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What lies ahead for community nurses?

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The government's major shake-up of the NHS, published earlier this month, included Our Vision for Primary and Community Care, a stand-alone document outlining junior health minister Lord Ara Darzi’s plans for the expansion of non-acute services (NT News, 8 July, p3).

These plans acknowledge that community nursing has received insufficient attention in the past. ‘What we are saying is there has been less focus on community services than in acute care,’ says Helen Fentimen, lead for the NHS’ newly created Transforming Community Services Programme (TCSP) board.

The board, under the leadership of primary care tzar David Colin-Thome and deputy chief nursing officer for England Viv Bennett, will take the plan forward.

‘The programme is in two parts; business improvement and clinical and service development,’ Ms Bennett said.

‘It will involve pulling all of the strands of work that has already been done and is currently being done on moving care in to the community in a way which is coherent for nurses on the ground,’ she added.

Ms Bennett said she hoped a project timeline would be in place this week and that there would be key milestones for the programme by August.

‘This is really good work. It recognises the central role of community nursing in developing high-quality care and it will show community nurses how to get involved in the opportunities that are now available to them,’ she said.

Speaking at the launch of the plan, Professor Colin-Thome said: ‘There will be a big focus in the development of community services – on health visitors, district nurses and school nurses. I do not think they have had enough focus and they are one-fifth of our workforce.’

So what type of community service will nurses be working for in future?

The plan outlines four main themes. As a priority, community practitioners will shape services around patients, promote healthy living, work to continuously improve care and lead services locally (see box).

Patients will have a greater choice of GP practice and will be surveyed on practice quality. They will register with one GP but will be able to be treated at larger clinics.

People with long-term conditions will receive tailored care plans and more will be done to address health inequalities and help people quit smoking, eat healthily and exercise more.There is a government promise that relevant training will ensure nurses can meet these needs.

Now, more than ever, the role of community nurses will be vital. By 2010 these nurses will have been instrumental in delivering 15 million personal care plans.

To facilitate this, the government is launching two efficiency initiatives – Productive Community Hospitals and Productive Community Services. These will be based on the principles of the NHS Institute for Innovation and Improvement’s successful Productive Ward scheme for hospitals.

A set of indicators or ‘metrics’ is also planned to enable community nurses to record what they do, how they do it and the time it takes them. This will give commissioners a greater understanding of the work being done and enable them to improve workforce planning.

In line with the NHS ‘cradle to grave’ ethos the programme board will work on an approach for health visitors and school nurses to take forward a child health promotion programme, due to start in the autumn, and district nurses will be involved in programmes around wound care, continence and stroke.

There is a buzz of excitement around the new plans but it is accompanied by caution.

Cheryll Adams, lead professional officer for Unite/CPHVA, said: ‘I feel extremely positive about the strategy. It recognises the impact of good clinical leadership but this is not going to go anywhere if there is not any work done around gaps in the community workforce.’

Ms Adams says a set of metrics will help address variations in service quality but she feels that Essence of Care benchmarks should already be doing this.

Warning that the programme board must be careful not to create extra bureaucracy, she added: ‘For clinicians to be able to embrace new innovations they will need to be able to see it adds value to their work. If it is going to be an extra lot of form-filling they are going to try to duck and dive it.’

Ann Duffy, Community District Nursing Association chief executive, also remains cautious. ‘We would welcome anything that will develop community nursing but there has to be the funds to make all of this happen,’ she said.

She is unsure how the Productive Ward scheme would transfer to the community. ‘In the acute sector you have the back up services and the staff and the support.

‘What with frozen posts, a large portion of district nurses coming up for retirement, an awful lot of driving and sitting in traffic – looking at some of their caseloads – I cannot see how they can free up any time.’

Another key strand of the plan will be to encourage uptake of nurse-led social enterprise schemes by allowing portability of NHS pensions.

This has unsurprisingly attracted a lot of attention. The government is confident that this new offer to nurses of being able to retain NHS pensions – a previous sticking point – will be effective in encouraging them to set up social enterprises, which have so far not expanded at the rate ministers had hoped for.

Chief nursing officer for England Dame Christine Beasley has told NT she believes there is a lot of interest among nurses in setting up their own not-for-profit schemes and that the pension issue was a ‘very big barrier’ (NT News, 1 July, p3).

But Ms Duffy remains unconvinced, suggesting that running such an enterprise would be at odds with the traditional caring ethos of nursing.

‘In becoming a business you lose a lot of the caring side of what nurses are about because it becomes all about money making and profit making,’ she said. ‘The bottom line with nurses is, it’s not about making money, it’s about putting the patient first.’

Unison senior national officer Mike Jackson has practical concerns, asking what would happen to pensions if a social enterprise is taken over by an independent sector company.

‘It is not as good as it looks because groups of staff can set up social enterprises to bid for work but might find themselves coming up against large predatory businesses. If they then have to move to be employed by a secondary provider they will not retain their pension,’ he said.

Union stakeholders also highlighted the lack of workforce detail in the document.

Ms Bennett revealed to NT that the Department of Health was looking at health visiting and school nursing numbers, though work is yet to start on looking at district nurse numbers.

‘Clearly what we will need to do is see if we need more [district nurses] as work moves out of hospitals and into the community but how many of them will be district nurses as we understand it now, we will have to wait and see,’ she said.

Reading between the lines, Ms Duffy suggested this could mean acute nurses being moved into community work, with
fewer dedicated district nurses being trained.

The government’s August timeline on the TCSP’s progress will be a real turning point in understanding how the vision for the community will be driven forward. But there should be no doubt among community practitioners. Change is certain and the success of any plan will depend on their response to it.


People Shaping Services

To produce a service that is responsive and based on people’s views. Patients will have a greater choice of GP practices and will be surveyed to see if their practice is providing an all-round quality experience. By 2010, 15 million people with long-term conditions will be given personal care plans, tailored to support their needs.

Promoting Healthy Lives

To support people in adopting healthy lifestyles. Health visitors, a child health promotion programme and all community nurses will be key to this. Practice and district nurses will develop a vascular risk assessment programme. Community nurses will be key in tackling health inequalities by helping people give up smoking, control alcohol use and improve diet and exercise.

Continuously Improving Care

A programme of professional development will be available to strengthen the clinical leadership skills of community nurses and health visitors. More time to ensure high-quality patient care will be made available, through two new productivity community schemes.

The health service will support local decision-making and give nurses the right to request to become a social enterprise.

Leading Local Change

To encourage more practice-based commissioning to continue to make health improvements and provide high quality care. To pilot new ways of providing more integrated care and provide staff with development programmes to learn about commissioning.

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