Keywords

9.1 Research Questions

  1. 1.

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

We have analysed and presented summaries of the key aspects of formal policy affecting district nursing services since 1948. We have done this under four thematic headings: the historical context; the role and function of district nurses; management and population covered; and financing services.

  1. 2.

    How do the policies change or remain consistent over time?

The integration of services has remained a continuous ambition, albeit one which has not yet been realised. Indeed, it remains a strong focus in current reform proposals. At the same time, the call to nurse more people in the community to reduce the burden of costly hospital care has also been constant through successive policies, especially following the 1974 re-organisation, and this currently forms part of the strategy of the NHS Long Term Plan 2019. Building upon this, current policy suggests a need to ‘dissolve the historic divide between CHS and Primary Care’ (NHSE, 2019, p. 13) but with no details as to how this is to be achieved. There has thus been a perceived need to shift care into the community over decades, and the fact that this has not yet been achieved suggests that new policy approaches may be needed. In particular, issues related to funding and system-level incentives arising out of the use of different types of contractual payment mechanisms for different sectors may be important.

More generally, there have been shifts in attitudes to the skills required by community nurses, with a gradual shift from emphasis on the provision of skilled nursing care in the home to a more case-management approach, with senior nurses planning care and engaging with other services, managing a team of less skilled staff. At times there has been the suggestion that community nurses should also provide health promotion and other preventative care, but this has never been consistently sustained and has gradually become diluted to a role in preventing hospital admission, rather than promoting health.

The tension between whether district nursing services should cover geographical populations or be attached to GP surgeries and provide care to their registered populations has been constant through policy since the 1970s. Most recently, there is tension around the delivery of services to Primary Care Networks, with a policy push for CHS to reorganise their teams around the geography of their constituent practices.

An early focus of policy was around the management of CHS, with a particular focus upon the tension between whether they should be managed by nurses or doctors. This tension has clearly been resolved in favour of nurse-led management via separate providers of community nursing services, with each iteration of NHS management structures since the 1990s having a role for senior nurses. Recent guidance on the constitution of Integrated Care Systems suggests that each must have a Director of Nursing.

  1. 3.

    What are the overt drivers of these policies?

Overall, health service policy across the decades has been, in part, driven by a longstanding desire to shift care from (presumed expensive) hospitals into the (assumed to be cheaper) community. Beyond putative savings, discharging patients more rapidly and preventing admissions to hospital offer potential benefits in terms of increasing hospital capacity to tackle waiting lists and in reducing iatrogenic harm such as hospital acquired infections. Moreover, policy documents imply the potential for increased patient satisfaction, embodied in the repeated use of the phrase ‘care closer to home’. Evidence to support these assumptions is limited, particularly in relation to cost savings (Checkland et al., 2013) but this has not prevented successive policies from being formulated to address this objective, with CHS clearly important if the objective is to be achieved. However, CHS have rarely been the prime focus of policy; in the historical eras we have covered, CHS have usually been reorganised or reconfigured around the needs of the rest of the service. In this context it is notable that CHS are barely mentioned in the 2021 White Paper (DHSC, 2021), with CHS mentioned in passing in a document which largely focuses upon acute providers. This suggests an underlying dominance in policy of the needs of large acute providers, with community services of all kinds lacking in political influence, despite the continued rhetorical statements emphasising is the importance of care near to home.

Beyond this, one of the most significant drivers since 1989 has been the ideological pursuit of competition between providers. This culminated in Transforming Community Services (DoH, 2009), with the result that community services became distinct provider units, either standalone or under the umbrella of a larger NHS Trust. At the same time, the drive for competition led to the payment regime known as Payment by Results for acute services, driven by the need for commodification of care bundles if competition is to be achieved (Harrison, 2009) alongside the need for incentives to increase activity in order to tackle unacceptable waiting times for treatment. CHS, by contrast, have continued to be paid according to block contracts, in part due to the difficulties associated with commodifying community-based care. Such contracts do not reward additional activity, ensuring that the desired shift of care into the community has not been incentivised. This has led to a consistent pattern by which community services are cash-squeezed in comparison with services which are paid according to activity, further limiting opportunities to increase care in the community. Addressing this will require the design of a payment system which does not incentivise expensive activity and which allows the active movement of resources from one sector to another. Such movement will require attention to the political influence enjoyed by different sectors.

These trends in turn are driven, in part at least, by the lack of good data about CHS activity and outcomes. Without clear ways of accounting for CHS activity it is difficult to argue for increased funding, and this in turn has further driven the funding limitations which have affected CHS over time. New community datasets are in development, but recent analysis of their potential usefulness found that the data are: not highly user nor access-friendly; difficult to link with any other publicly available data due to its aggregation and geography levels; difficult to link internally within the dataset itself; and relatively poor data coverage and reliability, with no information available as to what proportion of community service provider organisations are contributing data regularly (Malisauskaite et al., 2021).

Workforce issues have remained a constant problem over time, with both financial pressures and lack of senior qualified nurses driving an approach towards skill mix and care delivery by less qualified staff. This in turn limits the options for meaningful health promotion or a wider role for community nurses, as services become task-based.

  1. 4.

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

Disappointingly, CHS in general, and community nursing services in particular again figure in current policy by omission rather than there being any coherent vision for their role in the new system. The creation of ICSs has been discussed above. It has been argued by commentators that these proposals formalise many of the changes which have been happening locally, with organisations currently working together informally in order to try to provide more integrated care to patients. It is intended that the new architecture will facilitate cross-sector and cross-organisation working, with more emphasis on collaboration and less on competition between providers. ICSs cover large populations of between one and three million people, and have taken on the commissioning functions previously undertaken by Clinical Commissioning Groups. CHS will thus be commissioned by ICSs. However, ICSs cover large populations and it is suggested in the White Paper (DHSC, 2021) and associated guidance (NHS England, 2021) that much of the day to day work of commissioning will be delegated to what are called ‘place-based partnerships’. These will generally be established on geographical footprints similar to those previously covered by CCGs, covering, for example, Boroughs or towns. However, in summer 2022 after the establishment of ICSs in statute, guidance as to how service commissioning will be accomplished in practice is still awaited. Much of the White Paper setting out the new system was devoted to the role of acute hospitals, with CHS services only intermittently mentioned and with no clear policy proposals directed towards them. It is anticipated that community and other providers will work collaboratively together at place level and below this in ‘neighbourhoods’ to provide more integrated care which will support people outside hospitals, but the mechanisms by which this is achieved are not currently specified. Table 9.1 sets out the changes which may be of relevance to CHS providers.

Table 9.1 Summary of proposed policy changes
Full size table

From this summary it can be seen that many of the issues that we have identified through history remain salient. In particular, the new Act clearly situates CHS as predominantly concerned with supporting people to remain at home and to avoid hospital admission. This has been a policy focus over many years but, as we have highlighted, realising this policy ambition requires effective mechanisms for funding to flow from acute services to those in the community, something which is difficult under current pricing mechanisms. It has been promised that this will change, but the exact details of this are not yet available. Secondly, the new system requires CHS Services to collaborate at neighbourhood level with GP practices, but the question of geographical coverage is not addressed. Our historical analysis has demonstrated a constant tension over time between the organisation of community services over a geographical footprint as opposed to their organisation around the population covered by GP practices. Current guidance resolves this in favour of community services orientating themselves around the footprints of GP practices, albeit across groups of practices rather than individual ones. How easy this is to achieve remains to be seen.

Thirdly, although the current guidance associated with the Act signals a move away from competitive tendering for services, it is by no means clear how the new procurement regime will operate in respect of CHS which have been subject to competitive tendering in the past. Over the past decade or so there have been instances of community service provision shifting between providers as a result of such competitions. It is possible that the new regime will cement current provision, with existing providers (whether NHS owned or otherwise) being offered longer term contracts. On the other hand, it is also possible that the new regime may have the effect of condemning those CHS currently contracted out to be subject to further competitive tendering on the expiry of those contracts. Finally, the Act does not address the very pressing nursing workforce issues.

More generally, the new system offers a prominent place for large providers of acute services, and it is unclear how much influence community service providers will have at ICS level. Clearly arrangements as to representation on ICS Boards and Partnerships will be important, as will whatever is set in place to provide operational support for providers at Place level. Unless the NHS as a whole has a significant funding uplift (which seems unlikely), providing adequate funding for CHS providers to manage more patients in the community will require shifting resources between sectors. This may be difficult if acute providers have the strongest voice in ICSs, and it is further likely to be undermined by the needs for acute providers to tackle current treatment backlogs. These issues are complex and difficult to resolve; there is nothing in these current legislation which will necessarily support a stronger voice for CHS providers.

9.1.1 Conclusion

We have shown how, over time, there has been a consistent pattern by which community and district nursing services are rarely the focus of policy. Rather, changes have occurred in policy which have had a knock-on effect on CHS and the community nursing service, and these effects have often been to their detriment. Prominent amongst these has been the pricing regime that has tended to reward acute care to the detriment of care in the community. The current guidance surrounding the development of ICSs offers the possibility of more planned investment in CHS to support the policy objective of providing more care outside hospitals, but this will depend crucially upon the new pricing regime, which is yet to be established. It is worrying that the role of CHS leaders in ICSs and in Place-based partnerships remains unclear, and there is a significant danger that these entities will be dominated by large providers of acute services. Mechanisms for managing conflicts of interest among ICB members who are commissioners of care, many of whom will also be employees of provider organisations, are not yet clear, and there is a danger that the voice and needs of CHS will yet again remain unheard and un-regarded. The role of provider collaboratives is particularly concerning, as current guidance suggests that these ill-defined groupings may be responsible for significant budgets. The extent to which the needs of CHS are taken into account will depend crucially on ICS leaders having a broad vision that encompasses all types of providers.

More generally, it would seem that the organisational form of CHS providers has slipped from policy focus. We do not know what form of provision is best suited to providing integrated care in the community, and research could usefully consider the extent to which CHS ownership and organisational form affects service delivery in the current NHS structural context. Similarly, policy has defaulted to a model of skill mix provision, in which care is provided by less qualified nurses undertaking tasks under the supervision of a more senior nurse. The impact of different models has not been studied in detail and is not addressed in current policy. The provision of accurate information about community service activity and outcomes will be important but achieving this seems to still be some way off. Current policy envisages community teams working closely with groups of GP practices and further research is required to explore how this can be made to work in practice, given the complex geographies embodied in both CHS providers and Primary Care Networks. In summary, it seems that, as Griffiths pointed out, CHS remain:

Everybody’s distant cousin but nobody’s baby.

—Griffith’s (1988)