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Invest in boosting district nurse numbers, says QNI chief

The decline in the size of the district nursing workforce must be halted urgently in order for community services to develop, the head of the Queen’s Nursing Institute has warned. 

Speaking at the institute’s annual conference in London this week, QNI chief executive Crystal Oldman said: “We urgently need more district nurses.

“There are simply insufficient numbers of district nurses to provide the care needed.”

She highlighted that 90% of all clinical interactions now took place in community settings and the NHS was facing a “tsunami of long term conditions”.  

Ms Oldman cited a QNI report, published in June, that revealed “widespread and significant concerns” over the number of new district nurses being educated.

She called for a “master plan and commitment” to enable the “excellent work” already being done by community nurses to “continue to grow and develop”. “Part of that master plan includes investment into the education of our community specialist practitioners,” she told delegates.

Ms Oldman added that the QNI was “delighted” to have been involved in drawing up the Department of Health’s district nursing strategy, which was published in January. But she said the strategy – A new vision and service model for district nursing – must be backed with investment.

She said local NHS and education commissioners must work together to fund the nursing teams required to “deliver the care that patients, their families and carers want outside of hospital”.

“Let’s not forget that district nursing is a specialist area of practice…it’s not CPD that can be acquired along the way by taking a few modules and study days,” she warned.

A National Nursing Research Unit report also highlighted similar concerns this week and called for more “robust mechanisms for workforce planning”.

It questioned whether the district nurse workforce was “sufficient, in terms of overall numbers and skill mix”, highlighting the number being trained was exceeded by the number leaving and retiring.

The report cited official data showing the number of district nurses had fallen by 44% between 1999 and 2012, down from 11,500 to 6,400.

It also revealed that the balance between staff groups providing care in the community had shifted. In 2005, district nurses accounted for 20% of NHS staff recorded in the community, but this had fallen to 12% by 2012.

Ms Oldman also used her speech to call for the term “acute care” to be replaced by “hospital-based care”, in order to get away from the myth that community-based care was less complex.

“Nurses talk about working in the acute sector or the community sector,” she said. “There is something fundamentally wrong about this.”

“We’re comparing apples and oranges,” she said, noting that acute described the state of a patient’s health needs while community referred to the environment where the patient was looked after.

“We need to rethink out terminology, because it perpetuates the view that hospital-based care demands a higher level of skill and community-based care demands a lower level of nursing…which couldn’t be further from the reality,” she added.

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Readers' comments (14)

  • michael stone

    More community care - which is 'the plan' (if 'plan' can be applied to the recent NHS changes).- surely requires more DNs: this is surely obvious (and not news to everyone except the people controlling the money).

    By the way, did anyone notice that Nicholson explained in yesterday's Independent (page 2) that the NHS competition rules are getting in the way of good patient care ? I seem to remember somebody govermental - perhaps Hunt - explaining that Nicholson had a better understanding of how the NHS functions as a whole, than anybody else in the country: I suppose Hunt or whoever it was will now retract that opinion !

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  • can we also add in the Community Childrens Nursing teams in to the equation as these services suffer the same pressures with less funding/staff but have an increasing level of complexity to deal with .

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  • Part of the problem of recruiting hospital nurses into the community is that the NHS pension is not portable, and people will have to freeze it and start a new one with an alternative provider that the community care groups have chosen, which isn't as favourable, or have their own private one. Any nurse that already has a good amount of years in does not want to swap to a less favourable pension scheme. A local HR staff member has admitted to me that is part of the problem. They need to sort it out if they want experienced nurses to care for people in the community.

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  • Anonymous | 27-Sep-2013 2:33 pm

    that's ridiculous. isn't community nursing part of the NHS?

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  • Anonymous | 27-Sep-2013 2:33 pm

    "NHS pension is not portable"

    That's a new one on me and isn't true for us in the community in Scotland. I can move around the NHS and my pension moves with me. Is that a regional issue? Or are they trying to pull the wool over your eyes?

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  • I have been saying for ages that more community nurses are needed,due to the fact that more and more people are being treated at home and people who are more acutely ill. My role as a community nurse has changed considerably in the past five years. I have also worked in a/e so I know what acute nursing is. The role of the community nurse is expanding and more complex but as nurses retire or leave they are not being replaced. This needs to be addressed.

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  • tinkerbell

    I moved from ward nursing to the community last year, I sure hope my pension moved with me.

    this government is dismantling what was the nhs, they don't want public sector workers, they don' like it, and like every other public sector want it privatised, only they have taken a step too far with what was our nhs. It is now so fragmented and disorganised nobody knows what's happening in this re-disorganisation, not even nicholson it seems who along with the tories and lansley created this monstrous mess that is wasting millions if not billions of OUR money.

    They are programmed to destroy it, job nearly done!

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  • Portability of pensions all depends on whether your community provider is still part of the NHS. The govt did something called Transforming Community Services a couple of years ago, which slipped under the radar. Basically all the things like district nursing had to split from the PCT and could choose it's organisational form. Some stayed with the NHS, others formed social enterprises or got took over by Virgin or Serco, so no, NHS pensions didn't move across. Staff were shafted by stealth and lo and behold, recruitment is now a problem, because no one wants to work for reduced Ts and Cs that they've built up over years of service.

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  • michael stone

    tinkerbell | 27-Sep-2013 8:57 pm

    Tink, what the Independent told us about Sir David Nicholson (extracted) was:

    At an event hosted by the Health Service Journal, Sir David spoke candidly about the rules, which have already stood in the way of mergers and service changes that NHS managers and clinicians said were urgently needed. His comments were made under so-called Chatham House rules, which meant they could not be reported, but he later gave special permission for them to be published.

    "All of [the politicians who drew up the Health and Social Care Act] wanted competition as a tool to improve quality for patients," he said. "That's what they intended to happen, and we haven't got that...

    "I've been somewhere [where] a trust has used competition law to protect themselves from having to stop doing cancer surgery, even though they don't meet any of the guidelines [to carry such surgery out]," he continued.
    "Trusts have said to me they have organised, they have been through a consultation, they were centralising a particular service and they have been stopped by competition law. And I've heard a federated group of general practices have been stopped from coming together because of the threat of competition law. All of these [proposed changes] make perfect sense from the point of view of quality for patients, yet that is what has happened." He said that the law may have to change and that Jeremy Hunt, the Health Secretary, would have to act "quite quickly" to make possible "the big changes needed".

    The Department of Health said proposed NHS mergers had been considered by the Office of Fair Trading on only two occasions and that Mr Hunt was "absolutely clear that patient safety must always trump any competition concerns".

    I’ve a suspicion that you will suggest that at least someone in there, is speaking with forked tongue ?

    It is also nice that nobody could accuse the Daily Maul of inconsistency. There is a piece in the Review section of The Times today by Jeremy Paxman about WW1, and he tells us ‘… with Northcliffe sounding off about the country’s “two million superfluous women”. The Daily Mail proposed they be exported, rather than stay in Britain taking men’s jobs and inciting adultery and lesbianism’.

    By the way Tink, if you did tell me whether my ‘style’ was better at the link below, I didn’t catch it:

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  • tinkerbell

    michael stone | 28-Sep-2013 1:37 pm

    thanks for the nicholson explanation but quite frankly to me it all sounds like blah, blah, blah. Perhaps I am too simple to understand what it all means as cannot make head nor tail of it's waffle. There has been no action from all the waffle to improve what has turned the nhs into even more of a bureaucratic nightmare than it was before. These politicians have a lot of blood on their hands and their continual bleating about how they 'intend' to improve things is a long time coming. Frontline staff are basically rearranging the deck chair on the titanic.

    I can feel swear words coming on so I will stop short just to say if they really cared then they would stop all this nonsense and re-integrate health and social care and stop all the unnecessary zombie tick box mentality as of now. They have caused the nhs to go into meltdown so why should any of us believe another word they say, not so much speaking with fork tongue as lying bastards. The nhs has been turned into one complicated faff. It is only the frontline staff who are providing/producing anything of any worth despite being on the ropes. So as far as i'm concerned nicholson and his like can all fark off.

    Yes I did comment on your link previously, it was much more succinct and to the point.

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  • michael stone

    tinkerbell | 28-Sep-2013 2:05 pm

    The interesting thing, is that now Sir David N has been forced out, he is saying what he sees to be true - when they are in the job, they 'tow the line'.

    Lots of people are very aware of the problems caused by failures in 'the join' between NHS and Social Services (delayed discharges from hospital, etc) and are trying to address that - although exactly how hasn't been worked out yet, so far as I know. My prediction is the usual approach of 'putting in place some protocols' will be tried, with the usual complication that the protocols solve some problems but also create others.

    But the full integration hinges on the money: NHS care is not directly paid for by the patients but social care is, so blurring the boundaries gets very tricky.

    When I get some spare online time, I'll look through your comments page and see if I can find what you said about my DIC 'posers' - I agree that they are succinct and to the point, but even so they fail to attract the comments on them which I invite: feedback, feedback, oh for the want of feedback chaos reigned ! (didn't some king say that ?).

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  • Hello Tink. Hope you and your husband are well. I often reply to your posts but will stay Anon because of the troll goblins. All it means that if a community service like district nursing wants to integrate with adult social care or mental health or whatever, we have to faff about with a load of b@llocks in the same way that say Sky would if it merged with Virgin and the BBC because it'd create a monopoly. The Tories have put "choice" above common sense. All the choice I want to make is can my mum have a district nurse who isn't knackered and half dead with stress. If we had shared PGDs or equipment or rotas with the hospital, that's my taxes well spent. If I have to waste half the day on the phone trying to find who to talk to, it isn't. Nicholson is just saying competition law doesn't work in the NHS because in most places it is the only provider. And if we spent the money we pee away on woffle on more nursing staff, wouldn't the world be a better place? That'd be far to sensible though......

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  • tinkerbell

    Anonymous | 29-Sep-2013 8:25 pm

    Hi Anon, thank you for asking after us. We're fine (ish). Bit dizzy from the referral merry go round we've been on for something that should be, like you say, straightforward. My husband had an anaesthetic operation and came staggering out the back door of the hospital with no follow up and a plastic carrier bag. The staff were all very pleasant when I took him back to the post op ward having found him on the road. Apparently there isn't any follow up following his particular procedure. He says someone woke him up and said 'you can go now' and at first I thought he wasn't a reliable witness but I don't know anymore. I just happened to spot him as I was driving around trying to find somewhere to park. It was all a bit Victor Meldrew 'one foot in the grave'.

    We have since been offered a follow up appointment because we've asked for one.

    The world would be a better place but you and the clinicians are far too sensible for anyone to take any notice as the madness of what is happening is reaching momumental speed now and I no longer understand what it is I do anymore. It mostly isn't nursing, it's sitting behind a computer screen ticking endless boxes to say I have seen a patient or about to see a patient & have less and less time to see the patient cos' each patient generates a ton of paperwork. Apparently if I tick all the boxes correctly I will get my case load to go green on the computer stats program. I am now trying to turn it into a bit of fun (before I scream) and call 'bingo' when I achieve it. So far I have ten patients who I have managed to turn green and only 42 left to turn green with new incoming referrals most days. I will probably have retired or gone running to the hills before I ever achieve an all green caseload.

    Sometimes I think I might just stand up from my 'hot desk' and shout out, 'I resign -Laters' and just walk off into the sunset.

    I've loved my nursing career on the wards but this community malarkey is a constant merry go round of referring backwards and forwards between disciplines and passing on a phone call or email the someone else. How much more difficult could the system make it to get some help. What a game! Unfortunately I am too knackered to go back to the wards. After surviving without a decent meal mostly for the past 25 years, working 10 days in a row, rotating between days and nights, doing long days, I am starting to think it was only the camaraderie of the teams I worked with and the patients on the ward that kept me going, cos' I was actually just surviving on vapours.

    I hope you find that nurse for your mum but sadly I think most of my colleagues are in the same muddled, knackered state that I am.

    I often ask colleagues 'do you know what you're doing cos' I don't anymore' and then they say they feel the same way too.

    This more with less madness ain't working and very dangerous.

    I feel sorry for us ALL and think we MUST take ACTION but that's a ship that's sailed I fear.

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  • michael stone

    tinkerbell | 30-Sep-2013 6:42 pm

    Tink, its not about community care as such, but the RCP has added its twopence-halfpenny to 'what needs to happen' and DIC are asking for comments:

    The ideas in the report tend to make sense, like Francis, Neuberger, etc, but I've now seen enough reports to suspect that somewhere between the report and what happens on the ground, the objectives of the report writers will be almost entirely lost.

    An investigator said about one of the failed banks that plunged us all into crisis, something like

    'They managed to tick all of the boxes and follow the guideleines to the letter, but the bank's behaviour completely missed the spirit of ethical banking'.

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