Community and primary care nurses are ideally placed to support patients and carers in making lifestyle and behaviour changes to improve their health and wellbeing
This article sets out how changes to the health and social care landscape puts community and primary care nursing centre-stage.
Citation: Garratt H (2014) Nursing at the centre of community services. Nursing Times; 110: 48, 22-23.
Author: Hilary Garratt is director of nursing (commissioning and health improvement), NHS England.
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Huge changes in the NHS are posing challenges for health professionals. The general public expect to be consumers of care and there is a demand for health and social care organisations to be accountable for variations in care and quality - at a time when resources are limited.
The 2014 Care Act requires health and social care services to work together in integrated service models. Planning must be person-centred and include the needs of carers. Independence, choice and control are enshrined in the act and there is a need for workforce and culture change and an increased focus on patient outcomes.
The £3.8m Better Care Fund (NHS England, 2014a) was set up to support these models of integrated care. This requires all local health economies to submit a joint social care and clinical commissioning group delivery plan. Integrated community-based teams must aim to achieve a 3.5% reduction in unplanned hospital admissions by April 2015. This plan allows local economies to build on connections between community, primary care and social care and with a preventive focus on supporting people and their carers to reduce the use of residential care.
In practice, the National Collaboration for Integrated Care and Support (2013) has 14 pioneer sites delivering better joined-up care. The Integrated Care and Support Pioneers Programme is led by the NHSIQ and further information can be found at tinyurl.com/NHSIQintegratedCare.
The Prime Minister’s Challenge Fund is helping GP practices improve access to primary care, and 13 early adopter communities are working on the seven-day service improvement programme (NHS England, 2013). In September 2014, NHS England launched the integrated personal commissioning programme, which will blend comprehensive health and social care funding for patients and allow them to direct how it is used (NHS England, 2014b).
Patients and carers
The changes outlined above provide opportunities to embrace person-centred care, leading to better outcomes and better use of resources. Key to this approach is the delivery of better public health, NHS and social care outcomes, which include a strong focus on health, wellbeing and patient and carers’ views. Underpinning this personalisation agenda are the “I statements” (Think Local Act Personal, 2011) (Box 1).
Box 1. Examples of the “I statements”
Flexible integrated care and support: my support, my own way
- “I am in control of planning in my care
- “I have care and support that is responsive to my needs”
- “My support is coordinated, works well together and I know who to contact to get things changed”
The community and primary care workforce is already oriented towards person-centred care. These professionals work with individuals with whom they frequently have contact over long periods, often in their home environments. This means professionals understand their goals and values, and provides the opportunity to go beyond a medical model of care. People need:
- Information about their health;
- Options and choices;
- Skills and support to engage in their own self-care.
Self-management, self-care and patient activation are closely related and build on the strengths and capacity of patients and their carers to maintain their independence and maintain and improve their health. Patient activation describes patients’ skills and confidence in managing their own health and healthcare, and patient activation measures have been validated in the UK (Hibbard and Gilburt, 2014).
Risk stratification can help identify groups of individuals with long-term conditions who have low confidence, knowledge and skills and are at risk of developing comorbidities. These groups can be supported to achieve lifestyle changes such as gently increasing activity levels, improving diet, stopping smoking and drinking sensibly. Practice and district nurses are ideally placed to support them to make changes to improve their health and wellbeing.
A national programme has been developed to support locally led transformation of community and primary care nursing. The chief nursing officer for England has established this programme, in partnership with the Department of Health, Health Education England, Public Health England and the Queen’s Nursing Institute. The DH has worked with the QNI to engage practice and district nurses and develop the policy framework. The programme is summarised in Box 2.
Box 2. Programme of action for community and primary nursing
Commissioning: a commissioning toolkit with a suite of tools and guidance
Workforce: a comprehensive package of workforce development tools to enhance the current and future community and practice nursing resource
Public health: a communication strategy to engage clinical leadership to ensure integration of effective behaviour change interventions in care plans and clinical pathways as well as identifying and disseminating supporting commissioning tools
Integration: supporting tools for effective multidisciplinary working, care planning and risk stratification
Priorities are to improve outcomes for people with long-term conditions and the experience of the patient, carers and staff are key indicators of success.
Success in delivery of person-centred, affordable and integrated systems of care requires community and primary care nurses to have the support of service commissioners and providers. NHS England has appointed two specialist professional advisers who will focus on strategic workforce planning for district nursing and the development of a commissioning assurance framework for practice nursing.
The QNI (2014) has published a survey of district nurse education. This shows a 38% rise in the number of qualifying district nurses in 2014 and a 25% rise in the number of universities running NMC-approved specialist practice district nurse programmes in England in comparison with 2012/13. The institute is now leading the development of standards for community nursing.
The national community and practice nursing transformation programme is aligned with the challenges, drivers, emerging models of care and configuration of out-of-hospital services including:
- The issues of flat growth in the NHS and reduced local authority funding of social care, while population demographics are increasing demand;
- The need to reduce the preventable burden of ill health through primary and secondary prevention;
- The need for new skills to provide a wider range of out-of-hospital care;
- Workforce configuration and career pathway structure for community nurses, practice nurses and healthcare assistants;
- Employment models that facilitate integrated health and social care, integrated community and practice nurse teams, and use of the third sector as an element of provision;
- Premises (buildings) to facilitate more multidisciplinary ambulatory care and mental health services in communities.
These are in line with NHS England’s call to action on primary care (NHS England, 2014c) and the direct enhanced service for vulnerable people (NHS England, 2014d). A series of recent King’s Fund papers set out the evidence for models of care based on the principles outlined above (The King’s Fund, 2014a, 2014b, 2013).
The programme is also aligning with Compassion in Practice (NHS Commissioning Board, 2012), the strategy for nurses, midwives and healthcare assistants, and with the primary care call to action (NHS England, 2014c).
The health and social care system is moving towards a person-centred, collaborative approach to care. Community and primary care nurses play a key role in this. NHS England and partners are supporting the development of practice and district nursing. Community and primary care nurses have the skills, commitment and opportunities to partner patients, service users and carers, to support better outcomes and a focus on independence.
- The health and social care system is moving towards a person-centred, collaborative approach to care
- Community and primary care nurses play a key role in developing this approach
- These nurses have the skills and opportunities to build partnership with their patients and carers
- Partnerships with patients support self-care, behaviour change and better outcomes
- The development of practice and district nursing is supported by commissioning tools, workforce development and clinical leadership
Hibbard J, Gilburt H (2014) Supporting People to Manage Their Health: An Introduction to Patient Activation.
National Collaboration for Integrated Care and Support (2013) Integrated Care and Support: Our Shared Commitment.
NHS Commissioning Board (2012) Compassion in Practice. Nursing Midwifery and Care Staff. Our Vision and Strategy.
NHS England (2014a) Better Care Fund Planning
NHS England (2014b) Integrated Personal Commissioning Prospectus.
NHS England (2104c) Improving General Practice - a Call to Action.
NHS England (2013) Prime Minister’s Challenge Fund.
Queen’s Nursing Institute (2014) Report on District Nurse Education in the United Kingdom 2013-2014.
The King’s Fund (2013) Transforming Our Healthcare System. Ten Priorities for Commissioners.
The King’s Fund (2014a) Commissioning and Funding General Practice: Making the Case for Family Networks.
The King’s Fund (2014b) Community Services: How They Can Transform Care.
Think Local Act Personal (2011) Making It Real: Marking Progress Towards Personalised Community Based Support.