Debate: Community nursing

This resolution was passed

2017 saw the publication of the King’s Fund report Understanding NHS Financial Pressures. How Are They Affecting Patient Care? (Roberson and others, 2017), which reviews the impact of financial pressures on four services: genitourinary, district nursing (DN), total hip replacements and neonatal care. It concludes that financial pressures are having the greatest impact on genitourinary care and DN, resulting in increased episodic DN care and task orientation during visits, with limited opportunities to fully assess patients’ needs.

The report identifies many areas where staff are acting as ‘shock absorbers’, working longer hours and missing breaks in order to maintain a quality service, and notes that this situation is not sustainable. It discusses the cross-service impact of financial pressures between hospital and community services and provides evidence that the impact is better tolerated in hospital services. In community services, financial restraint has a greater impact on the range of service provision. Most community funding is via block contracts. These are unresponsive to growing demands on services, and this, along with the challenges to make further financial savings, is placing increasing demands on community service delivery.

The report provides further evidence of the impact of escalating financial pressures on the provision and quality of DN services. It demonstrates that the demand gap in DN services must be addressed. Risks for DN services include unmet patient needs and an impact on the quality of care provision. The report identifies that staff are ‘on their knees’ trying to maintain quality, but are straining under the pressure.

The RCN in Northern Ireland, particularly through its Community Nursing Network, has consistently highlighted the significant challenges facing community nursing. The Department of Health (DoH) has systematically cut the post-registration nurse education budget from £12.4 million in 2009-2010 to £8.3 million in 2016-2017. The RCN does not believe that current workforce projections will meet future demand for public health services or the DoH’s own strategic commitments.

In Wales, the RCN is calling for greater investment in community nursing services and in the ICT and EHealth technology needed to underpin them. Greater transparency is also needed on nursing activity and patient outcomes in this sector. Positive national developments include the creation of ‘primary care clusters’. The cluster design promotes joint working across all health and social care professionals and the integration of primary care services with key partners such as the Ambulance Trust, Local Authority and Third Sector. There is also interest in a possible extension of the safe nursing legislation to the community sector. Interim District Nurse Guiding Staffing Principles (Welsh Government, 2017) have already been produced by the Chief Nursing Officer.

In Scotland, there are numerous instances of services being planned within Integration Authorities (IAs). This requires a properly resourced community nursing workforce in order to ensure safe, effective, personcentred care. Vacancy rates are high within DN: 4.7% as of 31 December 2017 (NHS National Services Scotland – Information Services Division, 2018). Analysis undertaken by RCN Scotland in 2017 showed that many areas are struggling to recruit community nursing staff. With many community nurses coming up to retirement, the age profile of the community workforce is also a concern. The RCN is calling for the Primary Care Workforce Plan in Scotland to address this with new resources for district nurses in particular. We are also lobbying on the detail of the Scottish legislation on staffing for safe and effective care.

The RCN District Nursing Forum welcomes the recommendations of the King’s Fund report and asks that RCN Congress considers the need for funding and resources to follow the patient. This will ensure that community nursing capacity is able to meet increasing demand and provide high-quality, timely, responsive and clinically effective patient care at home. 

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