Warning signs at the rebirth of an idea

Innovative and market-led approaches to patient care are being reflected in specialist training. Magnus Shearer calls for an integrated approach.

Acres of newsprint have been devoted to the detailed examination of Government reforms which continue to push the development of an NHS along the lines of a market economy. Less well documented are the issues and dilemmas created by parallel changes affecting the traditional base for the provision of a major part of professional education throughout the United Kingdom.

Simply, the reforms aim to demonstrate greater accountability to the consumer of care, greater efficiency and efficacy, improving levels of quality and choice with empowerment of clients and staff - resulting in a service which can operate effectively to meet realistic and published standards.

To ensure that the service can meet the need of society the clear roles of "purchaser" and "provider" of health care have been implemented. It is not my purpose to explore these developments as they are all well documented and critiqued in many other arenas. However, it is crucial for us to acknowledge that this is the basis on which the health service now operates, with a major monitoring role in place for the purchasers. Many innovative approaches to care are being seen in the provider units, and as such may be the beginning of tangible results of the NHS reforms.

The reforms in education - in particular those facing nursing, midwifery and community health nursing - will to a large extent follow those in service areas. The model which will be in place is one of either a central national purchasing unit of the management executive of the NHS as in Scotland, or through regional health authorities, as in England.

In Scotland the advent of central purchasing for pre-registration nurse and midwifery education at diploma of higher education level - and initially some elements of continuing professional education - will pose new and exciting challenges for the tertiary education sector. A large number of education institutions will shortly be engaged in competitive tendering to provide education for given numbers of students, based on the manpower predictions and requirements of the NHS trusts and the independent sector. In a number of specialist areas yet to be defined there may be identified national centres where low level of need would make even six to eight contracts unviable.

One of the challenges which will arise from a major plank of the reforms is to ensure the integration of the current range of educational activity found in the colleges of nursing, midwifery and health studies which are at the moment part of the NHS. Integration must be seen in its widest sense and will, as the new contracts come into place, have to be transparent to the purchaser, the student, the teacher, the education institution and to society. It will not suffice to pay lip service to this requirement and the approaches to enable this - in terms of teaching practice based experience, research and consultancy - will need to be carefully thought through. Integration will need to be considered in ways in which all students and staff can be seen to gain added value - along with the educational institution - from exposure to the wider academic community. Students and staff will expect to participate and play a significant role in the total life of the institution through shared learning, contributions to the academic development of the institution and social experiences.

For some institutions the integration of a large and new body of students and staff will have a huge impact on the ethos and political shape of the organisation. In the areas of shared learning it will be imperative that this takes place across the range of courses which share common elements and cannot be assumed only to encompass what may initially be considered as health-related activity.

Within most institutions many areas produce qualified personnel who contribute to the health services. Opportunities will be promoted to encourage shared experiences in a multitude of courses encompassing computing, engineering and business studies in addition to health related studies, reflecting the width of backgrounds required by the new NHS.

Teaching staff will be exposed to the expectation that they will contribute to a wider range of courses operating at various levels. A recent article in Nurse Education Today, "Striking the Balance - a Nurse Teacher's Dilemma", by Peter Birchenall, suggested that the atypical entry of the majority of students poses a dilemma for the teacher in maintaining the balance between scholarly activity and ensuring that student need can be met.

Nursing, on the whole, has not scored highly in research assessment exercises and the wholesale assimilation of educational activity will pose further challenges as there will be an expectation of contributing through writing and research to the growing body of knowledge which supports the discipline of nursing.

While most nurse educators are excited by the challenge of the future, questions have been raised about the move to a new sector. Some commentators have openly queried the expectation that diploma-level courses can be the academic equivalent of the second and part third-year of an honours degree - a situation which arises when the minimum entry requirement is based on five Standard grades or equivalent. The other side of this argument is that in Scotland a significant section of the student population achieves a higher entry level than the minimum. It is essential that the profession, through the United Kingdom Central Council of Nursing, Midwifery and Health Visiting should have the right to expect that the minimum level set for previous courses should be uprated to reflect the position as we move into the next century. This has to happen rapidly if the problem of a potential lack of acceptance into mainstream education - and academic credibility in terms of outcomes and standards - is to be avoided.

While some commentators have posed such questions, a process of critical external validation from acknowledged academic centres judged that the courses which these students follow were at an acceptable academic level and could be delivered within the providing institution. There are, however, some unanswered questions regarding the amount of input required from social and life scientists to ensure the integrity of the programmes. No doubt some of these will be addressed at course reviews.

The wide range of academic qualifications held by teachers is well documented and institutions will need to ensure that the variety of expertise can be effectively integrated through contributing to cross-course teaching, assessments, research and supervision of postgraduate research students. As many teaching staff will not have had the chance to supervise research students, this must be encouraged as over a period of time the available pool will rapidly increase.

It is possible that the range of expertise may come as a surprise to a number of institutions when the profiles of colleges are examined as the majority of staff who will be integrated into the tertiary education sector are qualified teachers - something which has not been the norm in the majority of universities.

The approaches to the reform to end the isolation of nurse and midwifery education in NHS monotechnics is being approached differently in different parts of the UK. In England an apparently piecemeal series of mergers or associations has been progressing for a number of years, In Scotland a more radical process has been put in place.

Following a major inter-departmental review in the Scottish Office, the decision was taken to integrate fully pre-registration diploma-level nurse and midwifery education in the mainstream tertiary education sector. The process which has begun will result in the existing provision of a range of pre and post-registration activities through 12 colleges of nursing and midwifery and health studies being provided through six to eight contracts between the NHS management executive and institutions within the tertiary education sector.

As a result a major staff resource and a range of support resources will be transferred to the education sector on the basis of funding via the health service vote, with students receiving a non-means-tested bursary of about Pounds 4,500 per annum.

Interesting issues surround this area. It could be argued that in Scotland - because of the block start up - the advantages to the student, teachers and society of such a move will become obvious in the short term, but the longer-term effect of a process of rolling competitive tendering in education will need to be carefully evaluated. The successful providers will face many new and challenging facets of this process, not least of which will be encouraging and promoting innovation in educational delivery while maintaining high level quality. This will have to be demonstrated at an annual review of rolling contracts whose initial lifespan is five years. It is likely that this approach to the delivery of education within a process of competitive tendering will pose many questions over the coming years as this aspect of professional education becomes part of the market economy.

The potential for much wider use of this process is evident - in medical education, for example, where numbers can be determined centrally. It is tempting to speculate on the reaction of the medical faculties if such an approach were to be adopted in determining the future delivery of such provision.

The provision will expect that there will be no diminution of expertise. It is imperative within the context of the competitive world that sharing and reflection of experience and development of good practice are fully supported and encouraged to ensure a growing contribution to the body of knowledge which is nursing, midwifery and community health nursing.

Equally the major contribution which this range of educational provision brings to the tertiary education sector must be acknowledged - and not sidelined by being seen as a bolt-on to an institution which can be isolated if and when contracts are or are not renewed. This development must not in any way impinge on other funding for institutions but must play a full and active part in the total life of the organisation.

Magnus Shearer is head of the department of health and nursing at the University of Abertay Dundee.