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Exclusive: Invest in existing nurses not 'shiny' new services, says QNI leader

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A fundamental lack of understanding of the true value of nurses is leading to the creation of yet more “shiny new” initiatives at the expense of the profession, an influential nursing leader has warned.

Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute, said she feared the future of vital specialties such as district nursing were under threat, because they were not seen as a priority for funding.

“Why would you layer another service on top of what we have already got”

Crystal Oldman

She said a key challenge for the community nursing sector was that current performance indicators did not measure “positive outcomes” delivered by these professionals, such as preventing hospital admissions and helping people die at home.

The collection of this sort of data would help build a case for investment and was something that the QNI was looking into doing, said Dr Oldman, who has constantly used her platform as the charity’s leader to help bring the often-behind-closed-doors work of community nurses into the spotlight.

She was speaking exclusively to Nursing Times at the launch of a new report published jointly by the QNI and Royal College of Nursing called Outstanding Models of District Nursing, which aims to outline what could be achieved if district nurses were supported to fulfil their potential.

In the report’s foreword, Dr Oldman and RCN leader Dame Donna Kinnair highlighted concern that some policies may have the effect of making the role of the district nurse appear “obsolete”.

They pointed to the proposal, laid out in the new 10-year plan for the NHS in England, for new expanded multidisciplinary community health teams to provide fast support to people in their own homes as an alternative to hospital admission, backed by a record £4.5bn of annual funding.

This was already the role of the district nursing service, Dr Oldman and Dame Donna stressed. They said they were worried that any remodelling or dissolution of the district nursing service to a task-based approach carried “great risks to the care of patients”.

“Nurses being able to articulate our value is absolutely paramount to me”

Crystal Oldman

Dr Oldman told Nursing Times she feared the proposed redesign of the community health team would overcomplicate a service that district nurses were already set up to deliver.

She questioned why policy makers could not step back and think “as a strategy ‘we need to invest more in the team that can then provide that rapid response’, which is what district nurses can absolutely do, it’s in their training”.

“Why would you layer another service on top of what we have already got, which then comes with its own management and potential costs for setting up, when it would seem more effective and efficient and productive to invest in the service that we have got,” she said.

The QNI leader added: “What it shouldn’t be is investing in a shiny new service without thinking about the implications for that district nursing service and what might be done there.”

With the number of district nurses in the country plummeting 46% since 2010, Dr Oldman said the future of this speciality was at risk. “What would the community look like without district nursing, because that’s where we are heading at the moment,” she warned.

“What it shouldn’t be is investing in a shiny new service without thinking about the implications for district nursing”

Crystal Oldman

School nurses were facing similar problems, said Dr Oldman, highlighting how the government was investing in a new role to support pupils with their mental health, rather than upskilling school nurses who already had some training in this area.

The new education mental health practitioners will receive just one year of training and will then work across schools and colleges as part of the government’s goal of increasing access to, and availability of, wellbeing support for children and young people.

She told Nursing Times that she had “professional concerns” about the introduction of an “unregulated cadre of mental health practitioners” working with “potentially a group of the most vulnerable in our community”.

Like her earlier argument on district nurses, she questioned the reasoning for such a move, when “you’ve got a regulated profession, with a specialist practice qualification, in school nursing, who could be doing that work if we invested more into it”.

She added: “Unless the school nursing service can demonstrate what they do and the outcomes of what they do, you’re then in a difficult position because you can’t say I’m going to invest in school nursing because we know the outcome is this.”

Queen’s Nursing Institute

Crystal Oldman

Source: Kate Stanworth

Crystal Oldman speaking at the QNI annual conference in April 2018

Dr Oldman said the QNI was working on a project to showcase the work that school nurses do, noting how there was still a belief that they were only there to check children for headlice. “It is so not like that,” she said. “The work that they do is when we do have that resource is incredible.”

School nurses should be able to demonstrate not only the interventions they carried out, for example around sexual health, but also the outcomes of them, such as reducing teenage pregnancies, Dr Oldman said. “We don’t collect the data in that way at the moment,” she stated.

She said England “desperately, desperately” needed more of these professionals and called for every school to have a named nurse. Latest figures from NHS Digital show that the number of school nurses in England’s NHS has dropped by 24% over the past decade.

Conversely, one area of the community nurse workforce that is on an upward trajectory is general practice nursing. Dr Oldman said this was in part thanks to a 10-point action plan to bolster the workforce, which was launched by NHS England in 2017 and supported by £15m over three years.

“That’s why we are hearing more about it, quite rightly too. Timing wise that needed to happen,” said Dr Oldman, but adding that she was worried that nurses were being denied a place at the top tables in primary care.

As part of ambitions to break down organisational boundaries, groups of neighbouring general practices in England are being asked to form partnerships to jointly serve a population of between 30,000 to 50,000, working in sync with other key health and social care services in that area.

Each primary care network is required to appoint a clinical director and last month Dr Oldman exclusively told Nursing Times that she had reason to believe experienced nurses were being side-lined from the race for these positions.

She has approached NHS England about whether it would support the QNI to put together a development programme to help prepare nurses for clinical director roles.

However, in the current climate, Dr Oldman said she was aware of how difficult it was to get funding so the QNI was going ahead and creating the programme anyway because she knew it was needed – and hope the money would come later.

Her ambition is to ensure at least 50% of clinical director posts are held by nurses eventually. “In our world now, we have no mandate to do anything, so that’s why I feel charities are in a really good position to just create something,” she said.

“That response time that we have to say, we know that needs to be done, the nurses are telling us, it’s not us saying it, the nurses are saying to us ‘I’m not round the table’, or those who are round the table are going ‘oh my god, I need some form of support group’,” she added.

With a background in nursing as well as academia and management, Dr Oldman is a respected voice in the sector and has helped drive the QNI as an influential force on community nursing policy and research.

She said the organisation prided itself on being “solution focused”, and when it took a stance on an issue it did so on the basis of solid evidence and with intelligence from those on the frontline.

This leading position meant the QNI had been commissioned by Health Education England to create educational standards for programmes for registered nurses wanting to move into general practice and to the care home sector.

Dr Oldman said there was currently “huge variation” between the pathways that nurses could take with courses lasting anywhere between four weeks to a year.

The QNI is also hoping to get permission to create similar standards for nurses new to the district nursing service, but Dr Oldman said the charity was clear that people must obtain a specialist practice qualification in order to hold the title of district nurse.

With origins dating back to the 1880s, a core function of the QNI initially was to organise the training of district nurses, who would then become known as a Queen’s nurse. This has now become more of an honorary title given to those who demonstrate a high level of commitment to patient care and nursing practice.

Around 1,200 community nurses, health visitors and midwives currently wear their Queen’s nurse badges with pride and, as part of the package, are able to benefit from continuing professional development training from the QNI as well as a supportive network.

In return, Queen’s nurses are expected to help the charity with its policy work and may be asked to take policy influencers out into practice with them. Dr Oldman said this scheme had been “more successful than we ever anticipated”.

Care minister Caroline Dinenage recently revealed plans for a piece of work to improve understanding among the public and other health professionals about the role of community nurses, after she herself shadowed a Queen’s nurse for a day and said she was surprised by the breadth of the role.

“Policy makers quite often will go into practice and like Jeremy Hunt used to do, roll up his sleeve and be seen in a meeting in a hospital, meet and greet, lots of hand shaking and isn’t it all marvellous,” Dr Oldman said. “In the community, you can’t do that. You have to go in a car with a nurse and actually go into people’s homes.”

In terms of her own leadership, she said she was motivated by an “inner drive, slightly obsessive” focussed on “getting it right for patients, families and carers”. She said she had spent her entire career – 18 years of which was in the NHS – passionate about nursing.

“Nurses have the most wonderful opportunity and privileged and be able to care for people and support them to have better lives in a whole range of different environments,” she said, but suggested the profession was often an afterthought when it came to policy.

“Nurses are everywhere from birth to death, and yet we always come as a kind of ‘oh and the nurses’,” she said. “I suppose what drives me is that we can always improve on care, and nurses being able to articulate our value is absolutely paramount to me.”

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