Nurses need a voice in community care
The Five Year Forward View for the NHS in England proposes new models of care intended to integrate and align community services with hospitals and GP practices. Some nurses are concerned that one of these models will lead to a GP takeover of community services. Nursing leaders say they must be equal partners in planning the new models.
Perhaps more than any other branch of the profession, community nursing has been shunted around. For years, community nurses were part of the GP team. Then they moved to standalone organisations, before Transforming Community Care in 2008 hived them off into acute trusts, mental health trusts and community-focused organisations.
Now the Five Year Forward View (FYFV) – NHS England chief executive Simon Stevens’ vision for transforming the health service – signals another change. This time, community nursing will be part of new integrated organisations.
Although the FYFV is not prescriptive, it offers two models: the Multispecialty Community Provider (MCP), in which GPs and community services deliver integrated care; and the Primary and Acute Care (PAC) organisation, providing list-based GP and hospital services, as well as community and mental health.
Interest in these new models is high: there were more than 260 bids to be one of 29 ‘vanguard’ sites announced by NHS England in March. These sites will explore how the new models might work.
Behind the scenes, community nurses are worried. One senior source, who preferred not to be named, says some see opportunity in the changes, but many are cynical. ‘They have been moved around so much, and have lost many of their experienced managers in the process. They worry that the new models will simply be a takeover by general practice – the “my practice nurse can do that” syndrome – and once again their expertise and unique role will be devalued.’
Community nursing leaders acknowledge the concerns.
Robert Flack is chief executive of Locala, a community interest company providing NHS community services in Kirklees, West Yorkshire. It is one partner in the Calderdale vanguard MCP, alongside primary care providers.
Mr Flack stresses that he is positive about the opportunities this model brings, but adds that however challenging it may seem, community nurses will have to see themselves as part of urgent care. ‘Historically, the district nurse has a case load and if there is a crisis, someone else needs to deal with that, whether it is general practice or A&E,’ he says. ‘The MCP says we need to manage people across their whole care needs. So community nursing becoming part of crisis care plans is an absolute must.’
He is not sure that community nurses believe the changes will really happen. ‘Community nurses have been told for years that the future is the community, yet there has never been a clearly expressed move towards that.’
Mr Flack says he understands the fear of a ‘GP takeover’, but says the change planned for their practices is as big as, if not bigger than, that for community nursing.
Jonathan Lewis, chief executive of Bromley Healthcare, a community health trust in south east London, takes a similar view. Although it is not a vanguard site, Bromley’s six community nursing teams are already being organised around groups of GP practices.
‘In my experience, GPs value district nurses,’ says Mr Lewis. ‘Their complaint to us is that we do not have enough district nurses, and that is true. It is a struggle to recruit them.’
GP commissioners understand what patients in the community want, he says. ‘By extension, GPs understand the nursing role because they are constantly faced with patients who do not get enough nursing care.’
Put all this together in an MCP committed to investing in community nursing, and at last there might be a challenge to the hospital monopoly, he says. ‘I think this is a renaissance for community nursing.’
Wirral Community Trust is a vanguard site for the PAC model. Chief executive Simon Gilby says: ‘The model we are exploring is a whole system approach, with primary, acute, mental health and community services together. It builds on our social care strategy.’
He believes this will enable better care for patients in the community. But he adds that the principle caveat is not whether already overstretched community nurses are willing to change, but whether they have the capacity to change quickly enough.
‘We are working hard with them to get the right capacity and skill mix in place, but it is a challenge – and it will continue to be a challenge to make sure investment keeps pace,’ he says.
Bristol Community Health chief executive Julia Clarke agrees. Her trust is not involved in a vanguard, and she sees the area developing its own ideas based on local needs.
‘It’s not to do with new models but with demand and the complexity and acuity of patients in the community,’ she says. ‘That is what my nurses are talking about. They say “we have the skills but not the resources to do this”.’
In December 2014, NHS England set out the NHS Five Year Forward View.
It proposed new models of integrated care, bringing community services into alignment with acute and primary care providers.
These models are now being tested in 29 vanguard sites. Find out more at
NHS England is working with a range of partners on projects to support the transformation, including developing career paths and defining the competencies needed to work in the community.
RCN professional lead for primary care and community nursing Marina Lupari says work on training for community nurses, safe staffing levels, core competencies and career ladders is under way in a series of projects led by NHS England. These involve Health Education England, the National Institute for Health and Care Excellence, the Royal College of General Practitioners and the RCN. She too is optimistic about the future of community nursing.
For Queen’s Nurse Heather Henry, co vice-chair of primary care organisation the NHS Alliance, the talk about MCPs and PACs misses the point. ‘GPs are sitting in one corner talking about the future,’ she says. ‘They are doing this entirely separately from nurses. That’s a concern.’
Community nurses are looking for something different, says Ms Henry. They are more likely to be inspired by the Dutch Buurtzorg home care model, in which nurses design care around patients, than an MCP or PAC. But their voice is not being heard, and without it, real change will not take place, she argues.
GPs and managers may value community nurses, but do they value them enough to bring them into the discussion room? ‘There needs to be a better understanding that the lead clinicians focusing on ideas like MCPs need to make nurses their equal partners,’ says Ms Henry.
‘To make that happen, community nurses need nursing leadership’.