Integrated care: pride of the community

• District nursing is changing to reflect a modern service.
• The workforce is ageing and training has been slashed.
• Renewed commitment to the sector is necessary to deliver the vision laid out in the next stage review.

When Anna Gibbins started as a district enrolled nurse in the early 1980s in Cheltenham, Gloucestershire, she never took her hat off while on duty.

“I was issued with five dresses for summer, five for winter, a cardigan, a blazer, a wool coat and a pillbox hat that I wore at all times,” she recalls. “The Queen’s Nurse in charge told me ‘a district nurse never takes her hat off’, so I didn’t.”

This was just 25 years ago, in the days before the central sterile supply department took away soiled dressings - so they went into the grate. “Every house had an open fire,” says Ms Gibbins.

And district nurses were thrifty, re-using everything and fashioning items from what was to hand - turning eiderdowns into pressure relieving cushions, for example.

That world is hardly recognisable now and seems to have more in common with 150 years ago, when district nursing was founded (see box), than with 2009. In their anniversary year, district nurses are reminded of their past, but also looking to the future to find their place in the post-Darzi health policy landscape.

The home front

District nurses are defined by their place of work: people’s homes. With health policy aiming to provide care closer to home - whether managing long term conditions, preventing unnecessary emergency admissions or delivering end of life care - who better to help develop such services than a corps of district nurses?

That, at least, is the argument put forward by the Royal College of Nursing and Queen’s Nursing Institute, the charity that supports community, or district, nurses. The institute’s report 2020 Vision: focusing on the future of district nursing, published in January, stated: “The principles… that have lasted 150 years still fit the bill today. In today’s terminology, they are known as ‘better care, closer to home’, ‘patient choice’, ‘integrated care’ and ‘co-production’.”

“We know there are a number of people in hospital who do not wish to be there, in addition to the people who are admitted but did not need to be,” says RCN primary healthcare adviser Lynn Young. “The public say they want to die at home and that is pure district nursing. We can provide such care to fabulously high standards.”

Institute director Rosemary Cook says district nurses have the skills to deliver on the new agenda.

“There is a bigger difference between nursing in the home and in clinical settings than between primary and secondary care nursing. Nurses are unsupervised, which has implications for quality of care and their own safety. They have learnt to apply principles such as asepsis [techniques to reduce infection] in an environment where every single case is different,” she says.

Clinically, they have come a long way too.

“District nurses’ work has changed significantly because of the push to discharge patients earlier,” says Sally Bonynge, executive director for long term conditions at Central Surrey Health, a social enterprise led by nurses and associated health professionals.

“We are now taking some complex cases that would historically never have been able to come out of hospital,” says Ms Bonynge. “Yet with different ways of working, partnerships and extended roles there is always a way to do it.”

But do commissioners recognise this?

“It is somewhat taken for granted,” says Ms Cook. “[Primary care organisations] have had district nursing services for a long time and let them get on with it. They know what they do in the home is different but there has been no real scrutiny of the different elements that make up the kind of care they deliver.”

However, there are examples of organisations that have used district nurses’ skills to their full. Examples are in telehealth or in virtual wards, both of which are initiatives designed to help people stay at home and prevent emergency admissions.

Central Surrey Health is a learning centre for the NHS Institute’s productive community initiative.

“We are focusing on the district nursing team and changing current working practices,” says Ms Bonynge. “This could be even more exciting than the productive ward [the model on which the initiative is based], as it is so complex. There is only so much you can do to control the patient’s home environment.”

But all is not well in the sector. Both the QNI and RCN have charted rising case loads and falling numbers of qualified district nurses over recent years.

“There is a whole range of issues facing our members. The national trend has been to employ more healthcare assistants to do the work of district nurses. We are not against healthcare assistants, but you have to get the balance right and we are concerned that there has been a dilution of workforce that will get worse as the elderly population grows and more people need these services,” says RCN director Peter Carter.

The RCN says bald workforce figures showing a rise in the number of community nurses from 50,481 in 2000 to almost 62,000 in 2007 disguise a drop in district nurses, whose roles have been replaced with staff nurses and healthcare assistants. There are now around 10,800 district nurses employed in the NHS.

“If you align the workforce with the government’s push towards care closer to home we estimate that we have actually got about half the number of district nurses needed to do it properly,” says Mr Carter.

The workforce is ageing too. In 2007, 58 per cent of district nurses were over the age of 45 and 17 per cent over 55. Training has also been slashed, says Ms Young, so closing this gap will require long term commitment and investment in creating new training opportunities and attracting young nurses to them.

The QNI is also concerned. The 2020 report says: “District nursing services are currently being diluted by 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.”

Friends in high places

The role has some friends in high places, however. Health minister Anne Keen is a former district nurse and general secretary of the Community and District Nursing Association. Like any district nurse she is ready to regale you with tales of her time in the community.

“There was the time I got bitten on the leg by a goose,” she recalls with evident glee. “I was nursing a pig farmer but he refused to come out of the pig pen so I had to go to him, get him to drop his trousers, give an injection and then run across the fields chased by geese. I don’t think there are many health ministers who could say they have had that kind of experience.”

In 25 years of nursing, her time as a district nursing sister was her favourite, says Ms Keen.

“Your community is proud of you. You go through the front door and you are in a patient’s home. You have to be a confident practitioner and very knowledgeable.”

She is well aware of concerns about the role’s erosion - and of the potential for the role to develop in the near future.

“The high quality workforce of Lord Darzi’s next stage review is made for the role. We cannot afford to lose district nurses and we need to look after them.”

But skill mix will have to change, with district nurses delegating their skills and knowledge to others, she adds.

Ms Keen also agrees with Ms Cook about commissioners’ views of district nursing.

“We must spell out the value of district nursing to them more clearly. Nurses have not been very good at that in the past and it has been easy for people to dismiss them.”

Welsh chief nursing officer Rosemary Kennedy started as a district nurse in rural North Wales in 1973, caring for a village community and outlying farmsteads.

“We were very much part of the community, seen as ‘theirs’ and almost on a level with the school master or minister. It was a really wonderful feeling of belonging and knowing the people you cared for.”

The NHS in Wales also wants to move care closer to home and Ms Kennedy says she has brought a “huge amount” from her days in the district to her current role. She knows from experience the intensity of nursing that is possible at home, having cared for patients with acute coronary conditions.

“It was a question then of the balance between moving them 52 miles or caring for them at home.”

Ms Kennedy identifies capacity as the main challenge. Some of this will be addressed through skill mix changes, but getting the right levels of specialists will take time. A consultation on the future of community nursing in Wales is due to close in May. It will also consult on a new career ladder that would offer modular education, allowing nurses who want to test out the specialism the chance to do it step by step without having to make the jump in to a full time role or education.

“The crucial thing is that one size does not fit all,” says Ms Kennedy. “Our starting point is this: what is the community? What are their needs and how do we

meet them? In some cases they will be heavily weighted towards specialist nurses delivering intensive and holistic care. In others it will be different.”

Overall, there is a good deal of optimism about the future of district nursing. There are some dinosaurs around but there are many more innovators, says Ms Cook. There are areas where district nursing skills are being diluted and lost but some primary care trusts are investing in them, adds Mr Carter.

In England, there is the prime minister’s commission on the future of nursing and midwifery to look forward to, as well as the primary and community care strategy now being developed, which is chaired by Department of Health director general for commissioning and system management Mark Britnell.

“It is a time for optimism,” says Mr Carter. “We have a great deal of faith in Mark Britnell. If his ideas are properly supported it could transform community services.”