Finger on the pulse

The newly appointed Chief Nursing Officer for England, Sarah Mullally, is
certainly not the nonentity one NHS insider described her.  Her background of working in the health
service helps her ensure that policy is formed by front-line staff, by Nic
Paton

When Sarah Mullally was appointed chief nursing officer for England in
November 1999, she was dismissed by one nameless NHS insider as "a
nonentity". Mullally was certainly not a familiar figure within the NHS
corridors of power when she took on the role of the Government’s most senior
nursing adviser.

Her predecessor, Dame Yvonne Moores, had been the only person to hold all
three CNO posts, England, Wales and Scotland. By comparison, Mullally, just 37
when she was appointed, came to the Department of Health with no political
experience.

A former acting chief executive of Chelsea and Westminster Healthcare NHS
Trust, Mullally’s nursing career includes teaching at St Thomas’ Hospital, both
as a senior staff nurse and clinical teacher, followed by a stint at the Royal
Marsden as a specialist cancer nurse and a ward sister at Westminster Hospital.
It was only after this that she moved into administrative and managerial roles,
rising to the Chelsea and Westminster job in 1998/99.

High profile advocate of nurses

Nearly two and a half years on, Mullally is beginning to make her mark,
confounding the conspiracy theorists who suggested that the then NHS chief
executive Sir Alan Langlands and chief medical officer Liam Donaldson had been
looking for someone quiescent for the role. She has been a high-profile
advocate of Britain’s 420,000 nurses, midwives and health visitors, treading a
fine line between growing demands for the return of the matron and a more
traditional nursing function while working to promote the widening clinical
responsibilities that nurses have on modern wards.

For instance, in January last year she conceded there was a growing problem
of nurses neglecting their patients, but she has also seen the introduction of
nurse consultants.

She was closely involved in the launch in February last year of the first
national benchmarking standards for nurses, midwives and health visitors. And
in July last year she was appointed co-chair of the Government’s external
reference group working on drawing up its national service framework for kidney
patients.

In person, Mullally comes across as friendly, if not exactly gushing,
efficient and, of course, for a top Government appointment, totally on message.
She dismisses the suggestion that coming into the DoH as an outsider might have
made her job harder. "I have just got on and done the job actually,"
she says, but adds: "Coming out of the service has helped me to ensure
that policy has been formed by front-line staff."

Mullally makes sure she gets out of her Richmond House office to visit
nurses at work at least two to three times a week, something she considers
vital. She reels off an impressive list of where she has been in the past week,
an itinerary that criss-crosses the country.

"It is a real privilege to see what nurses are doing. I have the
opportunity to listen, to see what nurses and midwives are doing, what is
innovative," she explains.

"There are real similarities between the job I am doing, being a
director of nursing, and being a ward sister. It’s about working as a team and
doing your job as well as the team you have got. It is about walking the patch,
providing a role model and clearly stating what is the vision."

The big difference with the chief nurse’s job, however, is the size of the
job and the level of responsibility – of transferring her leadership role to a
national level.

"I am not a paediatric nurse, I am not a midwife. There are many things
I am not. But what I am is someone who can facilitate those nurses, give them a
voice. The real challenge is the scale that you do it on," she says.

Return to work policy

Mullally has been vocal on the need for more flexible working practices
within the NHS and the need to encourage nurses who have left the service to
return, two issues that are closely intertwined. Figures published by the
Government in December last year showed a net increase of more than 10,000
nurses and midwives working in the NHS last year and a gain of 27,000 since
1997, something Mullally is particularly pleased about. The Government’s plan
for the NHS set a target of 20,000 new nurses between 1999 and 2004.

"Although we have not solved the problem, the number of nurses that are
returning to the NHS continues to go up. That, I think, is the result of a huge
effort. When I talk to nurses, their concern continues to be getting the right
number of staff. They have recognised that we are beginning to do something
right," she says.

Recent advertising campaigns encouraging nurses to come back have had the
added bonus of working to change public perceptions about the profession, which
still at times appear to be locked in a time warp between Hatti Jacques and
Angels. NHS Direct, the nurse-led helpline, has also proved positive, she
argues, in showing people that nurses have a much wider role to play in a
modern NHS than changing bed pans or turning patients.

"But there is no doubt that the media does not always portray nursing
as it should do," she laments. "There is clearly a lot of work to do
about how we educate the media."

Occupational health nurses

For OH nurses, confusion over what they do is, of course, compounded by the
fact that employers often do not seem to know what they want from them – nurses
able to hand out sticky plasters and aspirin or highly qualified specialist
practitioners?

Mullally argues it is beholden on the OH profession to make the case for how
OH nurses should be perceived and what their role in the workplace should be.
The debate about the most appropriate qualification for OH nurses, and whether
it matches what employers, public or private, really want, is one that must be
addressed.

"What we need to do, working with employers, is to ensure that we are
describing the role, and ensure that people are clear in knowing what they can
expect from that service," she says.

If an employer has an OH service it must have people within it who are
competent to do the job, she stresses, but it is also right that OH services
offer a mix of skills at different levels. This is particularly an issue in a
service that, like mainstream nursing, is suffering from a lack of fully
qualified staff.

While GPs see themselves very much as the gatekeepers to the health service,
OH nurses, argues Mullally, have a key role to play in promoting public health,
particularly in working with employers and employees on access to public health
services.

Primary care trusts

The fulcrum in this relationship is increasingly going to be the primary
care trust, she argues. PCTs have a responsibility to assess the health needs
of the community and, as such, as time goes on OH nurses are going to find
themselves working ever more closely with such bodies, a process that has
already begun in some parts of the country.

"I believe that OH nurses are key public health practitioners. The key
relationship in the future, I believe, will be the relationship between
occupational health nurses and primary care trusts.

"What are the services that are being provided and do they meet the
needs of this community? PCTs are the organisations that are going to lead the
assessment of health needs in the community.

"If PCTs have that responsibility, they will want to be talking to OH
nurses. Historically OH nurses have always been keen collaborators. The issue
for them will be understanding their role and what the processes are," she
says.

Ultimately, she sees a partnership developing between employers, OH nurses,
community health teams and PCTs to tackle public health needs in a much more
joined up way. Within this partnership, the bridge between public and private
that OH nurses can provide may well prove critical.

But it is not only within the wider public health arena that OH nurses can
play a more important role, asserts Mullally. The exposure that OH nurses have
to the commercial world, and the lessons that can bring with it, is
under-recognised within the NHS.

"Occupational health nurses understand what it means to have ‘consumers’,"
she says. Specialist practitioners need to structure their service decisions
with the employer; they have to provide a commercial service.

"It is about how you listen to the different stakeholders and change
your service as a result. And it is not always about listening to those who can
voice their views the most," she adds.

NHS Plus

The launch by the Government in November of NHS Plus sent a clear signal
that ministers were finally recognising this point. Under NHS Plus, OH
departments within NHS trusts are encouraged to outsource their services to the
wider community, in particular to small and medium-sized enterprises that may
not currently have access to OH services, on a commercial basis.

The service is linked to a national network, with services flagged up on a
dedicated website for employers and employees. By clicking on where they are in
the country, employers are able to see what OH services are available to them.

Mullally agrees NHS Plus will never replace commercial services or indeed
NHS OH services. But what it will do is make channels of communication that
much easier.

"It is about OH nurses working together across OH boundaries. They can
learn from each other to ensure the spread of best practice. It is very much a
two-way process," she says.

A key achievement of her time in office so far, Mullally argues, was last February’s
launch of national benchmarking standards. Essence of Care outlines best
practice in eight areas – principles of self-care, food and nutrition, personal
and oral hygiene, continence, bladder and bowel care, pressure ulcers, record
keeping, patient safety and privacy and dignity.

The benchmarks, which Mullally describes as a "practical toolkit"
are expected to play a key part in helping nurses audit their work and improve
standards. Nurses, including OH nurses, can adapt them to fit into their own
work areas. She is also proud of the number of nurses who have gone through
leadership programmes, some 32,000 at the last tally.

Yet she adds: "There is no doubt that working in an organisation that
employs 1.3 million people, bringing about any cultural change is tremendously
difficult. Rather than us being patient advocates, I want to enable patients to
be their own advocates."

She may not be as much of a political animal as her predecessor, but
Mullally’s goals as CNO are admirably simple – to improve the experience of
patients and to raise standards.

"I want people who have used the NHS to be satisfied with their
experience," she says.

The National Health Service is not all bad and not all good, she admits.
"The challenge is to make it more consistent. If you talk to people about
how they define the quality of care, it will come back to the fundamentals of
nursing – hydration, nutrition, privacy, dignity and cleanliness."

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