Implementing KSF competency testing in primary care. Part 2: Evaluation of the pilot of an appraisal tool.

Assessment of competence is a way of measuring if staff are fit for purpose. Clinical competences, against which performance is measured, have been developed in a wide range of clinical settings in recent years (Department of Health (DH), 2008). Several trusts also operate an assessment centre in the recruitment and selection of staff, and these frequently involve competency testing in order to be certain that their new recruits are fit for their post. Agenda for Change (DH, 2004a) firmly links pay to the competences expressed in the Knowledge and Skills Framework (DH, 2004b; c) yet the KSF has not been implemented in all trusts. In part 1 of this article (Bentley and Dandy-Hughes, 2010), the process of Southwark PCT's competency project was described. This involved the process of writing measurable, manageable competences from the KSF, in order to develop staff to be fit for purpose. Part 2 evaluates the use of the appraisal tool that was developed from the KSF, and examines the role of the nurse consultant in education who led the competency project.

Implementing KSF competency testing in primary care. Part 1: developing an appraisal tool.

The delivery of an effective community nursing workforce relies on competent staff. Commissioners will need to be assured that their providers employ competent, efficient staff who give value for money. The Knowledge and Skills Framework (KSF) was introduced as part of Agenda for Change to identify the competences required, but competency testing using the KSF has not been fully implemented across the UK, and measuring competency, using the KSF indicators, still leaves much room for variation and a non-standardized approach. In the first of this two-part article, the authors discuss the process through which the provider services of one London PCT developed standardized competences using the KSF which were linked to staff performance and which provided clear areas for individual development.

Management of the diabetic foot ulcer: exercising control.

The incidence of diabetes is increasing and therefore patients with diabetic foot ulcers will become increasingly common in the community. The NHS model of Health and Social Care (Department of Health (DH), 2005) places a high emphasis on self care and disease management, and, as a long-term condition, diabetes mellitus requires efficient and effective management. The supervision and organization of the care of diabetic patients is multi-factorial and for this reason, a multi-disciplinary approach is essential for effective care, without which patients with diabetic foot ulcers are at high risk of complications. Diabetic wounds present differently to other chronic wounds; unless these are adequately assessed and treated, there may be devastating consequences for the patient--the most serious being major amputation and/or death. In the first article, accurate assessment was discussed; in this second article, the management of diabetic foot ulcers is explored.

Multidisciplinary management of the diabetic foot ulcer.

Diabetic foot ulcers are likely to occur in up to 25% of people with diabetes mellitus at some time in their life (Boulton et al, 2005). Without adequate management, there is a high risk of infection, gangrene, amputation and death. Over 50% of major amputations in the UK happen to people with diabetes, and within three years of amputation, 50% of patients will die. Diabetic foot ulcers need specific management, and some of the principles of moist wound healing do not apply. Diabetic patients with foot ulcers benefit from accurate and prompt assessment, diagnosis, treatment, and long-term follow-up in order to conserve the foot (Jeffcoate et al, 2006). Their management cannot be undertaken by one health care professional working in isolation, but should involve a multidisciplinary team to ensure that these complex wounds are treated appropriately. In this first of two articles, wound healing in the diabetic foot and the principles of assessment of the diabetic foot ulcer are discussed.

Choosing and using: patient choice in 'Choose and Book'.

Seventy six percent of people feel that the main healthcare priority should be to involve people in decisions over the treatment of their illness. One group of users in primary care that are likely to have diminished choice are the heaviest users: the elderly. Modernization of the NHS has placed the user as a consumer, thus creating a more user-friendly service that not only takes into account the role of the consumer, but actively engages with them. Increased patient choice provides a context for meeting patient expectations. Patient choice and patient centred care are evident within the NHS Plan, which outlines a vision of health services designed around the patient. This article will review the extent to which elderly patients have real and meaningful choices in the 'Choose and Book' system which operates within the primary care setting.

Improving quality of life in venous leg ulceration: a case study.

It is not uncommon to find that patients with venous leg ulcers have a reduced quality of life, but to prevent inappropriate management and thus contribute to the chronicity of these wounds, clinical practice must be based on sound evidence and application of research. The choice of compression options is fairly wide, but occasionally problems are encountered with tailoring a particular product to a patient. In this case study, a number of challenges were presented to the nursing team in implementing evidence-based practice and accommodating patient choice, but these were overcome and the patient's quality of life has significantly improved.

Clinical competence in sharp debridement: an innovative course.

A quick and effective way of promoting wound healing is to carry out sharp debridement where indicated, but this procedure carries a high level of clinical risk. Minimizing risk is an essential feature of clinical governance. A new course in wound debridement was developed at King's College, London in response to local NHS trust demand which required assessment of competence for this high-risk procedure. This innovative development crossed traditional boundaries, and required high collaboration between education and practice.

Older people as health service consumers 4: disempowered or disinterested?

Giving patients a greater say in the NHS is prominent in all national service frameworks (NSFs) and is evident in the expert patient initiative (Department of Health (DH), 2001a). One group of users who may have difficulty in making their voice heard are the elderly. The national service framework for older people (DH, 2001b) promotes user involvement in an attempt to achieve fair and equitable access to services for this group of patients who, statistically, make the highest use of the NHS and could be classified as consumers. This article, the last in a series on this topic, discusses whether a sample of older people in a village community have a consumerist ethos in regard to health care, and whether they are prepared to act in this way. Suggestions are made for better facilitating older people's involvement in and use of services.

Older people as health service consumers 3: obstacles to access in the village.

Faster access to hospital services, swift advice and treatment in GP surgeries and quicker access to information at home are among the improvements brought about as a result of recent Government policies in England. These developments have increased the infrastructure, such as walk-in clinics and extended surgery hours, but the responsibility lies with the patient to present themselves. Although older people use NHS services proportionately more than other age groups, they also tend to normalize disease symptoms, attributing them to ageing (Tod et al, 200a). This article, the third in a series which addresses older people's beliefs and behaviour in relation to health care, discusses the factors which influence the accessing of health services within an older, white village community in South England.

Older people as health service consumers 2: health and illness in a village context.

Involving users in the future shaping and development of health care services is part of the drive to restore public confidence in the NHS (NHS Executive 2002). A fundamental part of this process is working in partnership with patients, and attempting to include marginalized groups. Illness, infirmity and lack of knowledge may prevent older people from being actively involved in decisions about health care services, and the culture to which they belong may act as a further barrier. For true partnership and patient involvement, there needs to be a common understanding of the meaning of health and illness. This article discusses the prevailing cultural health beliefs within an elderly, white village community in South England.

Older people as health service consumers: background to a study.

User involvement in health care has received a high profile within the NHS Plan (Department of Health, 2000a), giving patients a greater say in their treatment and in the way that the NHS works. Older people, i.e. those over 65 years of age, as a group, are the highest users of hospital and community services (DH, 2001a). The national service framework (NSF) for older people (DH, 2001a) highlights the need to listen to older people, help them make informed choices and involve them in achieving a healthy lifestyle. While the NSF for older people rightly attempts to ensure fair and equitable access to health care services for older people, it is assumed that they want to be involved, and want to exercise their rights as users. This assumption needs to be tested. This study, presented as a series of four articles, sets out to explore if there is a consumerist ethic among older people in relation to health care. The first paper outlines some of the literature reviewed together with the methodology.

Achieving confidence and competence for lecturers in a practice context.

This paper demonstrates how the maintenance of competence and confidence was achieved and maintained through the authors' involvement, as lecturers, in hands-on care in two clinical settings: acute medicine and the community. The latter took place in the link area for one of the authors (JB). The process is explored by taking elements of a concept analysis, () namely antecedents, attributes and consequences of the lecturer in clinical practice. Through a facilitated action-learning approach, the authors interpreted their role as lecturers in practice, as advocated by and explored the extent to which current educational standards can be met by lecturers working in clinical practice. These standards underline the importance of the lecturer being competent and confident in practice. The Peach Report () identified how students' learning in a practice context has been intensely affected through changes in service delivery, and the need for appropriate preparation of nurses to work in this changing, complex health service was emphasised. It therefore follows that those involved in the preparation of students who are fit for practice should themselves deliver clinically relevant teaching which is based on recent practice experience.