Project 2000: a newpreparation for practice — has policy been realized? Part 2

Project 2000: a new preparation for practice- has policy been realized? Part 2 Rita M H Le Var

THE POLITICAL SYSTEM The relevant components of the Combined Policy Model for the consideration of the political system are: the decision system; the organizational network; the bureaucratic process; financial resources; political support; competence of key personnel; time; timing and coordination as constraints upon policymakers; and the environment. The decision system is the government, whereas civil servants in the Department of Health (Doll) can be seen to constitute the organizational network in this model. They include the senior civil servants or 'bureaucrats' and the 'professionals' - nurses, midwives and health visitors (Lawton 1986, p 34). The environment includes individuals, groups and organizations, as before. Following receipt of the United Kingdom Central Council of Nursing, Midwifery and Health Visiting (UKCC) proposals in February 1987, the D o l l carried out extensive consultation with the National Health Service (NHS) in the four countries. The information gained through the consultation constituted 'political intelligence' about what other organized interests preferred (McDonnell & Elmore 1991, p 179). The D o l l also undertook its own analyses of the manpower implications. Rita M H Le V a t HA (Ed), RGN, Dip N (A), Cert Ed, Director of Educational Policy, English National Board for Nursing, Midwifery and Health Visiting, Victory House, 170 Tottenham Court Road, London WIP 0HA, UK Tel: 0171 391 6258; Fax: 0171 3886957 (Requests for offprints to

RLV) Manuscript accepted 29 January 1997

Government's response to the UKCC In May 1988, the government responded to the U K C C (DHSS 1988). Further correspondence followed in 1989 (DHSS 1989, D o l l 1989a). The government accepted the need for change in the education system and the position of students. It supported the key proposals put forward by the UKCC: the new registered practitioner to provide care in institutional and

Nurse Education Today (J 997) | 7, 263-273 © J997 PearsonProfessionalLtd

non-institutional settings; the 3-year educational programme, with an 18-month common foundation programme (CFP) and branch programmes in the four rid& of nursing; supernumeraty status of students, with 20% service contribution; graduate teachers; the concept of the support worker (helper); the cessation of enrolled nurse (EN) training; and conversion opportunities for ENs. The government wishe&to discuss direct entry midwifery training ana the 18-month post-registration midwifery programme further with the UKCC. Non-means tested bursaries were supported, although the level of support for mature students, students with domestic responsibilities and those moving from jobs in the NHS required further consideration. The government supported closer links with further and higher education. It wished to discuss with the U K C C and the boards the development of a comprehensive framework for continuing education, including the provision of credits towards degrees. It looked forward to further work on the role and function of the specialist practitioner and more detail on shared learning proposals. Detailed proposals were to be prepared concerning the role, functions and preparation of the new support worker (aide) (Elkan & Robinson 1991). Support worker training was to be developed within the National Vocational Qualification (NVQ) structure, through the Care Sector Consortium. The government wished to discuss with the U K C C the number and status of teaching staff. It intended to emphasize to the health authorities the need for firm plans and targets for EN conversion. Further work needed to be undertaken to widen access into nursing.

Government's final agreement In October 1988, the D o l l asked regional health authorities to identify sites for participation in Project 2000 from autumn 1989, with plans submitted in January 1989 (NHS Management Board 1988). In May 1989, final agreement was received for Project 2000 to go ahead when the government announced the first wave of 13 demonstration sites (Macleod Clark et al 1995). It is apparent that the government's decision was influenced by the case made in the Project 2000 report. It depicted dearly and convincingly: the changes taking place in society and their implications for health care; the demographic changes predicted to occur over the next two decades reducing the number of young people being available for recruitment to nursing (Macleod Clark et al 1995); the need for flexible practitioners, better prepared to meet the changing health care needs of the

264 NurseEducationToday population in the future; and the inadequacies of the existing system of education, described as 'crucial deficiencies' byJowett et al (1994, p 1). Project 2000 had gained the support of the professions. According to Ball (1990), such consensus is rare. The government's agreement signifies that the policies produced reflected its thinking and the overall economic climate (Hofferbert 1974 cited in Jenkins 1978). This harmony with the government's views may be a reflection of the amount of work undertaken 'behind the scenes' with the civil servants who, according to Dale (1986, p 62), 'exercise wide decision-making discretion'. The contributions of key individuals are likely to have been vital, including the vision, drive, skill and experience of the Chairman and the Registrar of the U K C C and of the Chairman of the Project Group as well as the support and influence of the Chief Nursing Officer at the Doll.

POLICY O U T P U T S The relevant aspects of the Combined Policy Model for the consideration of the policy outputs are: the legislative process; financial resources; pohtical support; competence of key personnel; time; timing and coordination as constraints upon policymakers; and the environment. The key policy outputs are identified. Having received the government's acceptance of its proposals, the U K C C began the work of drafting the policy instruments, i.e. statutory instruments and circulars. This involved working with the D o l l lawyers to prepare the statutory instruments (Sis). The ENB was consulted on the drafts, as required in the 1979 Act. The resulting documents were Sis issued in August 1989 (SI 1989 nos 1455, 1456, U K C C 1989a). The SI 1989 no. 1455 created four new parts of the register: parts 12, 13, 14 and 15. SI 1989 no. 1456 contained detail pertaining to the course of preparation. This was to be no less than 3years in length, with each year containing 45 programmed weeks. The course would consist of a CFP and a BP, with each of these being no less than 18months in length. The BPs would be in adult nursing (for part 12), mental health nursing (for part 13), mental handicap nursing (for part 14) and children's nursing (for part 15). The U K C C reserved the right to determine the length of the period of practical experience of nursing outside the SI. The students were to have supernumerary status. The course in adult nursing leading to part 12 was to meet the requirements of the Nursing Directive (Council Directive no. 77/ 453/EEC). The U K C C also reserved the right

to determine the content of the CFP and the BP outside the SI. The course was to be designed 'to prepare the student to assume the responsibilities and accountability that registration confers, and to prepare the nursing student to apply knowledge and skills to meet the nursing needs of individuals and groups in health and in sickness in the area of practice of the Branch Programme and shall include enabling the student to achieve.., outcomes' identified in the SI. The outcomes focused on: the recognition of common factors that affect the physical, mental and social well-being of patients and clients in a social, political and cultural context; the use of research to inform nursing practice; communication skills; participation in health promotion; the identification of the needs of patients and clients and the ability to devise a care plan, contribute to its implementation and education; the ability to function effectively in a team; and supervision of assigned duties to others (UKCC 1989b). The SI had been drafted to permit new and experimental branches in the future. Besides the SI, the educational institutions and the professions had the project report and three further project papers (UKCC 1986a, 1987a, 1987b) to guide their thinking. In addition, the U K C C issued a circular in November 1989 (UKCC 1989c) which identified the standard of the Project 2000 programmes higher education (HE) diploma and the content of the CFP and the BP. A further circular (UKCC 1989b) identified the amount of rostered service to be provided by the students during the programme. This text then was a 'product of compromises' (Ball 1994, p 16). In relation to midwifery education, a new SI (SI 1990, no. 1624) was issued in 1990, which stated the lengths of the two types of programmes of preparation (3 years and 18 months), the supernumerary status of students, the need for the programmes to meet the Midwives' Directive (Council Directive no.80/155/EEC) and the outcomes of the programmes. A U K C C Registrar's Letter (UKCC 1990a) identified the standard of the programmes (HE diploma), required them to resemble the new programmes in nursing education in relation to links with HE, programmes being educationally led, the status of the student and the period of practical experience, including the period of rostered service contribution and stated the requirements for the content ofpre- and post-registration midwifery programmes later reiterated in 1991 (UKCC 1991). The UKCC's rules in Sis and its requirements in circulars resemble mandates, identified by McDonnell & Elmore (1991) as one of four main policy instruments. Such mandates, or

Project 2000 265 rules, govern the actions of individuals and organizations and are intended to produce compliance in terms of minimum standards. The D o l l provided guidance on Project 2000 implementation to general managers in 1988 (NHS Management Board 1988) and further guidance in 1989 on the preparation of implementation plans (Doll 1989b). Guidance was provided on the level of bursaries in June 1989 (Doll 1989c) and on the dependency additions in October 1989 (Doll 1989d). This latest guidance arrived after some Project 2000 students had already started their courses (Jowett et al 1994). The Doll left it to the regional health authorities to detem~ine the most appropriate management arrangements for colleges. Integration with HE was one of the options (NHS Management Executive 1992). The UKCC began the development of the framework of education beyond registration in 1989 with a further project entitled 'PostRegistration Education and Practice project' (PREP) (UKCC 1990b). The following policy outputs have been issued to date: the UKCC standards for education and practice following registration (UKCC 1994a), the SI on maintaining registration (SI 1995, no. 967), guidance on return to practice programmes (UKCC 1995a, 1996a,b), guidance on the programmes of education leading to the qualification of specialist practitioner (UKCC 1994b) and arrangements relating to the transitional period (UKCC 1995b, 1996c,d). The guidance on the specialist practitioner programmes includes standards for public health nursing/ health visiting. The NHS Executive (1995) has issued guidance to the health service. No additional funding has been made available by the government for the implementation of the policy outputs, as the funding required is understood to be already in the system. Therefore, funding will be by the employer and/or the practitioner. The programmes for the specialist practitioner include the notions of credit accumulation and transfer and shared learning with relevant specialties (UKCC 1994a). Work is being undertaken by the UKCC in relation to the concept of the advanced practitioner. The UKCC's standards for education and practice following registration (UKCC 1994a) contain standards for teaching. The UKCC has consulted on further proposals and it is expected that final standards will be available in March 1997. The preparation for the health care assistant (support worker) (Doll 1989a, NHS Management Board 1988) was taken up by the NHS Training Authority (NHSTA) together with the Care Sector Consortium, the lead industry body responsible for the development of standards of competence in the health and social

care sectors. The first sets of national occupational standards were developed by 1989, focusing separately on health care assistants and residential, domiciliary and day care. These two sets of standards were redeveloped and integrated into the Care Awards at levels II and Ill in 1992 (Care Sector Consortium 1996). The implementation of Working Paper 10 (NHS Management Executive 1989) resulted in the heads of educational institutions having clear responsibility for the education budget. The NHS Management Board (1988) expected to see reductions in EN training only as part of a planned move to implement the Project 2000 reforms, with resources released being applied to the new forms of training or to enhancing opportunities for conversion. SI 1989 no. 1456 enabled ENs wishing to become first level nurses to have three additional examination attempts (UKCC 1989d). The UKCC provided guidance on additional approaches to enable ENs to become first level nurses (UKCC 1988@ It included the notion of credit for previous learning. The UKCC undertook work on the DC test (UKCC 1988b), although this work was later abandoned. The policy outputs relating to widening the entry gate through NVQs, Scottish Vocational Qualifications, Scottish Vocational Education Council (SCOTVEC) modules and access courses included a range of circulars (UKCC 1988b, 1992a,b,c, 1993a,b, 1995c,d, SI 1993 no. 1901).

POLICY IMPLEMENTATION The components of the Combined Policy Model for the consideration of policy implementation include: financial resources, political support, competence of key personnel, time, timing and co-ordination as constraints upon policymakers; and the environment. An outline of the context of major changes in the NHS and education is included here, as they had a direct effect on the implementation of Project 2000.

The context Project 2000 was implemented at a time of unprecedented change in the NHS (Macleod Clark et al 1995). The establishment of a market economy in the NHS, described as a quasimarket by Le Grand (1996), through the implementation of the NHS reforms (Doll 1989e), had resulted in the purchaser/provider split in health care provision. District health authorities' growing purchaser remit and the development of trusts and directly managed

266

NurseEducation Today units required new communication links to be developed for education/service liaison (Jowett et al 1994). The implementation of Working Paper 10 (NHS Management Executive 1989) resulted in new contractual and funding arrangements for nursing, midwifery and health visiting education. The Community Care Act (Doll 1990) created changes in the role of mental health and learning disability nurses. The implementation of these massive changes as well as skill-mix reviews and the clinical grading exercise had the effect of overshadowing Project 2000 for service managers (Jowett et al 1994). For education managers, the demands of new developments, including the implementation of the ENB's Framework for Continuing Professional Education and the Higher Award (ENB 1991a) and the development of modules of continuing professional and academic education for practitioners, had the same effect (Jowett et al 1994). HE was also undergoing change, with polytechnics achieving university status and student numbers rising rapidly. According to Jowett et al (1994, p 3), it has been difficult to single out effects 'directly attributable to Project 2000 implementation', because of such large-scale contextual change. The effects of the anticipated demographic time-bomb did not seem to materialize due to improved recruitment and retention, the results of clinical grading and the deepening economic recession (Jowett et al 1994).

Implementational guidelines and implementation As stated in Part 1 (Le Vat 1997), a Project 2000 Action Group had been established at the UKCC. Following receipt of the government's conditional acceptance of the UKCC's proposals in May 1988, the ENB set up a number of working groups, which commenced their work in the autumn of 1988 to prepare guidance for the institutions regarding the preparation of Project 2000 courses. The working groups included representatives of institutions to avoid a situation where 'policy then "gets done" to people' (Bowe et al 1992, p7). Four months later, in January 1989, the guidelines and criteria for course development and the formation of collaborative links between approved training institutions within the NHS and centres of HE (ENB 1989a), were issued. An analysis of the guidelines and criteria against the requirements in SI 1989 no. 1456 reveals that they meet all the requirements. This compatibility, the result of close communication between the U K C C and the ENB officers working on draft documents and anticipating certain outcomes, is considered important by Bowe et al (1992). Jenkins (1978) regards

understanding the chain of complex interactions in the policy process as vital to the study of policy. The ENB's guidelines stated that the academic level of the pre-registration course should be no less than an HE certificate level. The ENB established a committee to consider Project 2000 submissions. The first Project 2000 course was conjointly validated by the HE institution and the ENB in September 1989. The academic level was HE diploma, in anticipation of the UKCC's forthcoming circular on the academic level of the course (UKCC 1989@ The ENB issued further guidance on practical experience in non-institutional settings (ENB 1989b), shortened and degree courses (ENB 1990a), external examiners (ENB 1991b), the diploma level of the course (ENB 1992a), modified Project 2000 courses (ENB 1992b), nursing and midwifery honours degree courses (ENB 1992c) and the number of BPs in Project 2000 courses (ENB 1993a). Continuing dialogue between the institutions and the ENB influenced the content of the policy statements. This is in keeping with the view of Bowe et al (1992, p 13) who state that policies are 'contested in and between the arenas of formation and "implementation"'. As to midwifery education, the ENB had been leading the work in relation to direct entry preparation for midwifery practice. In 1986 it had commissioned a project in this area. As a result of the findings and recommendations in the final report (Radford & Thompson 1988), the ENB (1987) developed guidelines for the preparation of these courses. The first courses were implemented in 1989. Separate guidance was provided on the 18-month course. The guidelines encouraged institutions to provide shared learning opportunities with other relevant student groups. The 18-month courses are funded by employers. Rationalization of schools of nursing was required in order for an institution to be able to provide a CFP and at least two and normally three BPs (NHS Management Board 1988). Formal links with HE or advanced further education were necessary (NHS Management Board 1988, ENB 198%). During the implementation period, these links changed to integration with HE (EN13 1993b, 1994a). The ENB began the rationalization of continuing professional education for nurses, midwives and health visitors in England in 1989 by establishing a 3-year project. This led to the development of the ENB's Framework for Continuing Professional Education and the Higher Award (ENB 1991a). U K C C representation on the steering group ensured compatibility with the U K C C post-registration standards development. Implementation of the Framework and of the Higher Award followed

Project2000 267 guidance issued in 1992 (ENB 1992d). The guidelines for the Higher Award contain the requirement for a system of credit accumulation and transfer. In July 1994, the ENB acknowledged that the Framework provides an important mechanism for meeting the UKCC's standards for education and practice following registration (UKCC 1994a, Le Var, 1995). The ENB's guidelines for the specialist practitioner programmes (ENB 1995a) enabled the first such programmes to commence at the beginning of the academic year 1995/96. The guidelines include a requirement for shared learning with other disciplines and professions. The ENB has issued its guidefines for the preparation of Return to Practice Programmes (ENB 1996a) and guidance on specialist practice transitional arrangements (ENB 1996b). As to teachers with degrees, the ENB had agreed some years earlier that from 1995, all newly appointed nurse, midwife and health visitor teachers must be graduates (ENB 1996c). Preparation on Project 2000 implementation was provided for teachers and practitioners locally. The maximum ratio acceptable to the ENB of nurse/health visitor teachers to students is 1:15 excluding principals. Each full-time teacher is counted as 0.8 whole time equivalent to facilitate teachers' involvement in teaching in practice settings. The ratio of midwife teachers to student midwives is 1:10 (ENB 1996c). Based on research findings (Murray et al 1994), the ENB is preparing standards associated with the provision of resources for educational programmes to facilitate greater flexibility in the provision of programmes and more sensitive measures of quality. Educational institutions ceased to provide EN training as they began to offer conversion opportunities. All EN training came to an end in 1995. The ENB estabfished a Working Group on Opportunities for Enrolled Nurses in 1987. It prepared a wide range of opportunities for ENs to convert to first level, and included the three additional examination attempts provided by SI 1989 no. 1456. These are contained in a 1991 circular which replaced earlier circulars (ENB 1991@ The Nursing Times Open Learning Programmes (ENB 1990b) created additional opportunities. McDonnell & Elmore (1991) state that policymakers prefer policy instruments which are consistent with their values. The ENB provides for local flexibility through the guidance in its policy outputs comprising circulars and publications.

Project 2000 Implementation Group was set up at the Doll in 1989 and continued to meet until 1993. It included representatives from the Doll, the UKCC, the ENB, the Department for Education and the regions. It issued guidance on the implementation of Project 2000, including guidance on calculations regarding levels of replacement and/or skill-mix, based on assumptions about the 20% service contribution of the Project 2000 students (Project 2000 Implementation Group 1989). The Project 2000 Implementation Group invited regions to submit bids from colleges for funds to support the introduction of Project 2000. It examined the submissions and recommended proposals to ministers for approval (National Association of Health Authorities and Trusts 1993). The NHS Management Executive (1991a) allocated an additional sum of £ 5 million to regions to help cover the costs of inflation, bursary increases and other local needs. It also issued guidance on the secondment o f N H S staffwishing to undertake Project 2000 courses (NHS Management Executive 1991b). Further advice was provided during the implementation period (NHS Management Executive 1993). The Project 2000 Implementation Group also provided further guidelines and formulae regarding the replacement for student service contribution, based on the experience of Demonstration Districts (Jowett et al 1994). The contribution of civil servants, to whose professionalism Jones (1991) attests, assisted the process of implementation. According to Jowett et al (1994), the whole picture relating to the funding and provision of staff replacement for student servicegiving seemed to become blurred by the enormous changes simultaneously taking place within the NHS, The regions had a major involvement in identifying colleges for Project 2000 proposals and implementing strategies for amalgamations of schools/colleges. Service managers' commitment and involvement were vital to the success of implementation. Besides managers, personnel and finance officers were closely involved at district level (Jowett et al 1994). According to the National Audit Office (1992), the implementation of Project 2000 was a complex exercise which required good communication between college staff and the service sector, in addition to firm direction and dearly defined responsibilities.

Involvement of the Doll, regions and districts

In nearly all of the six first-round demonstration sites studied by Jowett et al (1994), the initial impetus for districts' bids to become demonstration sites had come from the educational institutions. The National Audit

The Doll, regions and districts had a major role in the implementation of Project 2000. A

Implementation in institutions

268 Nurse Education Today Office (1992) was impressed with the level of commitment to Project 2000 and the hard work of staff in ensuring that submissions were delivered to the D o l l in a short time, despite planning being hindered by lack of knowledge about likely commencement. Policy texts rely on the 'commitment, understanding, capability, resources' and 'cooperation' of the implementers (Ball 1994, p. 19). Jowett et al (1994) describe the tremendous commitment and efforts of teachers in preparing the course submissions to the ENB, liaising with the service staff, developing links with HE, teaching the new currScuhim at diploma level and continuing to develop the course, together with HE representatives. This commitment may be partly explained by the fact that the teachers supported the changes. Their hearts and minds had been won (Bowe et al 1992). Also, there was opportunity for creative interpretation, involving productive thought, invention and adaptation (Ball 1994). Motivation is likely to have been a major factor in implementation. It is considered important by Jenkins (1978). Although at times the teachers were stretched to their limits, the success of implementation does point to the existence of an implementation capacity. Despite difficulties, the determined contributions of staff in colleges and health authorities ensured that, overall, implementation went relatively smoothly (National Audit Office 1992, Jowett et al 1994).

Time-scale for implementation The implementation of Project 2000 was carried out in 'waves', with the first wave being implemented in 1989/90. The fifth wave of implementation was in 1993/94. Project 2000 was thus implemented over a 5-year period, as opposed to 10years, as originally anticipated (jowett et al 1994). The government allocated a total o f £ 3 2 1 million for the five waves. The funding acted as inducement (McDonnell & Elmore 1991), as it set time-scales for action. It was a power (Jenkins 1978) behind the implementation drive. Due to the system of funding and validation, the early courses suffered from short planning time-scales (Jowett et al 1994). The speed of implementation prevented colleges from preparing thoroughly for the introduction of Project 2000 (Elkan & Robinson 1991) and left inadequate time for joint planning between nurse education and HE (Jowett et al 1994). This had an adverse effect on the quality of the courses and the working environment and relationships. Teachers were overwhelmed by the competing demands made on their time (Elkan & Robinson 1991).

POLICY OUTCOMES The components of the Combined Policy Model relevant to this section include: financial resources; political support; competence of key personnel; time; timing and coordination as constraints upon policymakers; and the environment. By the end of March 1996, 21 194 students had qualified from the pre-registration nursing education programmes leading to entry to parts I2-15 of the Professional Register. They have been prepared to provide care in institutional and non-institutional settings. There are 38 pre-registration (3-year) and 58 pre-registration (shortened 18-month) midwifery programmes of education being conducted. Between 1992/93 (when the first pre-registration midwifery students became eligible for registration) and 1995/96, 654 midwifery students from the 3-year programmes and 6050 midwifery students from the 18-month programmes became eligible for registration. In July 1996, 48 institutions were approved to provide the Higher Award. The first nurses and midwives received the ENB's Higher Award, at Honours degree level, in 1994 (ENB 1994b). A total of 117 practitioners have received the Higher Award to date. In all, 559 practitioners gained their specialist practitioner qualifications following successful completion of the programme in 1995/96. All the teachers are now in the HE setting. In all, 76% have a degree (first degree/Master's degree/doctorate). In addition, 17% are reading for a first or Master's degree, leaving only 7% without a degree and not reading for one (ENB 1995b). Practitioner preparation for teaching continues with ENB programme 997/998 'Teaching and Assessing in Clinical Practice' (ENB 1986, 1988) and the community practice teacher course (ENB 1991d, 1992e), pending the U K C C standards for teaching. By March 1996, there had been a total of 199 952 registrations for NVQs in health and social care and in all, 49349 certificates had been distributed (City and Guilds of London Institute 1996). Ball (1990) refers to professional status as one area of conflict and struggle within education. In this context, it must be remembered that the professions had supported the need for health care assistants (aides) properly prepared for their roles. However, questions remain regarding the eventual size of this workforce and the extent of N V Q provision. From this perspective, the increasing numbers of health care assistants and NVQs could be viewed as indirect consequences, outcomes

Project2000 269 which only emerge over time, and which may be of greater significance than the original outcomes (Dale 1986). They may even be regarded as unintended consequences (Wise

19831. All nursing and midwifery education was integrated into HE by August 1996 (ENB 1996d). Between 1986 and 1995, 32938 ENs have converted to first level, whilst 59 institutions are s611 approved to provide 301 second to first level programmes, including the Nursing Times Open Learning Programmes. Wastage from pre-registration nursing education (traditional and Project 2000 programmes) has ranged from 8% to 17% between 1989/90 and 1995/96, averaging at 13%. Wastage from midwifery education programmes has ranged from 7% to 15% in the same period, averaging at 10% (ENB Annual Reports). The figures are lower than the U K target of 19%. The goal had been to increase the number of mature students by 1000 per annum to 4000, i.e. by 25%. The numbers of Project 2000 students who were aged 27 or over at the commencement of their programmes and who successfully completed them in 1992/93, 1993/ 94, 1994/95 and 1995/96 were 203,996, 1932 and 2300 or 24%, 26%, 28% and 26% of all age categories, respectively. The percentage increase is encouraging, in the absence of figures on the total student population (ENB's figures). The target for male recruits was an increase of 500 to 2500. The numbers of male students (first level traditional and Project 2000 and second level nursing) becoming eligible for registration between 1992/93 and 1995/96 averaged at 3117 over the period. This figure surpasses the target. The professional outcomes, or effects (Bowe et al 1992), can be seen to be the products of the motivation and professional values of the staff of the ENB and the institutions. According to Jenkins (1978), some conceptual grasp of these aspects is central to an understanding of policy outcomes and impact. Ball (1994) emphasizes the importance of noting the general effects of different policies. Applied to Project 2000, the outcomes identified demonstrate that, to a large extent, the whole education system has already been changed. Support at political level has been crucial to these achievements (Jones 1991). However, some professionals have questioned whether the government's intended outcome is a smaller, albeit better qualified, professional workforce, an 'army' of health care assistants with NVQs, alluded to in the project report (UKCC 1986b), and gradual deprofessionalization of the professions.

CONCLUSION Answers to the central question When comparing the UKCC's original policy proposals, the changed proposals submitted to ministers and the additional proposals submitted at ministers' request, with the policy outcomes, it can be seen that all but four proposals have been realized in their original format as stated in the project report (UKCC 1986b). The proposal regarding the length of the CFP was modified to 18 months. A BP in midwifery preparation was not supported by the midwifery profession. Instead, direct entry midwifery preparation has been extended and developed. The supernumerary status of students was limited by the acceptance of a service contribution of 20% of the length of the programme. The proposal to set a teacher:student ratio of 1:12 has not been pursued. In addition, no new developments have taken place in relation to practitioners' formal preparation for teaching roles in practice settings, pending the UKCC's standards for teaching. A number of policy changes/additions in relation to the various stages in the policy process have been identified in this article. These changes/additions support the argument made by Bowe et al (1992) that policy changes are reinterpreted during the different stages of the policymaking process.

Substantive issues emerging The midwifery profession saw itself increasingly as a separate profession with few or no shared roots with nursing. As a group, it was an important variable in the Combined Pohcy Model. The U K C C had to accept the students' 20% service contribution. As a policymaker, it was constrained by the need to obtain government approval for the proposals. The government, on the other hand, viewed all the proposals together in the context of the need to ensure adequate health care provision within affordable financial limits. James & Jones (1992) refer to compromises between political expediency, social conscience and professional interests. With the passage of time, the term 'Project 2000' has become synonymous with the preregistration nursing education reforms. It is usefill to be reminded of the fact that the reforms addressed the whole educational system. To what extent the policies have been the right ones for the health service and society and how well they have been implemented, is for evaluation to answer. This is being done through a number of research and evaluation studies. The wisdom of introducing the pre-registration innovations first has been questioned

270

NurseEducationToday (Jowett et al 1994, Leonard & Jowett 1990, R y a n 1989). However, to have commenced the reforms with post-registration education, innovations w o u l d have presupposed that the pre-registration changes had been agreed in some detail. T h e tight timetable for implementation left little time for attention to be focused on the preparation o f practitioners. It is suggested that, when the U K C C ' s standards for teaching are available, there is an urgent need to enhance the preparation o f practitioners for their teaching roles in practice settings. The policy outputs relating to pre-registration nursing and midwifery education were produced within 6 years from the commencement o f the project in 1984. In comparison, the policy outputs related to the U K C C ' s standards for teaching and the advanced practitioner ( U K C C 1994a) are still awaited, 8years after the c o m mencement o f the P R E P project in 1989. Employing external assistance, as in the case o f Project 2000, could have helped the progress o f the P R E P project. Project 2000 has been a major exercise in policy formation and has determined action for the reform o f the education system (Lathlean 1989). Baroness Cumberlege, Parliamentary Secretary at the D o l l , acknowledged that it 'has revolutionalised the training o f the nursing profession and ensured that the education o f nurses has developed in line with the changes taking place in health care' ( D o l l 1993). 'That the reforms have been implemented at all in such turbulent circumstances is in itself no mean achievement' (Jowett et al 1994, p. 3). This policy review demonstrates what can be achieved when there is vision, strategy, political will, coordination, persistence and drive. This article tends to give a feeling o f neatness and orderliness in the policy process. As Ball (1990) has identified, it is difficult to retain messiness and complexity. In reality, as Dale (1986) has discovered before, the process was complex and at times had elements o f lack o f clarity, cmffusion and uncertainty.

Reflections on t h e literature B o w e et al (1992) point out that there is frequently a separation between investigations o f policy initiation and its implementation. Jenkins (1978) says the same about policy content and policy process. Undertaking a macro-review o f the whole o f the Project 2000 policy process has avoided these c o m m o n faults. T h e definitions o f policy by Jenkins (1978), Jones (1991) and Ball (1994), selected for this review, have been found to be relevant. The C o m b i n e d Policy M o d e l has proved useful as a guide for thought and analysis, confirming the views o f Jenkins (1978)

regarding the A m e n d e d Systems M o d e l o f the Policy Process. Project 2000 has generated an enormous change in the education system for nurses, midwives and health visitors. But are the outcomes what are needed n o w or in the 21st century? There is evidence already that others are taking a great interest in the whole o f the health care education and training structure, including that for nurses, midwives and health visitors, and putting forward radical proposals (Health Services Management U n i t 1996). The U K C C as the statutory standard-setting body must keep the fitness for purpose o f the education structure created b y Project 2000 under critical review to ensure that it remains relevant for the needs o f the 21st century. This action is anticipated in the C o m b i n e d Policy Model, where policy outcomes lead back to policy initiation. REFERENCES

Ball SJ 1990 Pohtics and policy making in education: explorationsin pohcy sociology.1Koutledge,London Ball SJ 1994 Educationreform:a criticaland post-structural approach. Open UniversityPress,Buckingham Bowe 1K,Ball SJ, Gold A 1992 Reforming education and changing schools:casestudiesin policy sociology. Rontledge, London Care Sector Consortium 1996 Letter from the Director to the Author, 2 August City and Guilds of London Institute 1996 Personal communication,July. London Dale R 1986 Perspectiveson policy-making.In: Pohcymaking in education course E333 module 1, part 2. Open University,Milton Keynes Department of Health 1989a Letter to the UKCC from Kenneth Clarke Secretaryof State for Health, 20 November Department of Health 1989b Project 2000 - checklistof issuesto be consideredin drawing up implementation plans. Doll, London Department of Health 1989c Personnd, Project 2000, student bursaries(a) Arrangementfor administration and calculation(b) Rates of student bursaries.Health notice HN(89)11 June. Doll, London Department of Health 1989d Project 2000, student bursaries.Letter to generalmanagersEL(89)P/165, 5 October. Doll, London Department of Health 1989e Working for patients. HMSO, London Department of Health 1990 National Health Serviceand Community Care Act. HMSO, London Department of Health 1993 Pressrelease:Government announces completion of Project 2000: Baroness Cumberlege hails 'revolution in nurse education', 12 February.Doll, London Department of Health and SocialSecurity 1988 Levcerto the UKCC fromJohn Moore Secretaryof State for Health and SocialSecurity, 20 May Department of Health and SocialSecurity 1989 Letter to the UKCC from Kenneth Clarke Secretaryof State for Health, 18 May Elkan R, RobinsonJ 1991 The implementation of Project 2000 in a district health authority: the effect on nursing service.A first interim report NPS 7. Department of Nursing Studies,University of Nottingham, Nottingham

Project 2000 English National Board for Nursing, Midwifery & Health Visiting 1986 Teaching and assessing in clinical practice (998). ENB, London English National Board for Nursing, Midwifery & Health Visiting 1987 Course leading to admission to part 10 of the professional register - registered midwife: three years. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1988 Teaching and assessing in clinical practice course for midwives (997), 2nd edn. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1989a Project 2000 - A new preparation for practice: guidelines and criteria for course development and the formation of collaborative links between approved training institutions within the National Health Service and centres of higher education, January. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1989b Circular 1989/28/RMHLV. Guidelines on practical experience in noninstitutional settings, November. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1990a Circular 1990/ll/RMHLV. Regulations and guidelines for shortened and degree courses of preparation leading to parts 12, 13, 14 and 15 of the professional register, April. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1990b Circular 1990/28/RLV. Nursing Times open learning programme for second to first level courses, November. ENB, London English National Board for Nursing, Midwifery & Health Visiting 199 la Framework for continuing professional education for nurses, midwives and health visitors: guide to implementation. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1991b Circular 1991/27/RLV. Guidelines on dae role, responsibilities and appointment of external examiners for diploma/degree courses leading to entry to parts 1, 3, 5, 8, 10, 12, 13, 14 and 15 of the professional register, November. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1991c Circular 1991/02/RLV. Spectrum of opportunities for enrolled nurses: guidelines for courses, February, ENB, London English National Board for Nursing, Midwifery & Health Visiting 1991d Circular 1991/21/MB. Guidelines for the community practice teacher course, September. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1992a Circular 1992/09/RLV. Council for National Academic Awards and English National Board for Nursing, Midwifery & Health Visiting: additional guidelines for the development ofpreregistration nursing courses leading to parts 12-15 of the professional register and the DipHE, March. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1992b Circular 1992/16/TS. Regulations and guidelines for the modification of existing Project 2000 courses to enable first and second level nurses, midwives and graduate entrants to undertake courses leading to parts 12, 13, 14 or 15 of the professional register, June, ENB, London English National Board for Nursing, Midwifery & Health Visiting 1992c Circular 1992/17/TS. Regulations and guidelines for full length preregistration courses leading to an award of an honours degree in nursing and admission to parts 12, 13, 14 or 15 of the professional register and full length pre-registration courses leading to an award

271

of an honours degree in midwifery and admission to part 10 of the professional register, June. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1992d Circular 1992/05/APS. Guidelines on the regulations for approval of institutions to offer the ENB Higher Award, February. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1992e Joint practice teaching initiative. Letter from Marion Balcombe, Director - primary health care education, 15 May. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1993a Circular 1993/01/APS. Number of branch programmes in Proj ect 2000 courses, January. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1993b A survey of the move of Board approved institutions towards higher education, December. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1994a Report of a national survey on the integration of Board approved institutions with higher education, December. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1994b Congratulations! First practitioners achieve the Higher Award. ENB News 14:1 English National Board for Nursing, Midwifery & Health Visiting 1995a Creating lifelong learners: partnerships for care - guidelines for the implementation of the UKCC's standards for education and practice following registration, June. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1995b Teacher establishment data synopsis, 31 March 1995. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1996a Return to practice: guidelines for programmes leading to the renewal of registration and re-entry to registered practice. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1996b UKCC standards for education and practice following registration: specialist practice transitional arrangements. Letter from Tom Langlands, Director - primary health care nursing, 5 August. ENB, Chester English National Board for Nursing, Midwifery & Health Visiting 1996c Regulations and guidelines for the approval of institutions and programmes. ENB, London English National Board for Nursing, Midwifery & Health Visiting 1996d Report of a national survey on the integration of Board approved institutions with higher education, May. EN]3, London Health Services Management Unit 1996 The future healthcare workforce: the steering group report. HSMU, University of Manchester, Manchester James J, Jones D 1992 Education for the future: meeting changing needs. In: Slevin O, Buckenham M (eds) Project 2000: the teachers speak. Campion Press, Edinburgh Jenkins W I 1978 Policy analysis: a political and orgaulsational perspective. Martin Robertson, London Jones B 1991 The policy making process. In: Jones B, Gray A, Kavanagh D, Moran M, Norton P, Seldon A (eds). Politics UK. Philip Allan, Hertfordshire Jowett S, Walton I, Payne S 1994 Challenges and change in nurse education - a study of the implementation of Project 2000. National Foundation for Educational Research in England and Wales, Slough LathleanJ 1989 Policy making in nurse education. Ashdale Press, Oxford

272

NurseEducationToday

Lawton D 1986 The Department of Education and Science: policy making at the centre. In: Hartnett A, Naish M (eds) Education and society today. Falmer Press, London Leonard A, Jowett S 1990 Project 2000:1 Charting the course - a study of the 6 ENB pilot schemes in preregistration nurse education. National Foundation for Educational Research, Slough Le GrandJ 1996 Knights, knaves or pawns? Human behaviour and social policy. Department of Social Policy and Administration, London School of Economics, London Le Var t~ M H 1997 Project 2000: a new preparation for practice - has policy been realized? Part 1. Nurse Education Today 17 (3): 171-177 Le Var R_ 1995 Evaluating research and development at the ENB. Nursing Standard 9 (47): 29-32 Macleod Clark J, MakenJ, Jones K 1995 Project 2000: perceptions of the philosophy and practice of nursing. ENB, London McDonnell L M, Elmore R F 1991 Getting the job done: alternative policy instruments. In: Odden A l:((ed) Education policy implementation. State University of New York Press, Albany Murray S, Procter S, P,.eed J, Sedgwick H 1994 An investigation into staff:student ratios in nursing and midwifery education. ENB, London National Association of Health Authorities and Trusts 1993 N A H A T briefing - National Audit Office report on nursing education: implementation of Project 2000 in England, no. 40, February. NAHAT, Birmingham National Audit Office 1992 Nursing education: implementation of Project 2000 in England. HMSO, London National Health Service Executive 1995 EL(95)36. Nurses, midwives and health visitors - standards for education and practice following registration, March. NHS Executive, Leeds National Health Service Management Board 1988 EL(88)MB/166. Project 2000 implementation. Chief Executive letter to general managers, 6 October. Department of Health and Social Security, London National Health Service Management Executive 1989 Education and training. Working paper 10. Doll, London National Health Service Management Executive 1991a Project 2000 implementation 1991/92. Letter, 3 September. Doll, London National Health Service Management Executive 1991b Project 2000. Letter to general managers EL(91)83, June. DoH, London National Health Service Management Executive 1992 Future management of colleges of health. Letter to regional general managers EL(92)70, October. Doll, London National Health Service Management Executive 1993 Letter to regional general managers EL(93)9, 26 January. Doll, London Project 2000 Implementation Group 1989 Project 2000 a guide to implementation. Doll, London Radford N, Thompson A 1988 Direct entry - a preparation for midwifery programmes. University of Surrey, Guild.ford Ryan D 1989 Project 1999 - The support hierarchy as the management contribution to Project 2000. Evaluation project discussion paper no. 4. Department of Nursing Studies, University of Edinburgh, Edinburgh Statutory Instrument 1989 no. 1455. The nurses midwives and health visitors (parts of the register) amendment (no. 2) order 1989, August 1989. HMSO, London

Statutory Instrument 1989 no. 1456. The nurses midwives and health visitors (registered fever nurses amendment rules and training amendment rules) approval order 1989. HMSO, London Statutory Instrument •990 no. 1624. The nurses midwives and health visitors (midwives training) amendment rules approval order •990. HMSO, London Statutory Instrument 1993 no. 1901. The nurses midwives and health visitors (entry to examinations and training requirements) amendment rules approval order 1993. HMSO, London Statutory Instrument 1995 no. 967. The nurses midwives and health visitors (periodic registration) amendment rules approval order 1995. HMSO, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1986a Project 2000 - the project and the professions: results of the U K C C consultation on Project 2000. Project paper 7, November. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1986b Project 2000: a new preparation for practice. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1987a Project 2000 - counting the cost: is Project 2000 a practical proposition? Project paper 8, February. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1987b Project 2000 the final proposals. Project paper 9, February. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1988a PS&D/88/05. The enrolled nurse and preparation for entry to a first level part of the U K C C ' s register, September. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1988b PS&D/88/06. Widening the entry gate into nursing preparation, September. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 198% PS&D/89/04(A). New parts of the UKCC's single professional register, November. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1989b PS&D/89/04(C). Project 2000 rules, November. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1989c PS&D/89/04(B). U K C C requirements for the content of Project 2000 prograIrmles, November. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1989d PS&D/89/04(E). Additional examination attempts for enrolled nurses, November. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1990a Registrar's Ietter 6/1990. Midwifery education - amendments to statutory n.ties and the Council's requirements for the content of pre- and post-registration midwifery programmes of education, August. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1990b The report of the postregistration education and practice project. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1991 P,_egistrar's letter 12/1991.1 Midwives rules, 2 Council's requirements for the content ofpre- and post-registration midwifery programmes of education, 3 A midwife's code of practice, June. U K C C , London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1992a P,.egistrar's letter 6/1992. The Courlcil's requirements for the use of Scottish Vocational Education Council (SCOTVEC) modules

Project 2000

for entry to pre-registration nursing and midwifery programmes - Council approved specific SCOTVEC national certificate module awards, April. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1992b IKegistrar's letter 7/1992. The Council's requirements for entry to nursing and midwifery pre-registration programmes using access to higher education courses, April. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1992c 1Kegistrar's letter 31/1992. The Council's requirements for entry to preregistration nursing and midwifery programmes using vocational qualifications, December. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1993a 1Kegistrar's letter 11/1993 The Council's requirements for the use of Scottish Vocational Education Council (SCOTVEC) modules for entry to pre-registration nursing and midwifery programmes, April. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1993b Registrar's letter 23/1993:1 Entry to examinations - programmes leading to registration as a nurse or midwife, 2 Vocational qualifications for entry into programmes of midwifery education, December. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1994a The furore of professional practice - the Council's standards for education and practice following registration, March. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1994b Registrar's letter 20/1994. The Council's standards for education and practice following registration: programmes of education leading to the qualification of specialist practitioner, December. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995a 1kegistrar's letter 19/1995. tKeturn to practice programmes, June. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995b 1Kegistrar's letter 9/1995.

273

The Council's standards for education and practice following registration: academic level ofprogrammes of education leading to the qualification of specialist practitioner in the transitional period, February. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995c Registrar's letter 11/1995 The Council's requirements for entry to preregistration nursing and midwifery programmes using vocational qualifications, March. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995d 1Kegistrar's letter 14/1995 The Council's requirements for the use of Scottish Vocational Education Council (SCOTVEC) modules for entry to pre-registration nursing and midwifery programmes, April. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1996a Registrar's letter 7/1996. The Council's standards for education and practice following registration - return to practice programmes, March. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1996b Registrar's letter 17/1996. The future of professional practice - the Council's standards for education and practice following registration (PtCEP): recognition ofunwaged experience, June. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1996c Registrar's letter 14/1996. The Council's standards for education and practice following registration (PREP): transitional arrangements - specialist practitioner title/specialist qualification, June. UKCC, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1996d 1Kegistrar's letter 15/1996. The Council's standards for education and practice following registration (PREP): transitional arrangements - specialist practitioner title/specialist qualification, June. UKCC, London Wise A 1983 Why educational policies often fail: the hyperrationalization hypothesis. In: Baldridge V, Deal T (eds) The dynamics of organisational change in education. McCutchan, Berkeley CA