The Maynard Doctrine: Darzi and nursing - time to tackle this time bomb?

The Darzi report rightly extols the virtue of outcome measurement, and reiterates yet again the problem of clinical practice variations. However its focus is primarily clinical, where clinical is defined as doctors getting involved in systematic comparative review of practice and subsequently getting their act together.

The largest workforce in the NHS is nursing. Nursing costs typically make up thirty-five per cent of hospitals expenditure and with growing employment in primary care, nurses are also an increasing cost there.

It is usually assumed that one in ten patients suffer an adverse event whilst in hospital. The principle carers of patients are nurses. There are few data about adverse events in primary care, but it is likely that misdiagnosis and inappropriate drug administration is as problematic there as it is in hospitals.

The policy themes of clinical practice variations, patient safety and improved quality of care are as relevant to nursing as they are to the two thousand doctors who took clinical time off to attend Darzi junkets across the ten strategic health authorities.

Yet where is the reform focus for these primary providers of good and bad care? Is offering them “preceptorships” and  other trinkets adequate to meet their needs and ensure good patient care?

Inspection of the nursing literature and observation of nursing practice at the patient level reveals both marked variations in practice and an absence of systematic leadership and demonstrably efficient incentives to create better practice and the delivery more uniform, evidence-based care to patients.

At the ward level, you might expect routine monitoring of hand hygiene practice, cleaning of equipment, taking of blood, insertion of canulas and avoidance of clutter that impedes access to patients and accumulates dangerous infections.

Do you see this? Yes! In some hospitals and wards, practice is excellent. But in many, it is not. Why do ward sisters and corporate directors accept this variation - and just why do Blair’s “modern matrons” tolerate such variations? How can these expensive decision-makers be incentivised to do better?

The old, true story
Darzi tells us the old, true story that practice variation can be dangerous for patients, and that doctors should improve their practices. However focus on doctors, be they “wise” consultants or dangerous juniors, in isolation from nurses’ behaviours is very unwise.

Nursing is changing continuously, but how much of this change is evidence-based and how much is evaluated? Take, for instance, the use of new technologies by nurses. Are practitioners well trained in their use? Is subsequent practice monitored to ensure adherence to protocols - or can nurses over-ride new IT systems and increase risks to patients?

The Audit Commission estimates that 10 per cent of hospital tariff claims are erroneous. To what extent is this the fault of coders and nurses entering incorrect information? Such errors undermine payment by results (PBR) and quantitative management systems - and put patients at risk.

Some hospitals are developing the Assistant Practitioner (APs) nursing role. What do these nurses do? Are they cost-effective substitutes or complements for Registered Nurses (RNs)? Is the development of the AP grade (often staffed by local, married women returning to the workforce after having children) a reflection of past error in removing the State Enrolled Nursing (SEN) role and focusing too intently on the development of graduate nurses?

Will there be fewer RNs in future, and will they be primarily managers of APs and other practitioners on the ward? If so, are they being selected systematically and trained appropriately to manage the patient journeys safely and efficiently?

You will not have noted detailed attention paid to these questions in recent Government reform documents. Doctors, nurses and all other staff can be good or bad for your health when you are a patient.

Darzi’s rallying cry to the doctors to get their act together is welcome. But the workforce planning he advocates cannot be for sectional groups: it is necessary for all NHS employees, and should focus more on improving the lot of the taxpayer and the patient by reducing inefficient variations in practice in nursing.