Community providers face new staffing requirements

NHS Improvement has published a draft report for district nursing services focusing on how to ensure “safe caseloads” for teams working in the community.

The document said providers of district nursing services should review staffing annually and use specially designed tools to plan staffing levels.

But while the guidance said there were several commercial caseload management tools available it added: “There is little published evidence of their reliability and validity.”

Crystal Oldman, chief executive of the Queen’s Nursing Institute, and chair of the committee that developed the guidance, said: “We were not made aware of any tool which met all the requirements.”

The guidance, which sets out what a tool should include as part of its analysis, said staffing decisions should also be “triangulated with professional judgement and comparison with relevant peers”.

Last year, a report by the King’s Funds described pressure on district nursing services as leaving staff “broken”, “exhausted” and “on their knees”.

The new safe staffing report did not recommend ratios of district nurses to patients and included healthcare assistants in its description of “nursing establishment”.

It said ratios were not the correct measure: “This is because many elements, which are not fixed, need to be considered to meet the needs of all patients within the caseload.

“Determining what the safe caseload is at strategic level requires assessment of the current and projected population needs, the skills within the team and across local organisations required to meet those needs, and how the identified skill shortfall will be addressed. New and sustainable ways of working, such as technology to support remote monitoring and a more agile workforce, need to be considered.”

It said boards should review staffing annually in line with existing guidance from the National Quality Board. These reviews should be “a systematic, evidence based approach to determine the required number and skill mix of staff”. This should then be benchmarked with other providers and take account of national guidelines, with professional judgement to take account of local needs.

Ian Upton, a patient who helped develop the guidance, said: “The most significant piece of evidence to emerge from this work stream, particularly the evidence review, is that there is a distinct lack of evidence.

“The design of the tools and processes for safe caseload staffing in the community is an intensely complex issue and has thus far defied attempts to generate adequate information for evidence based decisions.”

He added: “In an evidence-based culture, this raises a tough question: do we do nothing until evidence is gathered or do we take some action to tackle the known district nurse staffing problems? From a patient perspective, the ‘do nothing’ option does not sit comfortably – I do not believe we can wait for years searching for definitive evidence.”

Ms Oldman added that she believed the guidance would help providers “establish a robust and consistent way of understanding and documenting the demand for the district nursing service”.

She added: “During the development of the resource, many provider organisations shared the tools which they had developed. These included caseload management tools developed at a local level by the providers themselves – and others where the tools had been developed by suppliers of bespoke software. We were not made aware of any tool which met all the requirements.”

In relation to the involvement of other staff, including the nursing associates, in caring for patients, she said: “We must not underestimate the complexity of the service. Nursing associates are untested in this environment of care.

“We need to start with patient, family and carer needs and ensure that the right nurse with the right skills are able to meet the needs by delivering holistic, person centred care – not a task or a list of tasks delivered in a person’s home.”

A consultation on the guidance is open until 28 April