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

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.