NHS Wales Executive Board. District Nursing Workforce and Education

Transcription

1 Appendix 1 NHSWEB(00) NHS Wales Executive Board District Nursing Workforce and Education Sponsor: Jean White Chief Nursing Officer Contact: Paul Labourne ext: Who will present: Jean White This Paper is for decision PURPOSE The purpose of this paper is to set out the current position on the core universal element of nursing in the community: District Nursing. KEY SUCCESS CRITERIA Improved responsiveness and quality of care of district nursing services. Improved workforce information on district nursing services in Wales. Maximisation of the uptake of the opportunity the additional commissioned part time district nursing placements offer. Increase in the number of district nurses within the community nursing workforce. Reduce undue variation across district nursing service provision. Alignment of district nursing services with clusters, cluster development and cluster needs assessments. FINANCIAL CONSEQUENCES There are no direct financial considerations arising from the recommendations in the paper. However as the district nursing staffing principles are implemented any financial considerations will be planned through the IMTP processes. HUMAN RIGHTS, EQUALITY LEGISLATION AND WELSH LANGUAGE ACTS The subject of this report has been checked for compliance with the Human Rights Act, the equality legislation and Welsh Language Acts. Page 1 of 17

2 NEXT STEPS The Chief Nursing Officer will issue the district nursing staffing principles with the expectation that they are used to inform the 2018/19 IMTP s. If the recommendations in this paper are accepted, health boards will; Undertake actions to improve the quality of information recorded within ESR relating to district nursing and the qualifications community nurses have achieved. Stocktake and target community nursing staff who have undertaken the Fundamentals in Community Practice and additional modules to increase the number of district nurses within the workforce as an interim measure as the increase in commissioned numbers come on line. Review current practices to succession plan within community nursing services. And review the level of uplift within the service to maximise the opportunity the additional commissioned part time district nursing placements offer. Page 2 of 17

3 Report Requested by: Report Prepared by: Director General NHS Wales Nursing Officer primary, community, integration and innovation District Nursing Workforce and Education 1. Situation Wanless 2003, Design for Life 2005, Setting the Direction 2010, have all progressed the move to out of hospital services and the need to develop primary and community services. Prudent Healthcare 2014 is rooted in primary prevention and primary and community care Welsh Government published Our plan for a primary care service for Wales up to March 2018, followed by The Primary Care Workforce Plan 2015 both set out the crucial role community nursing services have in delivering primary and community care and the Primary Care Taskforce is driving key actions to give pace to these developments. This paper sets out the current position of district nursing. 2. Background A District Nurse is a nurse who has successfully completed training that has lead to a Specialist Practitioner Qualification (SPQ) being formally recorded against their Nursing and Midwifery Council (NMC) registration. The training is provided by Higher Education Institution (HEI) from 2008 this has been through a part time route over 24 months or a modular flexible route. Prior to this the options were a full time 12 month programme or the part time programme. The value of the SPQ is recognised both clinically and by organisations as it equips the district nurse to hold and manage a caseload. It assures the level of clinical leadership and risk management required of a at home service where it is by its nature harder to observe, monitor and manage care. Community nursing is the collective description of all nurses who work in the community including registered nurses who work under the direction of a district nurse. 3. Assessment Appendix 1 - Table 1 Commissioning Numbers. The table demonstrates that over recent years there has been a steady increase in the number of part time courses commissioned and an increase in the number of modules commissioned. Appendix 1 - Table 2 SPQ District Nurse Pathway Achieved. This information has been provided by the HEIs and demonstrates that between 2010 and 2016 the number of nurses successfully becoming a district nurse is in line with the number of part time commissioned courses. However a level of attrition would be expected and this may be being compensated for by the numbers of district nurses completing the modular route. District nurse leaders from across Wales report difficulty in releasing staff to undertake study due the continued pressure to meet service needs. They report headroom within the community nursing service does not account for staff undertaking the level of CPD required to support sufficient staff in undertaking both a SPQ district nurse recordable qualification part time route and staff undertaking modules that would result in a more flexible route to a district nurse qualification. Appendix 1 - Table 3 Other Awards Adult Nursing. The table demonstrates that very few nurses have undertaken awards that have not led to the SPQ recordable qualification with the NMC. The information behind this data is a mix of diploma, degree and masters level awards and suggests that these nurses have been in specialist community nursing roles and not district nursing. Appendix 1 - Table 4 Modules completed following completion of Fundamentals of Community Practice Module. Within this data there may be some double counting of those who have completed a second or third module. The trend in undertaking a second or third module is quite small in all HEIs Page 3 of 17

4 except for Swansea where in 2015 and 2016 significant numbers of second modules have been completed. It is difficult from the data to suggest how many nurses undertaking the modular route would be close to gaining the district nursing qualification. Appendix 1 - Table 5 District Nursing Numbers. The number of district nurses employed in Wales has steadily decreased from 2009 however the data shows a significant increase in numbers in 2016 due to a recoding issue being resolved for Cardiff and Vale University Health Board. This is to be seen as an improvement in data quality for the Cardiff extract rather than as a change in the numbers being employed. This may indicate that there is a data quality issues across this data set. Based on the StatsWales data (Table 5) release March 2017 there has been a 20% reduction in the number of district nurses employed across Wales between 2009 and Appendix 1 - Table 6 All community staff (nursing, midwifery, health visiting). The number of community staff employed in Wales has steadily increased from 2009 with a 20% growth by However this data covers all area of nursing, midwifery and health visiting and will also include school nursing and specialist nursing working in the community. It is not possible to extract the core universal district nursing service provided. Appendix 1 - Table 7 Additional data received from health boards. There is currently the requirement for WTE team leadership roles in Wales. StatsWales data (Table 5) suggests there are WTE district nurses within Wales. This may indicate that the current level of district nurses is sufficient to provide the leadership required within the current models of district nursing services. However service leaders are reporting that once staff attain the district nurse qualification they apply for promotion out side of the core district nursing service, opting for other roles within primary and community care such as specialised teams; rapid response, hospital at home or working with unscheduled care services. Service leaders are also reporting significant difficulty in appointing to deputy and team leader roles as there is not a sufficient pool of district nurses to recruit from. This is leading to the recruitment of staff without the essential qualification with the bond to become a district nurse within a fixed time period. The data from the health boards demonstrates the significant variance across Wales as to the number of community nurses per population, the size of the community nursing teams and the population these teams serve. It also demonstrated that as at September 2016 vacancy rates ranged from 1 to 12% with the average being 6% Benchmarking Over 2016 the National Collaborative Commissioning Unit in conjunction with Welsh Government commissioned the Benchmarking Network to undertake benchmarking activities around unscheduled care. As part of this exercise district nursing services went through a benchmarking data collection process. This is the first time Wales has participated in this exercise and the data collected in this first round was not complete for all areas or for all health boards. This was reported as issues with the limited access to informatics systems within community based services. There was also significant variance within the data collected, reflecting the significant variance in service provision as can be seen in appendix 1 table 8. This is in line with the Welsh Audit Office findings within its 2014 audit of district nursing services. The benchmarking concludes; Wales experiences similar levels of demand to England as measured by referrals per 100,000 population. A higher proportion of referrals are dealt with within 28 days in Wales than England. Investment and staffing levels both appear lower in Wales, based on the data supplied. However, the volume of face to face contacts per 100,000 population is only slightly below England, which appears to be being achieved through higher productivity delivered by District Nurses in Wales. Page 4 of 17

5 A higher proportion of the workforce is clinical in Wales, and hence a lower proportion of the overall budget is spent on non-clinical staff pay. The skill mix of clinical staff is slightly richer than in England. Performance is good on workforce key indicators (sickness and staff turnover) and vacancy rates are much lower than in England. Spend on bank and agency is also lower than in England. District Nurses in Wales appear to carry smaller caseloads than in England. Where reported, levels of SUIs and complaints are low for District Nursing services in Wales. On some other outcome measures (pressure ulcer incidence, dying in preferred place of care), performance is slightly worse than in England. Welsh Audit Office The findings were very similar across all the health boards though they recognised the significant variance across services. The recommendations over all the audits covered the following areas: Vision for the District Nursing Service Sharing of good practice Patient Experience Service Specification o Including referral criterion admission and discharge from the caseload Workload and Workforce Information o (Demand & Capacity) o Performance information (possible District Nursing Dashboard) Deployment of staff and scheduling A significant limiting factor within the WAO 2014 audit was the very limited use of information technology within community services to support the service management, service development and service feedback. It is hoped that the Welsh Community Care Information System (WCCIS) will address many of the current informatics issues raised by the WAO and support future bench marking exercises. Integrated Mediate Term Plans IMTP s Overview. The current iterations demonstrate very little discussion around core district nursing services, the strategic plan going forward and how they will further integrate with cluster development. The plans are not clear on how these core services will develop to meet the demands in demographic changes the plans articulate or how these services will meet the strategic policy challenge of providing greater services out of hospital. National work led by the Chief Nursing Officer Appendix 2. Through the Chief Nursing Officer and the Nurse Directors an all Wales working group has been looking at developing a workload and workforce calculation tool for Wales. This is at least four years away as a robust clinical data collection system is required and the current program to deliver the WCCIS to all health boards has a rollout plan over the next 36 to 48 months. In the interim the Nurse Directors have agreed to work towards a set of interim staffing principles to improve patient care, reduce variation in deployment of the core universal element of nursing care in the community - district nursing services and align these services within cluster and primary care geographical catchments (Appendix 2). The guiding principles are aspirational in nature however they provide a set of staffing principles to work towards to improve care to patients based on the current best available evidence. Although all the health boards have expressed concerns over the implementation of these interim guiding principles, health boards with large and dense urban areas (C&VUHB, ABUHB and ABMUHB) will have the most challenge in working towards meeting these principles. Financial Considerations Page 5 of 17

6 The volume and skill mix of district nursing teams depend on the needs assessments for the communities they serve and the demands those communities place on the service. This needs to be reflected within the cluster needs assessments and be drawn through to the IMTP s. However it is recognised that district nursing is currently working at its maximum capacity with good productivity compared to England and any further shift of activity into the community would require a similar shift in resource. Based on an assumption that the current service configuration has a sufficient volume of staff to meet the presenting demand an impact assessment has been undertaken to assess the impact of the interim guiding principles for district nurse staffing would have on skill mix and district nurse leadership requirements. This impact assessment estimated that the overall cost would be in the order of 1m to implement. Currently traditionally uplift for leave, sickness and continued professional development has not been built into district nursing budgets and with the significant increase in commissioned part time district nurse education numbers for (41 places to 80 places and the flexible modular route) the ability of health boards to release staff in year to maximise this opportunity is constrained by the operational cost of this time being lost to the service. It has been estimated that the cost in lost staff time for staff to undertake these modules and maximise the training opportunity equates to 1.2m at mid point band Summary / Conclusion There is a clear policy strategic drive towards out of hospital care. District nursing is the universal element of adult community nursing and district nurses provide the clinical leadership and risk management required to deliver care coordination within a multidisciplinary integrated service. Set against the demographic and strategic challenges these universal services need to be central to the IMTP s in order for the strategic planning required within the primary care plan. There has been an increase in the investment in the commissioning numbers of district nurses, the numbers of nurses successfully attaining the district nursing qualification is broadly in line with the commissioned numbers of part time courses. The SPQ District Nursing qualification should continue to be the programme of choice for district nurses as it provides the skills required, meets service needs and has recognised transferable qualities within primary and community services. The numbers undertaking a modular route is difficult to ascertain with nurses completing at least 1 module post Fundamentals of Community Practice. This may be an area health boards would wish to target locally to increase the numbers of staff who could complete an SPQ in District Nursing as they are currently only a couple of modules off the award. This would require more accurate recording of community qualifications attained within the Electronic Staff record ESR and would be an interim measure to quickly up skill community nurses to district nursing while the additional commissioned places come on stream. Service leads report difficulty in filling deputy and team lead roles within district nursing services due to a shortage of staff who are district nurses. Service leads also report service delivery constraints in releasing community nurses to gain the skills to become a district nurse. Sufficient uplift should be built into the district nursing workforce to support and maximise the commissioned training numbers. Information about district nursing services is difficult to obtain, WCCIS will go a long way in improving informatics about the service but will be at least another 3 years before introduced into all health boards. From the StatsWales information there has been a 20% reduction in district nurses since 2009 while over the same period there has been a 20% increase in the number of community nursing staff. There is some question over the ongoing accuracy of the number of district nurses and the number of community nurses includes other services and not just the core Page 6 of 17

7 universal district nursing service. To improve data quality around district nursing services would require more accurate and standardised recording of the service within ESR to enable an all Wales data extract. From the available information there is significant variation across Wales in service configuration and delivery and more than would be expected to meet local variation in need. The service when benchmarked against England has similar demand, less investment in staff and has a richer skill mix of staff per 100,000 population. It undertakes a similar number of face to face contacts demonstrating a higher productivity and better response times than England. Welsh district nursing services also show better key performance indicators and a lower level of complaints and serious untoward incidents. This could be as a result of the higher skill mix and smaller caseloads the teams have against those in England but may not be an indication that the service model is correct. The benchmarking also indicates that the teams are also working at the maximum of their capacity within their current service configuration. The Chief Nursing Officer and Directors of Nursing have agreed a set of district nursing staffing principles. These are an interim measure to work towards based on current known best practice and evidence until sufficient informatics systems can be implemented to support a district nursing workload and workforce tool as part of a triangulated approach to calculating required establishments. The principles support clusters and neighbourhood delivery of care, will reduce the level of undue variation in staffing delivery and ensure there is sufficient headroom to enable teams to release staff to undertake professional development and support the succession planning of district nurses. 5. Recommendation That the following matters be taken up with the NHS Wales Executive Board: Through the Directors of Workforce and Organisational Development undertake actions to improve the quality of information recorded within ESR including recording those working in the core universal district nursing service and the qualifications obtained by community and district nurses. Health boards stocktake and target community nursing staff who have undertaken the Fundamentals in Community Practice and additional modules to increase the number of district nurses within the workforce as an interim measure as the increase in commissioned numbers come on line. Health boards to review current practices to succession plan within nursing services and level of uplift to maximise the opportunity the additional commissioned part time district nursing placements offer. Health boards to work towards the Chief Nursing Officers interim guiding district nursing staffing principles to support the planning of community nurse staffing levels. Welsh Government to strengthen the IMTP planning guidance by using the Chief Nursing Officers interim guiding district nursing staffing principles. Page 7 of 17

8 Appendix 1 Table 1 District Nurse Commissioning Numbers Year Part Time Modules 07/ / / / / / / / / / / Table 2 SPQ District Nursing Pathway Achieved WEDS data provided by the HEI's HEI Glyndwr University University of South Wales Swansea University Cardiff University Bangor University All Organisations Total 211 Based on a 2 year program of study for the part time route Commissioned 2 years previously Total 206 Page 8 of 17

9 Table 3 Other Awards Adult Nursing WEDS data provided by the HEI's HEI Glyndwr University University of South Wales Swansea University Cardiff University Bangor University All Organisations Table 4 Modules completed following completion of the Fundamentals of Community Practice (Adult Nursing) WEDS data provided by the HEI's HEI Glyndwr University University of South Wales Swansea University Cardiff University Bangor University All Organisations Page 9 of 17

10 Table 5 District Nursing* Numbers in Wales (WTE) StatsWales Data March 2017 based on September 2016 information extract. Local Health Board Betsi Cadwaladr University Hywel Dda University Abertawe Bro Morgannwg University Cardiff and Vale University Cwm Taf University Aneurin Bevan University Powys Teaching All Organisations * District nurse / CPN / CLDN 1 st level only Table 6 All community (nurses, midwives, health visitors) (WTE) StatsWales Data March 2017 based on September 2016 information extract. Local Health Board Betsi Cadwaladr University LHB Hywel Dda University LHB Abertawe Bro Morgannwg University LHB Cardiff and Vale University LHB Cwm Taf University LHB Aneurin Bevan University LHB Powys Teaching LHB Welsh Ambulance Services NHS Trust Public Health Wales NHS Trust All Organisations Page 10 of 17

11 Table 7 District Nurse Team Information from health board district nurse leads September 2016 Health Board Current number of teams Current ave population per team Ave budgeted WTE per team Total budgeted WTE Population per budgeted WTE Total contracted WTE Sept 2016 WTE Vacancy Sept 2016 % vacancy as at Sept 2016 Budget ed Team Leader Budget ed Deputy Team Leader Total Budgeted Leadership Population PtHB % CTUHB % ABUHB % ABMUHB % C&VUHB % BCUHB % HDUHB % Totals % The table demonstrates the current variation between health boards with the variance in population against budgeted WTE ranging from a population of 1094 per WTE to a population of 2467 per WTE. Page 11 of 17

12 Table 8 Productivity Benchmarking with England The graphs also demonstrate the huge variance within Wales. Updated Page 12 of 17

13 Appendix 2 District Nursing Staffing Principles The district nursing staffing principles have been developed to provide an overall set of principles that empower district and community nursing to make a difference to individuals within the communities they serve. The principles need to be taken as a whole as interdependency between principles enables a triangulated three dimensional approach which captures the complexities of care in the community provided by district nurses in Wales. The principles are set within the following underlying operational context: Workforce assessment should be undertaken based on these principles at least annually and when an identified change in workload has been noted a district nursing team s workload. District nursing teams will be structured so they are coterminous with the cluster catchment / footprint and each cluster should have an identifiable cluster lead for the district / community nursing service. Each district nursing team or unit will have a distinct and identifiable geographical neighbourhood, zone or district within the cluster to enable the easy identification of the district nursing teams contact details from the patients address. The staffing make up of district nursing teams will be dependant on and reflect the cluster needs assessment of the population the team serves and the caseload the team carries this will include any care homes within the team s district and if the team is required to support Continuing NHS Health Care patients. The skill mix within the team will also take into account other community based services serving this district (for example reablement teams, rapid response or out reach teams, social care teams and third sector support). District nursing will apply prudent healthcare principles to workload and workforce. The District Nursing Staffing Principles and supporting evidence are set out on the following table: Principle 1. Professional nursing judgement will be used in determining district nursing team s establishments. 2. District nursing teams will be structured so they are coterminous with the cluster catchment / footprint. Each district nursing team or unit will have a distinct and Updated Supporting Evidence / Rationale / Guidance Ball 2014 provides a narrative summary of staffing levels and the use of professional judgement. The Scottish workforce evidence supports professional judgement methodologies. The Nurse Staffing Levels (Wales) Act refers to the use of professional judgement in the triangulated methodology prescribed therein. Placed based systems of care Ham (2015) promote the evidence in providing care over a identifiable geographical neighbourhood, zone or district. Page 13 of 17

14 identifiable geographical neighbourhood, zone or district within the cluster. 3. The skill mix within district nurse led teams should be predominantly nurse registrant supported by health care support workers dependent on the patients care needs. 4. Each district nursing team or unit will have a clinical lead District Nurse with a NMC recordable qualification (SPQ) or a post registration community nursing degree and leadership training. At least 20% of their time will be spent on case management and at least 20% of their time undertaking supervisory activities, aiming towards a full time supernumerary role as the needs of the team or unit dictate. A population of 9,000 to 18,000 will have between at risk of admission patients with at very high risk and as such a district nursing team or unit should serve a neighbourhood, zone or district of no more than circa 18,000 population. There is no lower limit to the size of the neighbourhood, zone or district or population size the district nursing team can serve. In its review of evidence, published in July 2014, Public Health Wales NHS Trust concludes that there is an emerging and strong consensus in the UK literature that planning and provision of primary care should be done at a small population level. Ball 2014 suggests an average team covers a population of just over 5000 people. Evidence suggests smaller district nursing teams both in staffing head count and population size, lead by a District Nurse have better quality outcome results within Wales as has been demonstrated through Fundamentals of Care Audits, the Welsh Audit Office review of District Nursing Services 2014 and observed within the quality audits undertaken by the All Wales Workload and Workforce Calculation Tool Working Group. Population size alone does not indicate the level of need within the population which should be the key determinant when planning the establishment to meet population needs. Typically the skill mix should be no less than 60:40 registrant to HCSW; or one registered nurse supervising up to two HCSWs. This principle is to support the appropriate supervision of community staff where direct supervision is difficult to facilitate. To provide clinical leadership and named accountability for a given team / population. To provide case management leadership within the team. This is to promote core universal nursing teams in the community lead by a District Nurses with a recordable qualification. A typical team (of 15 staff) would have one Community Matron with a recordable qualification (Ball 2014). Updated Page 14 of 17

15 5. There will be at least one deputy team leader District Nurse with a recordable qualification (SPQ) or a post registration community nursing degree and leadership training case manager within each district nursing team. 6. To promote the continuity of an individual s care and to develop expertise about assets within a community each district nursing team or unit within a cluster will have a staffing complement of no greater than 15 staff / 11 WTE % uplift will be used in calculating the headroom within a team. Updated At least one deputy team leader District Nurse with a recordable qualification or a community nursing degree and leadership training provides contingency in leadership, succession planning and the opportunity for the deputy to step up. To provide case management support within the team. A typical team (of 15 staff) would have two District Nurses with a recordable qualification. Ball (2014) The management and performance of teams based on team size is well documented Borrill et al (2000). In suggesting a maximum size of a district nursing team or unit there may be unintended consequences over future staffing. To mitigate the risk of this being seen as a maximum the need to create multiple teams to meet patient needs is an integral part of this principle. If the population s needs and workload assessment dictates a staffing complement of greater than 15 staff / 11 WTE, the geographical district the team or unit serves will be split into two smaller districts and two district nursing teams or units will be created 1, additional staff will be added to these teams to meet the needs of the population within each of the new districts. 1 Each district nursing team will have a District Nurse Team Leader and at least one deputy team leader District Nurse. This could be a temporary measure if the increases in patient needs (and thus the workload assessment) are also considered to be temporary. A typical district nursing team is made up of 15 staff representing 11 WTE Ball (2014) Evidence suggests smaller district nursing teams both in staffing head count and population size, lead by a District Nurse have better quality outcome results within Wales as has been demonstrated through Fundamentals of Care Audits, the Welsh Audit Office review of District Nursing Services 2014 and observed within the quality audits undertaken by the All Wales Workload and Workforce Calculation Tool Working Group. Health Boards report that smaller teams have better recruitment and retention than larger teams. The dividing of a population footprint based on demand is a process used within the Buurtzorg model of community care. Please refer to the How is uplift calculated? guidance in appendix 2. This is in line with other nursing areas. Page 15 of 17

16 8. Each team will have access to at least 15 hours administration support per week. This is to promote prudent care delivery by reducing the administration burden by the team and releasing clinical / direct patient care time. The administrative support would also provide a point of contact for the team to aid communication with the team. Updated Page 16 of 17

17 References Ball J, Philippou J, Pike G, Sethi G (2014) Survey of district and community nurses in 2013: report to the Royal College of Nursing. NNRU. London. Borrill et al 2000 The effectiveness of healthcare teams in the national health service Ham C, Alderwick H 2015 Placed based systems of care. Kings Fund. London Welsh Government 2015a Planned Primary Care Workforce for Wales, Approach and development actions to be taken in support of the plan for a primary care service in Wales up to Welsh Government 2015b Prudent Healthcare, Securing health and wellbeing for future generations. 17