Each mismanaged referral to a district nurse wastes five hours of their time, according to initial findings from one of the country’s first major studies into community nursing productivity.
Incomplete notes from acute trusts, long waits to get drug charts signed off by GPs and difficulties obtaining occupational therapy equipment are among the main bottlenecks revealed by the preliminary research, seen exclusively by Nursing Times (see above).
Central London Community Health (CLCH) – consisting of the provider arms of NHS Westminster, NHS Hammersmith and Fulham, and NHS Kensington and Chelsea – analysed each step of the referral process for its 18 member district nursing team in central London, and identified multiple hold ups in the system.
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Lead researcher and CLCH community nurse manager Claire Halkyard told Nursing Times the findings showed each bad referral cost a district nurse an average of five hours in follow-ups and unnecessary journeys.
She said: “There’s a feeling in the air that district nurses are not efficient, that they could work harder, better, smarter.
“So we looked at the issue and what we came up with was that they were working very hard – doing unpaid overtime – but what was stymying them were huge multi system problems with acute trusts and GPs.
“The issues [from hospitals] are basic demographics: when the patient is coming home, telephone numbers, addresses.
“Ordering them the right equipment at home is a process that often goes round in circles.”
Ms Halkyard added: “With GPs, it’s all about medication. It’s either patients coming back without medication or coming back with 20 bottles they don’t know what to do with. Plus the logistics of getting hold of GPs – 50 per cent of the time wasted is wasted in this way.”
The research also found many patients were discharged with little or no notice to community nurses, or were inappropriately referred to them and had to be refused or re-routed.
CLCH director of operations Jane Clegg said the project was prompted by an NHS London requirement to measure the time clinical staff spent dealing directly with patients. They then decided to look at why the ratio for district nurses was so low.
Ms Clegg said she hoped the findings would help people realise that it was often other parts of the system that were having a negative knock on effect on district nurses, rather than community services themselves being inefficient.
The McKinsey report into NHS efficiency – published by the Department of Health earlier this year – showed wide variations in the number of daily visits made by district nurses.
The top 15 per cent averaged between seven and 12 a day, with the bottom 15 per cent only managing between one and four.
Ms Clegg said: “What we want to do with the research is draw people’s eyes further upstream. We don’t want to put the blame on anyone, but a whole system look at this hasn’t been done.”
Royal College of Nursing primary care adviser Lynn Young estimated that, nationally, 30 per cent of a district nurse’s time was lost in the ways described in the CLCH research.
She said: “District nurses have a hard time because, with GPs, social services and hospitals, they have to deal with three different organisational cultures and three different ways of recording things.”
Hillingdon Hospital Trust deputy nursing director Bev Hall told Nursing Times she had worked with community services in her area to identify poor communications during discharge.
Citing wound care as an example, she said: “Sometimes a discharging nurse will assume wound care automatically goes to a district nurse when it could sometimes be handled more appropriately by a GP practice nurse.”
Queen’s Nursing Institute director Rosemary Cook said the picture varied across England’s workforce of around 12,000 district nurses.
She said: “We hear of places where there are lots of sticking points like this – often to do with inadequate information on discharge, and rapid or unanticipated discharge, especially on a Friday afternoon.
“The community nursing team often finds itself at the end of the line – they have to solve the problem or the patient will suffer, while… others in the line can just pass the problem on.”
She predicted the Transforming Community Services programme – which will see many primary care trust provider | arms integrate with acute or mental health trusts – could improve the process.
She said: “If community nurses are employed by the same organisation as the ward nurses, or as mental health nurses, it may become easier to integrate discharge processes, and the transfer of care from hospital to home, to the benefit of the patient.”