mol (6.0%) then
brief advice as above should be given by the
nurse. Risk assessment should be repeated at
least every three years.
High risk of developing type 2 diabetes
is confirmed if the FBG is between 5.5 and
6.9 mmol/L or the HbA1c
is between 42 and
47 mmol/mol (6.0 and 6.4%). Nurses should
refer the individual to a quality-assured intensive
lifestyle change programme to increase physical
activity (ideally to a minimum of 150 minutes
of moderate intensity physical activity a week),
to achieve and maintain gradual weight loss, to
increase dietary fibre through consumption of
whole grains and vegetables, and to reduce fat
intake, particularly saturated fat. Primary care
nurses will be involved in re-assessing weight,
body mass index and blood glucose status at
least once a year. There is a useful flowchart
included in the NICE guidance which
summarises the pathways for identification
and management of risk which is reproduced
in Figure 1.
Preventing type 2 diabetes:summarising the role of the primary and community nurseNurses should encourage adults in their care
to self-assess their risk of developing type 2
diabetes by the use of validated websites or
paper-based tools, or be able to direct people
to where they can have this done. As well as
conventional health care venues like dentists,
health centres, GP practices and optical
practices, community venues like faith centres,
shops, leisure centres and job centres will be
encouraged to make this facility available
and improve accessibility for raising people’s
awareness of their potential risk.
Practice nurses in particular will have
an important role in collecting relevant
information about individuals which will
enhance the effectiveness of the practice
computer-based risk-assessment tool. This
includes data gathered opportunistically, such
as current weight and recording family history
of diabetes. Individuals with high risk scores
will usually have the venous FBG or HbA1c
taken by a primary or community nurse.
Nurses should be familiar with the brief advice
to offer to those with low and intermediate
risk, and the advice and information needed
by those with a high risk score but whose FBG
or HbA1c
is not in the high risk range. They
should also have a good knowledge about
local support groups and resources to direct
individuals for support.
Although most primary and community
nurses are unlikely to be delivering them, they
should be familiar with the referral procedure
for local intensive lifestyle programmes. They
should encourage individuals at high risk of
developing diabetes to attend and promote a
‘keep well’ message. People may not perceive
there is a need for action until they actually
have diabetes. Nurses are also likely to be
involved in the long-term monitoring of these
individuals.
References Diabetes UK. (2012) Diabetes in the UK 2012. Key statistics on diabetes, 2012. Available from: http://diabetes.org.uk/Professionals/Publications-reports-and-resources/Reports-statistics-and-case-studies/Reports/Diabetes-in-the-UK-2012/ [Accessed September 2012].
Hex N, Bartlett C, Wright D et al. (2012) Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine 29: 855–62.
John WG, Hillson R, Alberti G. (2012) Use of haemoglobin A1c (HbA1c) in the diagnosis of diabetes mellitus. The implementation of World Health Organization (WHO) guidance. Practical Diabetes 29(1): 12.
National Institute for Health and Clinical Excellence (NICE). (2011) Preventing type 2 diabetes-population and community interventions. London: NICE.
NICE. (2012) Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. London: NICE.
World Health Organization (WHO). (2011) Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. Geneva: NICE.
PRACTICE: PEER REVIEWED
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12785 SMA Ad 210x297.indd 1 08/06/2012 15:29
38 | Community Practitioner October 2012 Volume 85 Number 10
FEATURE
CHILDIMMUNISATION
October 2012 Volume 85 Number 10 Community Practitioner | 39
FEATURE
A project to improve uptake of immunisation in north-east LondonCatherine Sekwalor describes a project working with the Charedi Orthodox Jewish community of Stamford Hill, north-east London, to promote immunisation
I was inspired to apply for leadership
funding offered by the Queen’s Nursing
Institute (QNI) to set up a project for the
Jewish people of Stamford Hill in the London
Borough of Hackney, because I have always
felt a real connection with this group. The
Charedi Orthodox Jewish Community (COJC)
is often described as a unique, insular and
hard-to-reach population. Due to historical
factors, they are a group of people who tend to
reject outside influence, being very proud of,
and keen to preserve, their cultural traditions
and way of life. Furthermore, I wanted to do
something worthwhile, which both promotes
and supports the community.
Once I had decided to apply for funding,
putting together the proposal for the project
was the hardest part. Having never done one
before I saw this as a daunting task. Where
and how to start, and picking an original and
innovative topic that had not been tapped into
was significantly important.
I wanted a subject matter that would be both
momentous and would make a difference to
the COJC. Fortunately, before completing
the application, I had attended a study
day on ‘writing a proposal’, which gave me
tremendous insight into what I needed to
consider. This also gave me the opportunity to
seek help from senior managers and a mentor
for guidance and support.
Inspiration for the projectOur service delivery plan identified a gap in
the service, highlighted by the Department of
Health (DH). Hackney has the lowest rate of
immunisation uptake in London, and this is
particularly low within the COJC of Stamford
Hill due to poor access.
The second was promoting the human
papillomavirus (HPV) vaccine, as this was
something the rabbinate (the religious leaders
of the COJC) had rejected, contending that
it did not apply to their community. The
principle aim of the project was to promote
immunisation, particularly HPV, in a positive,
non-confrontational way, and increase uptake.
Another reason for setting up the project was
a lack of awareness among health professionals
about the Jewish way of life, which was often
spoken about by the community members
themselves. We had heard complaints that
health professionals lacked understanding of
the community’s way of life and for this reason
the community at large were reluctant to
engage with them.
Health professionals also voiced the same
concerns, and this led me to seriously consider
the need for a booklet for professionals
working with the COJC that would give them
an insight into the Charedi Orthodox Jewish
way of life.
Although a book has already been written
for professionals on the subject, it lacks some
specific information, including how to engage
better with the COJC. The aim for my booklet
is to be a joint collaborative piece promoting
a better working relationship between the
community and professionals. I intend to use
it to dispel myths and misconceptions about
the COJC. One of these is that they are rich;
however, this is usually not the case. The COJC
have large families, with an average size of six
children per household. Most Charedi men
spend a great proportion of their time studying
the Torah and those who work do so within
Stamford Hill. This has profound implications
on Charedi households giving rise to high level
of poverty within the community.
InsightMy role as a clinical lead of the Orthodox
Jewish Health Team has given me great
insight into the COJC. Most of my work,
apart from managing my team, is with the
Rabbis and organisation leaders implementing
programmes in schools and in the community.
Delivering services to the COJC is not always
a smooth process, and extensive negotiation is
often required.
Most negotiation is around the issue of
cultural sensitivity, which is paramount in
the Charedi Orthodox Jewish way of life.
Before being used all literature must go
through stringent review to ensure cultural
appropriateness; for example, women or girls
cannot be featured on promotional materials
as this is seen as disrespectful to women.
Securing the backing of the Rabbis and
other COJC leaders will ensure the success
of this project and funding will place the
Orthodox Jewish Health Team in good stead
in the community. This will provide a gateway
to both health and other professionals to
deliver services to the community and help
improve access to services and minimise
health inequalities.
Catherine SekwalorClinical Lead for Orthodox Jewish Community & PSHE Division for Children’s Services, Diagnostics and OutpatientsHomerton University Hospital Foundation NHS Trust
The CPHVA is immensely proud of the professionalism,
passion and creativity that community practitioners and health
visitors undertake daily, across a diverse landscape of practice
environments.
This work continues to be undertaken in extremely difficult
times, often with little or no recognition or appreciation. Launched
in 2011 to counter the lack of appreciation for the professional
achievements of members, the CPHVA Awards acknowledge the
extraordinary work that members carry out every day with huge
dedication, and without complaint.
A date for the diaryThe CPHVA Awards will take place in the stunning setting of
Savoy Place, London on Thursday 14 March 2013, at a lunchtime
ceremony that is the annual opportunity to recognise the
achievements of the profession at your own national awards.
The occasion will begin with a reception at 12pm, to which those
shortlisted for each award will be invited to attend and enjoy
meeting and mixing informally with their peers, our key partners
and invited guests. After lunch, the presentation of the awards will
form the highlight of a wonderful day.
Now, the moment has come for you to nominate or be nominated
for the awards – your awards – to celebrate you, your colleagues,
your teams, and the positive work they accomplish.
How to get involvedFirst, study the categories and list anyone you believe should be
nominated for their outstanding professional contribution.
Next, prepare your nomination(s)From 1 October you will be able to complete the online entry form
at the website and upload the information about your nominated
person or team.
You need to make sure your nominations are submitted online no
later than 20 December 2012.
Your entries will be assessed by a CPHVA judging panel
throughout January 2013.
The judging panel will release a short-list of finalists, no later than
31 January, with no more than five finalists in each category.
All those shortlisted will be invited to attend the awards ceremony,
when the winners will be announced.
Profiles on the finalists and winners will be published in
Community Practitioner journal.
Nomination criteria You will need to visit the Community Practitioner journal website
(www.commprac.com) to enter your nomination(s) online.
You may nominate any colleague or team demonstrating
exceptional work performance. Self-nominations are permitted, but
The CPHVA and Community Practitioner are proud to announce the second CPHVA Awards, to recognise and celebrate the achievements and vital hard work of community nursing practitioners across the UK, each and every day.
A celebration of professionalism
CPHVA AwArds 2013
AWARDS2013
Proudly sponsored by:
you must provide a supporting endorsement from a senior officer,
senior employer’s representative, or college lecturer.
You need to briefly describe the nominee’s activities,
achievements, or contributions that you believe qualify them for an
Award. Please limit this description to 500 words.
These guidelines are intended to help focus your thinking when
completing the nomination form. They are not all-inclusive nor are
they intended as categories.
Nominations should describe the qualities nominees have
displayed in their chosen area of professional practice.
They could demonstrate: l outstanding care within their practice setting l an ability to be an advocate and professional role model l an ability to instigate, develop, coordinate and/or participate in
projects and programmes that have a positive outcome for the
health and wellbeing of the community l active participation in professional and/or community
organisations that foster and advance the health and wellbeing of
the community l a willingness to share their personal philosophy of community
and public health nursing practice l a vision for community practice l a commitment to safety and quality l a personal commitment to continuing education for themselves
and/or others.
CPHVA AwArds 2013
2013 Award Categories Community Practitioner of the year
Community Practitioner Team of the year
Health Visitor of the year
Community Nursery Nurse of the year
School Nurse of the year
Community Practitioner/Health Visiting team leader of the year
CPHVA Student of the year
Healthcare Assistant of the year
CPHVA Advocate of the year
CPHVA Trust Overseas Travel Bursary
Make your nomination online at www.commprac.com
42 | Community Practitioner October 2012 Volume 85 Number 10
Feature
Can a ‘sign-off’ experience with the health visiting service benefit students? The provision of a final placement before qualification – often referred to as a ‘sign-off’ placement – in the child field of practice can prepare students for their transition into health visiting
Kate Brown BA MSc RGN RHV RNT Principal LecturerMiddlesex University
In the push to achieve the Health
Visitor Implementation Plan target
of 4 200 extra health visitors by 2015
(Department of Health (DH), 2011a)
a range of measures are being directed
at student nurses to recruit them on
to specialist practice health visiting
programmes, including a ‘myth buster’
document from the Nursing and Midwifery
Council (NMC, 2011) and targeted mail
to the home address of recently and newly
qualified students.
One route to health visiting offered by
some universities is the 2+1 programmes,
where a graduate with a degree in a health-
related subject claims accreditation of prior
learning and achieves first registration after
two years and then immediately commences
their specialist community public health
nursing (SCPHN)/HV programme (NMC,
2011).
Another other option being taken by a
growing number of students is to complete
the three-year nursing pre-registration
programme and then join the health visitor
(HV) programme (NMC, 2011).
October 2012 Volume 85 Number 10 Community Practitioner | 43
Feature
Student nurse to health visitorThe NMC has argued that the current
pre-registration programmes ‘have greater
opportunities for practice learning in
primary care ... facilitating the graduate
to move onto a SCPHN/HV programme
without any requirement of post-
registration experience in primary care’
(NMC, 2011). In practice, the amount
of primary care experience in a pre-
registration nursing programme may vary
as some universities have found identifying
placements in primary care to be a challenge
(Dean, 2010).
In relation to adult nursing, several
universities have documented how a more
structured approach to placements in the
community setting has made it more likely
that students will apply and be successful
appointed to community posts (Shelton and
Harrison, 2011; Brooks and Rojahn, 2010).
Offering final year 12-week placements
to adult branch students within district
nursing at Middlesex University has made
a difference to the confidence of students
in applying and remaining in community
posts in adult nursing services. Therefore,
the university has decided to see whether
this can be replicated for health visiting with
students from the child field of practice.
It is too early to assess how many of the
newly qualified nurses who join the HV
programme will have longevity in health
visiting at a national level, but it is possible
that an important variable will be the
amount of exposure to the service which
occurred as part of their pre-registration
programme.
Students can join health visiting from
any field of nursing or midwifery. An
important starting point for reviewing how
the current pre-registration educational
programmes inform health visiting practice
are the NMC standards for pre-registration
nursing (NMC, 2010) or midwifery (NMC,
2009). While student nurses in any field
must gain generic competencies there are
also individual field competencies to be
achieved for adult, child, mental health and
learning disability. Arguably, each field has
something to offer health visiting.
The decision to offer child field students
this opportunity was partly a pragmatic one,
in that they can build on existing learning
opportunities in child health community
services. However, the BSc in Child
Health programme provides an important
theoretical underpinning to many of
the areas set out in the HV education
programme, such as early childhood
development, attachment and parenting, the
healthy child programme and safeguarding.
It could be argued that it is the students
of the other fields of nursing who, if they
have an interest in a HV career, need more
exposure to the service; therefore, we retain
an open mind about how this learning
opportunity could be developed for other
fields of nursing.
the sign-off mentor Since 2010 new nurse and midwives
registering with the NMC have been
required to be ‘signed off ’ by specially
qualified mentors. This is a requirement of
the NMC standards (NMC, 2008) and came
into place following NMC commissioned
research (Duffy, 2003), which showed that
some students were joining the register
despite mentors having concerns about
their competence. One of the NMC
requirements for sign-off mentor status can
be an important consideration in deciding
whether a HV team can accept students for
their final placements. The NMC uses the
term ‘due regard’ to describe the process
of mentoring students by someone who is
from the same field of practice and ‘due
regard’ always applies to the final placement.
This means that students of children’s
and young people’s nursing, for example,
should be mentored by registered children’s
nurses. A health visiting team’s decision
to accept students from a particular field
might, therefore, be determined by the
qualifications held by existing mentors
within the team.
Practice teachers can also act as sign-off
mentors; however, the demands of the HV
implementation programme mean that they
are already stretched meeting the needs of
health visiting students (DH, 2012).
acquiring ‘sign-off’ statusIncreasingly in the NHS preparing sign-off
mentors is an internal cascade process as
existing mentors assist colleagues in their
preparation. However, if a service does not
have a history of taking finalist students
then it is likely that it will need to work with
an Approved Educational Institution (AEI)
to ensure that mentors are prepared.
The NMC specifies that the sign-off
mentor needs to be supervised in signing
off on three occasions. The first and second
supervisory process can be undertaken
as a simulation or role play but the third
supervision must be with an actual student
(Glasper, 2010). The preparation of sign-off
mentors focuses on the three elements
(see Box 1).
Preparation in the local environmentOnce organisations have decided that they
can meet the NMC requirements of ‘due
l An understanding of the NMC registration requirements and the contribution they make to the achievement of these requirements
l An in-depth understanding of mentor accountability to the NMC for the decision they must make to pass or fail a student when assessing proficiency requirements at the end of a programme
l A working knowledge of current programme requirements, practice assessment strategies and relevant changes in the education and practice for the student they are assessing
Box 1. NMC expectations of the sign off mentor covered in the preparation period
Practice teachers can also act as sign-off mentors, but demands mean that they are already stretched meeting the needs of students
44 | Community Practitioner October 2012 Volume 85 Number 10
Feature
regard’ and ‘sign-off status’ there are other
important considerations for local managers
and the wider team; for example, is there
team agreement of what exactly a student
can do at this stage of their programme?
Most areas with a history of accepting
students will have needed to list the learning
opportunities in their area. However, the
discussion about the learning opportunities
for a final experience student will entail a
clear agreement about what they can do
independently, how the client’s safety can
be ensured and how the mentor can address
issues of accountability.
As most organisations will have existing
protocols for student health visitors, it is
sensible to adapt these for the more limited
capabilities of a pre-registration student.
One important difference is that, legally,
pre-registration nursing students are not
allowed to administer medication under
a patient group direction (PGD) and this
will limit their hands-on involvement in the
immunisation programme.
One of the essential skills that a student
must acquire before qualification is that
they must be able to explain the principle of
a PGD; and health visiting provides an ideal
opportunity to achieve this understanding
(NMC, 2010b) and the legal exclusion is, in
fact, an important aspect of their learning.
The sign-off mentor should also identify
what other challenges a senior student
should meet in relation to the immunisation
programme, eg, a senior student should be
practising how to give parents information
in relation to immunisation.
Many of the other aspects of preparation
for a student will not differ from those
associated with a more junior student.
However, a student who is to spend 12
weeks with the team will need a work space,
access to the client information system with
a student log-in and clarity about how they
‘fit in’ to any existing lone working policy
arrangements.
Selection and preparation of the studentThe ideal time to establish whether a
student is interested in a career in health
visiting would be at the end of the second or
beginning of their third year. Selection for a
final 12-week learning opportunity in a HV
team should take this into account. A third-
year child health student will have a number
of field competencies and essential skills to
complete (NMC, 2010b), some of which will
be achievable with an HV team and others
which focus on the sick child will only be
achievable in an acute setting.
It is vital for the student who intends to
have a sign-off opportunity with health
visiting to achieve those acute illness
competencies before they reach their final
12 weeks. The AEI and the service need
to agree a procedure for identifying and
then selecting those students who are
considering a career in health visiting early
in the third year so that the student can plan
achievement of their competencies.
If there are more expressions of interest
than opportunities available, a selection
process needs to be agreed. In our pilot we
have chosen to ask for written expressions
of interest which can be viewed by both
service and partners and ranking them.
Once the student has been selected they
need clear guidance about what to expect
from their final 12 weeks. An excellent
exercise is for the student to study the
Essential Skills Clusters where the NMC
specifies exactly what the newly qualified
nurse can be expected to do when they
join the register. There are five clusters
(see Box 2) and while most listed in first
three clusters are achievable with the health
visiting service, others which focus on areas
such care of infusions or other medical
devices must be achieved in other third-year
placements.
ConclusionThe health visitors who will be recruited
during 2011 to 2015 will be a significant
cohort. It might be timely to begin to log
their pre-registration experience so that
its impact on whether they remain in the
profession can be understood. The decision
to offer a sign-off placement could reap a
long-term benefit but all stakeholders need
to be appraised of the implications at the
outset.
references Brooks N, Rojahn R. (2010) Improving the quality of community placements for nursing students. Nurs Stand 25(37): 42–7.
Dean E. (2010) Pressure on universities to find more community placements. Nurs Stand 24(52): 12–13.
Department of Health (DH). (2012) Health visitor teaching in practice: a framework for commissioning, education and clinical practice of practice teachers (PTs). Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_129682 [Accessed August 2012].
DH. (2011a) Health visitor implementation plan: 2011-15. A call to action. London: DH. Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124202 [Accessed August 2012].
DH. (2011b) Educating health visitors for a transformed service. London: DH. Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_129682 [Accessed August 2012].
Duffy K. (2003) Failing students: a qualitative study of factors that influence the decisions regarding assessment of students’ competence in practice. Available from: www.nmc-uk.org/Documents/Archived%20Publications/1Research%20papers/Kathleen_Duffy_Failing_Students2003.pdf [Accessed August 2012].
Glasper A. (2010) Additional options for achieving sign-off criteria. British Journal of Nursing 19(10): 658–59.
Nursing and Midwifery Council (NMC). (2008) Standards to support Learning and Assessment in practice. London: NMC. Available from: www.nmc-uk.org/Educators/Standards-for-education/Standards-to-support-learning-and-assessment-in-practice [Accessed August 2012].
NMC. (2009) Standards for pre-registration midwifery education. Available from: www.nmc-uk.org/Educators/Standards-for-education/Standards-for-pre-registration-midwifery-education [Accessed August 2012].
NMC. (2010a) Education Standards for Pre-registration Nursing Programmes. London: NMC. Available from: http://standards.nmc-uk.org/Pages/Welcome.aspx [Accessed August 2012].
NMC. (2010b) Essential skills clusters and guidance for their use. Available from: http://standards.nmc-uk.org/Documents/Annexe3_%20ESCs_16092010.pdf [Accessed August 2012].
NMC. (2011) Health Visiting in England: an update on the NMC position. Available from: www.nmc-uk.org/Documents/Press/Health-visiting-clarification-2011.pdf [Accessed August 2012].
Shelton R, Harrison F. (2011) Community placement myths. Primary Health Care 21(2): 26–8.
l Care, compassion and communicationl Organisational aspects of carel Infection prevention and controll Nutrition and fluid managementl Medicines management
Box 2. essential skills clusters (NMC, 2010)
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CLASSIFIED
For more information or to advertise in Community Practitioner’s recruitment section, call our advertising team:
020 7878 2319Alternatively email us:
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Health Visitor Part Time 30 hoursSalary Band 6 equivalent depending on experienceThis is an opportunity to work in a large GP training practice, committed to providing excellent primary health care services and with a strong emphasis on staff training and development.
We are seeking a Registered Specialist Community Public Health Nurse to join our Health Visiting Team, providing forward-thinking and family-focused services for two GP practices in Newport Pagnell.
We can offer:-• Flexible, family-friendly working hours. • Induction programme and good support, working within an effective integrated nursing team
(health visitors, practice nurses, district nurses, specialist nurses and community matron).
This post is subject to an enhanced CRB check. Applicants will need to hold a current driving licence and have access to a vehicle.
Closing date 15th October 2012. Interview date 26th October 2012.
For an informal visit or discussion please contact Barbara McGivern, Health Visitor Team Leader, email: [email protected] tel. 01908 619909
Newport Pagnell Medical Centre Milton Keynes
Full job information and application form are available on our website www.npmc.nhs.uk Alternatively contact the HR Administrator, e-mail: [email protected]
tel. 01908 619749
Visitwww.commprac.com
for morefor morejobsYou can now follow both the Unite/CPHVA and journal on Twitter – join us and join in!follow @Unite_CPHVA and @CommPrac
For more information or to advertise in Community Practitioner’s recruitment section, call our advertising team:
020 7878 2319Alternatively email us: [email protected]
48 | Community Practitioner October 2012 Volume 85 Number 10
Venues across UK, plus in-house option. A five-day, comprehensive baby massage course for health professionals and parenting practitioners provided by Touch-Learn International, the exemplary training company. This highly acclaimed programme is accredited by the Guild of Sensory Development (GofSD) and the University of Wolverhampton.This quality training programme includes simple massage techniques, coupled with an in-depth knowledge to practise safely, ethically and professionally, so practitioners feel confident to teach parents in a variety of settings. Included within the course:● Strategies to empower parents ● All mechanisms identified in
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For further details of in-house training and UK dates please visitwww.touchlearn.co.uk.
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For further details please visit www.iaim.org.uk. In-house trainings are available on request.IAIM (UK) Chapter0208 989 [email protected]
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To show and teach to parents and carers invaluable techniques for family healthKey principles of underpinning neuroscience, psychodynamic and child development empowering parents to form a positive relationship with their baby and secure their baby’s development from birth to standing.
This two-day certificated course includes;
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2) Developmental Baby Massage Eight Weeks to StandingThe Correct Use of Baby Massage to:1) Develop circulatory and breathing
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3) High quality resource Peter Walker’s DVD ‘Developmental Baby Massage’ and international best selling book Developmental Baby Massage hard back copy with full set of course notes for all students.
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Special Interest Group: Children with special needsThe special needs interest group will be meeting on Friday October 19 from 10:30 to 3pm at Unite, 128 Theobald’s Road, London WC1 8TN There will be a guest speaker.
Health visitors and school nurses are welcome to attend. Lunch is provided and there will be a chance to meet and network with others in the same field.
For more information please e-mail Helen Pickstone: [email protected]
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