Written evidence from the Queen's Nursing
Institute (CFI 35)|
1. The Queen's Nursing Institute (QNI) is the
national charity concerned with the quality of nursing care patients
receive in their own homes. We aim to improve care by funding
nurse-led improvement projects, and inspiring nurses through the
example of our Queen's Nurses. We also aim to influence policies
that impact on the quality of care patients receive. The QNI does
not have a membership base: this response reflects the expertise
from our community nurse forum - which has more than 1,000 members.
2. The QNI welcomes the opportunity to respond
to the Health Committee's Commissioning: follow-up inquiry.
Community nurses are vital to development of the best care pathways
for patients in their homes - we believe a critical success factor
for GP consortia. Community nurses have valuable insight into
service delivery, including value for money, efficiency, and quality.
They also know their communities - able to look above the clinical
needs of individual patients - and support commissioners in the
securing the right services for patients in their homes.
3. Our submission responds specifically to paragraph
96 of the Committee's Commissioning Report - Integrating the full
range of clinical expertise into the commissioning process. By
way of illustration, we also showcase an example of commissioning
innovation led by community nurses and detail our concerns about
the continuing loss of nursing skills in the community. The QNI
would of course be very pleased to meet with members of the Health
Committee to discuss these issues further.
PARAGRAPH 96 - INTEGRATING
4. The QNI supports the focus on "clinical"
commissioning - that is, integrating the full range of clinical
expertise into the commissioning process. However, we believe
this must include clinical expertise that goes beyond the boundaries
of general practice. For instance, the commissioning process must
not focus solely on those nurses who are currently employed in
general practice. It is true that nurses in general practice have
contributed enormously to the achievement of quality outcome targets:
that is because they are employed so to do. Meeting the health
needs of the whole community cannot be achieved solely from within
the general practice: it relies on the work of other nurses, and
allied health professionals, who are employed by other organisations.
Commissioners need to recognise and involve this workforce
too. There is a huge opportunity, which has never been realised
through any other re-organisation, to break down barriers between
practices, and between practice-based and other teams, to provide
a much richer, integrated workforce for care in the community.
To support this process, we believe there is an urgent need to
create realistic opportunities for community nurses in particular,
to participate in the development of the new commissioning processes.
5. The QNI agrees that the divide between commissioners
and healthcare professionals is too great. Most frontline healthcare
professionals (of all kinds) do not see how they can make a contribution
to the new commissioning process. They feel they are powerless
minions of the commissioners, rather than partners in the process.
We believe there is an urgent need for a comprehensive development
programme to empower and engage frontline healthcare professional
in the new commissioning process. Healthcare professionals need
to understand how their experience, expertise and knowledge can
contribute to the commissioning functions - assessment, patient
involvement, quality assurance, evaluation and service redesign.
It is not enough for a national leadership and development programme
to focus solely on GPs at this time. This initiative would provide
professionals with the confidence to lead on commissioning.
6. Modern healthcare services are increasingly
nurse-led in response to changing healthcare needs. Accordingly,
some solutions to commissioning will inevitably be nurse-led.
7. In 2008, the QNI funded (as part of the our
Innovation Fund) a nurse-led project which set up a non-judgemental
drop-in wound care clinic for injecting drug users in Dewsbury
- a partnership initiative between NHS Kirklees, The Mid Yorkshire
Hospitals NHS Trust and the charity, Lifeline. The clinic offered
specialist advice and treatment in a non judgmental clean environment,
so preventing associated risks of infection that untreated wounds
can develop. The clinic was run by a fully qualified District
Nurse and a Tissue Viability Nurse Specialist. Project lead Jackie
Hatfield said: "Drug users who get a sore, abscess or open
wound in an injecting site tend to treat themselves at home in
sometimes difficult circumstances. Earlier treatment will be better
for users and more cost effective for local health services because
it will mean fewer people being admitted to hospital or visiting
8. The project successfully:
associated health risks to service users from untreated wounds.
In particular, clients who attended for regular wound care had
their pain controlled by better management, which in turn led
to better compliance with their drug treatment programme and improved
their general health ie nutrition, mobility and a reduction in
illicit drug use;
accident and emergency attendance for wound care in IV drug users.
This also included an awareness of the clinic in the injecting
drug user population and other healthcare professionals sign posting
the clients to the clinic; and
service users to engage in treatment programs. For instance many
clients return to the clinic for follow up treatment linking their
visit with their planned Lifeline appointment. It is an added
value to the client and has helped to improve patient outcome.
9. The clinic also enabled increased productivity
within a short time frame with clients in one place rather than
two nurses travelling to a client's home in what can sometimes
be a risky and unhygienic environment.
10. This project responded to a community health
need identified by community nurses. As a result of its success,
the clinic was commissioned by NHS Kirklees, with funding for
two afternoon clinics at Lifeline Dewsbury per week.
11. The need for skilled home nursing is rising
as the population ages, more people live with long term conditions,
and people are discharged earlier from hospital. One in four people
over the age of 75 need a district nurse's care at home, rising
to one in two people over 85. In total they visit
more than 2.6 million people a year. Yet the number of trained
district nurses has been falling for more than a decade, to fewer
than 10,000 in England. At the same time, the number of health
care assistants - trained to do specific tasks but who are not
qualified nurses - has more than doubled.
12. Current changes to the NHS will introduce
further alterations to the provision of community care. The QNI
is already receiving regular reports from community nurses about
reductions in staff numbers, down-grading of posts, ending of
innovative projects and a rush to retirement amongst colleagues
who are eligible. Morale is undoubtedly very low, and practitioners
are very concerned about their ability to sustain high quality
services and care.
13. The QNI believes that the skills, knowledge
and engagement of community nurses will be vital in the successful
implementation of the new commissioning framework. There is no
alternative workforce to help commission and deliver nursing care
services in the home. So it is essential that the workforce issues
are addressed early on - including the falling numbers of community
specialists, highly diluted skill mix, rapidly-increasing use
of health care assistants to do nursing tasks, and exclusion of
all but GPs from input into planning, commissioning and designing
14. In response to the current challenges, the
QNI launched a campaign last October, Right Nurse, Right Skills.
The campaign draws attention to the continuing loss of nursing
skills in the community, and the impact this is having on the
quality of care for elderly and vulnerable people in their own
homes. We are not campaigning "'against" healthcare
assistants. We are campaigning for a properly skilled and trained
home nursing workforce, so that patients receive the care that
they need. To date we have more than 1400 supporters.