Health CommitteeWritten evidence from The Queen’s Nursing Institute (ETWP 09)


Education, training and workforce planning are the most important topics in the health service debate, since plans for commissioning, provision, public health activity, efficiency or service improvement cannot be achieved without the right people with the right skills in the workforce.

The Queen’s Nursing Institute (QNI) has recently published a report specifically on nursing care in the home which identifies issues of real concern in the quality of care in this hidden environment, due to inadequate attention to education, training and workforce decisions.

Pre- and post-registration education for all health care professionals must focus on the special skills required to deliver care outside of traditional hospital settings, since policy, economic and demographic drivers all require an acceleration in the movement of care to the home and community settings.

Continuing professional development for the existing workforce must explicitly re-train practitioners for community-based work.

Strong national leadership and direction will be needed to ensure that local commissioners hold their diverse providers to the same essential principles in developing their workforces.

Large-scale retirement of highly skilled and experienced workers in primary care and community services (GPs, nurses and others) is a major risk to the development of community-based services and the movement of significant amounts of work from secondary to primary care.

Measures to protect the public and ensure high quality care in the community would include:

reversing the decline in the number of nurses specifically trained to work in the community;

ensuring experienced mentorship and support for practitioners new to community work;

supporting the authority and importance of community team leaders alongside ward sisters;

regulating health care assistants and standardising their training;

strengthening post-registration and CPD opportunities to learn community skills; and

monitoring diverse providers’ workforce policies to ensure that they employ sufficiently-skilled and well-supported practitioners.


1. The Queen’s Nursing Institute is a 125-year old charity which aims to improve the nursing care that people receive in their own homes and communities. We do this by funding innovative, multi-disciplinary improvement projects; by creating Queen’s Nurses to be roles models and leaders to others; by running large-scale projects ourselves, such as our Opening Doors project for homeless people; and by campaigning and lobbying to influence the policies that affect the quality of care.

Education and Training

2. Our recent report, Nursing People at Home—the issues, the stories, the actions,1 heard directly from patients, carers, members of the public and community health professionals about the experience of receiving healthcare at home. While 70% of people said their care was excellent or very good, in 30% of cases, care was not up to standard. The key issues were nurses or health care assistants—and 45% of people did not know who had treated them—who either lacked knowledge about the patient’s condition, or did not have the skills required to treat them, or were poor at communicating, or focused only on the task and not the patient, or showed little compassion.

3. Patients and families who responded to the survey showed clearly that they could distinguish the well-trained practitioner from the “task-taught” practitioner; and the inexperienced person from the experienced. The impact of poor care was evident to the patient and their family: they described unnecessary pain, stress and suffering; avoidable pressure sores; avoidable hospital admissions; and even times when poor care was blamed for hastening death.

Patients said:

“My 91 year old mother died at Christmas. Although she was confined to a wheelchair for 12 hours a day she was not regularly assessed re her tissue viability and ended up with a massive pressure sore. Carers were left to deal with the sore and dress it as best they could although they tried to get the district nurse to visit. Eventually I got the out of hours district nurse to come out and she was superb. Sorting out analgesia, pressure relief, appropriate dressings, and daily visits. Unfortunately my mother died 24 hours later and I feel that her last few weeks could have been so different with skilled nursing care.”

“I had excellent help and care from the local district nursing team who helped care for my terminally ill mother… unfortunately this could not be said of the untrained carers who attended one day eg turning up to bath with large rings, long nail … insisted on lying a [short of breath] oxygen-dependent patient flat to change sheets even though with help of me alone could get out of bed. When I stopped them lying her down and explained why she had become agitated and could not breathe, the non-nurse manager still insisted this was the only way to change a bottom sheet … Fortunately for my mother she no longer required care for the untrained staff as she died later that evening not really recovering from the episode of being laid flat.”

“I have recently had three months district nursing care and valued the skills of the most experienced nurses. The limitations of the less experienced were apparent in that they can do a task to a set written plan but not adapt to changes as they arise or respond to wider needs.”

4. At the beginning of the QNI’s Right Nurse, Right Skills campaign, the national press was reporting the case of Jamie Merritt, a tetraplegic man who lived at home, and who was permanently brain-damaged when a community nurse accidentally turned off his ventilator and did not know how to turn it on again, or to use the resuscitation equipment. Sadly, the incident was recorded because Mr Merritt was so concerned about the lack of skills in the nurses who cared for him that had installed cameras in his room. This case serves to highlight both the complexity of care taking place in the community today; and the key role of education and training for the workforce.

5. The nurses who responded to our survey identified three education/workforce factors that are currently threatening the quality of care to vulnerable patients at home:

(a)The reduction in commissions for specialist community courses, such as the district nurse course, leading to more nurses learning “on the job” or in ad hoc courses—the NHS national workforce census for England shows that the number of trained district nurses working in the community has fallen by one third in the last decade, and is now at its lowest ever level.

(b)The loss of experienced nurse leadership in community teams—there were many reports of redundancies as well as retirements amongst more experienced nurses, and the subsequent down-grading of their posts—some community nursing teams are now led by non-nurses, which reduces the advice and mentorship available to less experienced nurses. The district nurse qualification is no longer a pre-requisite for team leaders.

(c)The increasing reliance on health care assistants, who are currently unregulated and unregistered, and do not complete a recognised course of training, to deliver increasingly complex care in the home. The workforce census shows that the number of HCAs in the community has more than doubled in the last decade; and we have had reports of provider organisations aiming for a 60:40 untrained to trained workforce.

Nurses said:

“Nursing skills have been eroded and role which have traditionally involved community nurses have been spread among semi-qualified staff.”

“In essence the patients under these teams may NEVER come into contact with a district nurse and have access to the specialist skills and knowledge. This practice is both dangerous and unfair to patients and their families.”

“As a district nurse, I have seen more and more care given by health care assistants. When I go in, I have to spend a lot of time sorting out problems that have been missed or caused by lack of knowledge. I have come across several cases of wrongly used equipment and poor clinical judgement.”

6. The QNI supports skill mix in community teams, and believes that HCAs have a great deal to offer, particularly in innovative roles spanning health and social care, which help people to manage in their own homes and avoid hospital or residential care. However, we believe that HCAs should be regulated, and that it is unfair to expect them to substitute for trained nurses without adequate preparation, support and supervision. There is a danger that our current approach to HCAs is recreating all the problems and risks of Victorian nurse training, which led to the registration of nursing being set up to protect the public nearly 100 years ago.

Diversity of Providers

7. Current Government policy aims explicitly to encourage new providers from the independent and voluntary sectors to tender for contracts to deliver a variety of community services. Indeed, non-NHS organisations already provide much complex care in community settings, including voluntary sector hospices, drug services and terminal care provision; and independent sector mental health, drug and alcohol, and specialist equipment and support services.

8. Since the NHS workforce census does not cover non-NHS organisations, we are already in a position of being blind to the workforce composition, plans and competencies in these services. There is an argument for contracting solely on the basis of outcomes, and leaving the provider to decide who they need in the workforce to deliver those outcomes successfully. However, this builds in a significant risk for the commissioner—and the recipient of services—that could be avoided by more transparency about skills and education of the workforce.

9. Proposals to involve all employers in local networks for workforce planning and education commissioning, and to require them to contribute to the funding of education, go some way to ensure that non-NHS providers are “inside the tent”. But further vigilance may be required to ensure that behaviours already demonstrated within the NHS, to reduce workforce costs by down-grading posts, employing lower-banded staff, reducing education and diluting skill mix, are not replicated unseen by other providers.


10. Exacerbating the loss of leadership, experience and education in community teams is the demographic profile of this part of the workforce. 72% of the district nursing workforce is over the age of 40, compared to 43% in the hospital sector, according to research carried out in 2008,2 and therefore eligible to retire within 15 years.

11. In addition to this natural wastage, the QNI has been aware of many community nurses taking early retirement in response to the stresses of recent re-organisation, and the pressure to “do more with less”, the loss of colleagues, down-grading of posts and inability to deliver care of the quality they consider essential for patients.

Some of the comments in our survey were:

“We are not working outside of the hours we signed up for, we have less staff and morale is at its lowest ebb. We are about to lose two highly skilled D/Ns to early retirement because of these enforced changes and they will not be replaced with the same skill mix and one may not be replaced at all… many believe that the district nursing service is being dismantled to be sold off to the lowest bidder.”

“Fewer DNs are coming through training and many are retiring or using their qualification to move their skills to other areas.”

“Age profile of district nurses is 50 plus and retirements are leaving vacancies that cannot be filled as staff have not been trained in sufficient numbers to fill the gaps.”

12. It is important to stress that experienced, confident practitioners such as these are essential to the development of the future workforce. The increasing numbers of inexperienced, newly-qualified and non-community trained nurses moving into community work will provide very valuable new blood, energy and inspiration, but only providing they are supported, mentored and assisted by people who already have specialist community skills. Every effort should be made to retain experienced community nurses if we are serious about moving the workforce out of hospitals to deliver more care closer to home.

13. The recent reports of poor care on hospital wards have led to a focus on the pivotal role of the ward sister, and the need to restore her authority, status and responsibility. Similar attention and effort should be focused on the “district nursing sister” or community team leader, for the entirely pragmatic reason that we need them to develop the next generation of practitioners and to safeguard the quality of care for patients today and tomorrow.

14. We also need experienced community leaders to ensure that there is not a hidden scandal of poor care and tragic consequences taking place behind the front doors of vulnerable patients at home, right now.

December 2011

1 The Queen’s Nursing Institute (2011) Nursing People at Home – the issues, the stories, the actions. London: QNI

2 Drennan V and Davis K (2008) Trends over ten years in the primary care and community nurse workforce in England. London: St George’s/Kingston University

Prepared 22nd May 2012