Community nursing – the invisible service?

Published 29/11/2019   |   Last Updated 27/05/2021   |   Reading Time minutes

The Welsh Government’s vision for health and care describes a significant shift of services from hospitals to community settings over the next decade. Community nursing services play a key role in the delivery of care in, or close to, people’s homes. They are likely to become an increasingly important part of the NHS workforce. Despite this, the Assembly’s Health, Social Care and Sport Committee reports that we don’t have a clear overall picture of the community nursing workforce, or the patients they are looking after.

What is community nursing?

According to the Royal College of Nursing (RCN) in Wales, around two thirds of its members work outside of hospitals. This community nursing workforce includes a range of roles, for example health visitors, school nurses, GP practice nurses, specialist nurses, and community psychiatric nurses, as well as district nurses. Half of the nurses working in the community work in the independent sector in care homes and hospices.

District nurse-led community nursing services deliver care in patients’ homes. This can support individuals and their families to manage their health and maintain independence, avoid unnecessary hospital admissions and enable early discharge. The community nursing landscape has changed significantly in recent years, with new teams and services being introduced alongside the traditional district nursing service. This may have happened in a piecemeal way, rather than under an overall strategy.

Data to inform workforce planning

The Health, Social Care and Sport Committee’s inquiry into community and district nursing services heard concerns about a lack of national data on community nursing services across Wales. This includes information on the number and skill mix of nursing teams, as well as the patients receiving care in their own homes and their levels of need.

The RCN pointed out the disparity between the data available for the acute (hospital) sector, and for community services:

A classic comparison would be waiting times. We can look at waiting times and, yes, we can perhaps have discussions about whether they're the right measures or not, but they certainly give you a picture of what's happening in the acute service. We don't have a similar picture of what's happening [in community settings], and that concerns us because, first of all, it's a very vulnerable population that's being cared for at home, and, secondly, it concerns us because it's increasingly a large area of public spend.

The Committee called on the Welsh Government to improve data collection, and to ensure that the crucial role of community nursing in the future delivery of healthcare is recognised in workforce planning, recruitment and training.

On 7 November 2019, the Health Social Care and Sport Committee discussed Health Education and Improvement Wales and Social Care Wales progress in developing a health and social care workforce strategy for the next ten years. The strategy is expected to be formally launched in 2020.

Nurse Staffing Levels (Wales) Act

Wales was the first country in Europe to legislate on nurse staffing levels. The Nurse Staffing Levels (Wales) Act 2016 requires health boards in Wales to calculate and maintain nurse staffing levels in adult acute medical and surgical hospital wards.

There were concerns during scrutiny of the legislation that this may lead to nurses being ‘pulled’ from other areas to meet the requirements in acute wards. The Act therefore includes a broader duty for health boards/trusts to ‘have regard to the importance’ of providing sufficient nurses in all settings. It also includes provision to extend the duty to calculate and maintain nurse staffing levels to other settings in the future. Five areas are currently being explored, including adult mental health inpatient wards, paediatric inpatient wards, health visiting, care homes, and district nursing.

For district nursing, an appropriate workforce planning tool (required by the Act to calculate the nurse staffing level needed) is not likely to be ready for some years. As an interim measure, the Welsh Government agreed a set of district nursing staffing principles (September 2017).

The Committee recommended that the Welsh Government produce a strategy for extending the Act to all settings, including community and district nursing services. The Welsh Government rejected this, saying:

There are significant and numerous fundamental differences to the various settings in which nurses provide care in Wales. (…). It is far too early to begin to understand the level of complexity around that variability across all settings, a substantial piece of mapping work will need to be undertaken by the All Wales Nurse Staffing Programme before a national strategy could be contemplated. The Programme Manager has begun the early stages of that work.

In November 2019, RCN Wales published a progress report on health boards’ implementation of the Act. The report emphasises that safe nurse staffing levels are needed across all health settings, and reiterates calls to extend the legislation to mental health wards, children’s wards, community nursing and care homes.

Buurtzorg pilot

Alternative approaches to community nursing are currently being trialled in Wales.

Buurtzorg is a Dutch, nurse-led model of community care. Its successes include higher patient satisfaction, and significant reductions in the cost of providing care. A Buurtzorg-style model of neighbourhood nursing care is currently being piloted in Aneurin Bevan, Cwm Taf and Powys Health Boards. The Welsh Government accepted the Committee's recommendation that, subject to a successful evaluation, the pilot is rolled out to all community nursing teams in Wales.

In September 2019, the King’s Fund published a review of a Buurtzorg-inspired model tested in West Suffolk in 2017–18. The report describes the test as a ‘highly ambitious transformation project’. It highlights two specific barriers - beyond the project’s control – which significantly hindered the test’s progress. These were the recruitment crisis in nursing, and the lack of adaptive ICT infrastructure in health and social care.

These issues are not specific to England. One of the most common concerns raised by community nurses during the Committee’s inquiry was their inability to access the most appropriate technology to enable them to do their job effectively. The Committee made two recommendations aimed at improving the technology available to community nurses.

If the Buurtzorg pilot in Aneurin Bevan, Cwm Taf and Powys is found to be successful, we could start to see this being rolled out across Wales from 2020-21.

The Assembly will debate the Health, Social Care and Sport Committee’s report on Wednesday 4 December 2019, you can watch it on SeneddTV.

Article by Philippa Watkins, Senedd Research, National Assembly for Wales