Keywords

3.1 Historical Context

As mentioned in Sect. 2.1.1, this era saw the first major re-organisation of the health service since its inception in 1948 and was focused almost entirely upon management of services.

Intended to address management, co-ordination and organisational issues with the NHS, including weaknesses with the tripartite system, changes began in April 1974 following the passing of the National Health Service Reorganisation Act in 1973 and it took over 2 years to implement (Office of Health Economics (OHE), 1977). The re-organisation aimed to bring a ‘balance of services-hospital and community-throughout the country’ and to put an end to the fragmentation of the national health system (DHSS, 1972, p. 1), importantly, each professional discipline was intended to manage itself. Thus, the replacement model brought together the three separate bodies into a unitary, hierarchical system administered by 14 Regional Health Authorities (RHA) and 90 Area Health Authorities (AHAs). These authorities were controlled by central government (DHSS) but geographically organised and coterminous with local government boundaries. Along with shifting the management and financing of community nursing services from local authorities to the NHS, one of the other main changes was that AHAs became responsible for the planning and providing of both hospital and community services.

The new, locally focused and less hierarchical organisational structure was an attempt to bring clarity to the system not only in terms of responsibilities and accountability but also to facilitate co-ordination and integration of services especially at the district level (OHE, 1974), described below. Indeed, there was initial optimism that bringing community nursing under the NHS umbrella would usher in a new era of co-ordinated working between community and hospital nursing, as well as ‘other disciplines at all levels throughout the structure’ (Ottewill & Wall, 1990, p. 220). Hence, from the 1st April 1974, the responsibility for community nursing was transferred to AHAs, who also assumed responsibility for running Health Centres. However, the new structure did not realise many of its intended aspirations for community nursing and by 1982 it all changed again.

3.1.1 The Role and Function of Community/District Nursing Services

The model of district nursing remained as one of ‘nursing in the home’ following the re-organisation and again, there is little mention in the literature of what the role entailed during this period. A DHSS (1977b) circular entitled Nursing in Primary Health Care (CNo.77, 8—appendix to Priorities documents) made much of the place of district nurses in the primary care team and the benefit to patients of effective, co-operative ways of working—in particular, between health visitors and district nurses. The importance of non-nursing care or help with social needs was also acknowledged. The circular went on to define that a district nurse:

… is an SRN who has received post basic training in order to enable her to give skilled nursing care to all persons living in the community including in residential homes. She is the leader of the district nursing team within the primary health care services. Working with her may be SRNs, SENs and nursing auxiliaries. It is the district nurse who is professionally accountable for assessing and re-assessing the needs of the patient and family, and for monitoring the quality of care. It is her responsibility to ensure that help, including financial and social, is made available as appropriate. The district nurse delegates tasks as appropriate to SENs, who can thus have their own caseload, but who remain wholly accountable to the district nurse for the care that they give to patients. The district nurse is accountable for the work undertaken by nursing auxiliaries who carry out such tasks as bathing, dressing frail ambulant patients and helping other members of the team with patient care. (Baker & Bevan, 1983, p. 23)

However, the function of community nursing became increasingly important to policy agendas which emphasised out-of-hospital care and prevention of ill health. These being driven by rising costs of caring for a changing and increasingly elderly population. Indeed policy in this era was dominated by a ‘rhetoric of financial crisis’ according to Klein (2010, p. 79), especially towards the latter half of the 1970s, and steered the course of policy during this period. Thus, the focus on shifting care into the community to relieve financial pressure on the NHS was prominent in this era, and along with it, the corresponding reliance on community nursing to deliver these policy visions.

Several documents pivotal to the increasing focus on community nursing services were the 1976, Priorities for Health and Personal Social Services in England: A Consultative Document, the 1976a White Paper—Prevention and Health: Everybody’s Business and the 1981, Care in the Community: A Consultative Document on Moving Resources for Care in England (all DHSS). The ‘Priorities’ document as it is known was the first attempt by the DHSS to look ahead and determine healthcare priorities for the coming years. It established how limited resources could be allocated (DHSS, 1976a) and proposed a switching of balance towards an expansion of primary health care and community support services with a lower level of growth and financing in the acute hospital sector. Although only consultative, it is acknowledged that the ‘Priorities’ document was influential in the planning of health care for this era, laying out the need to improve out-of-hospital services for the mentally ill, the young and on how to address the probable extra workload brought about by the ageing population (OHE, 1977). Correspondingly, the message of the Care in the Community document was that ‘most people who need long-term care can and should be looked after in the community’ and proposed looking to local authorities and voluntary organisations, as well as the NHS, as a way of spreading the financial responsibility of this (DHSS, 1981a, p. 1). Similar sentiments were echoed in the DHSS, 1978 discussion document, a Happier Old Age, which stressed the need to care and support the elderly in the community for as long as possible, suggesting the voluntary sector play a larger part in keeping people out of hospital.

Commensurately, it was the community nursing services that were tasked with providing this care and thus their workload increased exponentially. District nurses became increasingly under pressure from a number of sources not least from having to care for patients with increasingly complex needs but with schemes such as earlier discharge from hospital, the introduction of out-of-hours services and ‘hospital at home’ (Ottewill & Wall, 1990, p. 296). Indeed, a 24-hour-nursing service, or a version thereof, was eventually implemented into the district nursing service by the majority of district health authorities to provide continuous care to those who, ‘might otherwise require hospital beds, to remain at home’ (DHSS, 1977a, p. 16). Hence, it was proposed that the spending on district nurses should increase by 6% per year and an increase in district nurse numbers to increase by the same, to meet the extra workload (Baker & Bevan, 1983). Interestingly, the balance of patients treated in the home had shifted by 1980 and ‘district nurses were treating five times as many cases among those aged less than five years and twice as many cases among those aged 65 and over’ (Baker & Bevan, 1983, p. 14).

Community nurses were also called upon to play their part in health promotion and preventing ill health as part of the government’s cost-cutting measures. The associated discussion paper to ‘Priorities’, Prevention and Health: Everybody’s Business (DHSS, 1976b) proposed to shift the responsibility for health onto an individual claiming that ‘as a society [we] are becoming increasingly aware of how much depends on the attitude and actions of the individual about his health’ (p. 7). However, this did not prove a fruitful strategy in terms of reducing expenditure, and much of the burden of this was pushed on to the district nurses’ workload. According to the document, district nurses were well placed to offer preventative advice to the elderly about ‘remaining active and about ways of safeguarding health’ (Baker & Bevan, p. 26), as well as being able to observe the general condition of individuals in their home and identify potential healthcare problems which would if ‘not corrected, prove difficult to manage later on’ (Baker & Bevan, 1983, pp. 26–27).

The themes of health surveillance and prevention were among key recommendations included in the Report of the Royal Commission on the National Health Service (1979) led by Sir Alec Merrison. It would be remiss not to mention the Merrison Report here given the influence of the committee’s findings on much of the policy discussed above and by implication on the district nursing service. Instigated in 1976 after some opposition to, and disillusionment with, the NHS restructure (predominately from the providers of health care), and to avoid a crisis within the service, Merrison and his committee were tasked with wholesale scrutiny of the NHS. This included investigating differing aspects of the healthcare system including community services. Whilst the recommendations of the report are many and wide ranging, it was relevant to district nurses in terms of examining the community nursing workforce skills, roles and acknowledging that there was little or no nurse manpower planning. The Royal Commission recommended expanding the role and responsibilities of district nurses, for example in ‘health surveillance of vulnerable populations, in screening procedures and health education and preventative programmes’ (Ottewill & Wall, 1990, p. 296). The committee also supported government plans to increase the workforce to meet the demand for its services and workloads as outlined above. To meet the needs of increased out-of-hospital care, some areas chose a route of community nurse specialisation—alongside more generalist district nurses—for example in stoma care, stoke, diabetes and coronary care, etc. (Ottewill & Wall, 1990, p. 296).

3.1.1.1 Team Work

Joint care planning, which in the early 1960s developed as a co-ordinating mechanism to enable the transition of care for the elderly from hospital into community, expanded further in the 1980s following the 1974 re-organisation. Joint care planning teams (area level) and healthcare planning teams (district level) were set up to facilitate collaboration between health and local authorities and in doing so embedding the concept of joint working as a key policy objective (UK Parliament, 1973; DHSS, 1977a). The multidisciplinary membership of joint care planning teams was seen to offer added advantage by pooling on staff expertise and knowledge to achieve common goals.

The emphasis on integration and collaboration post re-organisation built on the concept of teamwork. For community nursing, this resulted in the expectation that, as part of their role, they would be active members of multi-disciplinary teams. The new structure was expected to provide new opportunities for working whereby all teams were ‘to be multidisciplinary, so that nurses at all levels and in all situations [could make] an important professional input into any discussion or plan’ (Smith, 1979, p. 448). Smith argued it was inevitable that the profession in future would develop along these lines and therefore it was crucial that they were prepared to take on ‘extended responsibilities they will be well versed in the group dynamics of coping with multi-disciplinary group activities’ (ibid.). However, Appleyard and Maden (1979, p. 1305) suggested that the term became a panacea and ‘the establishment’s answer to difficult clinical problems in the Health Service’. They argued that there was little evidence that the approach was effective except for diverting attention from the individual and statutory responsibility of each member. They concluded that the NHS could not ‘afford an extensive multi-disciplinary framework’ citing logistical and clinical reasons (ibid.).

In this vein, intentions towards multi-disciplinary collaboration within primary health care proved to be more of a theoretical than practical development following the restructure. Community nurses were disillusioned by managers who did not embrace their roles and activities and who did not understand the potential and benefits of team working (Ottewill & Wall, 1990). Initial optimism around the concept of primary healthcare teams also declined. Such was the concern about the problems associated with primary healthcare team development, that a committee led by Wilfred Harding was formed to investigate and offer solutions (DHSS, 1981b). Amongst other aspects, such as professional relationships, The Standing Medical Advisory Committee and the Standing Nursing and Midwifery Advisory Committee looked to the structure and organisation of the district nursing service as a possible cause for impeding collaborative working. It was concluded that district nurses continued attachment to general practice, as opposed to geographical working, was beneficial to fostering team working but that this was contingent on conditions such as appropriate premises. However, it was also acknowledged that attachment in itself is not a pre-cursor to effective team working nor the creation of a primary care team.

When published, The Harding Report explored a set of standards to facilitate team working most notably: the importance of working collaboratively, the need for role clarification and setting common objectives in the primary care (DHSS, 1981b). There was, however, little evidence that these recommendations were implemented despite government’s continued emphasis on the role of primary healthcare teams (DHSS, 1986). To this end, Elliott (1978) suggested that preparing district nurses for how to work in a multi-disciplinary team should be part of the curriculum of the mandatory district nurse training to be introduced in 1981 (see below).

3.1.1.2 Education and Training

Although published in 1972, the Report of the Committee on Nursing, or the Briggs Report, was not actioned until 1979 when it was integral to the implementation of new models of nursing and nurse preparation (Bradshaw, 2010). The remit of the committee was

To review the role of the nurse and midwife in the hospital and the community and the education and training required for that role, so that the best use is made of available manpower and to meet present needs and the needs of an integrated health service. Briggs, 1972, p. 1)

There were several issues which provided background to the Briggs Report, which at the time were rooted in the rejection by nurses both of the ‘handmaiden’ ideal—and recognition that this was gendered in nature—and of the idea that it was a selfless vocation in which they were happy to labour for minimal rewards. The report aimed to bridge the gap between education and practice and took the education and training of all nurses as its focus with some proposals regarding regulations. Briggs concentrated on the need for continual adaptation. The report discussed the need for flexibility between hospital and community—with the implication that nursing in the community is the same as nursing in hospital, apart from the difference in the site at which care is delivered.

Responsibility for professional standards, education and discipline was vested in the new Central Nursing and Midwifery Council, created after a reorganisation of nursing bodies which developed a structure that would explore the training needs of the three professions (Nurses, Midwives and Health Visitors Act 1979, UKCC 1986). Mandatory training for district nurses was introduced in 1981, overseen by the Committee for District Nurse Training, in order for them to practice. During the period of 1976–1980 and despite much emphasis on community-based care, the number of district nurses that enrolled and entered training fell (DHSS, 1981b).

3.1.2 The Management of Community/District Nursing and Population Covered

One of the defining characteristics of the re-organisation was the introduction of the concept of the team or ‘consensus management’ approach defined as ‘decisions … need the agreement of each of the team members’ (DHSS, 1972, p. 15), hence services were organised to facilitate this approach.

However, following their transition to the NHS, management arrangements for community nursing services was complex compared to that of other community health services. Hospital and community nurses became part of one single nursing service located in districts with a District Nursing Officer in charge of co-ordinating activities. This was quite a departure from Local Authority Management, affording less local autonomy due to the removal of the democratic role of LAs but again was intended to facilitate greater collaboration and integration between the hitherto disparate services.

Districts were seen as a way to manage the large populations (between 500,000 and 1,000,000 people) covered by AHAs. Their role was administrative rather than as statutory authorities (Lorne et al., 2019), and they were managed by multi-disciplinary District Management Teams (DMTs)as per Fig. 3.1. DMTs worked by consensus and were responsible for the day-to-day operational management of planning, organising and providing healthcare services for local populations between 250,000 and 300,000 (OHE, 1977, p. 9).

Fig. 3.1
A flow diagram defines how the managerial, representative, and monitoring and coordinating functions flow between the teams of district management to A H A.

Framework of the District Organisation. (Reproduced with permission from The Reorganised NHS, 1977, OHE, p. 7)

Full size image

Based on this structure, the management of community nursing services should have been straight forward. However, the eventual reality was rather more complex. This was driven by a number of factors. First, services were further divided at sub-district level into a variety of models based on sectors, which were locally determined sub-divisions of the district. Two different models emerged: functional sectors, in which, for example, there was a sector responsible for community services and a sector responsible for hospitals; and geographical sectors, in which the sector covered hospital and community services in a defined area, or a mix of both. A third model (less common) involved care sectors in which, for example, a sector was responsible for the care needs of a group such as the elderly. It was at the sector level that policies for the type of service to be delivered were set.

It was the aspiration that by further organising districts into single sectors that integration and collaboration would occur between teams with shared interests and responsibilities. Instead, in some cases, the sectors only exacerbated separatist working (OHE, 1977, p. 209) and introduced complex managerial relationships.

Second, the nursing management structures were complex, driven by a desire here to increase the professional standing of nurses. The underlying motivation was that nurses should not be overseen by doctors. Again there were many layers of nursing roles across the regional, area and district levels that informed and were accountable to the other (Ottewill & Wall, 1990, p. 222).

  • Regional Nursing officer—planning and offering nursing input to plans as well as training

  • Area Nursing Officer—nursing input to plans and providing advice to LA

  • District Nursing Officer—planning for district, AND managed nursing services, both hospital and community.

  • Structures below this level were variable, but in general followed those proposed by the Management Arrangements for the Re-organised NHS or the Grey Book (DHSS, 1972), and these were taken up by the majority of AHAs in some form. Thus, district nurses were managed by Divisional Nursing Officers, who either covered functional divisions—i.e. midwifery, general, community OR covered hospitals or community services. They managed staff beneath them and held a budget.

However, these arrangements would prove to be short lived and the framework of the NHS structure was again under scrutiny, having been proved to be less successful and less popular than anticipated. The new structure was deemed to be too bureaucratic and unwieldy and further streamlining was suggested by the Royal Commission on the NHS (Merrison, 1979), essentially advocating a paring back of hierarchical layers. This led to the publication of the 1979 Consultative Paper—Patients First (DHSS, 1979) which proposed amongst other things, strengthening of management arrangements at local level and a focus on localism—which was welcomed by CHS. Specifically, it suggested that: ‘(1) for each major hospital or group of hospitals and associated community services, there should be an administrator and a nurse of appropriate seniority to discharge an individual responsibility in conjunction with medical staff, (2) the administrator and nurse should wherever possible be directly responsible to the district administrator and district nursing officer, respectively’ (Williams et al., 1980, p. 91/6). Wholesale re-organisation of the NHS was enacted in 1982 (Levitt et al., 1999), but it is noted that GP services came under the auspices of the Family Practitioner Committees (FPCs)—so separate from CHS.

In terms of population covered post re-organisation, this was left vague and continued to be a mix of both attachment to GP Surgeries and geographical. This was because the organisation of services below district level was a local decision and therefore ‘attachment’ vs ‘geography’ fell under this remit. The district boundaries were built around the idea of the ‘natural’ districts for health that were based on the existing use of community and hospital services rather than boundaries of the new health areas. The notion of ‘natural’ is problematic but what it meant in the context of the proposed changes was that health care was supposed to be planned and coordinated to meet the specific needs of local populations (OHE, 1974). According to McClure’s (1984) survey of district nurses, health visitors and community nurses in one AHA, nurses had been attached to general practice schemes for up to 10 years. By 1975, about 80% of AHA nurses were working in some form of attachment arrangement, a dramatic change from the mid-1960s, when less than 5% were attached to general practices (Reedy BLEC, 1980 unpublished data). The Way Forward—Priorities for Health and Social Services (DHSS, 1977a, Appendix)—reiterated the need for an increase in community nursing staff suggesting that the time they ‘spend on professional duties can be increased where general practitioners practice within defined geographical areas’. That model combined both attachment and geography and much the same is echoed in the 1980, Black Report, Inequalities in Health (DHSS)—a working party reporting on inequalities and health—which recommended that ‘where the number or scope of work of general practitioners is inadequate in such areas we recommend Health Authorities to deploy or redeploy an above-average number of community nurses attached where possible to family practice’ (Baker and Bevan, p. 16, para. 8.66).

3.1.3 Financing Community/District Nursing Services

Community health services were financed by AHAs, their employing organisation (Greengross et al., 1999). Funds came centrally from the DHSS to RHAs who distributed funds to the AHAs. However, the way funding was allocated was a continued source of dissatisfaction, especially following the unification of community and hospital services. Funding driven by supply and based on ‘historical precedent’ (Gorsky & Preston, 2013) had resulted in geographical health inequalities and inequitable access to health care. Here, deprived areas had historically received relatively less funding than their wealthier counterparts. Thus, in 1974, the DHSS commissioned the Resource Allocation Working Party (RAWP) (Gorsky & Preston, 2013) to review how, what and why, NHS capital and revenue was distributed so as to address better equitable and fair share of funding to regions. In the event, the RAWP allocated resources to regions based on formulae which tried to take account of their population levels and need based on weighting of usage of various activities weighted against national levels and standardised national mortality ratios. This, however, did not take account of disability which was problematic for CHS both because morbidity and disability rates varied across the country, but also because this directly affected their workload. Regions then allocated money to areas, using similar formulae. Money was not specifically earmarked for community services at area level—it was up to areas to decide how to allocate between districts, and up to districts how to allocate between hospitals and community. This raised concerns that CHS would not receive the necessary budgetary allocations. It should be noted, however, that actual budgets were held at sector (defined as sub-divisions of a district) level, and the nursing budget was separate from others at this level (Ottewill & Wall, 1990, p. 210).

Despite this, CHS actually benefited slightly from the RAWP formulae possibly due to the requirement for CHSs to grow faster than the acute sector resultant from the ‘Priorities’ documents. In real terms, on average, CHS received just 6% of capital allocations from 1974 to 1982 and approximately 6% of revenue, of this district nursing took the largest share (Ottewill & Wall, 1990). Some monies were also ring fenced to stimulate joint collaboration between HAs and LAs. The joint finance introduced in 1976 (0.5%–1.5% of total allocation to area) was supposed to mitigate institutional and administrative discrepancies allowing teams to secure a better outcome in terms of overall care (DHSS, 1976). Aimed at encouraging transfer of monies between health authorities and local authorities, it also extended the scope of community-based care for priority groups to include educational initiatives as well as housing. However, in practice, joint planning had mixed results although CHS did benefit slightly from the availability of joint monies (Ottewill & Wall, 1990, p. 214).

3.1.4 Summary

This era saw community nursing and especially district nurses, under increasing pressure from demand for their services—resulting from a combination of cost-cutting measures which focused on increasing care in the home, as well as an ageing population and lack of nurses. The re-organisation was intended to foster integration which was not realised. It became apparent that the structural changes did not produce any significant improvements in integrating health and social care and the attention shifted towards organisational and management solutions to the NHS’ problems.