Glasgow City CHP Item No. 6 CHP Committee Meeting Date: 23 October 2014 Paper No 2014/054 Subject: Presented by: Recommendation(s) Summary/ Background District Nursing Review David Walker, South Sector Director The Committee is asked to note this report and the progress on the review. Partnerships have been undertaking a wide review of community services over the last 2 years including health visiting, physiotherapy, speech and language therapy, podiatry and dietetics. These reviews have concentrated on improving efficiency, making services fit for the future and improving quality and governance structures as well as ensuring a sustainable financial profile. This review of district nursing (DN) proposes significant changes to the workforce, sets out a governance and quality framework, maximises the efficiency benefits of agile working and defines an equitable and uniform service model which will support the move to Health and Social Care Partnerships in 2015. The paper also outlines some of the contributions that a modernised district nursing workforce could make to the better management of long term conditions in primary care, the development of anticipatory care and the effects of an ageing population. As new service models develop it provides a firm basis from which the service can contribute its expertise in case management, its unique links to the broader health and social care system and its skills and flexibility. Policy/ Legislative Context Financial Implications Human Resources Implications Service User/Carer Engagement Equalities Implications None. Capital and revenue implications referred to in papers. Skill mix implications referred to in papers. None. None. FoI/EIR Status tick If not to be made public, exemption Public (Section/Regulation) to be relied on under FoI/EIR legislation must be inserted below.
Not Public Contains Personal Data DPA applies S.38 1. 1.1 Progress Report Three papers are appended: a) Review Business Case b) Service Specification c) Responses to Comments from Consultation 1.2 1.3 1.4 The review of district nursing (DN) will deliver increased time spent supporting patients and improved quality of care. It proposes significant changes to the workforce, sets out a governance framework and quality framework, maximises the efficiency benefits of agile working and defines an equitable and uniform service model which will support the move to Health and Social Care Partnerships in 2015. The proposals set out an initial phase of change for district nursing over next 3 years (2014/2017). The key components of the review are rebalancing the workforce, embracing agile working, defining caseload sizes and teams, redefining the patient s day, enhancing links with other parts of the health and social care system including out of hours and developing a structured governance programme including shared learning and education. The review demonstrates that there is significant scope to rebalance the DN service using a combination of re-profiling the workforce and releasing time by moving to agile technology, introducing consistent models of care, staff to caseload ratios, implement more efficient skill mix that will provide additional capacity and support the service to meet increased workload. 2. The Review has given the service an opportunity to review, revise and modernise the specification. It will be reviewed annually to ensure any emerging developments delivered by the service are recorded. 3. Responses to the consultation were considered and responses supplied. Comments were themed and included rationale for change, staff engagement, service model, team model, succession planning, IT requirements, patient involvement and agile working. 4. 4.1 Implementation Group In order to take forward the review an implementation group has been formed, chaired by Anne Mitchell, Head of Primary Care and Community Health, South Sector, and Chris McNeill, Head of Community Health and Care Services, West Dunbartonshire CHCP. This group will oversee the work streams and monitor the outcomes to deliver the proposals set out in the business case. 2
Appendix A District Nursing Service Fit For the Future Service Specification September 2014 1
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 1. INTRODUCTION... 3 2. THE VISION... 3 3. SERVICE DESCRIPTION... 5 4. PLANNED & UNPLANNED CARE... 5 5. REFERRAL... 6 6. RANGE OF SERVICES... 6 7. SUPPORTING DISCHARGE... 10 8. RECORD KEEPING... 10 9. PRACTICE DEVELOPMENT... 10 10. PROFESSIONAL SUPERVISION... 11 11. EDUCATION & TRAINING... 11 12. QUALITY & GOVERNANCE... 11 Appendix 1 Facing The Future Together... 13 Appendix 2 References... 16 2
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 1. INTRODUCTION 1.1 This document sets out the specification for the provision of district nursing services to the adult population of Greater Glasgow and Clyde. The service specification has been informed by a review of the current service and is underpinned by the Scottish Government vision for Modernising Nursing in the Community, the Quality Strategy ambitions of safe, effective, person centred care and the Scottish Government 2020 vision for the future provision of health care in Scotland. This specification sets out the vision for the service ensuring it is fit for the future. This is in keeping with the principles expressed by the Nursing and Midwifery Council, Royal College of Nursing, Community Practitioners Health Visiting Association, Unison, Unite and Queens Nursing Institute Scotland. 1.2 The core skills, values and beliefs that inspired district nursing from the beginning still drive district nursing in NHSGGC today: the importance of keeping people at home where they want to be, the unique relationship between nurse and patient as the prime therapeutic tool, working in partnership with families and carers, the importance of our expert assessment and clinical skills and the need to promote and enable patient independence. 1.3 We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management where everyone is able to live longer and healthier lives at home, or in a homely setting. 1.4 This specification set out how NHSGGC district nurses will respond to the demands of a modernising NHS which will bring with it changes to the way district nurses will work, be educated in the future, become equal partners in care delivery, in response to the changes to the therapeutic landscape in which they will practice as effective leaders and clinicians. 2. THE VISION 2.1 The district nursing service will deliver high quality, compassionate care and health and well being outcomes for all patients referred to the service. 2.2 They will do this by providing: care which is patient centered, safe and effective; care which is consistent, high quality and holistic; compassion in care alongside integrity, respect and dignity; competence from being highly trained and skilled using evidence based interventions; communication across interfaces with patients and other services as a seamless approach; being an advocate for patients and having the courage to challenge when things go wrong; commitment to improve health outcomes. 3
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 2.3 Priority areas for district nursing are: maximising health and well being and helping people remain independent; identify the need for early help and manage crisis intervention or where patient has long term condition or complex care needs; case manage and co-ordinate care for patients who are unwell or recovering at home; promote a positive patient and carer experience, empowering patients and enabling self care; working with a range of health and social care partners to provide services to adults and their carers at home or in other homely setting; building on and strengthening leadership and measuring impact; supporting positive staff experience both as individuals and within their teams. 2.4 District nurses will work with key delivery partners to improve the health and well being of patients: GP s; social care; acute services; hospice; carers; specialist nursing services; residential and care homes; voluntary organisations. 2.5 District nurses will manage the interface with a number of community services to ensure: effective delivery of care; effective information sharing; effective joint planning to meet patient and carer needs. We will deliver a safe, effective person centred care that achieves the best clinical outcomes for our patients. To achieve that aim, we will deliver the service upon; our organisational values, Facing the Future Together and adopting the 10 Essential Shared Capabilities All of these refer to how we will work with patients to guide our work by: working in partnership; respecting diversity; practising ethically; challenging inequality; promoting recovery, well-being and self-management; identifying people's needs and strengths; providing person-centred care; making a difference; promoting safety and risk enablement; personal development and learning. 4
3. SERVICE DESCRIPTION DISTRICT NURSING SERVICE FIT FOR THE FUTURE 3.1 District nurses are registered nurses with an additional specialist qualification in nursing adults in the home. The qualification is recordable by the Nursing and Midwifery Council (NMC). 3.2 The district nursing service is led by a Senior Nurse who has professional and operational responsibility for nursing staff within their service area. They are supported by Clinical Team Leaders who oversee a number of community nursing teams. The team members include, district nurses, community staff nurses and health care assistants. The district nursing team is led locally by the caseload holder who is accountable and responsible for a team of qualified and unqualified staff. 3.3 All patients will have a named nurse who is responsible and accountable for their care provision as allocated by the district nurse. The named nurse will be responsible for assessing, planning, delivery and evaluation of care in partnership with patients and their carers with respect for patient s individuality, rights, choice and cultural differences. 3.4 The district nursing service provides nursing care to house bound patients in their home environment and will also visit patients whose nursing needs indicate that the service requires them to be seen in another clinical setting such as care home or setting suitable to or defined by patients needs 3.5 Patients accepted onto the district nursing caseload will have access to all services provided by the district nursing team. The services are delivered within a framework of professional accountability and are underpinned by evidence based practice, equity, accessibility and the quality ambitions of safe and effective person centred care. 3.8 District nurses have a designated base but may work remotely supported by the use of information technology which will provide up to date real time information on patients and electronic communications such as email, access to clinical portal and emergency care summaries. 3.9 District nursing teams are aligned to GP practices and each GP practice has a named district nurse/s that provides a leadership role in terms of communication and engagement with the practice. 3.9 District nurses will complete documentation for each patient admitted to their caseload and maintain the community nursing information system (CNIS) in line with NMC standards of record keeping. 4. PLANNED & UNPLANNED CARE 4.1 Planned Care: district nurses are involved in the delivery of planned care to individuals with both complex and non complex health problems. District nursing interventions may be short term or longer based on the need of the individual patient. Planning for discharge from the district nurse caseload is considered at the beginning of the patient s period of care. 5
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 4.2 Unplanned Care: In addition to planned care district nurses often undertake unplanned episodes of care if the patient s condition dictates this with the aim of preventing hospital admission and rehabilitation of individual patients during this period. 5. REFERRAL 5.1 There is open access to all patients and their carers. To facilitate processing a referral to the service a referral form must be completed by the referrer to inform the district nursing assessment. The service will aspire to develop an electronic referral process within the future IM&T developments. 5.2 The service will undertake all non urgent and routine visits within a time scale agreed with the service user and accommodate a choice of am or pm visits wherever possible. 6. RANGE OF SERVICES 6.1 The service will provide case management, skilled clinical interventions, health education and health promotion encompassing a broad spectrum of technical expertise, in order to promote and maintain independent living. 6.2 Every patient referred to the service will undergo an assessment. The level of assessment will be commensurate with the presenting needs. Individuals with complex needs or multiple problems will undergo comprehensive assessment; this may be a district nursing assessment or a single shared assessment involving partner agencies. This assessment is designed to explore in detail physical, psychological, cognitive, social and spiritual needs and will include palliative care. 6.3 The service will deliver formal anticipatory care approaches with a strong emphasis on assessing risk, promoting health, managing crisis, preventing illness and prevention of hospital admission and readmission. 6.4 The service will support patients and / or their carers to develop the knowledge and skills required to improve their health and self manage their health-related condition. Carers will be involved in assisting with needs assessment. Carers will be signposted to appropriate agencies and will be given access to a carers assessment. 6.5 The service will facilitate timely discharges by in reach to hospital settings where possible and contribute to liaison and case discussion prior to discharge. 6.6 The service will assess for admission to nurse led beds for emergency respite and carer support in areas that have this service available. 6.7 Care Management: district Nurses will have a key role in the care of individuals with long term conditions and complex care needs. They have extensive experience of managing and co-ordinating patient care in the community. The district nurse may undertake the role of care manager for those patients requiring continuing care who often have complex needs and 6
DISTRICT NURSING SERVICE FIT FOR THE FUTURE disabilities related to long term conditions. These patients often require intensive packages of care which often involves input from health, social care and other agencies. Continuing care packages may include an element of supporting individuals at home and anticipatory care management. District nursing staff are responsible for the provision of the health elements of this care and will work in partnership with patients, carers, social care services and voluntary organisations to meet the needs of the patient. 6.8 Administration of Medicines: medications are administered by the district nurse where the route of administration requires clinical skill and competence. They may also support and advise patients to safely administer their prescribed medication, enabling the patient to remain at home. This may include assessment of suitability for a compliance aid or referral to managed medication service or local authority home care service in accordance with local provision. Medication delivery by the nurse includes by: injection; infusion subcutaneous / syringe drivers; PICC and Hickman lines; chemotherapy lines; optical route; vaginal route; rectal; topical; PEG tube; 6.9 District nurses who have undergone additional training and can prescribe items from the Nursing Formulary. Although not all district nurses are Non Medical Prescribers we will continue to develop this to support anticipatory prescribing. Nurse prescribers must maintain prescribing competencies. 6.10 Wound Care: district nurses are highly skilled in managing and promoting tissue viability; e.g. wound care, lymphodeama and pressure ulcer prevention. This care can range from post operative wound management through to the management of complex chronic wounds. The service is working towards Zero Tolerance of avoidable pressure damage in line with Board and national policy. 6.11 Leg Ulcer Management: provision of evidence based, high quality assessment and treatment for patients presenting with a leg ulcer. Doppler assessment of arterial function may be required as part of comprehensive assessment of patient care. We will aspire to provide local accessible community clinic based services for ambulant patients. 6.12 Continence: continence will be assessed and managed by district nurses independently or in collaboration with other health professionals such as the continence service supported pelvic health through empowerment rehabilitation and education (SPHERE). The aim of the assessment will always be to consider active treatment if possible and self management. 6.13 Catheter Care: this includes care of: support to patients who are unable to manage their catheter independently; 7
DISTRICT NURSING SERVICE FIT FOR THE FUTURE care of patients with urethral / supra pubic catheters; patient education and support to self manage own catheter where possible. 6.14 Bowel Care: assessment and management of bowel care will be provided by working with patients to enable to self management if appropriate. However, some patients may require district nursing input following assessment. 6.15 Aural Care: the emphasis of aural care will be on self management. Following assessment, treatment for ear irrigation may be performed by a member of the district nursing team. 6.16 Phlebotomy: venepuncture will be carried out for housebound patients and those in residential settings where there is regular and ongoing district nursing intervention as part of patient s ongoing package of nursing care. 6.17 Diabetes Management & Treatment: provision of diabetes care such as administration of insulin, blood glucose monitoring to patients who are unable to self administer insulin. This would also include monitoring, support and promotion of independence to patients where appropriate. 6.18 Stoma Care: this includes bowel stoma care, urostomy care, tracheostomy care and gastrostomy care. Care of this nature involves the support and education of the patient to enable him / her to self care. Some patients with continuing care needs have stomas which they are not able to self manage. District nurses together with home care staff may support these patients in terms of long term care and support. 6.19 Palliative Care: the district nursing service is involved in providing care and support from diagnosis to the palliative stage of illness. They work collaboratively with GP s, hospice, acute services, and local authority services to provide holistic care to patients who have cancer or non malignant disease. Their input ranges from symptom control, medication review and administration to disconnection of chemotherapy pumps and end of life care. District nurses will maintain the patency of central venous access devices by flushing of dormant lumen, site care and changing dressings. 6.20 District nurses will work within the Gold Standard Framework for palliative care; this may includes implementing an end of life care pathway in agreement with patient and family. This may also include verification of expected death and significant conversations around do not attempt cardio pulmonary resuscitation and preferred place of death. Care of this nature is often very intensive and includes all aspects of physical, psychological and emotional care for patients and their families. 6.21 Health Promotion & Health Protection Interventions: seasonal vaccinations such as flu / pneumoccocal; shingles; telehealth: We aspire to develop telehealth opportunities across the service; health promotion awareness and advice provided following patient assessment may include smoking cessation, alcohol awareness, dietary and weight management advise, mental health and well being. 8
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 6.22 District nursing teams may require to undertake a range of tests relevant to assessment and ongoing packages of care such as: doppler assessment; venepuncture; blood glucose monitoring; urinalysis; blood pressure monitoring; 6.23 This list is not exhaustive. We will continue to develop the service in line with the needs of our patients. Access 6.24 The district nursing service operates an open access for referrals; we will aspire to deliver a service across a 24 hour period with no gaps in service delivery. 6.25 The district nursing service works jointly with all health services and partner providers of care such as social work and voluntary organisations. 6.26 Often there is confusion as to who the care provider is. The following table is an aide to guide referrers to the most appropriate agency. Patients Requiring: Personal care (unless as part of a nursing package of care e.g. terminal / palliative care) Assistance to the toilet or commode (where no nursing need) Dispense medication or fill dossett box Check visits (where no identified nursing need) Routine phlebotomy ( unless as part of a nursing package of care) Collection/delivery of prescriptions or continence aids Visits to patients in care homes for the provision of core nursing care Equipment assessment where no nursing need [except for hoists and beds] Home care providers can assess and order hoists for patients as they are in their own home. Re assessment where community care packages have broken down Suggested Referral To: Refer to local authority home care service Refer to social work services Refer to pharmacists/social work and/or Voluntary services Contact family; refer to social work services Refer back to referrer In negotiation with the district nurse where domiciliary phlebotomy service is absent Contact family, refer to local pharmacy/social Work Contact the care home or care home liaison team Refer to social work services Refer to social work services duty social worker available OOH 9
7. SUPPORTING DISCHARGE DISTRICT NURSING SERVICE FIT FOR THE FUTURE 7.1 To facilitate seamless discharge for the benefit of the patient we will work in partnership with acute services to ensure: Referrals are arranged at the earliest point before discharge. Referrals for patients with complex care needs must be referred to the district nursing service at the earliest possible stage of discharge planning, district nurses should be invited to in reach and case reviews. Provision of moving and handling and pressure relieving equipment is arranged prior to hospital discharge by the most appropriate service. Patients must be provided with a 7 day supply of medication and / or wound dressings, continence aids. All patients who have been admitted with a pharmacy filled dossett box should be sent home with this service recommenced. Risk assessment and safety issues for district nursing teams considered and the service should be alerted accordingly e.g. personal safety, clinical risk, moving and handling, infection control risk. 8. RECORD KEEPING 8.1 Documentation of all assessments, care plans and evaluations of care are recorded within the Community Nursing Information System and all forms of records of care intervention by district nurses will be in accordance with NMC Record Keeping for Nurses and Midwives 2009 guidance. 8.2 Audit of nursing records are part of the district nursing and Board core audit programme and are carried out in line with the quality improvement agenda. 9. PRACTICE DEVELOPMENT 9.1 All of the staff within the district nursing team who are registered practitioners are expected to develop their practice to meet NMC requirements. Staff must have the knowledge and skills for safe and effective practice and recognise and work within limits of their competence. 9.2. All staff must take part in appropriate learning and education activities that maintain and develop competence and performance. This will be facilitated though the career and development framework for district nursing and supported by the practice development nurses. 9.3 The development of practice for registered practitioners is governed by the NMC code. There are two Prep standards that affect registration: The Prep (continuing professional development) standard; The Prep (practice) standard. 9.4 Nurses who do not comply with the PREP requirements will cause their registration to lapse. They will no longer be legally able to work in the capacity of a registered nurse. 10
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 10. PROFESSIONAL SUPERVISION 10.1 District nurses today are required to respond to a variety of care and complex situations. In order to do this effectively, they need to be able to engage in the process of clinical supervision and reflection. This involves an exchange between professionals where clinical practice is examined and explored, with the intent to change behaviour, perspectives and practices and so influence improvements in patient care. Each practitioner is expected to participate in regular clinical supervision sessions. 11. EDUCATION & TRAINING 11.1 Each staff member will have a learning and development plan based on the knowledge and skills framework and their individual learning needs. This will inform NHSGGC Learning and Development Framework for district nursing which is underpinned by the national career framework for district nursing. 11.2 This will assist the service to identify the practice and competence of the district nursing workforce which is required to provide high quality care in line with the quality strategy, deliver new and future services and support the integration of services by providing opportunities for nurses to further develop the necessary skills and competence in the design and delivery of care. 11.3 The district nursing service is also a facilitator of educational placements for pre and post registration training and other health care professionals. This is underpinned by the NMC standards for nursing education and practice at both pre and post registration nurse training and that of other health care professionals. This is underpinned by NMC Standards to Support Learning and Assessment in Practice, and NHS Education for Scotland Quality Standards for Practice Placements documents. 12. QUALITY & GOVERNANCE 12.1 The quality of service provided by the district nursing team will be in accordance with NMC, To safeguard the health and wellbeing of the public and provide a high standard of care at all times and the quality strategy ambitions of safe, effective, person centred care. 12.2 Staff governance is the system of accountability for the fair and effective management of staff. Staff within the service will be treated within the five components of the Board s staff governance standard as follows: well informed; appropriately trained; involved in decisions which effect them; treated fairly and consistently; provided with an improved and safe working environment. 12.3 The Nurses, Midwives and Health Visitors Act (revised 1997) legislates the service. 11
DISTRICT NURSING SERVICE FIT FOR THE FUTURE 12.4 District nurses will work in collaboration with patients and their carers to plan and deliver person centred care. The service aims to provide positive patient experience as an integral part of the service. This will be measured through patient and carers experience surveys. 12.5 The service will work to corporate evidence and research based district nursing clinical policies, guidelines protocols and procedures and will be updated following research. These will provide clarity and clearly define the level of service quality expected. In addition, they reinforce the fundamental point that the responsibility for the maintenance of the quality of service rests clearly at nursing team level. 12.6 The team leader and district nurse ensure that the quality of the service is consistently and continuously met by all members of their nursing team with support of senior managers. 12.7 To ensure that the quality of service remains abreast of public, professional and organisational expectations standards of practice will be will be monitored on an ongoing basis through a Core Audit Schedule which may be augmented as local need requires for individual community teams. 12.8 Clinical Quality Outcomes are evidence based indicators that support the measurement of quality, safety and reliability of care and focus on service improvement. We developed these to: demonstrate outcomes; measure patient and carer satisfaction; evidence the contributions made to both national and local targets; clarify for teams what they are expected to do and enable them to contribute fully to service and organisational objectives. 12.9 The service will be reviewed on an ongoing basis taking account of feed back from patients, users, and staff and impact of quality outcomes and audit reports. 12
Appendix 1 Facing The Future Together Our Patients Our Culture Increase our direct facing time with patients through demand and capacity planning to releases more time to spend with patients. Understand that the patients recovery is a journey that is unique to each individual patient, and that promotion of recovery requires a holistic approach. Recognise the rights of individual patients and their families and practice in a manner which respects their values diversity including age, religion, gender, race, culture, spirituality and sexuality and does not stigmatise or disadvantage individuals, groups or communities. Work in partnership with our patients using the service to assess their needs in the context of preferred lifestyle, recognising the role and value of carers. Identify individual s needs and strengths, and work in a way which empowers, enables, maximizes and promotes independent living. Working in partnership with people using the service, carers, families and significant others in planning and delivering care. Safeguard our patients and carers by confidently recognising and effectively managing situations where a patient in the care of the district nursing team is at risk of harm, abuse or neglect. This involves working with partner agencies to address harm and acting upon issues regarding poor practice both within the service and within other service areas. Promote a co-ordinated approach to hospital discharge and in reach that facilitates a seamless service leading to improved health outcomes and positive patient experiences. Reduce the incidence of admission and readmission to acute services through our contribution to anticipatory care and continue use of SPARRA data to identify vulnerable patients. Support the choice of patients requiring end of life care who may wish to die at home. Provision of an equitable, accessible, flexible 24 hour service over 365 days, based around the Patient s Day from 8am to 8pm to 8am. Deliver safe, effective and person centred care based on best available research and evidence based practice, which improves patient safety and reduces clinical risk. Provide compassionate care in the most efficient and effective way at the earliest opportunity within the patients care pathway. Work as equal partners to further develop integrated team working and care models with GPs, acute services, social work services and other partner agencies such as the voluntary sector. Co-ordinate care, ensuring that district nursing interventions undertaken contribute substantially to the quality of care experienced by our patients. Respond to meet future changes to the delivery of health care to manage our patients at home, prevent hospital admission and readmission, facilitate early discharge and support case management to meet the changing focus of the delivery of health and social care in the community. 13
Our Leaders Our People Adopt a public health approach to all areas of practice to reduce ill health and promote healthy lifestyle, ensuring that every healthcare related interaction supports patients to identify and address behaviours which undermine good health. Challenge Inequality, identify and take action to counter discrimination, disadvantage, inequality, and injustice and promote individual s rights to choice, privacy, confidentiality, and protection, whilst recognising and addressing the complexities of competing rights and demands. Develop and maintain constructive team working relationship with individuals and carer groups within the community and other service provider groups, in delivering and developing services and value the contribution of others and the different skills and knowledge within team members. Provide leadership at every level within the district nursing team which will drive safe, effective person centred care and drive positive incremental change through a continued focus on engaging staff and patients in care delivery. Lead and improve the quality of care through continuous qualitative review of service and clinical practice. Embed the 4 key areas of responsibility of Leading Better Care (2), the national leadership programme for senior charge nurses: - Ensuring safe and effective practice; - Enhancing the patients experience of care; - Managing and developing the performance of the team; - Contributing to the organisation s objectives. Lead and develop clinical practice in a manner that is non-threatening, supportive within evidence and values based framework to meet the needs of our patients and their carers. Evidence our contribution to the quality strategy though implementation and monitoring of guidelines, standards clinical quality outcomes, patient and staff experience surveys. Maximise the clinical expertise and contribution of the workforce to support new ways of working through a structured learning and development framework which is underpinned by the national career and development framework for district nursing practice. The learning and development framework will support staff to undertake new ways of working in terms of the shift in the balance of care from acute to community based services. The framework will focus on the enhancing the skill set of the team to improve their understanding of illness, enhance assessment and clinical decision making skills, long term condition management, palliative care and anticipatory nurse prescribing. Staff will Implement best standards of clinical practice and adhere to local and national quality guidelines, policies and protocols to optimise the most effective patient outcomes within a clinical governance framework. 14
Staff will be responsible for their own professional and personal development. This will involve identifying and questioning their own values and the implications for practice, keeping up to date with changes in practice, participating in life long learning, personal and professional development through clinical supervision, performance appraisal and reflective practice. Work in partnership with academic colleagues to provide high quality learning experience and clinical support of our current and future nursing workforce when on clinical placement through critical companionship and mentorship for newly qualified staff nurses. Our Resources We will provide sustainable, affordable and equitable district nursing services and work effectively and efficiently within allocated resources. We will respond to changing working practice and develop new ways of working that targets areas of efficiency and effectiveness through Leading Better Care, Releasing Time to Care and agile working initiatives. Ensure the right person with the right skills is at the right place at the right time. 15
Appendix 2 References Scottish Government Modernising Nursing in the Community (2012) The Healthcare Quality Strategy for NHS Scotland (2010) Scottish Government 20:20 Vision (2013) NMC Record Keeping: Guidance for Nurses and Midwives (2009) NHSGG&C Facing the Future Together The Ten Essential Shared Capabilities Framework for the Mental Health - Department of Health (2004) 16
Appendix B NHS Greater Glasgow and Clyde Review of District Nursing Service June 2014
CONTENTS Page No. 1 INTRODUCTION 3 2 THE CURRENT POSITION & RATIONALE FOR CHANGE 3 2.1 National Context 3 2.2 Local Context 3 2.3 Workforce 4 2.4 Service Structure & Organisation 4 2.5 Workload 5 2.6 Clinical Quality & Governance 5 2.7 Information & Communication Technology 5 3 PROPOSALS FOR CHANGE 6 3.2 Rebalancing the Workforce 6 3.3 Agile Technology 7 3.4 Caseloads & Teams 7 3.5 Redefining the Patient s Day 10 3.6 Enhancing Links with Other Parts of the Health & Social Care System 10 3.7 Clinical Quality & Governance 10 3.8 Performance 10 3.9 Learning & Education 10 4 FINANCE 11 5 FUTURE DEVELOPMENTS 11 5.2 Increased Clinical Interventions 11 5.3 Case Coordination 11 5.4 Anticipatory Care Planning 12 5.5 Managing Access to Non Traditional Resources 12 5.6 Clinical Information System 12 6 CONCLUSION & RECOMMENDATIONS 12 7 NEXT STEPS 13 2
1. INTRODUCTION 1.1 Partnerships have been undertaking a wide review of community services over the last 2 years including health visiting, physiotherapy, speech and language therapy, podiatry and dietetics. These reviews have concentrated on improving efficiency, making services fit for the future and improving quality and governance structures as well as ensuring a sustainable financial profile. 1.2 This review of district nursing (DN) proposes significant changes to the workforce, sets out a governance and quality framework, maximises the efficiency benefits of agile working and defines an equitable and uniform service model which will support the move to Health and Social Care Partnerships in 2015. 1.3 The paper also outlines some of the contributions that a modernised district nursing workforce could contribute to the better management of long term conditions in primary care, the development of anticipatory care and the effects of an ageing population. As new service models develop it provides a firm basis from which the service can contribute its expertise in case management, its unique links to the broader health and social care system and its skills and flexibility. 2. THE CURRENT POSITION & RATIONALE FOR CHANGE 2.1 National Context 2.1.1 Several key national policy drivers will have a significant impact on the DN service. The NHS Scotland 2020 Vision 1 envisages that by 2020 everyone will be able to live longer healthier lives at home, or in a homely setting supported by a healthcare system integrated with social care, and a focus on prevention, anticipatory care and supported self management. The National Quality Strategy 2 defines the core principles of service quality and the importance of clinical and staff governance structures which support the delivery of safe, effective, compassionate and patient centred care. The Scottish Government Modernisation of Nursing in the Community 3 promotes a framework in which professional leadership, and a learning and development culture can be developed and flourish. The Reshaping Care for Older People 4 agenda focuses on the provision of effective community based supports to achieve the principals of both the NHS 2020 vision and integration of adult health and social care by shifting the delivery of services to the community. The National Dementia Strategy 5 is clear that the number of dementia sufferers and their carers will grow exponentially and will have a significant impact on community services. Living and Dying Well 6 clarifies the need for equitable and person centred care for those at the end of life which also has significant implications for community nursing services. 2.2 Local Context 2.2.1 The NHS Greater Glasgow and Clyde Corporate Plan 7 identifies key local priorities including early intervention and preventing ill health, shifting the balance of care and Reshaping Care for Older 1 NHS Scotland 2020 Vision 2 National Quality Strategy 3 Scottish Government Modernisation of Nursing in the Community 4 Reshaping Care for Older People 5 National Dementia Strategy 6 Living and Dying Well 7 NHS Greater Glasgow and Clyde Corporate Plan 3
People. It includes a commitment to tackle inequalities and improve the quality, efficiency and effectiveness of our care. The current Clinical Services Review 8 has identified the need: to develop interface services provide timely access to high quality primary care deliver a comprehensive range of community services accessible 24/7 from acute and community settings provides coordinated care at times of transition or crisis particularly for those most at risk. The impact of shifting the balance of care into the community is being evaluated as part of the Paisley test site work. A reduction in the number in the number of beds and shorter lengths of stay across the board will require the review, in the implementation phase, to routinely measure the implications for community services. Regular reviews of workload including referrals, caseload sizes and complexity will be needed to ensure that the impact of changes in acute services and the impact on community are planned rather than reactive. The development of Health and Social Care Partnerships provides significant opportunities to develop community based services but also presents a challenge to ensure equity, consistency and service quality in an increasingly devolved landscape. 2.2.2 These local and national priorities have provided the basis for a re-examination of the district nursing service. The District Nursing Review Programme Board has overseen this work and has included a wide range of stakeholders including front line staff, partners from General Practice, acute and staff partnership representatives. Following extensive discussion and benchmarking, clear proposals about the future shape of the service and its contribution to the wider health and social care agenda have emerged and are set out in this paper. 2.3 Workforce 2.3.1 The district nursing service had (as at June 2013) 555 wte nursing staff of which 475 work in hours including rotational weekends and 79 who work out of hours in the evenings and overnight. Table 1: Staff Numbers by Grade (In and Out of Hours)* Grade 2 3 5 6 7 Total Number 3.05 77.69 282.65 177.74 13.6 555 % 0.5 14 51 32 2.5 100 * Workforce Data 2012-13 2.3.2 Of the current workforce 63% are aged over 50 and of these 27% are aged 55 or over with 18% over 58 years. There is therefore likely to be a significant increase in the current turnover of 8% in staff in the immediate future and over the next 5 years which provides both a risk and an opportunity for the service. There is no Board wide programme of succession planning. 2.4 Service Structure & Organisation 2.4.1 District Nursing services are devolved to Community Health Partnerships. There are a variety of service structures with teams mostly lead by Senior Nurses for adult services or Clinical Service Managers who are accountable to the Head of Service responsible for district nursing. Most partnerships have band 7 staff who act as team leaders or practice development nurses or who have specific specialist roles such as Diabetes Nurse Specialists. Caseload holders are band 6 DNs who hold specialist community nursing qualifications and lead nursing teams which vary 8 Clinical Services Review 4
considerably in size. The lack of consistent caseload size is a result of the practice attachment model and an historical recruitment pattern which required a district nursing qualification which in turn attracted a promoted grade. Most teams include band 5 staff nurses and some also include band 3 or 2 nursing assistants. The band 6 is accountable for the management of the caseload and the leadership and development of the team. 2.4.2 The core day shift pattern is 8.30am to 4.30pm. Staff rotate onto weekend day shifts. The out of hours service (OOH), covers evenings and overnight and provides some additional weekend day staff. There is a service gap between 4.30pm and 6pm and again between 7.30am and 8.30 am. 2.4.3 Clinical work patterns are orientated around this 8 hour day shift model compressing the patient s day and reducing access to district nursing by other services including GPs, hospital staff and social care partners. 2.5 Workload 2.5.1 Referrals to the service are received from GPs, acute services, social care, care homes, rehabilitation teams, mental health services and OOH colleagues including GPs. Unlike most community services, referrals are not made electronically and are often made informally by telephone, answering machine or face to face communication. Referrals are made to multiple points of access and there is no administrative support to manage these. This has an impact on clinical time as qualified staff have to record patient details creating risk and inconsistency in the management and recording of referrals. On average the service receives 2500 referrals per month. These are recorded on CNIS by the district nurses. 2.5.2 District nurses provide home based care. Interventions include palliative care, wound care, bladder and bowel management, management of diabetes and other long term conditions, tissue viability, care of Hickman and PICC lines, subcutaneous pumps and medicine management and administration. They also support the frail elderly. DNs are also skilled in case co-ordination and management. 2.5.3 The over 65 age range accounts for 78% of the average caseload with 25% in the over 85 age group - a population in which there is an increased prevalence of dementia and single person households. Caseload sizes vary between 46 and 96 patients. Of the patients identified in the GP contract for Anticipatory Care Planning as many as 60% are unknown to the district nursing service. 2.5.4 A recent workload study 9 showed that on average 50% of each working week is spent on clinical duties, 16% on travelling and 34% on associated workload (administration, staff deployment, referrals, clinical notes, specialist equipment ordering, teaching etc). 2.5.5 A review of clinical interventions (ranked 1-4 in complexity) by grade shows that although band 6 staff carry out the most complex interventions they are also regularly undertaking work at the lower end of the complexity scale. There are similar results for band 5 staff with band 3s undertaking low complexity tasks although in some areas they are undertaking tasks at level 3. The workload analysis shows that there are potential gains to be achieved in both clinical quality and time if inefficient aspects of the associated workload could be reallocated away from band 6 and 5 staff. There are circumstances where band 5 and band 6 nurses will undertake clinical interventions at all levels as part of a planned episode of care. 9 National Workload Tool 5
2.6 Clinical Quality & Governance Partnerships have local governance structures in place but these are not uniform. The service is supported by a professional advisory structure which provides professional nursing advice to Directors and Heads of Service. It has implemented the Leading Better Care programme. In addition there is a core audit programme and the service is continuing to develop clinical quality indicators. There has until recently been no corporate approach however to clinical guidelines, standards and protocols. 2.7 Information & Communication Technology District nurses have access to office based IT and mobile phones. DNs are required to return to base to update patient records, access information, order equipment, organise prescriptions and agree visit schedules. This reduces available patient facing time and increases travel time and costs. The current Community Nursing Information System was developed within NHSGGC in 2006. The system supports compliance with NMC record keeping standards and enables data collection but has a number of weaknesses and limitations. 3. PROPOSALS FOR CHANGE 3.1 The review has demonstrated that there is sufficient scope to improve the efficiency and effectiveness of the service and to prepare it for the demographic changes it faces. It also provides an opportunity to improve service quality and manage impending workforce pressures. The key components of the review are: rebalancing the workforce moving to agile technology defining caseload sizes and teams redefining the patients day enhancing links with other parts of the health and social care system including Out of Hours developing a structured governance programme including shared learning and education. 3.2 Rebalancing the Workforce 3.2.1 The current workforce profile results in qualified staff undertaking too many low complexity tasks. This reduces its capacity to care for an increasingly complex population and support the up-skilling of professional staff. Analysis of weighted populations predicts a rise of 10% in the numbers of patients on the DN caseload by 2018 and 20% by 2025 as a result of demographic changes alone. 3.2.2 In order to inform the workforce plan, and in line with national guidance, a range of workload tools were used. These included the National Workload Survey (augmented by the professional judgement of senior nurses, clinical team leaders, professional nurse advisors, Nurse Director for Partnerships and clinicians who were members of the workforce planning sub group) and application of local quality indicator results to give a triangulated approach to workforce planning. 3.2.3 This approach has included testing the minimum staffing levels required to run a safe service, introducing absence and leave as advocated in other clinical service staffing models. The outcome was also tested out with service managers who were asked to consider if the plan would fit the model of care required within their service areas. Alternative models of practice within NHSGGC (in particular Inverclyde and Renfrewshire) have been used as a benchmark to assess their delivery of service against potential models. 6