The size of district nurses’ workload usually depends on the age profile of the patient population served by the GP practice that employs them. I was involved in a project that aimed to produce a tool that would facilitate a more even and fair distribution of district nurses.
VOL: 97, ISSUE: 11, PAGE NO: 37
Christine Spens, RGN, RHV, RM, is primary care nursing development worker/health visitor, Winchester and Eastleigh Healthcare NHS Trust
The project, commissioned by the Winchester and Eastleigh Healthcare NHS Trust, researched and piloted three integrated nursing teams, and recommended a more even distribution of community nurses among all practices in the Eastleigh North and Mid-Hampshire Primary Care Group areas.
The existing allocation of resources was based on historical factors and did not relate to health need or the age profile of each practice population. The district nursing budget was taken to be finite. Data collected over a three-month period from all district nursing teams in the trust showed that the number of clients seen depended largely on the age profile of each practice - weighting practices using this information seemed to be a more appropriate way to allocate district nursing resources.
This approach was influenced by the Audit Commission’s first assessment paper of 1999, which called on trusts to define service objectives clearly, improve referral processes and hold regular caseload reviews. If resources are to be managed efficiently and targeted at patients, the objectives of the service need to be clearly stated.
As a starting point for the project, the core work of the district nursing service was defined. It was assumed that teams work in different ways, reflecting the needs of each practice and of practice populations.
Approach and research methods
When staff budget costs were assessed for each practice, they revealed wide variations. Before weighting was applied, the amount spent per capita on district nursing ranged from £5.18 to £12. Practice statistics were collected from the health authorities to enable the age profiles of each practice to be assessed.
To assess the dependency levels of patients on each caseload, the time spent by district nurses on dependent patients was calculated for each practice. Staff travelling time was also considered, with factors such as traffic congestion in urban areas and the need to travel greater distances at rural practices taken into account. We did not investigate diagnoses, as this would have been too complex and would not necessarily have produced useful data. This was confirmed by the Audit Commission’s information on patients’ use of district nursing services (1999).
Jarman (1983, 1984) figures were obtained from the North and Mid-Hampshire Health Authority, and these identified areas of deprivation relating to elderly people. The Jarman score weights many factors - the elderly living alone, those without transport and people living in substandard accommodation. These factors can be used to reflect caseload weighting.
Questionnaires were designed to allow district nurses to record the time spent with different patients over a three-week period; these also included questions on clerical and liaison time. Each team completed caseload questionnaires over a five-month period to take account of the changes that inevitably occur. The questionnaires also considered the ‘time dependency’ of patients in three age groups: 0-64, 65-84 and 85-plus. Each staff member recorded travel time over a three-week period. Following analysis of the questionnaires, staff discussed the method needed to weight various factors and to clarify any queries relating to the work.
Analysis of results
The results showed that the over-85 age group was represented highest in district nurses’ caseloads. Some variation between practices emerged with regard to the number of those aged over 85 in contact with district nursing services. The statistics were compared with the Jarman scores but did not correlate. This could be because of a lack of guidance on the referral and discharge of patients to the district nursing service or caused by differences in the care provided, possibly relating to staffing levels and referral patterns, rather than to actual need.
Calculations to decide the weighting of each of the three age groups were made from data supplied by staff. An average percentage of each group seen by district nurses service was made, based on the average length of staff time taken up by patients.
As the number of patients needing palliative care was variable, it was agreed that this group should not be weighted separately. Unless further studies prove that a particular practice has a consistently high number of palliative care patients, a relief team will be called upon to assist in times of heavy workload. Referral rates to the district nursing service varied considerably and did not appear to relate to rural factors or Jarman scores, thus clearly identifying a need for referral protocols.
Weightings were calculated from the data and related to the time spent per year by the district nursing team on particular age groups. The data was then used to establish how this related to the population size of each practice. Patients aged over 85 years on a caseload for a year take up an average of 35 hours of staff time (35 points). Patients between 65 and 84 years on a caseload for a year take on average 36 hours (36 points). Patients aged under 65 on a caseload for a year take an average of 41 hours (41 points).
It was found that an average of 20% of over-85s in a practice population were on the caseload of district nurses. There is a range across practices from 10% to 34%, and this probably relates to referral patterns and staffing levels rather than need, although further work is needed to confirm this. On average, 4.1% of 65-84s are on district nurse caseloads. This proportion ranged between 2% and 6%. On average, 0.16% of under-65s were found to be on district nursing caseloads at any one time. From this information, the following weightings were calculated:
- - For each 85+ in a practice population, the score is seven points;
- - For each 65-74-year-old, the score is 1.5 points;
- - For every 100 patients in the practice population under 65, the score is 6.5 points.
Each practice had its total score adjusted according to its travel time percentage. A budget for each district nursing team was calculated on the basis of each team’s total score and the total budget allocated by the trust for district nursing.
The area is characterised by different working practices, and it has been hard to identify the reasons for this, apart from a combination of staff levels together with historical, and possibly rural, factors. A more in-depth study might reveal that different nursing practices and referral and discharge criteria are in use.
Nursing practice needs to be evaluated in the light of clinical governance and evidence-based practice. It is possible that rurality should be allowed more weight than merely allowing for extra travelling time. However, discussion with experienced practitioners has proved inconclusive, although it is interesting to note that in this area Jarman figures (1984) show that the greatest need is in urban areas, not the country. In this case, rurality and deprivation may compensate for each other.
The equity tool, albeit a simple one, shows the average time dependency on the district nursing service of different age groups in a practice population. However, it reflects a limited piece of work on which to base a readjustment of staffing levels, based on current practice in the Mid-Hampshire and Eastleigh areas.
The findings of the equity study correlate with the Audit Commission’s review of district nursing in 1999. A skill-mix review to optimise efficiency within a given budget is needed as well as extensive work that would address referral, discharge and treatment protocols to standardise practice in line with clinical governance.
If changes to redistribute funds were made too rapidly and without the service review procedure, those teams due to lose a significant proportion of their staff budget would find their workload hard to manage. During the review, well-staffed practices could be expected to assist poorly resourced ones. When vacancies occur in a well-resourced practice, the replacement of staff needs to be evaluated. Once the review is carried out and policies are in place, the findings of the study can be implemented.
This formula can be applied regularly to take account of changes in practice populations and budget changes that might take place as a result of The NHS Plan.