FULL REPORT OF RESEARCH ACTIVITIES AND …...16 FULL REPORT OF RESEARCH ACTIVITIES AND RESULTS Nursing in the New NHS: a sociological analysis of learning and working Background The

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FULL REPORT OF RESEARCH ACTIVITIES AND RESULTS Nursing in the New NHS: a sociological analysis of learning and working Background The modernising of the NHS is part of a wider government agenda for changing working patterns and ensuring the delivery of high quality, value for money public services. The NHS is a large complex organisation which has been through many reforms by governments from the left and right, nonetheless problems remain with resources, capacity, structure, organisation and working practices. In the late 1990s a series of papers came out of the Departments of Health in London and Edinburgh addressing the need to bring the NHS into the twenty first century. Medical successes, demographic changes and societal expectations of the health service have led to a need for radical reform of the NHS. The Scottish Office paper1 laid out the vision of

‘a service which is designed from the patient’s viewpoint, which delivers clinically effective care and which does so quickly and reliably in high quality facilities’.

In this reformed health service people will have ‘local access to teams of health care professionals working together’. The Wanless Report (2002)2 noted that in the future there will be fewer hours of work available from a number of professionals in the NHS most notably medicine, because of the European Working Time Directives (EWTD), this he notes will lead to a less productive service. This European legislation is one of the main factors driving the NHS reform. The focus of the NHS Plan3 is on teamwork and as the nursing workforce is central to the provision of health care in the UK, both in the NHS and the independent sector the Plan includes the expansion of the nursing input to the service. The modernisation plan was based on wide consultation and included plans for substantial investment in the health service. Notably, it included a new service, NHS 24, a call centre-based service to be staffed in the main by nurses. The modernisation plan for the NHS involves new ways of the professions in health care working together in order to place the patient in the centre and to organise care in such a way as to allow the 1 Scottish Office (1997) Designed to care: renewing the NHS in Scotland CM 3811 2 Wanless D (2002) Securing Our Future Health: Taking a Long Term View HM Treasury: London 3 Scottish Office Department of Health (1997) Designed to Care, CM3811, The Stationery Office: Edinburgh Department of Health (1997) The New NHS Modern, Dependable, CM3807 Stationery Office: London. Department of Health (2002) The NHS Plan, A Plan for Investment, A Plan for Reform Stationery Office: London.

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Scottish Executive Health Department (2000) Our National Health, A Plan for Action, A Plan for Change The Stationery Office: Edinburgh

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patient a smooth journey through the service.4 The ideas associated with the NHS Plan include teamwork, professional regulation and organisational change. The Plan involves new demands on nursing, and consequently on nursing education. My plan of work during the Fellowship was to study the modernising process from the different perspectives of service, higher education and professional regulation; to complete a book on health care ethics; also to work on a co-authored qualitative research methods text. The main finding in my empirical qualitative study concerning ethical issues in intensive care5 was that the most important factor in the handling of the ethical aspects of intensive care work was the ability of the team to work together. Intensive care teams did not always agree on all difficult clinical decisions. However, due to an overall strength of loyalty to the team, they survived disputes and were thus able to continue to deliver high quality care. As multi-professional teamwork is a central plank of the NHS modernising agenda, it follows that the nature and quality of teamwork will be important for its success. The study of the modernising of the NHS draws upon the sociology of the professions literature.6 Given the complex nature and magnitude of the modernising agenda I set out to produce a commentary on the Plan as it develops. Related issues are both theoretical and practical involving blurring or re-drawing of traditional professional boundaries and questions of competence and professional regulation. I was also interested in the relationship between the service and education as the skills and knowledge requirements for some of the new roles became apparent. Objectives The overall aim of the research was to understand the place of nursing in the new NHS from the perspectives of service provision, education and professional regulation. There were five more detailed objectives:- 1. To discover how the different parties – clinicians, managers of the nursing service,

higher education, professional bodies - respond to and develop the Department of Health proposal for the NHS modernisation.

2. To analyse the conceptual and practical issues raised for nursing by the

implementation of the NHS Plan • Objectives 1 and 2 were met through the qualitative research study involving taped

interviews, the study of policy documents and attending meetings and working

4 Scottish Executive (2002) Working for Health: the workforce development action plan for NHS Scotland 5 Melia K M (2001) Ethical Issues and the importance of consensus for the intensive care team Social Science and Medicine 53 707-19 Melia K M (2004) Health Care Ethics: lessons from intensive care Sage London

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6 Freidson E (1994) Professionalism reborn Polity Press: Cambridge Hughes, E C (1971) The sociological eye Aldine Publishing: Chicago

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conferences hosted by the Scottish Executive7 8 [Details under Methods and Results below]

3. To communicate the findings in the form of published papers and conference presentations.

• Objective 3 was met - the commentary has been organised around several issues which will be developed in the coming year for publication in health care, nursing sociology and health policy journals.

4. To complete a book, Health Care Ethics: lessons from intensive care Sage: London,

and to draw parallels between the new NHS emphasis on a patient-centred service and the book’s main theme of the importance of consensus for the intensive care team.

• Objective 4 was met. The book took longer to produce than anticipated due to re-focusing during writing in order to develop the teamwork analysis. The publication date is March 2004, I have received an advance copy.

5. To gain experience in undertaking policy-oriented work and to integrate previous and

ongoing work in the fields of the sociology of the professions and health care ethics. • Objective 5 was met by the opportunity that this Fellowship gave me to study the

policy documents from the Scottish Executive Health Department, the professional regulatory bodies and to follow the consultations relating to the establishment of the Special Health Board – NHS Education for Scotland and the new regulatory bodies, the Nursing and Midwifery Council and Health Professions Council9 The fact that the work of the group concerned with nursing recruitment and retention, the Scottish Executive’s Facing the Future Group10 has evolved as the Pay Modernisation agenda was taking shape has allowed me to experience policy being developed and implemented.

Methods The research was conducted within the qualitative research tradition. The starting point was the idea that the complex nature of the NHS modernising plan meant that there may be varying responses in service and education to its development, responses which may produce unintended consequences11. The work entailed examination of the proposals for

7 Facing the Future Report of the 19th November 2001 Convention on Recruitment and Retention in Nursing and Midwifery 8 New Roles in nursing conference 2003, Edinburgh sponsored Scottish Executive Health Department and the RCN Scotland 9 Health Professions Council (HPC) is the new independent, UK-wide regulatory body responsible for setting and maintaining standards of professional training, performance and conduct of the 12 healthcare professions that it regulates. 10 Scottish Executive Department Facing the Future Group working on recruitment and retention issues in nursing, 11 Merton RK (1957) revised edition Social Theory and Social Structure Free Press: New York

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modernisation and the papers which built on them.12 Similarly the establishing of the new regulatory bodies for the health care professions was accompanied by a number of consultation papers and the final proposals.13 During the life of the Fellowship a number of changes in the regulation of professions and arrangements for post graduate education for the health care professions took place, this gave the opportunity to study the links between reform and professional regulation. 14 15 16 Qualitative tape recorded interviews were conducted with key people in the service and education sectors, and in the special health board NHS Education for Scotland and the professional regulatory bodies. Also I interviewed civil servants in the SEHD and the Minister for Health. A total of 55 interviews were conducted. The fieldwork yielded nearly 2,000 pages of transcript from interviews and meetings. This amounts to a rich and varied dataset which will be mined and analysed along a variety of lines and lead to several publications and further avenues of analysis to develop as the Plan unfolds, particularly as the new models for re-design emerge and the nature of teamwork becomes clearer. The interviews were recorded and transcribed. At meetings I took full notes and wrote them up later, often by debriefing onto a tape and having it transcribed. The data were handled through interpretive analytic methods of constant comparison, searching for themes, regularities, deviant cases and so on to build up a picture of the response to the NHS Modernising Plan. My aim was to produce an informed account and commentary on the modernising process from the perspective of nursing. The analysis was carried out without using a computer application. The subject matter of the interviews relate closely to the policy documents and so the analysis builds up through analytic note making and memos.17 18 A flexible approach was taken to data collection as it was not clear at the outset that the plans to observe working groups in the Scottish Executive would be feasible. As it turned out, the series of eight events, led by the Scottish Executive’s Facing the Future Group on nursing recruitment and retention and led by the Health Minister, provided data gathering opportunities. As these events brought service and education together, the workshops I had planned as feedback and data sessions were difficult to justify. Instead I held just one such workshop in a Health Board where the relationship between the NHS Trust and the university was well developed and the postgraduate Dean of Medicine was

12Department of Health (2002) HR in the NHS Plan: more staff working differently Department of Health: London 13 JM Consulting (1998) The regulation of nurses midwives and health visitors: report on a review of the nurses midwives and health visitors act1997 JM Consulting: Bristol 14 NHS Executive (2000) Modernising Regulation – the new Nursing and Midwifery Council: a consultation document 15 NHS Executive (2001) Modernising Regulation of the Health Professions: consultation document 16 Department of Health (2002) Reform of the General Medical Council a paper for consultation 17 Schatzman L and Strauss AL (1973) Field Research: strategies for Natural Sociology Prentice-Hall: Englewood Cliffs, NJ

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18 Silverman D (1993) Interpreting qualitative data Sage: London; Miller G and Dingwall R (1997) Context and method in qualitative research Sage: London

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involved in the workforce planning agenda. This was an opportunity for me to present the analysis to date and the discussion yielded further ideas and commentary. The discussion was useful in sharpening the analysis and leading to new avenues, especially around the possibilities for the NHS and universities working together. The professional and general press coverage of the NHS Plan provided another data source. Ethical concerns were limited to the usual matter of guaranteeing anonymity to those interviewed. The documents that I consulted were publicly available. Results The headline in a Sunday Times (12 10 03) article ran, Nurses to take on ‘doctor role’ In many ways this sums up the challenge of the NHS modernising agenda. This newspaper version of the changes in the NHS is in a way right and the concerns that the headline was designed to raise are real. How can nurses do doctors’ work? Are doctors doing the wrong work? How will nurses know what to do? Are they safe? How will we know? These are all matters of finding ways of gaining and measuring competencies, and getting the right skills to the right place with the different professional groups having confidence in the division of work. The NHS is seeking to provide high quality care through multi-professional teams of professional and non-professional health care workers. Moreover, it seeks to become a model employer, offering opportunity for skills development, education and training so that individuals reach their potential and employers, both in the NHS and independent sector, can recruit staff with the right training and of high quality. A key part of the of the reforms include moves towards involving the professions in shared learning. 19 The interviews confirmed that the vision in the plan, namely to deliver patient –centred, high quality, multi-disciplinary care in easily agreed upon by all, but it is clear that workforce planning is driving the agenda.20 21 Workforce planning, recruitment and retention of health care staff are central to the NHS reforms. There are three contractual agreements involved in the pay modernisation, they are the Consultant Contract 22 General Medical Services 23 (general practice) contract and Agenda for Change24. The Agenda for Change seeks to place all health care workers, aside from medical staff and some senior management, on one pay spine. One problem with Agenda for Change is that it raises expectations among the health care workforce, not all of these can be met 19 Scottish Executive (1999) Learning Together: a strategy for education, training and lifelong learning for all the NHS in Scotland Department of Health: Edinburgh 20 Scottish Executive (2002) Working for health: the workforce development action plan for NHS Scotland Scottish Executive: Edinburgh 21 Department of Health (2002) HR in the NHS Plan: more staff working differently Department f Health: London 22 NHS Plan – proposal for a new approach to the Consultant contract. www.doh.gov.uk/consultantcontractproposals 23 General Medical Services Contract (General Practice)

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24 Department of Health (1999) Agenda for Change: modernising the NHS pay system Department of Health: Leeds

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and in the long run that could cause more problems than it solves. The Plan is set out in positive terms, but there will be winners and losers among health care staff and patients. If this large scale effort to place all health care workers on a single pay spine is not successful then the way will be open for local pay deals. This will not sit well with the professional groups but may well suit government plans. Local pay bargaining would fit with the internal market in the NHS to which the Foundation Hospitals in England are returning. This will give rise to some interesting cross border differences since the Scottish health service is to abolish the Trusts in April 2004.25 So whilst England is heading back to the internal market, Scotland’s plans are to return to something closer to the 1948 position. . It is argued in the discussions about NHS reforms that the solution to the health service workforce problems lies in working smarter and differently. This is to be brought about through re-design of the services with an emphasis on patient care pathways and resulting in a redrawing of the traditional demarcation of work between the different health care professions26. Nursing and the AHPs are expected to provide part of the solution to the problem created by the new working arrangements for doctors and the move towards the production of a consultant-led service. We should not assume that it is only nurses who are to work differently. The solution being proposed for example for the provision of out of hours care is to look at different multidisciplinary models, working flexibly to provide quality service in new ways. A commentary upon the unfolding of the NHS Plan can be summed up in terms of vested interests and unintended consequences. So long as the Plan is stated in general terms and discusses broad or theoretical approaches to some future organisation of health care delivery, the reforms are not contentious. However, as the detail is worked out the enthusiasm for the broader picture is muted and more specific and particularised attitudes towards the Plan are adopted. The results of this analysis are best characterised as a set of issues which arise from the study of the NHS modernising agenda. These issues are interrelated, but there is a key message, and it is that nursing, medicine and AHPs have the same problems of recruitment and retention and that these are workforce issues above all else. The problems experienced are strikingly similar even though the professional characters and cultures vary. Issues concerning recruitment, retention, work satisfaction, practice supervision and the teaching and learning of professional skills are common to all the practice disciplines in health care. This sharing of common problems and concerns becomes evident once the different professions are viewed as a whole and in workforce terms. How skills are passed on and safety is assured and crucially how the service continues to be provided during the development of the NHS Plan are the central issues for all professional groups in health care.

25 Scottish Executive (2003) Partnership for Care Scotland’s Health White Paper

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26 Centre for Change and Innovation (2004) Decide to Admit v. Admit to Decide Report on the National Conference Unplanned Care for medical conditions. October 2003 Scottish Executive: Edinburgh

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This central point about framing the problems in workforce terms seems obvious once stated. However, there is a long history of regarding the health care professions in terms of their relationship to the dominant profession of medicine.27 This leads to viewing the professions in terms of hierarchy as opposed to teams. It is only as a result of a detailed analysis such as this that an alternative way of understanding the phenomenon presents itself. In this case, the workforce analysis starts to become evident, and indeed with hindsight, obvious. New roles are being introduced in piecemeal ways as the modernising and local re-design takes place. New roles need to be integrated into the system already in progress. This will only come about if there is joint workforce planning taking place in parallel with the development of education plans. These are essentially workforce issues linked to educational needs. The professions also share problems concerning post graduate education.28 29 These workforce and education issues can be described in terms of tensions between service needs and professional traditions and interests. The central question is: Are we reproducing the professions or producing the health care workforce? It is clear that the universities and the NHS need to work in partnership finding new ways of working together. A central issue for the practice disciplines is how to match the evidence of clinical competence and the necessary skills for good clinical practice with the traditional forms of credentialing in the universities. In other words practice disciplines need to map university qualifications onto skills. Education is producing tomorrow’s health care workforce, therefore the NHS has an interest in the education of that workforce. Insofar as a general conclusion can be drawn it would be this, there are many agendas, vested interests and unintended consequences contained within the process of modernising. It should be remembered that these may have good outcomes, not all unintended consequences are negative. As the detail unfolds and some of what it might mean for individuals takes hold there is a risk of the plan being destabilised if not derailed as different groups respond according to their own best interests as opposed to those of the service as a whole. This is perhaps best demonstrated in the study of the plans for teamwork and new divisions of labour which require to be managed. Nursing has always been a managed occupation, the NHS Plan involves a move towards managing medicine as part of the new form of work organisation involving re-design of services such that different health care professionals will work in new ways sometimes taking on work previously undertaken by others. As the analysis progressed and details of the consultant and the general medical service contracts were developed, the differences in the approach to the contracts of doctors compared with those of other health service staff became clear. The media coverage of the consultant contract was mainly of the high profile objection from the BMA along with a hardened ‘take it or leave it’ response from the government The Scottish contract 27 Freidson, E (1970) Profession of Medicine: a study of the sociology of applied knowledge University of Chicago Press: Chicago 28 Department of Health (2002) Unfinished Business: proposals for reform of the SHO grade

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29 SEHD (2002) Future Practice a review of the Scottish medical workforce [Temple Report]

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was settled more readily than the English. The parallel of the fire-fighters’ dispute with the government was marked insofar as the response was in the same style of ‘go away and think again’. Only after the angst died down did it become evident that both the consultant contract and the general practice contract have significance for the rest of the healthcare team. This is where it is clear that workforce planning and shared education need to be undertaken in tandem.30 It is the pay modernisation which makes a lot of the changes in the modernising agenda become real and the difficulties manifest. At the present stage of development of the Plan in Scotland medical and nursing colleagues are coming together to plan for a service in which there will be less medical hours available. The opportunity to study this involvement of doctors and nurses in a policy area has been interesting . One main theme that comes through in the analysis is the shaping of the nursing agenda by medical concerns the main one being the desire for a consultant-led service. We can also add to this shaping of nursing’s agenda the political goals of social inclusion and the existence of targets for the widening of access and participation in higher education for the health professionals. It is clear that the nursing profession cannot develop in isolation in these modernising reforms. The focus of attention has been on the opportunities for medicine to devolve some of its work to nursing. This has been welcomed in part, but there is need for caution, and the professions should not underestimate the consequences. Early evidence from research in primary care suggests that the reactions are mixed where nurse-led services are concerned.31 There was a tendency for nurses to serve vulnerable populations which are often poorly served by general practice This somewhat missed the point of the Plan and raises the question of a two tier health service. The NHS Plan has been developed in a very open media-dominated way and public impressions of the re-designed service are important to its success. Nurse-led services are defined in the research as ‘a combination of extended nursing roles and a culture that promotes equality between different professions and the empowering of patients’. It is easier to establish a new role than it is to change professional cultures and empower patients. Indeed the link through to patient benefits is often asserted rather than argued for in the policy and discussion documents. General practitioners’ decisions to relinquish their personal responsibility for providing care, described as opting- out, can result in the public impression of the modernising being one of a dilution of service. It is of course the case that we are moving with the NHS Plan towards what is sometimes described as a doctor-light service. But it has to be remembered that the Plan also aspires to delivering a consultant-led service. An associated problem with this is that whilst we need more doctors to bring an improved

30SIWPG (2002) Planning together Final Report of the Scottish Integrated Workforce Planning Group

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31 Lewis R (2001) Nurse-led Primary Care: learning from PMS Pilots King’s Fund: London

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service about the EWTD32 makes it difficult to gain enough experience in the same time period. This makes any plans to reduce the number of years required to become a consultant appear dangerous if they are stated baldly. One has to weigh opportunity to learn in terms of hours, but also in terms of alertness during those hours. This is why the training of junior doctors is under review.33 The inter-relatedness of education, service and conditions of employment matters illustrates the complexity of the Plan and how it almost inevitably leads to difficulties along the way as it unfolds and the various consequences become apparent. It is not always the case that nurses are the best option when it comes to medicine passing up some of their work this is for reasons of cost and shortages of nurses.34 35 Physicians assistants are being trained in a few HEIs, to date it seems that the recruitment pool for these courses is graduate nurses. It does not seem to be the best of ideas look to areas which are already suffering shortages to solve a problem in another part of the system. There is probably a need for some role of doctor’s assistant, the question is where should that group be recruited from. If role substitution is not well thought out when nurses and AHPs take up some of the medical work, it may be a case of moving the problem around. In discussions of new roles for nurses,36 it was notable how many who were in new roles said that they put in many extra hours and that their new work was rather outside the system already in place and so they had to negotiate their role. There is an irony here: if the intention is to reduce medical hours for reasons of overwork and tiredness (European rules) and to improve efficiency (the consultant contract) unless solutions are integrated into the system, it simply moves the strain to another part of the service. If nurses are to pass work to the health care assistants, there will be questions of regulation of that group. The re-design of service and reallocation of work may lead to wider and more general questions of the utility of eventually having just one regulatory body for all of the healthcare workforce. It has been notable how quickly the reports of inquiries into professional failure found their way into the government policy and consultation documents37 and so risk-management, ethical issues and professional regulation are high on the agenda. A move to one regulatory body has its appeal,

32 European Working Time Directive 33 Department of Health (2002) Unfinished Business: proposals for reform of the SHO grade 34 Scott A and Skåtun D (2003) Cost benefit analysis of role substitution and development in nursing Unpublished paper from the Health Economics Research Unit: Aberdeen 35 Buchan J (2002) Behind the headlines- a review of the UK nursing labour market in 2001 RCN: London 36 SEHD Facing the Future Group (2003) New Nursing Roles – deciding the future for Scotland: Final Statement [Consensus Conference on New Nursing Roles RCN and SEHD November 2003, Edinburgh]

37 The Bristol Royal Infirmary Inquiry (I Kennedy Chairman) (2001) Learning from Bristol: the Report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995 [www.bristol-inquiry.org.uk]

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The Liverpool Children’s Inquiry Report (Chair Michael Redfern QC) (2001) HC 12- II, 30 January 2001

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however its introduction might be a togetherness too far for the medical profession and would re-open debates about what constitutes professional nursing. Again, unintended consequences suggest themselves. It is too soon, both in terms of the modernisation process and my analysis, to offer any final views on the place of nursing in the modernised NHS. What is clear is that there will be changes in the way we think about nursing services and a change in education and preparation for practice. Everett Hughes38 suggested back in 1951 that the ‘bundles of tasks’ which make up the work of the different professions are from time to time unpacked and re-sorted. This is one of those times, we are not speaking of ‘bundles’ but of re-design, multidisciplinary teams and health care staff working differently, this is the language of this re-sort, however, the activity is much the same as that described by Hughes over fifty years ago. There is a tension in prospect between re-design and teamwork on the one hand and professional interests and career development on the other. In terms of how the modernising agenda affected the nursing profession, the signs are that the changes could eventually be profound. Nursing and the AHPs will not only be taking on work previously undertaken by medicine, but also giving up work to others. Nursing has a problem defining what counts as nursing, and historically is less good than is medicine at giving up roles. During the fieldwork, conversations with AHPs suggest that their roles are rather more readily circumscribed and are based on diagnosis and intervention and it is therefore easier to see what work could be given up to assistants and what can be taken on from others, the boundaries between orthopaedics and podiatry is but one example. The rhetoric in the Plan is multi-professional working, which is presented in nursing circles as either offering opportunities for new roles, or extending roles in a being ‘dumped on’ sense. The quick fix of so-called nurse- led services is not without problems. ‘Nurse-led’ it is not an emancipating term for nursing (although some seem to see it that way) as it is often a substitution for medical work. Nurse-led service is an expression used by managers and clinicians who see either professional gain or cost savings in the use of nurses in clinics and other areas where traditionally one would find a doctor. The public impression may well differ if they perceive such developments as a diluted service. In summary it can be said that the modernising of the NHS will entail service re-design and development of multi-disciplinary teamwork, with the possibility of new work roles and even new disciplines emerging. In the policy documents and discussions within the Scottish Executive there is a good deal of talk of culture change being required for the modern NHS to come about. This is best evidenced in the tendency to invoke re-design or culture change when discussions of how to get to the new style of working in practical terms become difficult. The professions are so entrenched, that some flash points are required to make change happen. However, although re-design is much invoked the point was made during my fieldwork that there is very little clarity about what it will actually 38 E C Hughes (1951) Studying the Nurse’s work American Journal of Nursing Vol. 51

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look like. The solution does indeed lie in re-design and the necessary culture change to go with it or, as some have it, a culture change with re-design to support it organisationally. Whichever way round it is, what currently amount to little more than rallying calls for culture change and the re-design of the NHS are the two essentials for a modernised NHS and, as the details of reform are filled in, will take on organisational forms. It is the detail which will be important, as is often the case, it is where the devil and the success or otherwise of the Plan reside. These interrelated issues will be developed over the coming year for publication in nursing, health service and sociological journals and audiences. • Vested interests in the context of re-design and the reallocation of the work among

the health care professions are examined. Professional interests vs. service needs. The idea of tribes and teamwork, skill mix and the increasing use of non-professional staff. Bringing medicine into the team, medicine as a managed occupation.

• Unintended consequences of the modernising Plan can be positive or negative. The

need to re-design general practitioner services is producing some interesting developments in Out of Hours Services for what is being called ‘unscheduled care’ and a more prominent place for NHS 24 telephone call centre service than was initially acknowledged.

• A discussion linking a teamwork approach to ethics to that in the modernised NHS.

This raises questions of professional regulation, competencies and the possibility of eventually having one regulatory body for the health care professions.

• Reforms creating mixed messages for the public- modern matrons and nurse

consultants. The new NHS will not be popular if the public perceive nurses to be filling in rather than being the professional of choice- images of a diluted service?

Activities • Invited by the Director of the Scottish Executive Health Department ‘s Centre for

Change and Innovation to take part in the seminar launch of Talking Matters – developing the communication skills of doctors. (September 2003).

• Invited by the Association for the Study of Medical Education, on behalf of Council

of Heads of Medical Schools and Council of Deans and Heads of UK University Faculties for Nursing & Health Professions, to write a report and commentary on the Conference on Widening Participation in Education for Healthcare Professions (London October 2003)

Outputs Melia K M (2004) Health Care Ethics: lessons from intensive care Sage: London

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Impacts • Throughout the study I established opportunities to continue beyond the life of the

Fellowship. The Scottish Executive Health Department’s Centre for Change and Innovation and NHS Education for Scotland expressed interest in my work. I plan to continue to track developments and contribute to the NHS reforms in Scotland.

• Insights into the workings of NHS Education for Scotland and the new arrangements

for education for the health care professions have been useful in my role as Head of the new School of Health in Social Science, currently includes nursing and Clinical Psychology and planning to work collaboratively with a neighbouring university’s nursing and AHPs Departments.

• Working papers presented: September 2003 BSA Medical Sociology Annual

Conference; January 2004 University of Edinburgh School of Health in Social Science Seminar [open to NHS ].

• Contributions to related debates at the Council of Deans and Heads of UK University

Faculties for Nursing & Health Professions and the Scottish Heads of Academic Nursing meetings.

Future research priorities • Continuing work on the NHS modernising through contacts made in the Scottish

Executive Health Department and NHS Education for Scotland. • Boundaries and Borders: a comparative study of health and social care in England

and Scotland: a research proposal. Preliminary work is underway with University of Edinburgh colleagues in social work and public sector management accounting and at the LSE, Management Science.