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.

Ministerial approval for commencement of work on paramedic prescribing

Ministerial approval has been received for the commencement of preparatory work to take paramedic independent prescribing proposals forward to public consultation.

The College of Paramedics have been campaigning for a number of years to review the current legislation around non-medical independent prescribing and the case for paramedic independent prescribers.

The Allied Health Professions (AHP) Medicines Project was set up as a joint initiative by NHS England and the Department of Health to extend prescribing, supply and administration of medicines to allied health professions.

The aim of the initiative is to facilitate service redesign; increase patient choice; improve access to medicines; and make best use of allied health professionals’ skills, while maintaining patient safety.

Independent prescribing for paramedics is among the key proposals that the NHS England AHP Medicines team are focusing on.

A case of need has been developed for this proposal based on improving quality of care for patients in relation to safety, clinical outcomes and experience, while also improving efficiency of service delivery and value for money.

The consultations and supporting documents will be developed over summer, with the aim of seeking ministerial approval to publish the consultations later in the year.

Following public consultation, there will be significant further work to be undertaken, including submission of consultation findings for consideration by the Commission on Human Medicines, who will make recommendations to ministers regarding any potential changes to medicines legislation.

Taken from Journal of Paramedic Practice, published 10 September 2014.

Prescribing for paramedics?

This month, the Journal of Paramedic Practice contains an article from the College of Paramedics on the recent ministerial approval for the commencement of preparatory work to take paramedic independent prescribing proposals forward to public consultation.

In it, it outlines the work of the Allied Health Professions (AHP) Medicines Project, a joint initiative by NHS England and the Department of Health, which aims to extend prescribing, supply and administration of medicines to allied health professions.

The concept of independent prescribing for paramedics is not a new one—the Department of Health’s (DH) ambulance review Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DH, 2005) recommended that prescribing for paramedics should be actively explored. Since then, the College of Paramedics have been actively campaigning to review the current legislation around non-medical independent prescribing and the case for paramedic independent prescribers.

Under current medicines legislation, paramedics are able to supply and administer a range of medicines, on their own initiative, as part of their normal professional practice for the immediate and necessary treatment of sick or injured persons (DH, 2010). However, it is not currently possible for paramedics to write a prescription for a patient. This is largely because in an emergency situation, it would be unlikely that paramedics would need to write a prescription. Instead, their priority would be to stabilise, treat and transport the patient as necessary. However, the need for paramedics to provide a broader range of treatment in both emergency and urgent (non-emergency) settings has become increasingly apparent.

Paramedics are treating more patients at their homes, thus avoiding the need for many patients to visit A&E. Additionally, paramedics who have undertaken further training, such as emergency care practitioners (ECPs), often work independently in these two types of settings.

The Department of Health’s vision for urgent and emergency care is that ‘patients are provided with 24/7 services which are integrated together, so that patients get the right care wherever they access the health system’ (DH, 2010). The ambulance service plays a key role in allowing for this integration due to the flexibility of the roles that are undertaken by ECPs and other advanced practitioners in delivering care to patients at home and in the community.

The benefit of prescribing for paramedics is clear: not only would it support better integration of urgent and emergency care services, it would enable patients to avoid having to make an additional visit to another healthcare provider. The work that the College of Paramedics is undertaking with NHS England, the Association of Ambulance Chief Executives and Health Education England, therefore, is integral if this is to become a reality.

References

Department of Health (2005) Taking Healthcare to the Patient: Transforming NHS Ambulance Services. DH, London

Department of Health (2010) Proposals to introduce prescribing responsibilities for paramedics: Stakeholder engagement. DH, London

Taken from Journal of Paramedic Practice, published 5 September 2014

Street Triage Mental Health Scheme introduced to West Midlands

A pilot ‘street triage’ scheme from the Department of Health has been launched in the West Midlands to ensure people with mental health issues are kept out of custody and receive the right treatment.

The scheme will see paramedics from West Midlands Ambulance Service NHS Foundation Trust and nurses from Birmingham and Solihull Mental Health NHS Foundation Trust join forces with West Midlands Police to attend incidents involving people who require immediate mental health support.

The pilot follows similar schemes that have taken place elsewhere in the country, which have shown a reduction in the demands on police and ambulance time.

Dr Andy Carson, medical director for West Midlands Ambulance Service, said: ‘This is a fantastic and exciting opportunity for the Trust to work alongside partners to ensure the highest quality of care is delivered to some of the most vulnerable people from within our community. We welcome this opportunity and firmly believe this will ensure mental health provision will be amongst the best in the country.’

Jon Short, chief executive at Birmingham and Solihull Mental Health NHS Foundation, said: ‘There’s been a huge fuss in recent years over how much front-line police work deals with mental health issues.
‘Lots of their call-outs are to disturbances in the street or domestic issues. Police have limited powers in these issues, so the outcome is often an arrest.

‘The triage will allow trained paramedics and mental health nurses to assess people more thoroughly and to make police aware of the range of options available to them, such as if the person involved needs counselling or other care.’

Taken from Journal of Paramedic Practice, published 27 January 2014.

Antimicrobial resistance is a ‘ticking time bomb’

The Chief Medical Officer Professor Dame Sally Davies has announced that global action is needed if we are to overcome the ‘catastrophic threat’ of antimicrobial resistance.

The warning, made in her second annual report, highlighted the lack of new antibiotics discovered in the past two decades.

Despite new infectious diseases being discovered on an almost yearly basis, very few new antibiotics have been developed.

This means that we have limited resources to manage the increasing number of infectious diseases that are ever evolving to become resistant to current drugs.

‘We need to work with everyone to ensure the apocalyptic scenario of widespread antimicrobial resistance does not become a reality,’ said Professor Davies. ‘This is a threat arguably as important as climate change for the world.’

The importance of preserving current antibiotics was also emphasized. Professor Davies argued that in order to retain the effectiveness of existing antibiotics, responsible prescribing must be adhered to.

‘All physicians who prescribe antibiotics have a responsibility to their patients (and public health) to prescribe optimally,’ she said.

To help meet the challenges set out by Professor Davies, the Department of Health is planning to publish a UK Antimicrobial Resistance Strategy.

This five-year strategy will focus on championing the responsible use of antibiotics by ensuring NHS staff have the necessary knowledge, skills and training to prescribe antibiotics effectively.

Professor Davies stressed that governments and organizations across the world, including the World Health Organization and G8, need to realize the seriousness of the problem.

‘If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics.’

Taken from Practice Nursing, published 19 Mar 2013.

LAS improves out of hospital cardiac arrest survival rates

As part of a call to action from health secretary Jeremy Hunt to reduce the number of avoidable deaths in the UK, the Department of Health has published an outcomes strategy on cardiovascular disease (CVD), which will support the NHS and local authorities in delivering improved outcomes for those with or at risk of CVD.

The announcement comes following The Lancet’s recent report on the UK’s health performance, which highlighted that the UK was a long way behind many other countries.

CVD affects the lives of millions of people and is one of the largest causes of death and disability in the UK. However, fast responses to emergencies can save lives and, in some cases, reduce disability.

According to the strategy about 50 000 out of hospital cardiac arrests (OHCA) occur each year in England. Due to a variety of reasons, such as co-morbidity, resuscitation may be inappropriate, and so attempted resuscitation by ambulance services occurs in less than 50% of cases.

However, there is significant variability between ambulance services in rates of successful initial resuscitation (13-27%) and survival to hospital discharge (2-12%) following an OHCA. If survival rates were increased from the overall average (around 7%) to that of the best reported (12%), it is estimated that an additional 1 000 lives could be saved each year.

The strategy revealed that since 2004/2005 the London Ambulance Service (LAS) has improved overall OHCA survival to hospital discharge from a rate of 4% to 11% in 2011/2012. This is as a result of quicker response times; taking heart attack and cardiac arrest patients direct to heart attack centres; and improving bystander resuscitation.

Despite improvement in the LAS, variation in the quality of acute care in other parts of the country mean that much can still be done if patient mortality from CVD is to see considerable change.

The CVD outcomes strategy claims that the NHS Commissioning Board (CB) will work with the Resuscitation Council, the British Heart Foundation and others to promote automatic external defibrillator (AED) site mapping/registration and first responder programmes by ambulance services, and consider ways of increasing the numbers trained in cardiopulmonary resuscitation (CPR) and using automated AEDs.

Taken from Journal of Paramedic Practice, published 14 Mar 2013.

Australia introduces HPV vaccination for boys

Australian schoolboys have begun receiving vaccinations to protect them against cancers and disease caused by the human papillomavirus (HPV).

HPV is a common infection that is associated with cervical cancer and genital warts. It has also been linked with other cancers such as throat cancer, although not as strongly.

‘We’re confident that extending the program to males will reduce HPV-related cancers and diseases in the future,’ said Australian Health Minister Tanya Plibersek.

Following the introduction of the vaccine to girls in 2008 to help reduce the risk of cervical cancer, Australia has become the first country in the world to publicly fund HPV vaccinations in boys.

The action has resulted in organizations such as the Throat Cancer Foundation to urge the UK to follow suit. However, the Department of Health for England has held its ground, saying that due to the lack of scientific evidence, there was no plan to implement the vaccination of boys into the NHS programme.

According to the Throat Cancer Foundation, the vaccine costs as little as £45 per person, and treatment for throat cancer costs the NHS around £45,000 per patient, meaning there is considerable cause for discussion of the topic.

Taken from Practice Nursing, published 18 Feb 2013.