The vast majority of community healthcare providers are deeply worried about staffing and fear current workforce plans will not deliver enough district nurses, health visitors, and specialist nurses to realise ambitions of providing more services closer to home, reveals a new report.
The report by NHS Providers on the state of community health services paints a stark picture of an over-stretched sector struggling with funding shortfalls, staffing shortages and lack of recognition.
“All too often NHS community services are marginalised, underfunded and short staffed”
It features a survey of trusts, which reveals 45% of those that provide community services are currently “worried” or “very worried” about whether they have the right number and skill mix of staff to deliver quality care. Meanwhile, 62% are worried about being able to maintain adequate staffing in 12 months’ time.
The survey of 71 trusts in all – 51 that provide community services and 20 that do not – also revealed deep concern about the supply of key staff groups such as nurses.
In all, 86% reported they were “worried” or “very worried” about whether national workforce plans would deliver enough community nurses, including district nurses – who were described by one community service leader as “the glue that holds the whole health and care system together”.
More than three quarters – 76% – said they were “worried” or “very worried” about the supply of health visitors, and that went up to 81% when it came to having enough community specialist nurses.
This is despite the fact government plans set out in the Five Year Forward View for the NHS envisage a significantly expanded role for community services like district nursing and sexual health clinics.
“Cuts to training budgets have prevented nurses from joining the community nursing workforce, prompting further staff shortages”
The new report – titled NHS Community Services: Taking Centre Stage – highlights a decline in the community nursing workforce, which has reduced by 14% since May 2010 and amounts to the loss of 6,000 posts.
In particular, it described the role of district nurse as “vital”, yet flagged up that the number of district nurses has reduced by 44% since 2010, with the community nursing vacancy rate currently at around 9.5%.
“There is some evidence that these nursing shortages are risking the quality of patient care in community settings, as they put pressure on staff and their caseloads,” warned the report.
It highlighted that district nurses played a crucial role in supporting people with long-term conditions, helping older people with a complex needs and caring for those who are recently discharged from hospital or near end of life.
“In a patient’s eyes, they are often the linchpin between primary and social care, hospital teams and care homes,” said the report.
“However, there are not enough district nurses to meet current or future demand, and district nursing has an ageing workforce making supply an even more pressing issue,” it said.
“For a long time, community services have flown under the radar at national level in the NHS”
It stated that national policy had successfully increased the supply of community nurses in the past – such as the national target to boost the number of health visitors – yet such efforts have fallen by the wayside due to a lack of ongoing focus.
“Since the target was not renewed in 2015, the number of health visitors has fallen by 19%, showing how when the national impetus falls away, so do the results,” said the report.
The report highlighted a lack of national quality data and targets for community services and said the forthcoming national workforce strategy “needs to deliver the appropriate number of community staff and raise the profile of careers in the community sector”.
“Health Education England’s national workforce strategy must ensure appropriate priority is given to the supply of community nurses,” said the report.
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“Staff will need to be redesigned, upskilled and supported to work according to different models of care and a population health approach, if this is not already happening,” it said. “The community sector needs a more flexible workforce that can take a holistic approach to care.”
The report showed that community trusts were facing ever-shrinking budgets, with 52% who took part in the survey reporting funding in their area had fallen in this financial year.
Many – 44% – said they were cutting costs while 30% said they had cut staff. In all, 82% said they were “worried” or “very worried” that community health services would not received the investment they need to deliver the ambitions of the Five Year Forward View.
Other issues highlighted included the fact that community service providers were subject to frequent competitive re-tendering, which could be a “burdensome distraction from their core strategic task”.
The report identified that community interest companies (CICs) set up to deliver community services, including nursing services, were struggling with the same workforce challenges as trusts.
“They are losing nurses to general practices in particular, as primary care can offer a less pressurised working environment,” said the report, which saw researchers carry out a number of in-depth interviews with community trust and CIC leaders.
“While CICs are proud of their staff engagement and satisfaction scores, they flagged that these scores have started to decrease and sickness absence rates are starting to rise. These measures show that staff are feeling the pressure of increased demand on services, which potentially risks the quality of care,” said the report.
It suggested strategies that might help could include a national target for health visitors and district nurses, or development funding specifically for community services, said interviewees.
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NHS Providers chief executive Chris Hopson said community services had the potential to take a leading role in the transformation of health and care services and were already at forefront of delivering new, integrated models of care that have seen nurses, GPs, hospital and social care teams.
“And yet – as our survey makes clear – all too often NHS community services are marginalised, underfunded and short staffed,” said Mr Hopson.
“It is patients who are paying the price for the failure to follow through on past commitments, as the rest of the health and care system struggles to keep up with rising demand for treatment,” he said.
“We need to see to see community services given greater priority at national level and within sustainability and transformation plans and integrated care systems,” he said. “These services need adequate funding, and action to address staff shortages.”
Janet Davies, chief executive and general secretary of the Royal College of Nursing, said underfunding and staffing shortages had left community services “in a precarious state”, which was putting pressure on emergency care and damaging quality.
“District nurses support the most vulnerable people in our society, yet constraints on funding and staff numbers, coupled with increased demand for their services, are dramatically affecting their ability to provide quality care,” she said.
“Cuts to training budgets have prevented nurses from joining the community nursing workforce, prompting further staff shortages,” warned Ms Davies.
“Investing in an expert district nursing workforce and community services must be a priority to ensure safe, effective, person-centred care,” she stated.
As well as highlighting the issues facing the sector, the report featured examples of where community service providers were successfully working with others to improve care.
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For example, the Hospital@Home service run by Sussex Community NHS Foundation Trust in partnership with Brighton and Sussex University Hospital sees community nurses and therapists look after patients with complex needs at home.
“Patient feedback is positive and the scheme is popular with staff who have the opportunity to develop and practice skills that would normally be used in an acute setting,” said the report, which also flagged up the financial benefits.
The cost of a patient cared for by Hospital@Home is 27% less than if they were looked after in an acute setting over the same period.
The community trust’s chief executive, Siobhan Melia, said community staff needed support, training and robust supervision to thrive.
“For a long time, community services have flown under the radar at national level in the NHS. But locally they have been quietly delivering a huge amount for those that rely on their services and the wider communities they serve,” she said.
“We see the impact of funding and workforce pressures every day and there are particular challenges for staff working in the community,” she said.
She added: “They need access to support and supervision as well as training opportunities to ensure that they can continue to deal with the most complex of cases and keep people safe in their own homes.”