A shortage of health visitors and school nurses has led to patchy child services says Rosalind Godson
The Department of Health held a public consultation last autumn to discuss the forthcoming quality accounts, the latest stage in the quality framework. All NHS providers - acute services from 1 April 2010, with community services joining next year - will complete this annually to show quality improvement, as it is acknowledged that doing things right the first time saves problems occurring later on.
In the community, nurses are already familiar with Transforming Community Services, where practitioners will deliver good quality as standard and constantly seek to improve services. Ideally, therefore, services should be benchmarked against quality standards in the national service frameworks, the Healthy Child programme, You’re Welcome quality criteria and National Institute for Health and Clinical Excellence guidance.
This has to be put in the context of all staff being expected to improve their productivity, by which managers mean improving outcomes with fewer resources.
‘Child protection services cannot be adequately sustained because health visitors are not able to visit families in their homes and carry out proper assessments’
In reality, most primary care trusts have stringent cost saving packages in place, leading to frozen posts, a lack of training and a reduced service. This is compounded by the fact the commissioning arms of PCTs are entering into outcome based contracts with provider arms, which frontline staff have no hope of fulfilling. This is partly because a poor use of skill mix has led to an erosion of sufficiently trained staff who can deliver those outcomes.
School nurses, health visitors and district nurses, for example, are now asked to cover for absent colleagues or take on a vacant caseload, even if they are having difficulty coping with their existing one. In some areas, this is obscured by the use of corporate caseloads. This is where caseloads are amalgamated across the PCT with a view to prioritising all the work and sharing it out evenly among fewer staff. But this still means that staff are overwhelmed as the workload is impossible. They can no longer deliver a suitable service and may not even finish the priority tasks.
Meanwhile everything must be properly recorded and entered into the all consuming computer system. This leads to staff taking client records home to complete in the evening as there is simply no time in the working day.
Continuing practice development is impossible to arrange as there is no one to cover; some nurses, particularly practice nurses, are told to do their professional updating in their own time. Clinical supervision gets neglected, and there is no time for reflective practice. When staff complain, they are told to prioritise their work, but they did that several years ago - there is no more slack in the system.
For a planned change of service to take place, there are clear protocols: there must be a 13 week consultation with all stakeholders, including service users; there should be a needs assessment and an equality impact assessment to make sure health inequalities are not widened. The new service should be supported by policies that have been drawn up and passed by the joint staff side committee.
Sadly, many places have resorted to crisis management to cover shortages, resulting in patchy services throughout the country, and lots of ineffective work:
- Child protection services cannot be adequately sustained because health visitors are not able to visit families in their homes and do proper assessments;
- Staff are drafted into areas where they don’t know the patients, families or the issues;
- Parents find that their health visitor led clinic has changed to a baby weighing one, where they can no longer expect advice and support;
- Special schools suddenly find that their school nurse has been withdrawn and they are offered a skeleton medicine giving service instead;
- Teachers find that school nurses have been stopped from helping to deliver the health and sex education modules;
- Looked after children’s nurses find that there is no one available to do the annual health assessments.
Crisis management is often conducted by email; a new directive appears in the inbox, with no opportunity for discussion about how it relates to existing policies and protocols. Sometimes the situation may be unsafe, such as when a community nursery nurse is told to cover a clinic on her own, in a venue not known to her and with no procedures in place. Or when school nurses are told to do home visits in the holidays, with no clarity about whether the families are expecting this.
The consequences to staff morale are devastating, with many losing motivation and desperate to retire. When a practitioner is told to double their work, the implication is that previously they had spare time - but they will have been telling their manager for months that they are unable to cope with the workload.
Is there a way to deal with this professionally? All registered nurses, including managers, must ensure they work within the Nursing and Midwifery Council’s code of conduct. The code is clear that nurses must advocate for patients, supervise and support those to whom they have delegated work, deliver evidence based care, work within the limit of their competence, and report concerns in writing if the environment of care is putting people at risk. It is time we did so.
About the author
Rosalind Godson is professional officer at Unite