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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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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.

To join Unite/CPHVA, please see: www.unitetheunion.org

Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN Tel: 020 3371 2006

Unite/CPHVA

Unite/CPHVA members receive the journal free each month and have free access to all content from 2004 onwards via the online archive.

Non-members of Unite/CPHVA and institutions may subscribe to the journal to receive it every month and access the online journal archive.

Non-member subscription rates: Individual (UK) £125 Individual (rest of world) £145 Institution (UK) £145 Institution (rest of world) £195

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Subscription enquiries may be made to: Community Practitioner subscriptions, Ten Alps Subscriber Services Abacus e-Media Limited Bournehall House, Bournehall Road Bushey WD23 3YG

Tel: 020 8950 9117 [email protected] www.cphvabookshop.com

The journal is published on behalf of Unite/CPHVA by: Ten Alps Creative One New Oxford Street London WC1A 1NU Tel: 020 7878 2300 Nick Stimpson – Managing Director

For editorial contacts, please see the panel over the page.

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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

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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


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


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


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


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


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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In an observational study of 1522 patients, physicians and patients were satisfied with success achieved in terms of scar appearance and feel.1 Kelo-cote® is suitable for scars of all ages. It is available as a spray or a gel and with or without SPF 30 UV protection.

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September 2012 SIP/KEL/505

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ASSOCIATION


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 ...


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


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


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


NEWS FEATURE


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


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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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



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



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.



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


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


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



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


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



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



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)



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


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


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



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


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


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


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-


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)


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.


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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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


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.


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


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


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)


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.


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FEATURE

CHILDIMMUNISATION


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


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).


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


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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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

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Calpol Infant and Sugar Free Infant Suspension Product Information:Presentation: Suspension containing 120mg Paracetamol per 5ml Uses: Treatment of mild to moderate pain and as an antipyretic. Can be used in many conditions including headache, toothache, earache, teething, sore throat, colds and infl uenza, aches and pains and post immunisation fever. Dosage for Children over 3 months: Do not give more than 4 dosesin 24 hours and leave at least 4 hours between doses. Children 4 to 6 years: 10ml. Children2 years to 4 years: 7.5 ml. Children 6 to 24 months: 5 ml. Children 3 to 6 months: 2.5 ml. Dosage for Infants 2-3 months: Post–vaccination fever at 2 months: 2.5ml, and a second dose, if necessary, after 4-6 hours. The same two doses can be given for the treatment

of mild to moderate pain and as an antipyretic in infants weighing over 4kg and not bornbefore 37 weeks. Contraindications: Hypersensitivity to paracetamol or other ingredients Precautions: Caution in severe hepatic or renal impairment. Interactions with domperidone, metoclopramide, colestyramine, anticoagulants, alcohol, anticonvulsants and oralcontraceptives. Patients with rare hereditary problems of fructose intolerance should not take this medicine. Due to the presence of sucrose and sorbital in the Infant Suspension,patients with glucose-galactose malabsorption or sucrose-isomaltase insuffi ciency should not take this medicine. Maltitol may have a mild laxative effect (Sugar-Free only). Parahydroxybenzoates and carmoisine maycause allergic reactions. Pregnancy and

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Diprobase Prescribing Information

Please refer to the full SPC text before prescribing this product.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to MSD Pharmacovigilance UK on +44 (0)1992 467272.

Code: 08/14 DERM-1032320-0006 Date of preparation: August 2012 © Merck Sharp & Dohme Limited, 2012. All rights reserved.

Uses: Diprobase Cream and Ointment are emollients, with moisturising and protective properties, indicated for follow-up treatment with topical steroids or in spacing such treatments. They may also be used as diluents for topical steroids. Diprobase products are recommended for the symptomatic relief of red, inflamed, damaged, dry or chapped skin, the protection of raw skin areas and as a pre-bathing emollient for dry/eczematous skin to alleviate drying effects. Dosage: The cream or ointment should be thinly applied to cover the affected area completely, massaging gently and thoroughly into the skin. Frequency of application should be established by the physician. Generally, Diprobase Cream and Ointment can be used as often as required.

Contra-indications: Hypersensitivity to any of the ingredients. Side-effects: Skin reactions including pruritus, rash, erythema, skin exfoliation, burning sensation, hypersensitivity, pain, dry skin and bullous dermatitis have been reported with product use. Package Quantities: Cream: 50g tubes, 500g pump dispensers; Ointment: 50g tubes, 500g jar. Basic NHS Costs: Cream: £1.28 (50g), £6.32 (500g); Ointment: £1.28 (50g), £5.99 (500g). Legal Category: GSL. Marketing Authorisation Numbers: Cream: PL 00025/0575; Ointment: PL 00025/0574. Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire, EN11 9BU, UK. Date of Revision: February 2012.

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20122 MSD DIP HCP Painting_Comm Prac Aug 12.indd 1 29/08/2012 11:32

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