Mixed Funding Within the British Health Care System: An Examination of the Effects on Professional Relationships Between Paediatric Oncology Outreach Nurse Specialists and Other Health Care Professionals

Stemming from the White Paper Working for Patients (DoH 1989a), the National Health Service (NHS) has undergone major reform over the last decade. Central to this process has been the ethos of a market driven economy, with increasing reliance on 'income-generating' schemes. Voluntary sector funding has been particularly called upon to assist with establishing 'new' nursing services, which are commonly clinical nurse specialist posts. A particularly successful example has been found in the naissance of the Paediatric Oncology Outreach Nurse Specialist (POONS). In order to improve the services offered to children with cancer and their families, bereaved families have been actively involved in raising funds to establish charities to fund POONS posts. The ways in which charities have been established have largely resulted from the personal experiences of families wishing to improve on the services they received during their child's care and terminal illness. As a result of this, personal agendas have influenced the strategies of the charities concerned. However, the ways in which these strategies impinge on POONSs and those who they work with has, to date, not been examined. This research explores how the strategies adopted by key charities funding POONSs influence their working practices and the structure and organisation of their services. A second aim is to examine whether, in tum, the relationships between POONSs and other health care professionals with whom they work, are affected by the strategies adopted by different charities who provide funds for POONS services. Empirical data were collected from all POONSs throughout the United Kingdom and the Republic of Ireland. Forty three POONSs were interviewed either by telephone or in person. Two 'Funder' models were identified, reflecting the divergent strategies of the two main charities funding POONS posts: the Cancer Relief Macmillan Fund (Macmillan model) and Cancer and Leukaemia in Childhood (CLIC model). A third model was associated with funding from smaller professionally-directed charities and the NHS. These models were built upon in undertaking case studies at three locations, during which a diverse group of health care professionals were interviewed. In all 65 focused interviews were held transcending community and acute hospital sectors. POONSs associated with the Macmillan model were identified with having a handsoff approach to nursing and worked at regional children's cancer treatment centres. Those affiliated to the CLIC model provided hands-on care to children at district general hospitals (DGHs). Those identified with a 'Mixed Funders' model displayed elements of the other two models, adopting a mixed hands-on and hands-off technique and working at both regional centres and DGHs. Two professional relationship typologies have been developed: one that exists between POONSs and primary health care teams, and a second between POONSs and hospitalbased health care professionals. The former typology comprised three types of relationship: 'Empowerment' associated with hands-off care; 'Disempowerment' associated with hands-on care and 'Partnership' identified with both hands-on and hands-off nursing care. Four types of 'partnership' were evident in a second typology: 'Relinquishment' where POONSs at DGHs provide hands-on care to children in hospital, handing over the care to ward staff only in their absence; 'Hierarchical Ascendency' where consultants at DGHs control the work of POONSs; 'Integrated Reciprocity' where regional POONSs and hospital colleagues share the care of children, mindful of each others' roles; and 'Independent Reciprocity' when regional POONSs share the care of children with other hospital-based staff, sometimes obliviously. In general, the ways in which POONSs' services are structured, organised and delivered, the degrees of knowledge achieved by them and the relationships formed between POONSs and other health care professionals are significantly affected by the nature of funders within the current mixed economy of health care. The nature of funding has implications for the professionalization of nursing, for the theoretical construction of interprofessional relationships, and for future policy directions within the NHS. This thesis is dedicated to those many families that I have known and supported through the deaths of their children without whose plight and in whose interest, this study would not have been inspired. In particular it is dedicated to Paul and his mother Olive who inspired me to become a community nurse which assisted in the naissance of the nursing specialty which has become known as 'POONS'. Any names that appear in this text are fictitious to maintain anonymity I In futurity, I prophetic see, That the earth from sleep (Grave the sentence deep) III In the southern clime, Where the summer's prime Never fades away, Lovely Lyca lay. V 'Sweet sleep, come to me Underneath this tree; Do father, mother weep? Where can Lyca sleep? VII 'If her heart does ache, Then let Lyca wake; If my mother sleep Lyca shall not weep. The Little Girl Lost IX II Shall arise, and seek For her Maker meek; And the desert wild Become a garden mild. IV Seven summers old Lovely Lyca told. She had wandered long, Hearing wild bird's song. VI 'Lost in desert wild Is your little child. How can Lyca sleep If her mother weep? VIII 'Frowning, frowning night O'er this desert bright Let thy moon arise, While I close my eyes. ' Sleeping Lyca lay While the beasts of prey, Come from caverns deep, View'd the maid asleep. William Blake (1757-1827)