"Tracey Burns, Director of Nursing at the King Edgar NHS Hospital Trust was assigned to head a project to improve the efficiency of patient flows throughout the hospital's system. The case describes how nurses are empowered to play a more proactive role in the process of discharging patients. In addition the Trust was going through a financial crisis, it had difficulties meeting government's waiting list targets and was receiving adverse media coverage. The case looks at how the nurses finally took responsibility for making the final decision to discharge individuals - traditionally the physician's job. The task was difficult as it meant the balance of power between physicians and nurses would alter, but in order for the process to change, there would have to be close cooperation between the two parties."

This case shows how Fiona Jenkins, Head of Physiotherapy for South Devon Health Services, reviewed and redesigned the stroke service care pathway. She had just four months to present a proposal and then implement it in accordance with the National Service Framework (NSF) guidelines. These guidelines specified that a stroke specialist should examine all individuals admitted with a diagnosis of stroke. Her challenge was to coordinate the different stakeholders - primary care, secondary care and social services. In addition, she had to do this without any additional funding. The case describes the different options open to her and how she decides on a plan. Some of the players are suspicious, and even threaten to resign if the plan is implemented.

This case shows how Fiona Jenkins, Head of Physiotherapy for South Devon Health Services, reviewed and redesigned the stroke service care pathway. She had just four months to present a proposal and then implement it in accordance with the National Service Framework (NSF) guidelines. These guidelines specified that a stroke specialist should examine all individuals admitted with a diagnosis of stroke. Her challenge was to coordinate the different stakeholders - primary care, secondary care and social services. In addition, she had to do this without any additional funding. The case describes the different options open to her and how she decides on a plan. Some of the players are suspicious, and even threaten to resign if the plan is implemented.

Deborah Jamieson, Advanced Practitioner at the University College London Hospital (UCLH) National Health Service (NHS) Trust, had been employed to set up nurse-led pre-admissions clinics within the Trust and to improve the existing day surgery clinics. The case describes how she manages to recruit and train nurses to run these clinics. She draws on her experience in the US to encourage the nursing staff to take on more clinical responsibilities. The case examines how nurses' roles are developing within the NHS as they take on more tasks that have traditionally been the responsibility of doctors and consultants (attending physicians). The case describes how Jamieson changes the mindset of the key players (managers, consultants and anaesthetists), and how she implements the pre-assessment clinics and improves the existing day surgery pre-admission process. Patient satisfaction is increased and fewer operations are cancelled, thus reducing costs for the Trust.

This case examines how Martin McShane, a general practitioner and physician manager at the Moss Valley Medical Centre, changes the mindset of all the key players involved in caring for the elderly and implements a proactive, prevention-oriented care model. McShane is up against all the different elements of the NHS - primary care, social services and acute care. Through skilful management of the various players, he succeeds in smoothly integrating new systems throughout the region. A nurse-led service for tracking hospital admission and discharge of elderly patients is introduced, with systems implemented to improve continuing care of patients and communication between services that ultimately reduce hospital stays and admission rates.