Health policy frames our professional roles; it defines nursing practice and knowledge, prioritises and targets resources and directly impacts on our patients' day-to-day lives. Nurses might argue that we ‘don't do policy’ but, in the highly politicised setting of the NHS, when nurses are in the front line of health policy delivery, this is not an option (Traynor, 2013). For example, NHS England's new NHS Long Term Plan (2019) guarantees investment in community practice, primary care, mental health and improved integration so that health and social services, and local government, work in partnership to deliver more personalised care (NHS England, 2019). This policy requires implementation of new service models (see case study A, Box 1), bespoke patient-focused care and greater use of digital technology, all of which directly impact on nurses: what knowledge they need, how they work, how they develop as a profession (see case study B, Box 2). Health policy provides the context to modern nursing practice. Policy is all around us and to be effective as practitioners we need to understand it.
Defining policy
A policy is a position or course of action reflecting decisions, intentions and choices made by governments, society, or other group that sets out how resources and actions will be prioritised to address areas of concern (Allsop, 1995; White, 2012). Where policy focuses on health, governments seek to change its practice, delivery, financing and/or organisation by directing the activities of healthcare organisations such as the NHS (Buse et al, 2005).
Health policy means different things. It relates to content: improving the population's health; but it also relates to process: how things are done; and to power: who influences and drives it (Walt, 1995). So an increasingly complex picture emerges when considering what health policy is and how it impacts on nursing practice. In addition, it is derived from many sources: through guidance (eg, via the National Institute for Health and Care Excellence (NICE), regulation (eg, the Care Quality Commission (CQC) and/or legislation (eg, the Health and Social Care Act 2012). Legislation gives legal force to policy, regulation and procedure (Blakemore and Warwick-Booth, 2013). Table 1 provides further information and examples of the different forms that policy takes.
| Legislation | Regulation | Policy | Guidelines |
|---|---|---|---|
| Definition: policy, regulation and procedure enacted in law | Definition: to control, direct and maintain standards in health and social care. A regulatory duty can be ascribed to an organisation by legislation | Definition: goals, ideas, priorities set out by governments and their departments. Can be informed by legislation and regulation | Definition: recommendations on how professionals deliver clinical care, or interventions to promote public health or how to improve outcomes through service improvements. Can be informed by legislation and policy |
| Examples of legislation that apply to health | Examples of regulation that apply in healthcare | Examples of health policy | Guidelines that apply to health are issued by organisations such as |
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Policy influences and development
Policy is driven by politics, ideology, evidence-based research and lobbying from interest groups (Traynor, 2013); and since health policy in the UK is devolved to England, Wales, Scotland and Northern Ireland, political influence and ideology are regionally distinct (Blakemore and Warwick-Booth, 2013).
One area where scientific research has driven policy that directly affects the nursing profession is in tackling universal public health concerns such as smoking, alcohol and sugar intake and exercise; and these policies are increasingly divergent between health regions. How such issues get noticed or make it on to the policy agenda is directed by political and media agendas and the lobbying influence of pressure groups with commercial or special interests (Traynor, 2013). Consequently, what influences and supports the development of health policy is messy and the reality of translating evidence, ideology, power and media pressure into policy, and then practice, is not linear or easy to understand (Harvey and Kitson, 2015). To illustrate the challenges and complexities an example would be health policy in relation to the care of people with long-term conditions (LTCs).
Health policy in relation to care of people with LTCs
The UK's population is living longer, is more likely develop an LTC with age, and often suffers multiple comorbidities (Department of Health (DH), 2014). Increasingly, care of people with LTCs demands innovative and preventive responses from nurses. What might once have been deemed acute conditions—such as heart failure or cancer—are now seen as chronic and long term. Traditionally, nurses have focused on disease and its symptoms; now they need a broader approach, one that takes account of the complexities of caring for people with LTCs. Health promotion, complex treatments and a shift in the organisation of care from acute response to the greater integration of health and social care, are now major influences on UK health policy.
In 2013, the World Health Organization (WHO) stated that the UK has a high prevalence of overweight and obesity in adults, with 2008 data showing that 64.2% of the adult population is overweight and 26.9% obese (WHO, 2013). Linked to these high rates of excessive weight is data from 2012, which shows that 39% of the adult population in England did not meet the minimum guidance for physical activity (WHO, 2013). Alongside smoking and excessive alcohol consumption, taking insufficient exercise and being overweight are the four modifiable health behaviours that contribute significantly to the risk of developing LTCs. In relation to the author's own geographical area of practice, the north-east of England, Public Health England (PHE) data (2016-2018) shows high rates of alcohol-related harm and of smoking; the worst levels in England, with poor rates of physical activity and 66.1% of the adult population overweight (PHE, 2019a), which translates into high rates of mortality from all cancer and cardiovascular disease in persons under 75 years of age (PHE, 2019b). This evidence gives a clear indication of the factors influencing and driving health policy and how lifestyle affects our long-term health. (Similar, geographically distinct public health data is available from the Scottish Public Health Observatory (2018)).
In an effort to reduce the impact of chronic disease, nurses enable key health improvement policy by directly tackling smoking and alcohol intake while encouraging increasing physical activity and promoting awareness of the importance of maintaining a healthy weight. Since LTCs cannot be ‘cured’ the nurse's role is to enhance an individual's functional status, to help people live well and to educate them in preventative measures so that they stay well. Two key policy documents—in England the Five Year Forward View (NHS England, 2014) and, in Scotland, Gaun Yersel! The Self Management Strategy for Long Term Conditions in Scotland (NHS Scotland and Long Term Conditions Alliance Scotland (LTCAS), 2008)— acknowledge that the population is living longer but that, as people age, they are more susceptible to conditions that previous generations might not have survived (Nolte and McKee, 2008). These policies have become levers for change in nursing practice.
The likelihood of being diagnosed and living with an LTC are dramatically affected by an individual's socioeconomic status (Loretto and Taylor, 2007; Annesley, 2015). People living in the most deprived areas of the UK are more likely to have at least one LTC, with clear evidence that people facing the greatest social deprivation are more likely than those in affluent areas to acquire one LTC by the age of 40 and to develop a second by the age of 50 (DH, 2014). This epidemiological, demographic and socioeconomic time bomb is of significant concern to governments and health professionals (WHO, 2011). A number of contemporary public health policy themes have emerged in response, such as:
Experience shows that legislation can be slow to affect public health policy. For example, the Alcohol (Minimum Pricing) (Scotland) Act 2012, aimed at preventing alcohol-related harm, was passed in 2012 but only came into effect in May 2018. However, policy implementers have shown themselves to be more responsive. In Scotland, for example, clinical managers embraced the message contained in Gaun Yersel! and, in partnership with district nurses, have driven the policy into direct front-line nursing practice (Annesley, 2015). In England, the Five Year Forward View (NHS England, 2014) has informed subsequent policy initiatives and underpins the new NHS Long Term Plan (NHS England, 2019).
Current health policy focus and implications for nursing
Alongside LTCs, obesity and mental health problems in children and young people are key topical health policy issues that place nursing provision under increased pressure. It is estimated that 10% of those aged 5–16 years have a diagnosable mental health condition (Mental Health Foundation, 2015); and, in 2016–2017, 20% of children aged 11–12 were identified as obese (NHS Digital, 2018). Childhood obesity is particularly pronounced in the north-east of England, with 22.8% of children aged 10–11 identified as obese (PHE, 2019c). Poor diet and obesity across all age ranges is contributing to a rising incidence of type 2 diabetes (PHE, 2014). Although policy is developing in response, nurses are already dealing with the everyday consequences of the crisis in health. Sometimes, nurses must take the initiative, as illustrated in the policy case studies in Box 1 and Box 2.
The evolving policy context is overtaking traditional interventions, so nurses should be aware of new approaches and seek best practice where they can—for example, recognising people's power to help themselves and considering strategies to help people change their lifestyle, drawing on the work of behavioural and social sciences (PHE, 2018b). The complexity of these issues also means that a single institution cannot be relied on to solve them: the NHS needs to join forces with local councils and voluntary and private sector providers to achieve better integration of services. As the contexts of care delivery, location and method change, nurses must transform their roles and adapt to keep pace with such changes in society, as well as responding to the financial challenges to best manage resources and ensure safe, high-quality patient care.
It is implicit that for health policy to succeed it must be implemented. The process of policy delivery can appear unpredictable, messy and complex (Cairney, 2012). To help understand how policy is delivered in practice, it is useful to consider the policy process in a five-stage model (Anderson, 2011):
However, this model perpetuates the perception that policy implementation is top-down. In reality, and as revealed by research, it is recognised that such hierarchical models are too simplistic (Schofield, 2001); that a range of actors shape and inform policy; and that bottom-up strategies work alongside policy directives to interpret and put initiatives into operation.
This shift in understanding is reflected in the implementation of the Health and Social Care Act 2012, which marked a move away from centralised control of the NHS in England (Iacobucci, 2017a). It sought to reorganise the NHS in a number of ways, but most significantly through the establishment of clinical commissioning groups (CCGs), which passed the purchase of health services, for a local community, to GP-led collectives (Moran et al, 2017). Nurses, in the form of a governing body nurse, also play an important role in the leadership, governance and decision-making of CCGs (Dempsey and Minogue, 2017). Here health policy has directly impacted on the opportunities in influence and leadership that nurses can demonstrate, with the voice of the nursing profession shaping the context of care for local communities. These opportunities have been provided by the enacting of policy and allow nurses to exercise their power in policy implementation.
Nurses also adapt and apply policy to their practice in, for example, primary care where district nurses have been shown to respond directly to the UK policy demand to shift the focus of intervention from hospital to a community setting (Haycock-Stuart and Kean, 2013).
In summary, health policies aim to influence care and affect nursing directly by changing:
These policy themes are not mutually exclusive. They overlap as they seek to acknowledge the changing needs of the population and respond to requirements to improve public health and the closer integration of social and health care. Policy implementation directly impacts on nursing and reinforces the need for nursing leadership to deliver policy in practice (Haycock-Stuart and Kean, 2013). But delivering policy on the ‘front line’ highlights the demand for a different type of leadership. Indeed, the importance of nursing leadership is a core principle of the current English nursing and midwifery strategy: Leading Change. Adding Value (NHS England, 2016a).
Policy agendas may conflict directly with professional principles, challenging nurses' ability to deliver patient-centred care. To implement front-line policy, nurses need additional training, workforce resources and the development of specialist knowledge. These resources may be absent or in short supply. For example, policy ideas addressing prevention and health promotion require nurses to use coaching or motivational interviewing to meet policy directives: ‘making every contact count’ (NHS England, 2016b). These are new skills, which pose a significant challenge and a potential barrier to policy implementation.
More thoughtful policy making should engage those who will be directly impacted, so the process ought to include frontline nurses to help anticipate conflicts and resistance and mitigate barriers to implementation. A good example of this bottomup approach to policy is the development of NHS Scotland's policy promoting self-management for people with LTCs. Gaun Yersel! (NHS Scotland/LTCAS, 2008), written by the Scottish Department of Health in collaboration with voluntary sector workers engaged with people living with LTCs. Much can be learned from its success, which promoted efforts to encourage participation and collaboration, ensured positive communication and a strong patient focus on self-management (Annesley, 2015). Success was ensured by leadership from the policy-makers and those targeted with implementing patient self-management in practice: specialist nurses and district nursing teams.
Despite this progressive approach to policy development Gaun Yersel! still posed challenges in implementation. A health policy that focuses on promoting personal responsibility can be seen as ‘healthcare on the cheap’, since it subtly shifts the responsibility of treatment from practitioner to patient. Even more concerning, promoting personal responsibility over professional expertise best serves those who can already help themselves, resulting in a ‘policy paradox’. Self-management is most successfully exercised by people who already understand how to manage their LTCs but does little to help those who can least manage their LTCs: people living with more than one LTC and those who are socioeconomically disadvantaged. The unintended consequence is that policies focusing on personal responsibility polarise and accentuate health inequalities, rather than creating an environment that reduces them. This is a huge healthcare challenge for the whole sector, from policy makers to nurses (Annesley, 2015).
Organisation of health care in the UK
Health policy and spending are devolved to the four regions of the UK, since 1999 in Scotland and Wales and 2000 in Northern Ireland (Murray et al, 2013). So, while the four regions have faced similar challenges, they have approached them with contrasting policy solutions (Greer, 2004). NHS England has focused on the internal market as its driver and promoted a top-down managerial model, while NHS Scotland's approach has been to promote professionalism, using networks of clinicians to plan resource allocation and agree how care should be prioritised (Greer, 2004). The contrast between a heavily managerial, market-driven model in England and a clinician-led model in Scotland explains why the health policy stories of both regions have diverged.
In England and Scotland health policy priorities are largely similar but the means by which these priorities are converted to policy differ. Both regional health services prioritise public health, children and young people, mental health and inequalities in health, technology and workforce (NHS England, 2017; NHS Health Scotland, 2018). However, NHS England still takes what could be interpreted as a ‘disease-informed approach’, as well as focusing on the competitive purchase of services as a driver for improvement (NHS England, 2017). In Scotland the policy approach is informed by a desire for integration of health and social care, with a strong emphasis on collaboration, fairness, inclusivity and a healthy environment (NHS Health Scotland, 2018). In England, therefore, nurses are both purchasing provision and acting as the primary agents for policy delivery; in Scotland, nurses are more directly integrated into policy interpretation (Annesley, 2015).
The health policy story in Wales and Northern Ireland is less well developed. Wales abolished the purchaser-provider split in 2009 and focused on performance management through the leadership of NHS trust chief executives, adopting what has been described as an innovative local approach to health policy (Bevan et al, 2014). In contrast, Northern Ireland, whose elected Assembly is currently suspended, has made the least progress in implementing health policy (Bevan et al, 2014). Northern Ireland's approach has been described as permissive managerialism, led by civil servants with little political interest or involvement from policy implementers (Greer, 2005).
See Figure 1 for an overview of the key organisations that make up health care in the UK, which illustrates the different sources of health policy across the UK. Box 3 includes useful websites containing further policy information and guidance
Policy implications for the nursing profession
Policy matters for the nursing profession: for who a nurse is; for what nursing means and how nurses do their job. Policy addresses existing and anticipated areas of concern in healthcare and its organisation; and one important challenge in the 71st year of the NHS is workforce pressure, not just on staffing levels and costs but in relation to roles, responsibilities and skills mix. Currently, 600 095 nurses are registered with the Nursing and Midwifery Council (NMC), with a documented decline in RNs coming from Europe following the EU referendum in June 2016. In April 2018 the NMC reported that ‘between April 2017 and March 2018, 3962 people left [the NMC register]— an increase of 29%’ (NMC, 2018a). This, combined with the replacement of NHS bursaries for nursing and midwifery students with tuition loans in August 2017 (only in England; Scotland, Wales, and Northern Ireland have maintained an NHS bursary) is having a considerable impact on nursing numbers, one that is likely to worsen the NHS staffing crisis.
One policy response, as advocated in Lord Willis' review The Shape of Caring (Willis, 2015), is the development of the nursing associate role, designed to bridge the gap between the roles of healthcare assistant and RN. However, this scheme will only operate in England and presents an unknown challenge for nursing's professional regulator (NMC, 2018b). The impact of this new role on nurse staffing levels in England will take time to emerge. Hopefully, it will go some way to redressing the imbalance in nurse staffing numbers in England, which currently, out of the four regions of the UK, has the lowest rate of whole time equivalent nurses per 1000 population at 5.8, with Scotland having the highest at 7.9 nurses per 1000 population (Bevan et al, 2014). However, there is concern that this role represents a dilution of skill mix that will do little more than plug a staffing gap and constitutes a retrograde step, which will neither promote professional status nor recognise the investment needed to ensure high-quality nursing care (Rafferty, 2018).
Conclusion
This health policy article has demonstrated why nurses need to understand policy. The NHS faces considerable challenges, and these are reflected in many of the policy themes explored here. Nurses and nursing need to recognise and adapt to these challenges if we are to move forward and continue to provide universal, equitable, comprehensive and high-quality care (Iacobucci, 2017b). Health policy and its implementation relies on nurses to bridge the gap between policy and practice. The impact of health policy on nurses' ability to deliver and coordinate care is of contemporary and ongoing relevance and is reflected in Platform 7 of the new NMC Future Nurse Standards (NMC, 2018c). Policy and its process are essential elements of nursing and will govern the future development of the profession.