As we enter another New Year, what a start we have encountered. A&E departments and hospitals overwhelmed with ambulances still queuing outside, unprecedented strike action, COVID-19 still hanging around (although we seem to go through the same crisis in A&E every winter despite and before COVID-19) and crisis management in community services.
Bleak, very bleak.
Have you ever sat with your mug of coffee, watching all of the above on the breakfast news and felt sad, angry, frustrated, disappointed or helpless? I was having another one of those (seemingly now, daily) moments this week prior to meeting up with two very good nursing friends of mine for our New Year get-together. I primed them in advance that I wanted to get their take on the current state of play in community healthcare services in preparation for my writing this editorial piece. As you may imagine, once we started talking we carried on for a few hours; there is so much to discuss at the moment and far too much to write about here. I need to tell you that my colleagues are both ‘long in the tooth’ district nurses — one an educationalist and the other, a senior operations manager—and both are currently in the thick of it, just like many of you reading this.
So, what did we talk about?
We talked about how the NHS appears to leap from crisis to crisis, poor staffing, the impact of the cost-of-living issues on healthcare staff, fuel prices, constant costly local transformation and cost improvement measures, with neither appearing to have a notable impact on care improvement. We expressed amazement about a new emerging pressure, whereby acute sector senior managers are requesting support from community service managers for human resource to work in A&E departments. The irony being that the acute pressure is impacted on by lack of availability of community nursing and social care human resource.
We discussed our love of the TV series ‘Call the Midwife’ and how it demonstrated the historical implementation of the NHS week by week. We spoke about how much change there had been in healthcare, most significantly since the implementation of the Community Care Act 2014—an Act that has a statute in English law, the principles of which, with the current erosion of community services, appear now to be very much in danger of being forgotten. For example, can we be sure that we are making adequate provision for safeguarding adults when we know that workloads are far exceeding the capacity of the community nursing services? When we know that community nursing services are being asked to act as a failsafe service for acute hospitals and social care because they are overwhelmed, do we call this integration of services? Is this how it was set out in the Act? We did not think so. Yet, everyone in healthcare is surely aware of Sir Robert Francis’ Mid Staffordshire enquiry and again, changes made in law, which introduced standards in 2015 applicable to healthcare recruitment, learning and development. These standards ensured that ‘key aspects of services are safe and effective, caring, responsive and well-led to meet patient care needs successfully.’
We expressed concern that elements of local transformation over the last 10 years have not reaped the benefits promised but had, at times, added more pressure, particularly from constant requests for information and cost improvement demands. We talked about an example of how developments in training for Specialist Practice Qualifications (SPQs), which were meant to improve district nursing development and patient care through the implementation of new prescribing programmes and training, had seen, in some cases, a migration of said qualified nurses. These nurses had moved over to general practitioner (GP) practices to work as advanced nurse practitioners because Band 7 grades were being offered alongside mentorship from GPs. Great for general practice and probably much needed at the moment, but a disaster for district nursing services. Alternatively, those that choose to stay in district nursing are often forced to take lower grades because that is all that is available (cost improvement measures) and find it a struggle to secure mentorship, much needed for them to practice safely. The time required for a specialist practitioner to utilise new assessment and prescribing skills to do justice to patient care is impacted upon by the shortage of staff. Was this change to training and development well thought through from a strategic and transformational perspective and is it what Sir Francis recommended to ensure that services are safe and effective? The Queen’s Nursing Institute (QNI) has been very clear in its recent New Workforce Standards for District Nursing (QNI, 2022), stating that timed task approaches to patient care is unsafe and yet, digital scheduling has been brought into play (transformational change) in order to plan workload. This change, in some areas, has put increasing pressure on community nurses to ‘rush’ around in order to cover the workload (staffing deficit pressures).
There was much more we talked about and I am sure you are busy adding to my list as you read this.
We concluded that one of the most devastating blows to community nursing services has been the cost improvement programmes, which resulted in downgrading of roles, including the loss of team leader grades in many areas. Now, as a consequence in the current staffing crisis, it has become extremely difficult to recruit qualified nurses into community nursing positions because the grades and pay are considered to be too low. This leaves the community nursing services running at constant staffing deficits of over 10% in some areas.
It left us worried that community nursing services were in danger of being set back by decades. But what are the solutions? Well number one, of course, is that we need more resources and that requires investment, which offers attractive and appropriate pay and grades. There needs to be a radical rethink about how acute and community services can work together, how nurses are employed and deployed. With a diminishing human resource, it needs to be managed and allocated carefully. You do not see staff in supermarkets only doing one job, they are allocated to work where they are needed most; is this a strategy to consider? Stop with the local transformation programmes and concentrate on national transformation. Surely, there really cannot be very much more waste to remove from the system in cost improvement?
Finally, should we fear conversations that allure to privatisation of healthcare services? Can anyone explain how much money has been wasted so far on community healthcare contracts with private organisations looking for and not finding a profit margin at the cost, again, to recruitment and patient care? Who is responsible for the implementation of these contracts in the last decade, should they be held to account, in part for the decimation of community services in certain areas of the country? Surely, there should never be a search for profit in healthcare while investment is needed for improvements, including recruitment and retention.
But we stopped at the politics and ordered a takeaway and raised a glass to all nurses in the UK who continue to do a brilliant job on the ground (despite the politics).