Vision 2020: Outlining One Recent Key Policy Documentation and How it Influences a Practice

Vision 2020: Outlining One Recent Key Policy Documentation and How it Influences a Practice

The need to address public health need emanate from government of the day in respond to public out cry, it formulate polices, to address current health issues. Over the years’ policies such as stop smoking, how to survive cancer, saving lives, and so on have not only created awareness amongst the population but also improve the health of certain sections of different communities. One of such policies is the ‘Vision 2020- focusing on the future of district nurses.’ This essay will focus on one aspect of this policy, (Compassion in relation to End of Life Care) and analyse how it influences current and future practice. It will critically analyse the economic, political and philosophical underpinnings of the policy, and appraise the ethical and moral implication for practice whilst drawing on appropriate principles, theories and frameworks. A conclusion will be drawn which will justify the formation of the policy.

Vision 2020 emerged as consequence of health care establishments frugal activities. In certain cases patient were routinely neglected by Trust pre-occupied with cutting cost, that they lost sight of the fundamental responsibility to provide compassionate care. The policy published in January 2013 has 6 main aspects of fundamental care, which are, compassion, care, competence, courage, commitments, and communication. Compassion within the end of life care involves the use of the Liverpool care pathway (LCP) as incorporated in the Gold Standard Framework for end of life care. Compassion is defined as a way of living with an awareness of one’s relationship to deal with others (Reach 1992, p 58, cited in Wilmot (2003) It is particularly distinguished from related qualities such as sympathy, empathy, Kindness, and caring by the intention to act upon the suffering of others. This enables patients/clients to feel valued, as their suffering is both acknowledge and acted upon. In his report on the Mid Staffordshire incidents, Sir Francis pointed out the uncaring attitude and failure of the nursing professionals to maintain basic human dignity. This is clearly against acceptable nursing practices as the NMC code of conduct emphasizes that nurses/professionals should show compassion in care (Rea).A similar report was highlighted in the Winterbourne view, where bad mal-practices were rife and the nursing professionals failed yet again to uphold self-respect.

These are pointers to the society that nurses and other health professionals seem to have forgotten the values of nursing care. The resulting trauma to the public was well documented in the media. Compassion in Vision 2020, is a part of the policy to re-enforce what nursing care is all about. Death is no longer medicated in contrast to what it used to be, and individuals have a choice to decide where they want to die, most often in their own home within the community, close to their loved ones. (Taylor G & Hawley H, 2010)

The L C P for the Dying Patient is a tool used, which enables healthcare professionals to focus on care in the last hours or days of life when a death is imminent. It is tailored to each patient’s physical, social, spiritual and psychological needs, as well as the family as a whole. {It requires senior clinical decision making, often Family, patient and next of kin, GP, and palliative nurse/district Nurse that requires good communication, a management plan and regular reassessment}. The LCP aims to support, and not replace, clinical judgment. Once the last few days are recognised by the experienced clinician and verbalized to the patient’s relatives, lots of interpersonal communication is required to manage the complexity that ensue. A multi-disciplinary approach to care is undertaken as soon as the end of life care is recognized. During the end of life care, only very necessary regular medication are administered, usually at this stage, symptoms monitoring drugs, such as anti-emetic,anti- anxiety, and analgesic administered through a syringe pump. Other medications may sometimes be given too depending on individuals cases. This syringe pump is reviewed twice a day, or as needed, this is to ensure that the patient is comfortable and symptoms are well controlled by the volume of medication in the pump. In addition, the syringe pump may have malfunctioned and therefore therapy required has not been delivered. This exemplifies some of the ways compassion in care is implemented within the primary care setting. Family involvement from the beginning is imperative as they are the first caregiver and the ultimate monitor of the patient and the pump. Therefore effective interpersonal communication with them is essential.

In a North London boroughs, with high rate of cancers, the LCP is predominantly used to cater for patients’ symptoms control. The UK currently have 10 million people over 65 years old with an estimated 19 million people to be over 65 in 2050. ( 2012 . The potential for long-term conditions is consequently high, as well as the current rates of cancer, will result in a huge demand for health care in the current economic climate. Specialist health care professionals, therefore requires compassion to remain fundamental principle in nursing care.

Critically analyse the economic, political and philosophical context of the policy

Economical Aspect
Compassion in care is not measurable in financial terms; however, the cost of repairing the damage for lack of compassion is innumerable. The policy had to be delivered by policy users for patients, and would require the extra training for staff to be able to deliver this. It also requires a way of measuring the compassion for it to be reasonably meaningful to those in receipt of it and their families. By and large, the delivery will be through the well-known health needs assessment, which is subject to vigorous questioning by the assessor.

From the economic point of view, the concept of need for compassion, translates to a dynamic relationship, between supply and demand of services, therefore the more limited the resources, the less the supply, irrespective of the demand (Taylor & Hawley 2010). Health need is economically defined as capacity to benefit from health care intervention and health need assessment become part of the process of reconciling supply and demand. (Blank and Burau 2007)

According to Wright et al 1998, (cited in Sinse, 2001) health need demands are objective and valid method used in evidence based approach to commission and plan health services. It is therefore an activity, which quantify demand and indicate value for money. Methods of measuring ill health, end of life care and assessing the effectiveness of the health care intervention in relation to expectation of the NHS, which when created, had the main expectations that as population got fitter, cost of spending will reduce (Beveridge Report, cited in Sinse, 2001). On the contrary, rising cost have contributed to the current emphasis on measurable outcomes, for example, years added to life, and life added to years (Sinse 2001). This therefore questions the place of the LCP and end of life care that mostly depend on donations from patients’ families and charities.

With regards to end of life care, therefore, outcomes may or may not be measurable. In the current times, a range of competing views, that defines the health and healthcare provision, promoting action, provide a rational for an equitable healthcare, passing out limitations, as danger of dealing with the messy, diverse reality for human need, by neglecting to engage with the possible consequences in suffering and distress for those in need (needs being legitimated). The NHS seems to be spending more money in litigation rather than training staff. Also the cutbacks and privatization as well as commissioning seem to outwear resources in place. While government is trying to let people to self regulates, with patchy services, varying from one borough to the other, all eyes now rely on government to solve all problems, while primary care is increasingly remaining at the centre of care in the community, with the abolishment of PCTs.(WH 1978)

The new Labour, first elected to government in 1977, then re-elected in 2001, and again in 2005. Going through a number of iterations of the policymaking, reviewing progress while introducing specific policy response, which has been either immediately main streamed or time limited experimental process. During its lifetime, it has drafted specific policies in relation to discrete areas such as public health, education or housing. This plunges out core themes, as life long learning, social exclusion, and the respect agenda, which therefore underpins policy initiatives. On such policies, is the “2020 Vision” focusing on the future of the district nurses, with examples set in the white paper, creating a patient led NHS(DH 2005b), committed to revitalising public policy following eighteen years of Neo Liberal government and create a health and welfare system fit enough for the contemporary times. So, by rejecting the traditional social democrats, Liberal Democrats (New), therefore embarks on the “third way” policy-making activity. (Orme et al, 2011.)

Burau and Blank (2007), states that there will never be a limit a political debate quality of care in the home, regard balance between individuals and collectives responsibilities. The contemporary NHS appears to be a budget conscious and target driven, questioning the place for care and compassion, with the market system. The coalition over from the New Labour has created a third way collectivist approach. (Taylor & Hawley 2010) Policy therefore can be seen as an interplay of interest, where different interest, are articulated by pressure groups, organisation and social movement. Baggot 2011, defines pressure group as an organisation, that seeks to represent interest or preference in society, and has a degree of independence, from the government and is not a recognised political party. It can then be argued that, vision for district nurse, is not a policy from a political party.

Philosophical Aspect
The idea of nursing care compassion go as far back as the Florence Nightingale era, compared to the contemporary nursing where paper work appears to take over compassion in care .The World health Organisation, (WHO)(1978), declares that people have the right to participate individually and collectively in the planning and implementation of their care. We are in the Neoliberalism with the economic liberalisation and privatisation, which is decreasing the public sector and increasing the role of the private sector. This is where Vision 2020, can be described as a selective rather than a universal policy, where money is targeted to those perceived to be in need. The question is how this feeds in with the target driven economy, with almost all aspects of health being commissioned,(limited resources). District nursing can only be improved through partnership between businesses, and the local authorities. Also a call for action for District nurses to improve their pivotal role in the community and made aware of the closing boundaries between jobs. Policy implementation depends not only on the policy itself but also on the organisational culture of an organisation, i.e., the way it is structured, this goes as much as to the hierarchy, leaders, or managers, and how individuals interpret it, which again depends on communication channels. New researches suggest that poor understanding of professional roles among health care professionals., can also contribute to patients feeling neglected. (Williamson et al 2010) The ‘new NHS’,was focusing on the primary care, where nurses amongst others were seen as central to government developmental plans and the strategic leadership roles for health authority created statutory duty for the quality of care provision. These PCTs have been abolished and replaced by clinical commissioning groups in April 2013, and we are yet to experience the new ways.

Critically appraise the ethical and moral implications for practice drawing on appropriate principles, theories and frameworks.
According to Beauchamp and Childress (1989),(cited in Seedhouse 2009) there are four main principles in medical ethics. Principles of beneficence (acting in the best interest of patients/clients, within limits of competences), non-maleficence (do no harm, checking on benefits outweighing harm in nursing/medical profession) respect of autonomy or self-determination and finally principle of fairness or justice. Compassion in nursing agrees with these four principles, as district nurses are called to always act in the best interest of the patients/clients, respecting their autonomy, empowering them, and doing no harm. This policy therefore implements these principles, in principle. It is closely linked to deontology, which is in the guidelines of professional conduct for nurses, who have duty of care to patients

Critically reflect on the implications of this policy for future practice
The public now is increasing attracted to medical technology, which is a major part of the NHS liberation, where patients through the Internet and other sources will become very demanding. According to Cuba (1984), cited in Sinse 2001, a policy is a standing decision by the governments, and strategies to solve a problem, and its impact should be mostly by the clients/patients. It goes further to argue that policy can go to the extent of suggesting a course of action, but not what actions should be considered. This means that policy as the Vision 2020, for District nurses, must also refers to the decisions made by manager and nurses. End of care can never be qualified at a global level as it is very intimate. Vision 2020, stresses on two main parts, that is, the community and clinical settings, i.e. walk in centres, community hospitals, the community (District nursing) therefore plays a significant part in shaping policy at almost all levels. Specialist advice and support to GPs especially relating to taking ‘do not attempt resuscitation’ (DNAR) decisions in the community. More people would realise their choice to die at home if GPs were willing to take these decisions as per trust policy. Without a signed DNAR notice, London Ambulance Service will always have to take the patient to hospital if they are called, even if the patient has requested to die at home in their care plan.

For future practice, for compassion to be practiced in the community, we recommend good collaborative working in the community amongst all health care professionals. Different areas of expertise have to be brought together, through enhanced understanding they derive from interaction with other professionals, in order to ensure that patients/clients needs are met appropriately. (Wilmot, 2003) Also calling for more support to be given to District nurses with evidence and training, ensuring we have the right staff, with the right skills at the right time, for each patient. Though this brings into question the private sector and the training procedures, with regards the local practice area, it will be great if District nurses teams are offered more palliative care training, ideally, to be able to have at least one palliative specialist per team, rather than always having to depend on the palliative team itself, as in a north London borough.

A report by the Kings Fund (Firth Cozens and Cornwell, 2009) identifies factors that hinder compassion, as values instilled in clinical training, fear of distress, stress and work overload. It suggests that this can be overcome by more training, which then questions if the new government scheme (of individuals wishing to study nursing to work as health care assistant for one year, prior to training), will work in the future. This is supported by Dewer et al, 2010, who suggest that through use of emotional touch points, individuals can build up experiences through various interactions with health services and individual nurses. This again is contradicted by many writers as Maben et al, 2010, who disagree stating that when time is short, nurses turn to focus on technical and mechanical tasks rather than compassionate care. Nevertheless, Allan and Smith (2010), point out that failure to link education with practice to personal care, based on surveys carried on the ward as well as community settings, where Health care assistant are often role models in compassionate care compared to student nurses who value technical expertise over personal compassionate care. Reinforcing the basic fundamentals values of nursing at all times.

Culturally sensitive services that ensure that all ethnic and cultural groups have the same level of choice in their preferred place of death. Barriers to implementation of this policy as mentioned above will probably be skill gaps amongst professional, inadequate research and training due to limited resources. The government is now requiring future nursing students to be carers for one year before training to be staff nurses in order to learn compassion, ignoring the stress under which nursing work with very little job satisfaction.

As seen above, this policy published by the present government is evidenced based on a major need in contemporary nursing profession based on past experience, but for this to be accomplished, there is a need for resources to be made available, (clinical commissioning groups) a culture of the culture of the Organisation and nurses attitude. Also more training to be given to nurses as well as good leadership with regard to clinical governance. Also the one-year pre-training to learn compassion is yet to produce outcomes.

Reference List
1. Baggot, R (2004) Health and Healthcare in Britain, Basingstoke, Palgrave Macmillan.
2. Blank, RH, & Burau V (2007) Comparative Health Policy, Basingstoke, Palgrave Macmillan,
3. Gambles M., McGlinchey T., Latten R., Dickman A., Lowe D. & Ellershaw J.E. (2011) ‘How is agitation and restlessness managed in the last 24 hours of life in patients whose care is supported by the Liverpool Care Pathway for the Dying Patient’ BMJ Supportive and Palliative Care. 1 (3) pp. 329 – 333.
4. Goodrich J. Transactional and relational aspects of care. In: Understanding the Patient
Experience of Care. Second Annual Nursing Times Nursing Quality Conference Delivering
5. High Quality Nursing Care. 2009 Nov 18; London.
6. Hawley H(2010) Key Debates in Healthcare, Berkshire , Open University Press
7. Marinker, M (2006)(Ed) Constructive Conversation about Health. Policy and Values , Oxon, Radcliffe publishing ltd.
8. Orme, J, Powell J, Taylor P, Grey M, (2010), Public Health for the 21st Century, New Perspective on policy Participation, and Practice, 2nd ed, Berkshire, Uni Press Taylor G.
9. Radcliffe M. Compassion is no harder to measure than rain. Nurs Times. 2010a; 106(17):
10. Seedhouse, D (2009) Ethics, the heart of health Care 3rd ed , West Sussex, Wiley Blackwell.
11. Walt, G. (1994) Health Policy: An introduction to process and power. London: Zed Books
12. Wilmot, S (2003).Ethics Power and Policy-The future of Nursing in the NHS…………….
13. Williamson , G R Jenkinson T,& Proctor-Childs T(2010) Context of contemporary Nursing, 2nd ed ,Exeter, learning matters ltd
14. Department of Health (2012) Compassion in Practice: Nursing, Midwifery and Care Staff – Our vision and strategy—practice-pdf (accessed 19/02/13)
15. Alsop A (2010) Collaborative working in end of life care: Developing a guide for health and social care professional. International Journal of Palliative Nursing Vol. 16 No. 13
16. Care Quality Commission (CQC) (2010) Essential Standards of Quality and Safety. CQC. London.
17. Department of Health (2006) Our Health, Our Care, Our Say: a new direction for community services. London, DOH
18. Department of Health (2008) End of Life Care Strategy – promoting high quality care for all adults at the end of life. DH. London
19. Department of Health (2009) End of life Care Strategy ‐ quality markers and measures for end of life care. DH. London
20. National End of Life Care Programme (2010) The route to success in end of life care – achieving quality in acute hospitals, via 16/02/2013)
21. National Institute for Clinical Excellence (2011) Quality Standards: End of life care for adults. Accessed via\
22. Royal College of Physicians Liberating the NHS: No decision about me, without me, Department of Health, 2012
23. Improving outcomes and supporting transparency: Part 1: A public health outcomes framework for England, 2013-2016
24. World Health Organisation (2013) Health Policy (Accessed 17/02/2013