Keywords

Community nursing services are an under-researched area of the UK health system (Goodman et al., 2003). Often forgotten or appearing as an afterthought in policy documents, they nevertheless play an important role in service delivery. Indeed, the NHS Long Term Plan (NHS England, 2019) places a heavy emphasis on improving care outside hospitals, promising additional investment for both primary and community services, but also highlighting a need for ‘increased efficiency’. In this book, we use an historical lens to consider how policy might need to change to achieve these aims. We confine ourselves in this book to community or district nursing services provided for adults; we do not examine maternity or child health services. Specifically we use the district nursing service as a lens by which to examine community nursing policy throughout history given that it is largely a specialist community and home nursing service. A definition of community/district nursing used in this report is provided at the end of this section.

In their 2003 assessment of the research and policy literature relating to community nursing, Goodman et al. (2003) highlight the multiple contradictions and tensions inherent in the role and argue that the professional status of what in the UK are called ‘district nurses’ has historically been limited by two parallel trends: the low status of the patient group for which they care and the higher status afforded to ‘specialist’ practitioners over ‘generalists’(Martin et al., 2009). It should also be recognised that nursing in general has low status, which is partly attributable to its gendered nature (Davies, 1995). In the policy field, whilst successive governments have paid lip service to the importance of community services, investment has rarely followed, with payment systems, contractual models (Allen, 2002) and a dearth of high quality data (Audit Commission, 1999) all contributing to a relative disadvantage for community services when compared with specialist services provided in hospitals.

Since 2014, there has been a strong focus in policy on improving the integration of care in the NHS (NHS England, 2014, 2019). The Five Year Forward View argued that:

The traditional divide between primary care, community services, and hospitals—largely unaltered since the birth of the NHS—is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three. Over the next five years and beyond the NHS will increasingly need to dissolve these traditional boundaries. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. (NHS England, 2014, p. 16)

Community Health Services (CHS)—and particularly those provided by community nurses—are a very important element in this ambition to create a more integrated health care system. Nursing services provided in the home, alongside more specialised community services provided in clinics and care provided by social care services, are important in: supporting patients to live independently; working alongside general practices to manage patients with long term conditions in the community; providing care which enables people to avoid hospital admission; and providing care which allows patients to be discharged from hospitals, thus reducing lengths of stay. Achieving these things requires community service providers to work across multiple boundaries, working with social care, primary care, mental health and acute hospital services. Ensuring that these different services join up with one another is a key task in supporting the development of care which is experienced by patients as efficient and integrated.

Building upon the Five Year Forward View, the NHS Long Term Plan (NHS England, 2019) identifies a number of ways in which community services will be strengthened and supported to ensure that they can deliver the care which is needed. These include:

  • Increased investment, linked to investment in primary care services

  • Closer working with primary care providers via Primary Care Networks

  • Improved data collection about community service provision

  • Greater use of digital and telemedicine systems to support service delivery

  • Systems to support earlier discharge from hospital, including better planning in the early stages of acute hospital admissions

  • Increased efficiency in community services, including more time spent face to face with patients

  • Changing legislation to allow the creation of new NHS integrated care delivery organisations

In understanding how these things might be achieved and what policy changes may be required to support this, it is first necessary to understand the factors which have led to the presumed ‘inefficiency’ and lack of integration in the current system. Community services as they exist today are not the result of a planned development of services over time. Rather, they are the result of multiple ‘sedimented’ (Cooper et al., 1996) policies which have incrementally accumulated to generate the system as it stands today. Importantly, few major policy changes in the history of the NHS have addressed community services directly; more often, the system design factors underpinning community service provision have emerged as a by-product of changes introduced to tackle problems elsewhere in the NHS. For example, in spite of policy objectives over many years that there should be increased investment in care outside hospitals, the ‘payment by results’ cost per case funding system for hospital care, which does not extend to community services (Department of Health, 2002), has made this difficult to achieve. In addition, when community services have been the direct target of policy, these have often not been followed through. For example, the ‘Transforming Community Services’ programme in the late 2000s (Department of Health, 2009) was quickly overtaken by a wholesale reorganisation of the NHS under the Health and Social Care Act 2012 (HSCA, 2012).

As Berridge (2011) has pointed out, history has an important role to play in public policy, with a judicious appreciation of past policy an important tool for ongoing policy development. With that in mind, we offer an historical policy analysis of community nursing services in UK policy since the advent of the National Health Service. Our aim in doing this is to provide an analysis of the issues and opportunities facing community services which is rooted in what has gone before, using past policy as a tool with which to consider how future policy might most effectively deliver the aspirations of the NHS Long Term Plan (2019) to invest in and revitalise health care services provided outside hospital.

In this review we consider policy relating to community nursing services over a number of eras. Deriving in part from Ottewill and Wall’s (1990) history of the development of Community Health Services, alongside our own past research (Lorne et al., 2019) and Klein’s (2013) foundational account of the politics of the NHS (amongst others), we divide the history of the NHS into seven loosely defined eras which each form a separate chapter:

  • 1948–1974—Community Health Services as a Local Government service

  • 1974–1982—A unified geographically based health system

  • 1983–1990—The era of General Management

  • 1990s—The introduction of the internal market

  • 2000s—Transforming community services

  • 2010–2015—The Health and Social Care Act, NHS fragmentation

  • 2015–date—Focus on integration

For each era we consider the major policy documents and reports relevant to community nursing services in order to answer the following research questions:

  1. 1.

    What are the key government policies in respect of the organisation and provision of community nursing services since 1948?

  2. 2.

    What are the overt drivers and aims of these policies?

  3. 3.

    How do the policies and/or drivers change or remain consistent over time?

  4. 4.

    What lessons can we learn for current policies concerning the organisation and delivery of community nursing services?

In order to address these questions, for each policy era we address the following topics:

  • The presumed role and function of community nursing services

  • The management of community nursing services

  • Population coverage

  • Finance and payment mechanisms

Our discussion then looks across the eras to answer our research questions and draws out lessons and themes of relevance to the current policy context.

1.1 Definitions: Community Nursing/District Nurse

Before setting out on the journey of documenting an historical account of community nursing it is first pertinent to provide the definitions upon which this report is based. According to NHS England (2015), community nursing encompasses a diverse range of nurses and support workers who work in the community including district nurses, intermediate care nurses, community matrons and hospital at home nurses. This book is focused particularly on those nurses who provide services to patients in the home and community, and for this, we are concerned mainly with the role of the district nurse.

There is a lack of consensus around definitions of the district nurse and the term is used in different ways through time by different organisations and bodies, and often interchangeably with the term community nurse. However, there is consensus around specialist training, education and the type of patients requiring home care. The Queens Nursing Institute (2016) definition of a District Nurse is:

A District Nurse is a qualified and registered nurse that has undertaken further training and education to become a specialist community practitioner. (Queen’s Nursing Institute, 2016: Ch1)

The Department of Health document, Care in Local Communities (2013, p. 10) takes District Nurses to mean:

  • ‘Qualified nurses with a graduate level education and specialist practitioner qualification recordable with the Nursing and Midwifery Council.’

  • ‘Care provided in a variety of community settings by district nursing teams. This care includes a wide range of care, for example, supporting patients with long-term conditions in their own homes and providing complex and palliative care. Comprehensive high quality district nursing services have the potential to reduce use of hospital sector and residential social care.’

Further, The Royal College of Nursing (2013) suggests that the fundamental goal of district nursing is: ‘The planning, provision and evaluation of appropriate programmes of nursing care, particularly for people discharged from hospital and patients with complex needs; long-term conditions, those who have a disability, are frail or at the end of their life’ (p. 8).

As we will document, there has been a consistent trend within the UK for nursing teams delivering care in the community to include less well-qualified staff alongside qualified district nurses. Increasingly, care assessments are done by qualified district nurses, whilst care is provided by general nurses and by health care assistants working under supervision. In our account we therefore refer consistently to community nursing services and community nurses in discussing policy more generally, but refer specifically to district nurses where relevant in terms of issues of training or qualifications. We recognise that Community Health Services also include services provided by specialist nurses, midwives and child health services including school nurses and health visitors. However, our policy history does not focus upon these services, as they have been subject to different policy drivers and pressures. Our focus is therefore upon community nursing services provided for adults in the community, with a particular focus upon the role and function of district nurses.