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District nurse services in East Anglia relying on more HCAs

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District nursing services in parts of East Anglia are increasingly reliant on healthcare assistants, according to research carried out by the Royal College of Nursing.

Information released under the Freedom of Information Act revealed significant differences in skill mix trends for the community workforce across the region.

In particular, it suggested a recent fall in the ratio of nurses to HCAs in Suffolk and much of Essex, though the picture is more positive in Cambridgeshire and Norfolk.

“We are concerned to see that in some areas it appears the district nursing skill mix is being watered down”

Karen Webb

The RCN Eastern branch looked at the balance between registered community nurses and HCAs over a two-year period between January 2011 and October 2013.

In 2013, 96% of the district nursing service in Cambridgeshire was provided by nurses and only 4% by HCAs, but in Suffolk it was run by 55% registered nurses and 45% HCAs.

Across England as a whole last year, 75% of district and community nursing teams were registered nurses, according to a separate report by King’s College London.

However, the RCN research suggested only two providers in the East of England matched that ratio – East Coast Community Healthcare and Cambridgeshire Community Services NHS Trust.

By contrast back in 2011, half of NHS community providers matched or exceeded the 75% registered nurse ratio, including Cambridgeshire, Hertfordshire, South East Essex, Central Essex and Suffolk.

The largest shift from registered to unregistered community nursing staff over the two years has come in Suffolk and Essex – with the exception of South West Essex – according to the college.

Karen Webb, RCN director for the Eastern region, said: “We are concerned to see that in some areas it appears the district nursing skill mix is being watered down.

RCN eastern region

Karen Webb

“Our concern would be that a service relying heavily on healthcare assistants is about cutting costs and not about high quality patient care,” she said.

Ms Webb warned that the government’s policy of shifting more patient care from acute hospitals into the community “will be very difficult to achieve when district nursing is being cut and…unregistered nursing staff are being left to cope on their own with little supervision”.     

“District nurses deserve the right training, the right staffing levels, and the right mix of skills to deliver high quality patient care,” she said. “NHS commissioners and providers continue to need to grasp this problem.”

Organisations saw the following changes to the mix between registered nurses and unregistered HCAs in community services:


AreaRegistered nurses in community teams in 2011Registered nurses in comunity teams in 2013 Change in skill mix
Suffolk  82%55%-26%
 Central Essex     78%65%-13%
 SE Essex      76%65%-11%
 Hertfordshire     76%71%-5%
 NE Essex  74%69%-5% 
Bedfordshire   49%49%+5%
Great Yarmouth/Waveney 70%75%0%
SW Essex 49%55%+6%
 Norfolk     46%56%+10%
 Cambridgeshire   82%96%+12%


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