District nursing services
Over the past year we have been looking in depth at district nursing services. Part of this work involved us exploring what is already known about these services. How many people receive district nursing care? How many patient contacts are taking place? What happens during those contacts? Has activity changed over time? Has the work become more complex?
We discovered there is a remarkable dearth of national information, meaning the answer to many of these questions was ‘We don’t know’. In hospital care, since the development of ‘hospital episode statistics’ in the late 1980s, every patient episode has been recorded, but there is no equivalent national data on community health services. A community information dataset is under development, but this is currently only available for local data collection and extraction. It remains unclear when national collection will be realised. The HSJ recently reported that this dataset is unlikely to be available until 2018–19; however, NHS Digital, (formerly the Health and Social Care Information Centre) and responsible for overseeing the data collection, maintains that national collection will be under way from next year.
And what about the workforce? How many people work in district nursing services? How much has this changed over time? Has the skill-mix changed? Analysis of workforce statistics for community nursing is also fraught with difficulty because of a lack of data from independent providers, transfers of staff from NHS to independent providers over time, and a lack of detail in the way the data is presented, meaning it is not always possible to separate out staff working in different types of community services.
And what do we know about patient experience? Are people happy with the district nursing care they have received? Is this improving or getting worse? Currently, very little information is collected about people’s experience of using community health services; the only source of national data is Friends and Family Test scores. The national patient experience survey programme covers community mental health but does not extend to other community health services – although the Care Quality Commission has recently consulted on extending the programme.
In 2014, Catherine Foot and colleagues explored how community health service providers measure and manage care quality. They observed that quality and outcomes ‘remain to a large extent unknown at the national level’, and warned of the ‘serious risk that poor or declining quality will not be identified promptly’. Nearly two years on, this risk seems greater than ever.
The NHS is under intense financial pressure, and performance against key targets such as A&E waits and referral-to-treatment waiting times is deteriorating. These targets are highly visible, and grab headlines and political attention when they are missed. But declining performance in community-based services is largely invisible, and nowhere is this more evident than in district nursing care, which is delivered behind closed doors in people’s homes. This is particularly worrying as the people affected are often very vulnerable and are among those most likely to be affected by cuts in social care and voluntary sector services.
To build a picture of activity in district nursing services, we spent several months travelling around the country, interviewing people receiving care and their carers at home. As a result, we are well aware of the practical challenges of collecting patient experience data for care delivered in people’s homes, but are convinced of the need to do so. We found evidence of district nursing services under enormous strain, with increased demand in terms of both the number of people receiving care and the complexity of care provided. Meanwhile, available data on the workforce indicates that the number of nurses working in community health services has declined, and the number working in senior ‘district nurse’ posts has fallen dramatically.
Our report outlines a framework for understanding quality in district nursing services; during our research we heard many examples of excellent care and the hugely positive impact this can have for the health and wellbeing both of people receiving care and their carers. But we also heard evidence that the demand–capacity gap means that care may deviate from this model of good practice: we found examples of 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.
National bodies are making promising efforts to improve data on workforce, activity, quality and patient experience. These efforts must be realised if we are to shine a light on care delivered in community settings, and to understand the support community health services require to enable them to deliver the vision of ‘care closer to home’. This is also essential for the patients who rely on these services – they are literally a lifeline for many of them.
