The Queen's Nursing Institute

The Queen's Nursing Institute works with the public, nurses and decision-makers to make sure that good quality nursing is available at home for everyone when they need it.

Healthcare at home

Workshop Number 1: From the Cradle to the Grave

London May 25th 2011

The main idea behind the workshop was to look at the affect of substance misuse throughout life, from pregnant women and pre-natal babies, through childhood, to adult life, moving onto older people and palliative care.  Finally, there was a presentation from the Department of Health covering Government strategy.  Speakers ranged from nurses and Health Visitors, through to academics. The day was Chaired by Pippa Bagnall, who is a Fellow of the QNI. She has a nursing background and has worked as Chief Executive for a PCT and has also been an advisor to Government. She now works as a Consultant.

SESSION 1:  Sally Unwin SRN, RM
Qualified as a General Nurse at the Middlesex Hospital and then as a Midwife in St Paul’s Maternity Unit in Cheltenham.
Her interest in caring for pregnant women with substance misuse problems began in 2000 and funding for her post as a specialist midwife started in 2002. She currently works as a Specialist Midwife for Substance Misuse in Gloucester and coordinates maternity care for approximately 30 women annually. She is also a supervisor of midwives and have strong belief that all mothers and babies should receive the highest standards of care to ensure safe outcomes to pregnancy.

Questions for Sally:
Q I had a woman patient who continued with using crack cocaine and all of her babies were stillborn.
There is a risk  of bleeding during pregnancy and placental problems  can  occur with use of crack cocaine which may lead to a poor outcome for the foetus. If venous access is poor, this can be a problem in an emergency situation (Eg if a caesarean is needed).
Q What about alcohol withdrawal treatment for babies?
If babies show signs of withdrawal, they should be reviewed by a paediatrician and will be treated according to their symptoms, babies are at risk of being small and premature. There is no treatment for Foetal Alcohol Syndrome. Dr Raja Mukherjee is the UK's leading medical specialist on FASD and runs a pediatric clinic for children and babies born with Foetal Alcohol Syndrome (FAS).

Q what about later life? Is there evidence that these babies become substance misusers themselves?
There are studies and research is being done into this. The Hidden Harm Report -'Responding to the needs of children of problem drug users '(Advisory Council on Misuse of drugs 2003) gives clear guidance on supporting children and families. The children can often have poor concentration and become labeled as having ADHD at school and then often have poor attendance.

SESSION2: Jane Cook and Maxine Jenkins
Jane is health visitor and has been working with excluded groups since October 1985. The focus of her work has been tackling health inequalities, identifying gaps in services, improving access to services, developing services that are of a high standard, appropriate and equitable. Jane has been involved in developing models of service delivery within a safeguarding framework for individuals, families and groups in the geographical areas where she works which also promotes social justice. Maxine Jenkins - Following a period of 4 years of working in a young male offenders institute she decided to train as a health visitor. She qualified in 1997 and was fortunate enough to obtain a position to work with homeless families in January 2000. Since then she has worked with families seeking asylum for 4 years and is currently working with homeless families again in Leicester. Both are Queen's Nurses.

Questions for Jane and Maxine:
Q How do you go dealing with the situation relating to women who have children taken in to care after giving birth?
This is one of the most difficult areas to deal with. The mum will need counseling and should be referred onto someone to deal with the emotional issues surrounding the child being taken away. This is often swept under the carpet and not dealt with and the woman may have had several children removed from her.
Some women who present as single homeless are in fact mothers but that issue has usually not been addressed and so woman may not have had counselling or postnatal care. The consequences for them may have been to then deal with the loss by self harm – abusing alcohol/drugs. Good practice should be:
1. Those women who have recently given birth should have access to postnatal care/checks, including advice re contraception
2. For women who may be homeless and may have had children taken in to care psychological care should be provided

SESSION 3: Jane Gray and Claudine Evetts
Jane joined the NHS in 1976 and in 2001 Jane joined Leicester Homeless Healthcare Team & completed a Post Graduate Certificate in Primary Care.  Jane’s clinical role is Consultant Nurse for the Homeless & she is joint clinical lead with GP Dr Anna Hiley.  She has valuable experience in multiple & complex case management & public health & communicable disease control. Jane is a mentor & support to nurses both locally and nationally according to need. Now as Director of Nursing & Development for the newly launched social enterprise “Inclusion Healthcare”, Jane is determined to add sound business management skills to her portfolio.
Claudine Evetts is  a registered nurse for ten years with a background in A&E, Gynaecology and Women’s health, before working in custody and then moving over into the harm reduction role within the voluntary sector.  She has worked for Addaction for the last 7 years as a blood borne virus nurse screening, immunising and supporting substance users with their health needs and securing treatment for those that need it. She has developed the service with Addaction, creating a homeless pack for clients if NFA. Claudine is also a Queens Nurse.

Questions for Jane and Claudine:
Q are Hepatitis B vaccinations given to all babies?

Hep B vaccines are not given to all babies only those whose mother has been diagnosed as hepatitis B and even then the follow up is hit and miss in the community at GP services and I think this may well be due to the lack of education in this field or understanding the importance.
Hepatitis B was, on several occasions put forward to be included in the immunisation programme for children but for two or three reasons was never included these reasons are, cost, political impact as parents panicked when the MMR was put together and immunisation rates dropped down, The amount of education needed to get the public understand it’s in their and their children’s benefit to have the immunisation.
Q what about child protection?
Safeguarding of the vulnerable child is paramount. There are women who have issues like learning disabilities, are homeless or have other complex problems who slip through the net. We need to reflect on current practice and refine this locally. We also need to look at making sure that pre-birth planning is consistent.
Q you deal with lots of complex cases and so do I, how best can we learn from our work?
we need to reconfirm our knowledge and also be able to articulate the case to commissioners on these complex cases. We need to look at it in a holistic way.
There is good practice guidance, look at NICE guidelines. It’s a case of ‘prove it or lose it’.
Access to services and outreach are essential services.

Discussion group

In this session, delegates were asked to think about what they had just heard and what the main points of interest were. They were also asked to think about what they could take back to their own jobs. Click here to see what they wrote.


SESSION 4:  Professor Brenda Roe 
Brenda is Professor of Health Research at the Evidence-based Practice Research Centre, Edge Hill University and Honorary Fellow at PSSRU, University of Manchester. Her interests focus on the development and evaluation of health care and systems for people with continuing care needs in the community, such as older people and those living with chronic conditions and disability. Organisation and delivery of services, perspectives and experiences of users, clinical effectiveness, evaluation of health care and systems, dissemination and utilisation of research, health policy and health promotion are also areas of expertise. She is also a Fellow of the Queen’s Nursing Institute. As well as holding academic positions she has also been a Non-Executive Director for a number of Health Authorities and NHS Trusts. 

Questions for Brenda:
Q what about getting accommodation for older drug users in care homes?
They are often not that old in years, but the substance misuse ages people faster. They will often also have additional physical and mental health problems so it is very difficult to find placements for people.
The criteria for people who are old or older and for services are variable. Older drug users may have accelerated experiences of ageing and so the needs of individuals are important.

Q What about Supporting People funding?
Supporting People did raise the profile of the housing needs of drug users, but the funding is now disappearing, so this will continue to be a real problem. Housing is the key to this.

SESSION 5: Sarah Davis
Sarah joined the Marie Curie Palliative Care Research Unit as a research nurse in 2008. Her role involves recruiting patients to palliative care research studies, liaising with clinical staff and working with senior researchers in the unit designing and developing specific studies to improve care for patients at the end of life. She has recently been working with St Mungo’s looking at advanced liver disease in a homeless population.

Questions for Sarah:
Q What about involvement with local hospices?
This has happened, but only for cancer patients, rather than those people with Advanced Liver Disease. Hospices do not allow alcohol to be drunk, so this can be an issue for people who wish to continue to drink.
The Gold standards framework, a model of best practice in palliative care, is used successfully by nurses with people that are homeless to help plan and coordinate care when they are approaching the end of life.
It is a model that is used in the community and could be used by hostel staff with the patients consent, as a tool to plan and coordinate care
Q what about advance care planning?
 this tends not to happen on a regular basis. This is an example of the lack of equity in palliative care.

In this session, delegates were asked to think about what they had just heard and what the main points of interest were. They were also asked to think about what they could take back to their own jobs. Click here to see what they wrote.

SESSION 6: Sara Mason
Sara Mason leads the Drug Policy team at the Department of Health.  She drafted the health elements of the new cross-government Drug Strategy and is leading the development of pilots to test payment by results for drugs recovery.  Previously she has worked at the Department of Education on issues relating to pre-school children. 

Questions for Sara:

Q. It can be a positive step for an individual to be on a substitute prescription, there are many variables and the relapse rate can be high if someone stops taking drugs completely.  Why is this no longer supported?
A.  That is not the case.  Substitute prescribing continues to have a role to play in the treatment of opioid dependence and its value has previously been confirmed by NICE.  However, the Drug Strategy makes clear that we want to have a greater ambition for those dependent on drugs and that this should be a first step on the road to recovery, not the end result.

Q. Do we know what the real problems really are? For instance, injecting amphetamines is not counted. I am concerned that all the money will go into the Local Authority and we will lose best practice
A.  We are not just focusing on heroin and crack as previous strategies have.  This is about addressing all drug use, whatever that might be. 
Separately the Department of Health has set out its vision for a public health system in the White Paper published in December.  This proposed that drugs and alcohol services would be part of public health and that responsibility would sit with local authorities.  We have also stated our intention that there will be a Public Health ‘ring fence’ and we will need to look carefully at how we incentivise delivery on both drugs and alcohol as we develop the detail. This has since been confirmed in the update paper published on 14 July.

Q.  Funding for residential rehab has been drastically reduced, it’s not compatible with trying to get people drug free.
A.  It is for local areas to build their system to reflect local needs.  The strategy recognises that there isn’t one recovery journey and that it will mean different things to different people.  We are encouraging local areas to make sure recovery is at the heart of their offer and that a range of provision is available to meet needs.

Payment by Results Pilots

Q. this seems a little naive and we won’t be able to do it
A.  Recognise that introducing a Payment by Results approach for drugs is challenging and that we may get some of this wrong.  That is why we are piloting the approach and ensuring that a robust evaluation is in place.

Q. it costs more to treat people, than for those that no longer require treatment – is this why payment by results is being tried?
A. This is about looking at whether a Payment by Results approach can further incentivise providers to support individuals into sustained recovery so they can rebuild their lives and make a productive contribution to society.  It is about making sure that the benefits realised through investment in treatment services is sustained and hopefully preventing relapse.  
Q What evidence is there to support a Payment by Results approach in these areas?

A.  The evidence here is limited, as the model we are proposing has not been tried before.  This is why we are piloting it and putting in place a robust independent evaluation.


Supporting Carers

Transition to Community

Homeless Health