Demand on district nursing services leaving staff ‘on their knees,’ says King’s Fund

Adobe Spark (4)A growing gap between capacity and demand in district nursing services has led to staff feeling ‘broken’, ‘exhausted’ and ‘on their knees’, the King’s Fund has said.

A new report (Maybin et al, 2016) published by the think tank has examined the care for older people who receive district nursing services in their own homes. It considered what good-quality care looks like from the perspective of people receiving care, their carers and district nursing staff. This was done by conducting a review of existing policy and research literature, having scoping conversations with national stakeholders, conducting focus groups with senior district nursing staff, and carrying out interviews with patients, carers and staff in three case study sites.

By seeing how patients’ preconceptions of good-quality compared with their actual experiences, the think tank sought to establish what factors support ‘good care’, and figure out what is getting in the way.

Their research indicated that activity has increased significantly over recent years. This applies both to the number of patients seen and the complexity of care provided. From 2005–2014 the number of people living in England has increased by almost 20%, with the most substantial growth seen in the oldest age groups. Additionally, the population aged 85 years and above has increased by just under a third.

It is anticipated that that is set to increase, with the number of people aged 65 years and over expected to rise by almost a half and those aged 85 years and over set to almost double (Mortimer and Green, 2015; Office for National Statistics, 2015). With this increase in age, the likelihood this population will live with chronic disease, multiple health conditions, disability and frailty also rises (Health and Social Care Information Centre, 2014; Oliver et al, 2014).

While demand for services has been increasing, available data on the healthcare workforce suggests a decline in the number of nurses working in community health services over recent years. Additionally, the number working in senior ‘district nurse’ posts has fallen dramatically over a sustained period.

Compromise in quality of care

The result of these pressures is that quality of care is being compromised. Examples highlighted in the report indicate an increasingly task-focused approach to care, staff being rushed and abrupt with patients, reductions in preventive care, visits being postponed and lack of continuity of care. This in turn has caused a deeply negative impact on staff wellbeing, with unmanageable caseloads being increasingly reported. In many cases, staff are leaving the service as a result. Additionally, the King’s Fund has argued that if the ability of district nursing services to deliver appropriate care continues to be undermined, there will be consequences in terms of additional hospital admissions, delayed discharges and dependence on social care.

The King’s Fund have warned that those most likely to be affected by the pressure faced by district nursing staff are often the most vulnerable members of society, who will therefore most likely be affected by cuts in social care and voluntary sectors. They warn that what is more concerning is that this is happening ‘behind closed doors in people’s homes, creating a real danger that serious failures in care could go undetected because they are invisible’ (Maybin et al, 2016).

Recommendations outlined in report

As a result of the issues identified in the report, the King’s Fund have issued the following recommendations as immediate priorities:

Match the stated intention to move care into community settings with greater attention to this service area. Despite intentions by policy makers and regulators to deliver ‘care closer to home’, the direction of resources, monitoring and oversight remains distinctly focused on the hospital sector. The report therefore recommends that community services must be involved in, and central to, the development of new care models and Sustainability and Transformation Plans.

Involve district nursing service leaders in local plans for service redesign. Too often the voice of district nursing service leaders is absent at the system level. The report highlights the valuable role of district nursing and how it is of central importance to the wider health system. The service enhances the health and wellbeing of people living in their own homes, often caring for people with complex and multiple health needs, and helps prevent deteriorations in health and the need for additional services. Therefore now, more than ever, this important but pressured service needs to be part of discussions about future service redesign.

Respond to the issues facing community health and care services, and the needs of people who depend on these, in the round. To address the wide-reaching problems faced by all services, not just district nursing, the report recommends NHS England and Health Education England, together with local commissioners and providers, look in the round at the staffing and resourcing of community health and care services for the older population, taking into account the capacity of people receiving care, their unpaid carers and local communities.

Renew efforts to establish robust national data on capacity and demand in district nursing services. This would include establishing a standard for demand–capacity and workload planning tools in this area, as is currently being undertaken by The Queen’s Nursing Institute and NHS Improvement. The report highlights that the absence of robust national data on activity levels in district nursing services and of a clear dataset on trends in staffing numbers, makes it very difficult to demonstrate, understand and monitor the demand–capacity gap within this service area.

Accelerate the uptake of digital technologies and support implementation. The report argues that adopting new technologies should remain high on the agenda of providers and local service leaders as a strategic area for development, as district nursing stands to benefit significantly from enhanced digital support, if it is designed and works well. Technologies that enable remote working, such as iPads and other tablets, have the potential to improve efficiency and productivity, as well as enhancing quality and safety through timely access to notes at the point of care and supporting communication between professionals.

Develop a meaningful form of oversight for care delivered in people’s own homes, which is sensitive to the unique characteristics of this care. The report stresses the need for national oversight systems to be developed in order for their frameworks to meaningfully capture and reflect care quality. Current national mechanisms of quality assurance and accountability, which are largely designed to assess hospital care, are poorly suited to measuring quality in the community.

Develop a sustainable district nursing workforce. Undoubtedly the most important recommendation, the King’s Fund warns the shortage of suitably trained staff to fill roles in district nursing services is a major cause for concern. Services are increasingly unable to recruit and retain staff. With many of the current district nursing workforce approach retirement age, and others choose to leave due to service pressures, it is understood that this situation will likely worsen.

Conclusions

District nursing services have a key role to play in the national health system, allowing patients to be treated in their own homes and avoid unnecessary hospital admissions. They allow patients to maintain their independence, maintain long-term conditions and manage acute conditions. However, this is only possible through a sustainable workforce. Insufficient staff numbers place unmanageable pressures on the existing workforce as well as other areas of the health service. This report highlights a dissonance between the policy drive to move more care out of hospitals into community settings, and the capacity problems being experienced in district nursing services. It presents a number of recommendations for addressing these issues and calls for the need to develop a robust framework for assessing and assuring the quality of care in the community.

References:

Health and Social Care Information Centre (2014) Focus on the health and care of older people. NHS Digital, Leeds. http://digital.nhs.uk/catalogue/PUB14369 (accessed 23 September 2016)

Maybin J, Charles A, Honeyman M (2016) Understanding Quality in District Nursing Services. The King’s Fund, London. http://www.kingsfund.org.uk/publications/quality-district-nursing (accessed 22 September 2016)

Mortimer J, Green M (2015) Briefing: The Health and Care of Older People in England 2015. Age UK, London. http://www.ageuk.org.uk/professional-resources-home/research/reports/care-and-support/the-health-and-care-of-older-people-in-england-2015/ (accessed 22 September 2016)

Office for National Statistics (2015) Population estimates for UK, England and Wales, Northern Ireland: Mid-2014. Office for National Statistics, Newport. http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/2015-06-25 (accessed 22 September 2016)

Oliver D, Foot C, Humphries R (2014) Making our health and care systems fit for an ageing population. The King’s Fund, London. http://www.kingsfund.org.uk/publications/making-ourhealth-and-care-systems-fit-ageing-population (accessed 23 September 2016)

Taken from British Journal of Community Nursing, published 3 October 2016.

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Ensuring the district nursing role does not die out

Adobe Spark (2)Recent figures published by the Welsh Government have revealed a 42% reduction in the number of district nurses in Wales between 2009 and 2015 (BBC News, 2016). The number of district nurses has fallen from 712 in 2009 to 412 in 2015, with six of the seven health boards in Wales reporting a reduction.

This follows trends seen in England in recent years, which has reported a 47% reduction in the number of qualified district nursing staff in the past decade (Royal College of Nursing (RCN), 2014). Frequent figures such as these have resulted in a warning from the RCN that district nurses are ‘critically endangered’ and face possible extinction by the end of 2025 (RCN, 2014). Consequently, it has called on the Government to fulfil its commitment to increase the number of community staff to 10000 by 2020.

Origins of district nursing

The district nursing role originated in 1859, when a wealthy Liverpool merchant, William Rathbone, employed a private hospital-trained nurse to care for his dying wife. He was struck by ‘the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided.’ Following the death of his wife, Rathbone set up a training home in Liverpool to give nurses the skills necessary to treat patients in the home.

The title came from the fact that Liverpool was split into 18 districts based on the parish system, so the nurses became known as ‘district nurses’.

There is little research, but a publication from the Department of Health revealed that more than 2.6 million people receive care from district nurses each year, in England and Wales alone, according to statistics gathered nationally (Department of Health, 2004). It is anticipated that this number will only increase.

Due to the increasing elderly population and number of people with long-term conditions, district nurses make a notable contribution to the NHS. Having specially qualified staff who are trained to deliver care to patients in their own homes, should reduce pressures on GP surgeries and emergency departments. However, the shortage of district nurses means many feel they are being pushed to breaking point. Reports of regular additional hours, activities left undone due to lack of time and a desire to leave the job are not uncommon.

The RCN have said the reduced numbers of district nurses has placed extra pressure on GP surgeries and emergency departments. Increases in caseloads from 30 patients to up to 150 means contact time is kept to an absolute minimum. This results in patients not receiving the appropriate care they need and therefore feeling they require further consultation by their GP or at the emergency department.

The future vision of district nurses

In 2009, The Queen’s Nursing Institute (QNI) published its 2020 Vision of the future of district nursing (QNI, 2009). It marked the 150 year anniversary of district nurses and highlighted their role in health care. Fundamentally, the principles of district nursing have changed little in 150 years and consist of ‘better care, closer to home’, ‘patient choice’, ‘integrated care’, and ‘co-production’ (QNI, 2009). As a specialism, district nurses are ‘practitioners, partners and leaders’ of care in the home (QNI, 2009).

Some of the issues identified in the QNI report surrounding district nurses included: ‘loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education’ (QNI, 2009).

It is important to highlight that there is a notable difference between nursing found in clinics, surgeries and other areas of primary care; and that found in patients’ homes. It is for this reason that the district nursing role remains an important part of the NHS.

The British Journal of Community Nursing and the QNI carried out a survey in 2008, gathering information and views from district nurses in England, Wales and Northern Ireland about the state of their specialism. The survey found that 13% of respondents’ employing organisations no longer use the title ‘district nurse’ at all. It also revealed that in those organisations that still use the title, more than 30% do not limit its use to those with a district nurse qualification (QNI, 2009). In some cases, the title was given to team leaders or case managers, with or without the qualification. Additionally, the survey revealed that only 48% of employing organisations continue to require district nursing team leaders to have the district nursing specialist practitioner qualification. Another 19%, who did at the time the report was published, plan to discontinue this requirement.

A follow-up report from the QNI published 5 years after the 2020 Vision, revealed an increase in the level of confusion about job titles, qualifications and roles concerning district nurses (QNI, 2014). As a result, one of the key recommendations of the the report was for a renewed investment in the district nursing specialist practitioner qualification.

Focus surrounding qualifications for district nurses was raised at the most recent RCN Congress, which passed a resolution calling on RCN council to lobby for all district nurse caseload holders to have the relevant specialist practitioner qualification (Ford, 2016). This arose amid concerns over the future of the district nursing role and its protected title. The Forum called for a practitioner who is ‘equipped with skills to manage a role that is highly complex and requires skills in negotiating, coaching, teaching and effective team management’ (Ford, 2016).

The current climate

The situation surrounding the place and role of district nurses within the NHS has gradually changed over the years. For example, it is no longer the sole role to be found delivering nursing care in the home as there are now a multitude of community roles working at different levels. The issue with this is that the meaning attributed to the district nurses’ unique title has eroded somewhat. As mentioned, some employers are using the title without the accompanying specialist qualification, further muddying the waters. District nurses are excellently placed to offer leadership over other health professionals in the home. However, if they have not received adequate training they will struggle to have the strong leadership skills required.

Within Simon Stevens’ Five Year Forward View he called for the introduction of a new care model known as Multispecialty Community Providers. One of the benefits of this model is to allow for the expansion of primary care leadership to include nurses and other community-based professionals. This new way of delivering care and ability to offer a wider scope of services is made possible by allowing the formation of extended group practices as federations, networks or single organisations.

Conclusions

District nurses offer a much-valued service to the NHS through their ability to treat large numbers of people at home, allowing patients to avoid having to go to hospital if they receive the appropriate level of care first-time around. However, this is only possible if the number of district nurses does not continue to fall. The reality is that those still in the role are under increasing pressure, as they find their workloads ever-increasing. The Government must fulfil its commitment to increase the number of community staff, and in particular, the number of district nurses.

Now, more than ever, is the time to reinstate the district nurse.

References

BBC News (2016) Royal College of Nursing concern over fall in district nurses in Wales. BBC News. http://www.bbc.co.uk/news/uk-wales-36828072 (accessed 17 August 2016)

Department of Health (2004) Patient Care in the Community: NHS District Nursing Summary Information for 2003–04, England. The Stationery Office, London. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4092113.pdf (accessed 17 August 2016)

Ford S (2016) All district nurses ‘should have specialist qualification’. Nursing Times. http://www.nursingtimes.net/news/community/all-district-nurses-should-have-specialist-qualification/7005789.fullarticle (accessed 18 August2016)

Health Education England (2015) District Nursing and General Practice Nursing Service Education and Career Framework. HEE, London. https://hee.nhs.uk/sites/default/files/documents/District%20nursing%20and%20GP%20practice%20nursing%20framework_0.pdf (accessed 17 August 2016)

Royal College of Nursing (2014) District nurses face ‘extinction’ in 2025. RCN, London. https://www2.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025 (accessed 17 August 2016)

The Queen’s Nursing Institute (2009) 2020 Vision: Focusing on the Future of District Nursing. QNI, London. http://www.qni.org.uk/docs/2020_Vision.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute (2014) 2020 Vision Five Years On: Reassessing the Future of District Nursing. http://www.qni.org.uk/docs/2020_Vision_Five_Years_On_Web1.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute, NHS England (2014) Developing a National District Nursing Workforce Planning Framework: A Report Commissioned by NHS England. https://www.england.nhs.uk/wp-content/uploads/2014/05/dn-wfp-report-0414.pdf (accessed 15 August 2016)

Taken from British Journal of Community Nursing, published 2 September 2016.