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Botched referrals cost district nurses five hours each


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.

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.”


Readers' comments (8)

  • this is the problem of in-house research, and too my mind is characteristic of a whinging unproductive health service

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  • This article is so true!! it is not untill i read it that i realised all the extra work which does go into a 'bad' referral. In my experience it is certainly true that all 'good' referrals take much less time, you generally just need to arrange the visit and nothing else. I know that the referrer is probably busy and are just wanting to discharge these patients but in my experience community nurses are just as busy, so it just adds to our work load (and can give the referring area a bad name). Also i dont know if any other community nurses do this, but we have to 'datex' bad referrals, which takes up even more time!

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  • I feel that nurses in acute hospitals sometimes feel that community nurses have the easy option but this is not true and bad referrals do not help. The number of referrals we get for patients catheterised and it says on the discharge they have been sent home with all catheter equipment is just a joke. With wound care the ward may send home dressings for a couple of days then ask for daily dressings to be done, but it can take over a week to get the GP to do a prescription and get the dressing into a patients house, we do not have supplies of dressings at our bases, other than basics and this again can take time to sort out.

    As the writer above states we should do an incident form each time we get a bad referra,l but quite often this just does not happen due to time taken to fill in the form. I am not sure which way we are going with Transforming Community Services but maybe if it is with the acute trust this will make the system more streamlined and the them and us situation, which appears to exist, will die away.

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  • I agree that DN referrals can be lacking in good information and relevant instructions however, we do have a good discharge co-ordinator who has been praised for her handovers. But, we also have problems with some (only some), DN's not carrying out the instructions especially for dressings. When our patients come back to clinic, we find skin grafts removed (!) as they thought they were excess skin, filthy, infected or dry wounds because the DN's don't go in to change them and ask the patients to do them themselves, PEG tubes not cared for and infected as they give up visiting. We even have DN's refusing to look after patients because they are too busy and we have to negotiate things. If patients are not diabetic or have leg ulcers some DN's are not interested. Most of our patients are elderly and many have co-morbidities which although do not need to remain in hospital cannot get to the practice nurse who we use whenever a patient is mobile or have relatives who will take them there. This is a two sided issue but I take on board that we need to be better with our information at discharge to help them.

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  • As a District Nurse I take great offence to the above comments, if you do have issues with your distrist nursing team you need to take it up with them. What a ridiculous comment to make that unless patients are diabetic or have leg ulcers we are not interested, this is exactly the sort of attitude towards district nurses that needs to change. We are a highly skilled workforce that have many clinical skills. We are struggling at the moment with lack of staff due to a freeze on recruitment and finding it difficult to fit patients in and often work over our hours. We need to start working together for the future.

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  • How ridiculous! Why do you use such complicated system which probably has far too many people involved to make it efficient. It is hardly surprising it is time wasting and worse for the patients serious errors are made such as sending nurses without the relevant experience to look after complex cases such as those on life support. How can anybody have confidence in such a system. Furthermore, the care seems to be outside the aegis of the NHS and farmed out to private companies and nurses with different standards. It is a total shambles and a disgrace and probably does not conform with the EU regulations.

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  • DN's 'give up visiting'?!! DN's refusing to see patients because they are too busy??!! Community Nurses have a duty of care to patients just like every other nurse so such comments are very offensive. Unless you have spent any time working with nurses in the community there is probably still a wildly misguided view that all we do is drink tea with our patients. The fact of the matter is we are a cinderella service at the end of the line where we are left to deal with the problems created by other services through poor communication, inadequate planning and inability to see the bigger picture. Furthermore, caring for large, varied and complex caseloads of patients means our service cannot have a waiting list and there is no ceiling limit to referrals. Community nurses do a wonderful job of balancing all of these issues and providing the most up to date evidence based care possible.

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  • I am now a Community Nurse and have been for the last 2 years, but prior to that I came from an acute hospital ward. I will openly admit that knowing what I know now, I realise I did not have a clue as to what Community Nurses actually did and how hard they actually work.
    I started working in the community for a slower paced role as the nights and days didn't work well with me. I have since learned that the Community is far from slow paced!
    Although the Community and the types of stresses we deal with vary from that on an acute ward, we are nevertheless just as stressed and hard working.
    I came across this article as during work today was discussing ways to improve the referral process within our borough. I agree referrals are often limited, lacking in information/detail and sometimes we don't even receive a referral therefore, making the District Nursing team look unprofessional as the patients and family's contact us complaining we have not attended.
    I feel that the referral process as whole needs to be reviewed and more to the point Nurses need educating about the services we provide, just as I now know I did before I worked as a Community Nurse.
    Hospital Nurses and Community Nurses need to work as a team in order to effectly manage their patients.

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