Keywords

8.1 Historical Context

Building upon the Five Year Forward View (NHSE, 2014) (described in previous chapter), the NHS Long Term Plan published in 2019 (NHSE, 2019) suggested that policy would deliver a ‘new service model’ focused on ‘patients get more options, better support, and properly joined-up care at the right time in the optimal care setting’ (p. 6). ‘We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services’ (ibid., p. 13).

Overall, the Plan proposes the creation of a layered system that formalises more integrated approaches to service delivery across geographical levels as set out in Fig. 8.1.

Fig. 8.1
A table lists the levels of neighborhood, place, and system based on their functions and priority areas from the N H S long-term plan.

Components of the new system. (Adapted from: https://www.england.nhs.uk/wp-content/uploads/2019/06/designing-integrated-care-systems-in-england.pdf(p. 3))

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Such a system is somewhat at odds with the legislative framework established by the HSCA 2012 (HSCA, 2012), and so the NHS Long Term Plan (2019) proposed a number of legislative changes which would support these developments. Further guidance from NHS England was issued in November 2020 (NHS England, 2020) with a White Paper setting out concrete proposals for legislative change in February 2021 (DHSC, 2021). At the core of the proposals was the creation of statutory organisations at so-called system level, with the responsibility for overseeing the more integrated provision of services for a geographical population. Currently 42 such ‘Integrated Care Systems’ have been established, initially in shadow form, and established in statute in July 2022. At the same time, the requirement to follow European Competition Law has been removed, reducing the need for competitive procurement processes (although in summer 2022 it remains unclear what the replacement procurement regime will require).

The Health and Care Act (H&CA, 2022) does not address the organisation of Community Health Services directly at all and by default assumes that these services will continue to be delivered by the broad range of providers currently doing so, whilst assuming that the wider changes being enacted will make care more ‘integrated’. It is, nevertheless, possible to discern a number of potential implications for CHS in general and district nursing services in particular, which we will address in subsequent sections. Overall, it is clear that the Act situates community-based services as essential in the context of an overall desire to reduce the amount of care which takes place in hospitals, with a continuing focus on: case-management approaches which seek to streamline care for individuals; early discharge and ‘hospital at home’ approaches to minimise length of stay in hospital and reduce admissions; and co-ordination with primary and social care services. A particular approach highlighted in the NHS Long Term Plan (NHSE, 2019) is the creation of community-based ‘rapid response teams’ able to respond quickly to need and put in place more intensive services to support patients who might otherwise need admission.

Needless to say, the success of this approach is dependent upon the capacity and capabilities of a skilled and fully resourced workforce to deliver them. Historically, however, the district nursing workforce has been in decline and according to figures published in a report by the RCN and QNI in 2019, has declined by 46% since 2010, leaving just ‘4,000 District Nurses to provide care to a population of approximately 55.8 million in England alone’ (RCN &QNI, 2019, p. 4). The decline in district nursing staff presents a paradox between health policies which seek to deliver more care closer or at home (Drennan, 2019) and as such will need to be addressed in order to meet the challenges of delivering the Long Term Plan.

8.1.1 The Role and Function of Community/District Nursing Services

Within the NHS Long Term Plan, CHS in general and district nursing services in particular are situated as a key component of an NHS which aims to keep people out of hospital as much as possible. Within the system as envisaged, community services providers are required to liaise and co-ordinate with primary and social care to deliver an increasing proportion of care outside hospitals. The mechanisms by which it is envisaged that this will occur are: the increasing use of multidisciplinary teams, across neighbourhoods and sectors; and the continued development of case management approaches by which community-based staff take responsibility for the overall care required by patients with complex needs. A report published in 2018 by NHS Providers about the commissioning of community health services emphasises these points:

In fact, there is a real opportunity for community services to not only contribute to but take a leading role in the transformation and sustainability of future models of care given their ability to:

  • act as system integrators as they offer a valuable interface with other parts of the health and care system, particularly with primary and social care, and work across organisational boundaries

  • understand local populations, hard to reach groups and place-based working, meaning they are well placed to tackle health inequalities

  • address population health as they work collaboratively with and within multiple other parts of the public sector, such as schools and care homes, so can help tackle the wider determinants of health (social, economic and environmental)

  • promote public health through universal interventions and local relationships with other public sector organisations, given their spread across a geographic area, as well as encourage self-care and patient activation

  • spread the learning from their work in vanguards testing new models of care, particularly from multispecialty community providers where community services have been working together with general practitioners, nurses, hospital specialists, mental health and social care services to deliver integrated care in the community

  • identify, strengthen and bring together community assets to promote health and wellbeing (e.g. voluntary organisations, informal networks). (NHS Providers, 2018)

Whilst these approaches may be justifiable and of value in supporting the aspiration to improve population health and increase care outside hospitals, in the absence of a change in the funding model they risk putting increasing strain on community nursing teams already under pressure, particularly as social care provision is squeezed by the impact of austerity on Local Authority funding (Lowndes & Pratchett, 2012). They also bring with them issues related to skill mix, with such roles requiring high levels of skill. This means that there is a risk that qualified district nurses are pulled away from front line care teams in order to take on these more co-ordinating roles.

8.1.2 The Management of Community/District Nursing and Population Covered

In the vision set out under the NHS Long Term Plan (2019) and subsequent White Paper(DHSC, 2021), district nurses will be important members of multidisciplinary teams planning and managing care for complex patients, as well as taking leading roles in engaging across sector boundaries. The complexities of population coverage associated with this cross boundary working bring to the fore the longstanding tensions around geographical coverage vs attachment of district nurses to GP surgeries. The NHS Long Term Plan(2019) and the associated White Paper (2021) put in place an additional contract for general practices whereby groups of practices would work together across geographical ‘neighbourhoods’ as Primary Care Networks (PCNs) to provide additional services. Additional funding has been provided to support this. Several of these new services require GPs to work closely with community nursing teams, including additional support for patients living in care homes (Coleman et al., 2020) and so-called anticipatory care planning, which involves multidisciplinary teams engaging together to plan care for frail and complex patients. In pursuit of these aims it is suggested that Community Services providers will rearrange their community nursing teams to cover the same geographical footprints as PCNs. This is far from straightforward, as PCN footprints are based around GP practice registered populations, which are not necessarily neat or geographically contiguous (Hammond et al., 2020).

At the time of writing, the complexities arising from the negotiation of these new working relationships and cross-sector working are still in the process of being worked out. The Health and Social Care Act 2022 created Integrated care Systems (see Fig. 8.1) on a statutory basis. New Integrated Care Boards (ICBs) have been set up, overseeing Integrated Care Systems (ICSs). Each Board must have a representative of a local NHS Trust or Foundation Trust, as well as a Primary Care representative. At the same time it is intended that significant responsibilities and funding will be devolved from System to ‘Place’ level, although what structures might be established at this level remains unclear despite the enactment of the Bill into law. Many community providers cover large geographical populations(NHS Providers, 2018), and so it seems likely that each provider may need to engage with a number of different Places and PCNs. How management and oversight of teams established to support this new geographical arrangement of cross-sector services will work remains to be seen. In summer 2022 further guidance on these issues is awaited.

8.1.3 Financing Community/District Nursing Services

The report by NHS Providers (2018) highlights the financial pressures facing CHS providers, and identifies block contracts and lack of high quality data as factors holding back service development. In the new system based around statutory Integrated Care Systems it is envisaged that Systems will receive a population budget, which they will be responsible for allocating to the different types of service and to sub-system level geographical ‘places’, subject to certain national-level allocations such as those directed towards PCNs and GP practices. It is envisaged that funding mechanisms will move away from activity-based payments for acute services, using a system of block contracts which incorporate some mechanisms to recognise activity, with overall financial balance achieved at the System level. Even after the creation of Integrated Care Systems, the new approach to funding has still not been fully specified. It seems at least theoretically possible that an ICS might decide to redirect funding from acute services into community services or primary care; this suggests a funding system with some similarities to that seen in previous eras, when redistribution between sectors was the responsibility of District or Area Health Authorities. However, the significant difference between previous finance systems and that currently proposed is that in the past the distributing Authority was independent of service providers. Under the current Act, decisions about the distribution of funding between different sectors will be made by a board (the ICB) which includes representatives of those providers, raising questions as to how it will be ensured that decisions represent the best interests of the population rather than the relevant providers (Checkland et al., 2021).

How will this arrangement affect the district nursing service? The RCN and QNI (2019) argue that investment and commitment in the service is needed to maintain a sustainable district nursing service. They suggest that a ‘national standardised data collection system and data set within England, collecting meaningful data that recognises ‘value for money’ and is not just seen as a ‘notional saving’, thus promoting a strong economic case for investment in the district nursing service and providing systems at an operational level nationally, regionally and locally to prepare and support the district nursing service’ (p. 5).

8.1.4 Summary

Under the new Act, service provision is moving away from a competitive model to one based on co-operation and collaboration between sectors across geographical populations, with funding moving away from an activity-based model to one where finances are balanced at System level and planned reallocation of funding between sectors is possible. However, many aspects of how the newly created system will function remain unclear, and decision making bodies (ICBs) will potentially be dominated by large scale providers with significant conflicts of interest. The role of district nurses is increasingly being reimagined as that of case management and care co-ordination, with more senior nurses acting in these roles as well as managing teams of less well-qualified staff who deliver hands-on care. The tension between organising community services to cover geography as opposed to being centred around GP registered populations remains, albeit expanded to the larger PCN population rather than that of individual practice populations. Nevertheless, this change looks likely to require reconfiguration of many district nursing teams, with ongoing concerns about the availability of the workforce required.