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CQC highlights creative use of nursing roles to meet demand

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Nurses are helping to prop up struggling services by stepping outside their usual remits and putting their valuable skills to new use, according to a new report by England’s care regulator.

The Care Quality Commission’s latest State of Care document, published today, has shone a light on how nurses are “working safely beyond the boundaries of their traditional roles” to help colleagues meet increasing demand.

“The efforts of staff, leaders and carers despite these challenges must be recognised and applauded”

CQC report

The CQC highlighted the potential of the controversial new nurse associate role in helping to address workforce challenges due their ability to rotate across hospital, community and social care settings.

In addition, it said nurse practitioners had been seen to “considerably” reduce delays in urgent care centres, because they could prescribe medicines without needing approval from a GP.

Among the initiatives listed in the report are:  

  •  In Oxfordshire, some GPs have employed nurses to carry out regular patient reviews and home visits that would have usually been done by a doctor
  • In York, nurse associates are rotating around hospital, community and adult social care providers
  • Yorkshire Ambulance Service has also offered placements to nurse associates
  •  Frimley Park Hospital in Surrey has a senior nurse at A&E who carries out initial assessments and offers patients self-care advice.
  •  In Coventry, advanced nurse practitioners are leading an urgent primary care assessment service
  • Advanced nurse practitioners in Cumbria are helping keep people in crisis out of hospital through a “hospital at home” team and acute assessment unit

The report also stated how “passports” were being used in some parts of the country to allow staff to easily move across health and social care roles and develop the breadth of their skills and experiences.

The CQC’s annual assessment for health and social care services in England for 2017-18 revealed that the quality of services had largely maintained, and in some cases improved, since last year, despite continuing challenges around demand, funding and staffing.

The regulator added: “The efforts of staff, leaders and carers to ensure that people continue to receive good, safe care despite these challenges must be recognised and applauded.”

However, it said people’s experiences of care varied depending on where they lived in country and how well different parts of the local systems worked together. The report said communities faced an “integration lottery” rather a “postcode lottery”.

“This report lays bare a health and social care system that is only being kept afloat by the tireless work of its remaining staff”

Tom Sandford

It determined that ineffective collaboration between local services resulted in people not being able to access the care they needed in the community, which in turn led to increased demand for acute services.

The CQC called for a change in the way health and social care was funded to provide an “incentive” for integration of services and to develop a “person-centred” approach to care. People need health and care that revolves around them, not the other way around, the report stated.

“The alternative is a future in which care injustice will increase and some people will be failed by the services that are meant to support them, with their health and quality of life suffering as result,” it added.

In addition, the report showed how the nursing recruitment challenges across the country varied between sectors.

Between 2009 to 2017, there was a 40% fall in community matrons and a 44% drop in district nurses. During the same period, the number of nurses caring for adults in hospitals increased by 8%.

Meanwhile, the registered nurse vacancy rate in adult social care rose from 9% in 2016-17 to 12% last financial year, the report said. The impact of the Brexit vote on the nursing workforce is already being felt, the document noted.

It said the number of new EU nurses and midwives registering to work in the UK fell from 9,389 in the year to March 2016 to 805 in the year to March 2018, while the number leaving rose from 1,981 to 3,962 over the same period.

The report highlighted the effect the shortages were having on the current workforce. It said staff were unable to undergo training because there were not enough colleagues available to cover their normal duties, and that some were getting “burned out” due to increased workloads.

Tom Sandford, director of the Royal College of Nursing in England, said: “This report lays bare a health and social care system that is only being kept afloat by the tireless work of its remaining staff. But we’re almost running on empty. Nurse vacancy rates are soaring across all settings – 41,000 in England alone – and this is having a direct impact on patient care.” 

Tom Sandford

Tom Sandford

Tom Sandford

Mr Sandford said the extra investment promised to the NHS by the government “can’t come soon enough”, but warned that the “time for tinkering is over”.

He added: “We need proper investment in nurse education to begin to address the tens of thousands of vacancies that are jeopardising safe patient care.

“The government must also produce a fully funded workforce plan that responds to population need, and prioritises nurse recruitment and retention, underpinned by legislation,” said Mr Sandford.

As well as healthcare, the CQC issued a stark warning about the “fragility” of the social care sector due to rapidly rising demand, resulting in a predicted funding gap of £3.5bn by 2025.

It said the number of older people who do not get the care and support they need to carry out essential daily task had risen by almost 20% in two years to hit a new high of 1.4m.

Nine out of 10 council areas in England could see a shortfall in care home places by 2022 unless urgent action is taken, the document cautioned.

“The likely consequences of this are more and more people being unable to get quality and reliable care and support”

Ian Hudspeth

Adult social care is also facing serious recruitment and retention problems, with the overall vacancy rate rising from 6.6% in 2016-17 to 8% in 2017-18, the CQC said.

It added: “While the government made a welcome NHS funding announcement in June 2018, the impact of this, and last week’s short term crisis funding for adult social care, risks being undermined by the lack of a long-term funding solution for social care.”

Reacting to the report, Ian Hudspeth, chair of the Local Government Association’s community wellbeing board, said the document provided more evidence for the “desperate need” of securing a more long-term and sustainable solution for how social care was paid for in England.

“Councils across the country are working closely with their counterparts in health for the benefit of people requiring services, however with people living longer, increases in costs and decreases in funding, adult social care is at breaking point and its potential for helping people to live the lives they want to lead is at risk,” he said. 

Ian Hudspeth

Ian Hudspeth

Ian Hudspeth

“Over recent years, councils have protected adult social care relative to other services,” he said. “But the scale of the overall funding picture for local government as a whole means adult social care services still face a £3.5bn funding gap by 2025, just to maintain existing standards of care.”

He added: “The likely consequences of this are more and more people being unable to get quality and reliable care and support, which enables them to live more fulfilling lives.”

A long-awaited green paper on the future of social care in England was due to be published this summer but has been delayed to coincide with the release of the NHS long term plan this autumn.

The CQC report shows that as of 31 July 2018:

  • 3% of adult social care services were rated outstanding (2% were rated outstanding at 31 July 2017)
  • 79% of adult social care services were rated good (2017:78%)
  • 17% of adult social care services were rated requires improvement (2017:19%)
  • 1% of adult social care services were rated inadequate (2017: 1%)
  • 6% of NHS acute hospital core services were rated outstanding (2017:6%)
  • 60% of NHS acute hospital core services were rated good (2017:55%)
  • 31% of NHS acute hospital core services were rated requires improvement (2017:37%)
  • 3% of NHS acute hospital core services were rated inadequate (2017:3%)
  • 8% of NHS mental health core services were rated outstanding (2017:6%)
  • 70% of NHS mental health core services were rated good (2017:68%)
  • 21% of NHS mental health core services were rated requires improvement (2017:24%)
  • 1% of NHS mental health core services were rated inadequate (2017:1%)
  • 5% of GP practices were rated outstanding (2017: 4%)
  • 91% of GP practices were rated good (2017: 89%)
  • 4% of GP practices were rated requires improvement (2017: 6%)
  • 1% of GP practices were rated inadequate (2017: 2%)
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