Workload pressures are increasingly forcing a change in dynamic between the traditional roles of community and practice nurses, suggests a report that paints a picture of a system in “crisis”.
GP surgeries are increasingly using their own practice nurses for home visits, instead of district nurses, according to the report by the King’s Fund.
“Community nursing became more remote from general practice”
King’s Fund report
Yesterday the think-tank revealed what it described as “concerning suggestions” that workforce pressures on nurses and GPs were reducing the monitoring of patients with long-term conditions in the community.
It cited how the current workload pressures facing both the general practice and the community nurse workforce was negatively impacting on their ability to carry out annual medication reviews for housebound patients with chronic conditions, unless they were on existing caseloads.
It also warned of a breakdown in communication between the two in some areas, usually dependent on whether community nurses were based in the same building as the practice.
“GPs told us that they once felt close to community nursing teams and regularly relied on them for help with blood testing, ongoing monitoring and preventive interventions,” said the report titled Understanding pressures in general practice.
It warned that doctors and practice nurses now felt their community colleagues were “rarely able to do more preventive, chronic disease management tasks, except for patients already on their caseload”.
“Practices were sometimes opting to use their own nurses to carry out home visits”
King’s Fund report
The report stated: “All the practices we visited reported that the work of community nurses has changed significantly in recent years, with consequences for general practice.”
It added: “We also found that as community nursing became more remote from general practice, practices were sometimes opting to use their own practice nurses or healthcare assistants to carry out home visits, particularly for monitoring.”
It quoted several practice nurses, one of which said that the district nursing team was no long able to see her practice’s housebound patients unless it was “for their own reasons”, such as changing dressings after being discharged from hospital.
“We’ve then got to find the resources to go and do that [visit patients]. And that’s changed quite a lot. They [district nurses] don’t do the full range of treatment we feel is necessary,” she said.
Another practice nurse said: “The district nursing service is under a lot of pressure… District nurses have to be absolutely strict that those patients [they visit] have to be housebound… They are under so much pressure.”
The King’s Fund noted that recent pressures on community nursing were “well documented”, with growing numbers of frail older people with multi-morbidity who required nursing care in their own home. It highlighted that this trend had been accompanied by a drive to offer more care close to home, prevent unnecessary hospital admission and facilitate early discharge.
GP doctor applying wound dressing
“Despite the increasing demand for community nursing services, there has been a decline in the number of nurses working in this setting, particularly those with a district nursing qualification,” it said.
The warnings about the pressure tensions between community and practice teams formed part of an overall assessment by the King’s Fund on the challenges currently facing general practice in England and the root causes behind it.
It described general practice as being “in crisis”, with substantial increases in workload in recent years that had not been matched by growth in either funding or in workforce.
The think-tank found that consultations grew by more than 15% between 2010-11 and 2014-15. Over the same period, the GP workforce grew by 4.75% and the practice nurse workforce by 2.85%.
“Pressures on general practice are compounded by the fact that the work is becoming more complex and more intense,” said the King’s Fund.
The report said there was “no surfeit of experienced practice nurses available” and nursing faced “similar issues around recruitment and retention” as primary care did for doctors.
It cited the Health and Social Care Information Centre’s general practice census in 2014, which found there were 15,062 whole-time equivalent nurses working in general practice, an increase of 119 on the previous year.
Latest figures from the centre, published last month and not included by the King’s Fund, show a slightly improved pictures, with 15,398 whole-time equivalent nurses working in GP surgeries in England in 2015, a 336 increase on the year before.
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However, the King’s Fund also quoted a survey of general practice nurses in 2015 that found a third were due to retire by 2020 and more than 40% reported that their nursing team did not have sufficient numbers of appropriately trained and qualified staff to meet patients’ needs.
“Practice nurses and health care assistants we spoke to undertook a wide range of roles, including health promotion clinics, health checks, immunisations, phlebotomy, patient education and wound care,” said the report.
“Others had developed specialist roles in chronic disease management, cervical screening or minor illness clinics,” it said.
But the report highlighted research showing that while nurses were sometimes able to substitute for general practitioners, they were not necessarily a cheaper alternative as they tended to have longer consultations and recall patients more frequently.
“Some GPs we spoke to emphasised the benefits that highly experienced practice nurses could bring but reiterated the view that less highly trained and experienced nurses tended to recall patients or refer on unnecessarily,” said the report.
It warned there was also a perceived lack of opportunity for nurses to develop their skills, poorly defined career paths in primary care nursing and a general lack of governance to ensure that all those in the primary care nursing workforce both had and maintained their skills.
The King’s Fund report follows a recent report from the Queen’s Nursing Institute pinpointing the pressures facing practice nurses in London and the publication of NHS England’s General Practice Forward View plan, which promised an extra £2.4bn a year for general practice services by 2020-21.
But one of the King’s Fund analysts, Beccy Baird, added: “Investment alone won’t help the crisis in general practice. To avoid the service falling apart, practical support to do things differently is crucial and must be underpinned by an ongoing understanding of what is driving demand and activity.”