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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The need for optimism at a challenging time for the NHS emerges as key theme of Ambulance Leadership Forum

The Association of Ambulance Chief Executives’ (AACE) annual Ambulance Leadership Forum (ALF) took place this year on 9–10 February at the Hinckley Island Hotel in Leicestershire. Designed to stimulate debate and ideas about the on-going development of emergency and urgent care, delegates were encouraged to share best practice and discuss issues pertinent to the sector.

The theme for this year’s event focused around the future look and feel of ambulance service provision and was largely based on AACEs document published last year, A vision for the ambulance service: 2020 and beyond. This vision presents ambulance services as mobile healthcare providers operated in an extended range of care settings, doing more diagnostic work, more treatment, more health promotion, and providing patients with more services that before.

Delegates were welcomed to the conference by AACE chair and West Midlands Ambulance Service NHS Trust CEO, Anthony Marsh, who called on attendees to embrace the new ambulance initiatives on offer and improve outcomes. He noted that ‘the challenge we are confronted with now [in the NHS] offers us a real opportunity,’ and hoped proceedings for the day would help influence national policy.

The landscape of urgent and emergency care: implementing the Five Year Forward View

The opening address was given by Chris Hopson, CEO of NHS Providers, who asked whether the provider sector had the capacity to deliver the changes outlined in NHS England’s Five Year Forward View? Hopson said that all Trusts would be under pressure to achieve their financial targets in 2016–2017 and that one of the biggest debates would be over standards and performance, especially for ambulances. He highlighted that the majority of providers have found themselves in the ‘needs improvement’ box in terms of Care Quality Commission rating, and that we cannot fix many problems found in the NHS unless we have more vertical integration of health and care and horizontal collaboration.

Prof Keith Willett, national director for acute episodes of care for NHS England, then spoke on the new landscape for urgent and emergency care. He started by mentioning he sat on a sharp fence between the clinical world of service providers and Whitehall, and noted it is a sharp fence. The current provision of urgent and emergency care services sees 24 million calls to the NHS and 7 million emergency ambulance journeys a year. Willett said for those people with urgent but non-life threatening needs we must provide ‘highly responsive, effective and personalised services outside of hospital, and deliver care in or as close to people’s homes as possible.’ For those people with more serious or life-threatening emergency needs, he said: ‘We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery.’ As we move into the final phase of the Urgent and Emergency Care Review, the focus is on implementing new models of care and ways of working. He stressed that the ambulance service needs to come to the fore and drive change, and that no paramedic should make a decision in isolation, but should have support from whole of the NHS.

Transforming health and social care: innovation and leadership

Following the first coffee break of the day, Bob Williams, CEO of North West Ambulance Service NHS Trust, spoke on devolution in Manchester. After providing a background to the health and social care system in Greater Manchester and the Greater Manchester Devolution Agreement, Williams outlined the principles around the Greater Manchester devolution plan, which include: radical upgrade in population health prevention, transforming care in localities, standardising acute hospital care, and standardising clinical support and back office services. Williams said Greater Manchester devolution offers an opportunity to transform health and social care, and that ambulance service has the tools, the players and the crucial elements to help make the healthcare system changes needed.

Prof Paresh Wankhade of Edge Hill University then spoke on leadership in the emergency services, focusing on interoperability and innovation. Wankhade first set the scene by outlining the leadership challenges faced by emergency services, before highlighting the key issues impacting workforce development, the need for suitable leadership for empowering and motivating staff, provided a critical overview of the state of interoperability, and closed by speaking about innovation in an era of uncertainty. For the ambulance service, he noted an increasing demand but lesser proportion of life-threatening calls, and that performance and quality are unsustainable with current levels of funding. He went on to say that there is very little evidence to suggest that enough is being done to support the workforce for new challenges and performance pressures, and that there is an important role for the College of Paramedics to prepare practitioners for the future.

Leading in challenging times

After lunch, delegates heard a recorded message from Lord Prior of Brampton, parliamentary under secretary of state for NHS productivity, who commended the work that is being done by ambulance services across the country, and apologised on behalf of the secretary of state for health, Jeremy Hunt, who had to pull out the conference last minute.
This was followed by Rob Webster, CEO of NHS Confederation, who gave one of the most engaging talks of the day on leading in challenging times. He began by explaining there has been a 24% increase in activity for Category A calls for ambulance services since 2011. He went on to stress the need for values-based leadership and system leadership, and that leading should come from every seat in the NHS. If senior ambulance managers do not understand the organisation’s values, then it is difficult to expect staff to understand them. He closed by noting that the NHS is made of people, and that it is the collective commitment, drive and energy that make up an organisation, and what makes a successful future.

Janette Turner, director of the medical research unit at the University of Sheffield, then spoke on managing urgent care outside hospital. Looking at data from March 2015, 27.9–57.6% of 999 calls were not conveyed to emergency departments in England. On population utilisation of emergency ambulance services the UK receives 13 calls per 100 population, compared to Belgium, which has the highest number of calls per population in Europe at 33. Turner said that outcomes of evidence on telephone-based service involved accuracy, compliance, satisfaction, costs, service impact and access. While accuracy is high for minimising risk, inaccuracy tends to come in the form of over triage. Considering the role of management by ambulance clinicians outside hospital, Turner said a small number of high-quality studies support extended paramedic roles as they offer safe decisions, reduced emergency department transports, high satisfaction and are cost effective. However, she did note that decision-making is complex and needs to be underpinned by the right education.

Introducing new delivery models

After another coffee break, Richard Murray, director of policy at the King’s Fund, spoke on new delivery models for urgent and emergency care and NHS Planning Guidance. Murray outlined the key features of NHS Planning Guidance before discussing the implications for urgent and emergency care and ambulance providers. He said it was a game of two halves: a one-year plan for 2016/17, with existing organisations as the key building block, switching to place-based plans for 2017/2018 to 2020/2021. Taken together, Murray said they offer a radical re-drawing of the boundaries in the NHS.

The final talk of the day was delivered by Dr Phil Foster, assistant medical director for Yorkshire Ambulance Service NHS Trust, who spoke on the West Yorkshire Urgent and Emergency Care Vanguard. He explained how the service’s collective local vision was for all patients with emergency and urgent care needs within West Yorkshire to get ‘the right care in the right place—first time—every time.’ The aim was to give patients access to urgent and emergency care through 999 and 111 and given an improved experience with care provided closer to home. This would be a standard service offering across West Yorkshire.

Celebrating excellence at the AACE Outstanding Service Awards

The evening saw delegates celebrate the AACE Outstanding Service Awards. Sponsored by Ferno UK Ltd in aid of the Ambulance Services Charity, ambulance service employees form across England who have gone above and beyond the call of duty were recognised and commended for their outstanding service. The Outstanding Paramedic Award went to Abigail Evans, a cycle response unit paramedic for London Ambulance Service NHS Trust. The Outstanding Mentor or Tutor Award went to Chris Mathews, a critical care paramedic with South East Coast Ambulance Service NHS Foundation Trust. Outstanding Innovation and Change Awards went to Adam Aston, a paramedic with West Midlands Ambulance Service NHS Trust and Thomas Heywood, a clinical manager for Yorkshire Ambulance Service NHS Trust. The Outstanding Non-Paramedic Clinician Award went to Steve Wainwright, and emergency care assistant for East of England Ambulance Service NHS Trust. The Outstanding Control Services Employee Award went to Craig Foster, a call operator for North East Ambulance Service NHS Foundation Trust. The Outstanding Manager Award went to Karen Gardner, operations manager for North East Ambulance Service NHS Foundation Trust. The Outstanding Support Services Award went to Tez Westwood, Hazardous Area Response Tram support technician for East Midlands Ambulance Service NHS Trust. The Outstanding Senior Management Award went to Tracy Nicholls, head of quality governance for East of England Ambulance Service NHS Trust and the Outstanding Welfare and Wellbeing Award went to Ben Lambert, a team leader for South Central Ambulance Service NHS Foundation Trust.

Workshops allow delegates to discuss emerging themes

The second day, co-hosted by NHS Confederation, featured a morning of facilitated workshops, concluding with a conference summary and forward view. Delegates were given a choice to attend workshops on the themes of ‘our workforce’, ‘technological and digital enablement’, and ‘vanguards and innovation’.

A summary of the main themes discussed in the workforce workshop include the need to engage with staff meaningfully, understanding culture but also taking change, collaboration, and a recognition of whether or not we are doing as much as we can on mental health and race equality.

The technology workshop had a key theme around innovation, and an emphasis that ambulance services are much more than a transportation service. There was a strong feeling that there needs to be better capture and use of data in technological advancements, that procurement needs to be looked at as a whole-systems approach, and that ambulance services should embrace social media.

Within the vanguard workshop there was a clear sense of the great work that is being done across the country. It was recognised that a lot of the components of a really good system are in place, but that we have to learn from each other’s organisations. There was also an emphasis on ensuring that the right culture is in place within services.

With difficulty comes opportunity

The conference came to a close with Anthony Marsh commending the optimism shared by delegates during what is a challenging time for the NHS. He quoted the BBC programme Inside Out, saying there is ‘no need to be miserable, we are winning the war.’ Martin Flaherty, managing director of AACE, then remarked on how sobering it was to hear about the challenging times ahead, particularly around finance. However, he said with difficulty comes opportunity and that as a sector we are always doing our best when in difficulty.

Delegates left with much food for thought and plenty of ideas for implementing change within their own services. Feedback has been positive, with one delegate saying: ‘Excellent conference, completely relevant to our practice in emergency medicine,’ while another remarked: ‘I think the organisation was superb and the quality of speakers and breadth of subject matter was really relevant.’ Congratulations must be extended to AACE for an engaging two days, and delegates can look forward to returning for another year.

Taken from Journal of Paramedic Practice, published 4 March 2016.

Ambulance services run up £6 million deficit for first quarter

Ambulance services in England have run up a £6 million deficit for the first 3 months of the 2015–16 financial year.

According to figures published by Monitor and the NHS Trust Development Authority, four NHS Ambulance Trusts and four NHS Ambulance Foundation Trusts are in deficit.

These figures form part of the wider combined deficit of £930 million for the 151 Foundation Trusts and 90 other NHS Trusts and in England, which is more than the entire full-year deficit for 2014–15 of £829 million.

Foundation Trusts ended the first quarter with a deficit of £445 million, which was £90 million worse than planned. NHS Trusts were revealed to be £485 million in deficit, which was £63 million worse than anticipated.

David Bennett, chief executive of Monitor, said:

‘Today figures reiterate the sector is under massive pressure and must change to counter it.’

He added: ‘The NHS simply can no longer afford operationally and financially to operate in the way it has been and must act now to deliver the substantial efficiency gains required.’

Richard Murray, Director of Policy at The King’s Fund, said:

‘These figures confirm that NHS providers are heading towards an unprecedented end of year deficit.

‘The reported overspend of £930 million at the end of the first quarter is more than the deficit for the whole of last year. This reflects a very sharp deterioration in financial performance among all types of providers, with 96% of acute trusts and more than half of mental health trusts now reporting deficits.

‘On this basis, warnings of a deficit of at least £2 billion by the end of the year are well-founded.’

He added: ‘Unless emergency funding is announced in the forthcoming Spending Review, a rapid and serious decline in patient care is inevitable.’

Taken from Journal of Paramedic Practice, published 22 October 2015.

Survey reveals women face barriers to becoming senior leaders in NHS

The results of a survey published on 18 July by the Health Service Journal (HSJ) suggests that women are still facing barriers to becoming senior leaders in the NHS.

1075 people responded to the survey that was organised by the HSJ and The King’s Fund, 90% of whom were female.

The survey revealed that 49% of the women who responded thought that having children put their career at a disadvantage, while two thirds felt a greater pressure to prove themselves than their male counterparts.

Despite women making up three quarters of the NHS workforce, just 37% of senior roles on clinical commissioning group governing bodies and NHS provider boards are held by women.

Nicola Hartley, director of leadership development at The King’s Fund, said: ‘Although women make up the large majority of the NHS workforce, they remain seriously underrepresented in leadership. These survey results, which chime with what we are told by the women we work with, show that they face serious obstacles in gaining senior roles. There some great women leaders in health care but the pace of change has been incredibly slow. These findings should act as a prompt to examine why we have too few women in the most senior roles and what we can do to change that.’

Taken from Journal of Paramedic Practice, published 23 July 2013.