Health CommitteeWritten evidence from the Royal College of Nursing (LTC 81)

1.0 Introduction

1.1 With a membership of over 410,000 registered nurses, midwives, health visitors, nursing students and health care assistants, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2 Nursing staff play a key role in coordinating care between services. The RCN has played a significant role in the debate on the management of long term conditions as well as the integration of health and social care services in this context. The RCN welcomes the opportunity to submit evidence to Health Committee on this important topic.

2.0 Executive Summary

2.1 The RCN supports efforts to achieve integrated care and has previously participated in the Government’s work in this area, most recently through the NHS Future Forum’s consultation.1 We welcome the Secretary of State’s prioritisation of long term conditions as a priority area within the NHS Mandate.

2.2 Many RCN members, particularly those working in the community, work at the interface of health and social care and implement integration at a local level. Nursing staff are, therefore, well-placed to offer advice and information on best practice in this area.

2.3 In view of this inquiry, the RCN supports the following measures to achieve better integrated care for people living with long term conditions.

Allocation of community resources: With a larger proportion of health and care now taking place in the home or in community settings, a more urgent approach is needed to reallocate resources and skills to the community, including increasing staff numbers.

Specialist nurses and a single point of care: People living with long term conditions, as well as other health and care professionals, often benefit from the specific knowledge and skills of specialist nurses. They are skilled at navigating the often complicated path of health and care services as well as being able to provide a single point of contact for patients throughout their care.

Health and Wellbeing Boards (HWBs): The creation of HWBs is promising and something which should be invested in. HWBs could be critical in providing locally tailored integrated care, providing that they have adequate funding and autonomy, and are compromised of personnel with the appropriate skill mix.

Personal health budgets (PHBs): For some people living with long term conditions, PHBs and personalised care can dramatically improve their outcomes and experience. Where this works it should be continued and properly managed. However, this is not necessarily the most beneficial approach for all people living with long term conditions. Provisions must be available from already existing services to assist those for whom PHBs are not the right fit.

3.0 The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness

3.1 Nurses working in the community can play a key role as community champions and ambassadors engaging with people about their health. To ensure improved integrated care and to help stop the “revolving door” of hospital readmissions following discharge, community nursing services must be invested in. There is an increasing need for community nursing expertise if health services are to effectively meet the emerging challenges of long term conditions. These challenges include; a growing number of older people and other vulnerable groups requiring nursing at home; the associated drive to prevent hospital admissions for those with long term conditions; and to ensure end of life care can be delivered in the home. Unfortunately, rather than being supported to rise to these challenges, the RCN Frontline First campaign has highlighted that the community nursing workforce has actually contracted.2

3.2 Increased self care brings many benefits, not only for the individual, but for clinicians, commissioners, the NHS, Government and society as a whole. Self care empowers individuals to take ownership of their condition and some aspects of their treatment, such as managing their medication and making changes to their lifestyle. Nurses play an essential role in this process, encouraging and teaching patients how to manage their condition themselves. It is often specialist nurses, whose knowledge and expertise is specific to a particular condition, who are best able to carry out this role. However, specialist nurses’ jobs are under threat, they are often senior nurses meaning they can appear as an expensive outlay to an employer, the full benefit they bring to the care system and to the patient is also often underestimated. In times of financial constraint specialist nurses are often the first to be cut or redeployed to inappropriate settings.

3.3 When considering long term conditions it is also important to include health prevention as part of the conversation. Many long term conditions, such as diabetes, can be managed better by initial prevention and prevention of deterioration. The RCN is concerned that the budget available for prevention work, in terms of public health services commissioned by local authorities, is relatively small. The need for local authorities to show immediate progress against public health outcomes framework measures will divert resources from long term prevention measures.

3.4 Even with the budget for public health ring fenced, the RCN has real concerns over the future funding of preventative services as local authorities position themselves to provide these services during a period of great financial constraint. Much of their budget will be spent on demand led services, such as sexual health services and substance misuse services, leaving little left for prevention work on issues such as obesity and smoking.

3.5 Health prevention must be considered equally alongside intervention by commissioners.

4.0 The readiness of local NHS and social care services to treat patients with long term conditions (including multiple conditions) within the community

4.1 Health and care services in the community have a duty to provide those with long term conditions with continuous care across all services including acute, community and welfare.

4.2 Nurses are ideally placed to provide this continuity and often act as the single point for all care needs. As care coordinators, nursing staff play a key role in working to ensure that patients do not notice where one service starts and another ends. Their broad clinical expertise gives them a unique insight into a patient’s needs, enabling them to anticipate gaps in the system and to ensure that services are in place throughout the patient’s journey. Nursing care is a fundamental tool in enabling a seamless, joined up patient experience.

4.3 It is worth noting that people with learning or physical disabilities also frequently live with long term conditions. These patient pathways are often less well managed because of the complexity of multiple services required and the lack of integration between them. The RCN would like to see the skills of disability nurses used effectively to work collaboratively with GPs and other professionals, to inform and advise, on the best care pathways for those people.

4.4 The RCN is confident that professionals in the community have the necessary skills to manage the needs of those with long term conditions. However, in order to achieve the readiness desired to achieve integration and seamless care, a genuine commitment to move services from acute settings to the community, must be made. Resources must be reallocated so that there is sufficient capacity to deal with the number of people who live with long term conditions as well as the increasing amount of care taking place in the home.

4.5 In order to deal with the changing needs of the population, we must see a real shift of resources and expertises from acute settings to the community. The latest official statistics show that in the last ten years the nursing workforce has not shifted from the acute to the community sector to help meet this significant challenge.3 In terms of resources and expertise in treating those with long term conditions, what is proven to be beneficial to community nursing staff is the support of specialist nurses. They can support community staff to better improve care for their patients.

4.6 The RCN report Specialist nurses: Changing lives, saving money,4 identifies the crucial role that specialist nurses play in managing long term conditions. They provide direct patient care and educate patients on how best to manage their symptoms, as well as offering important support following diagnosis. In many cases the involvement of a specialist nurse can prevent patients being re-hospitalised or presenting at primary and emergency care settings. In a joint document with Parkinson’s Disease Society, Multiple Sclerosis Society and the RCN, Developing integrated health and social care services for long term conditions,5 the role of specialist nurses and community matrons was highlighted as being central to good management of long term conditions.

5.0 The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long term conditions

5.1 Clinical Commissioning Groups (CCGs) are still in their infancy, it is, therefore, somewhat too early to tell the effectiveness of the practical assistance available to commissioners in the new commissioning system. However, given the role that nurses’ play in managing the care of those with long term conditions and the expertise that they hold, it is vital that CCGs draw upon this expertise at board level to ensure the best possible commissioning decisions are made.

5.2 There is some confusion around which services will be commissioned through CCGs and which will be commissioned on a broader, national basis through specialist commissioning. This is particularly concerning in the context of long term conditions. For example, it appears that neurological services will be provided through specialist commissioning, meaning that there will be an overlap of commissioning systems for the services required by the patient. The RCN would like to see clarity on the remit of CCGs and specialist commissioning and a commitment to a joined-up approach to ensure seamless provision of services.

5.3 The RCN has raised concerns throughout the passage of the NHS (Procurement, Patient Choice and Competition) Regulations, relating to section 75 of the Health and Social Care Act 2012. The RCN is concerned at the delay of the Government and Monitor in issuing robust guidance which sets out clearly when and how commissioners will need to use competition when allocating contracts to providers. The RCN has made it clear that commissioners must not be forced in to using competition based solely on financial reasoning or where they believe it is not beneficial for the patient. Financial incentives for the provision of integrated care should not be the only incentives. Integration of services must be patient-led and have commitment from all health and care professionals.

6.0 The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions

6.1 A measuring tool for integrated care is often the successful implementation of a single point of care, where all services are provided through one assessment which is controlled, funded and provided through one source. Whilst this is not unheard of, it is certainly uncommon. The RCN supports the notion of a single point of care and although we know many nurses unofficially fulfil this role, we would like to see steps taken to formally imbed this in patient care.

6.2 A single point of care can provide the continuity and flexibility required to manage the care of people living with long term conditions. Long term conditions are constantly fluctuating, therefore, the provision of services must be flexible and responsive to altering conditions which can deteriorate or improve rapidly. A single point of care can be beneficial in effectively monitoring and assessing a person’s condition and what services are required at any given time.

7.0 Obesity as a contributory factor to conditions including diabetes, heart failure and coronary heart disease and how it might be addressed

7.1 Causes and contributing factors of long term conditions, such as obesity, can be addressed through effective public health interventions, education, public health training for community nurses and support for local services. The integration and communication between local public services such as local government, schools, and health and care services is vital in educating young people about the risks of developing long term conditions.

7.2 Health and Wellbeing Boards (HWBs) have the potential to play a very significant role in promoting integration of services, providing multidisciplinary oversight for long term condition services and promoting public health across services. We welcome the duty on HWBs to encourage integrated working between all health and care providers and commissioners, for example, encouraging the use of pooled budgets and integrated provision of services. However, the RCN is concerned that if HWBs are not granted adequate financial autonomy from local authorities, who will fund HWBs to varying levels, the impartiality of HWBs will be called in to question. Without this autonomy they will struggle to act independently of the local authority, or to work in meaningful partnership with representatives from other organisations. In addition to this, there needs to be a correct skill and knowledge mix on the HWB boards to effectively target local population needs.

8.0 Current examples of effective integration of services across health, social care and other services which treat and manage long term conditions

8.1 The RCN has identified a number of different nurse-led and innovative working practices and processes which facilitate the delivery of integrated care for individuals accessing the health and care systems. These include examples of utilising single entry points and single assessments, multidisciplinary teams, early intervention and regular needs reassessments and discharge planning. Two recent examples are detailed overleaf.

8.2 Stroke assessment services at Mid Yorkshire Hospitals NHS Trust

Mid Yorkshire Hospitals NHS Trust has implemented a round-the-clock stroke assessment nurse service. The service provides stroke assessment nurses 24 hours a day, seven days a week for staff to refer patients to. Through its access to stroke assessment nurses, the service facilitates rapid assessment, delivery of thrombolyisis and ensures stroke patients are admitted directly to the Hyperacute Stroke Unit, where appropriate. Early commencement of rehabilitation, drawing on a number of services, provides multi-faceted and integrated treatment for patients from diagnosis through to recovery.

8.3 Breathing Space Clinic, St Joseph’s Hospice, Hackney

Nursing Standard’s “Nurse of the Year 2013”, Matthew Hodson, a Clinical Nurse Specialist at Homerton University Hospital in East London, set up a clinic with colleagues for people with advanced chronic obstructive pulmonary disease (COPD). Recognising that there was little support for patients with COPD, Matt launched the Breathing Space clinic in 2011. The clinic is a multi-disciplinary, inter-organisational hospice based pilot to support the holistic needs of COPD patients. The clinic helps patients better manage their illness, control symptoms, improve their outlook and plan for their future. A multi-professional and integrated approach is used for all patients with care from a palliative care consultant, a COPD nurse consultant and a palliative care physiotherapist to manage the symptoms of COPD and improve quality of life.

9.0 The implications of an ageing population for the prevalence and type of long term conditions, together with evidence about the extent to which existing services will have the capacity to meet future demand

9.1 An ageing population, an increasing rate of lifestyle related illnesses, and patients suffering complex long term conditions are all contributing to a significant rising demand on the NHS and wider care services. Alongside this, the current financial situation that the UK finds itself in has led to huge pressure upon public spending and services.

9.2 Although the Department of Health and NHS has escaped budget cuts like those seen in other Government departments, it is still required to make efficiency savings of at least £20 billion by 2015 and it is widely expected that this figure is likely to rise. Cuts to other public services, such as local government, are having a knock on effect on the NHS. For example, local authority funding restrictions have affected local social care provision and other supportive services. These cuts increase demand for health services creating a bottle neck of activity and pressure on the NHS.

9.3 The RCN has frequently highlighted its concern about the need to properly address the way in which we care for the increasing number of older people, who have complex and demanding needs. In the RCN document, Safe staffing for older people’s wards,6 we stress the importance of ensuring the correct staffing levels and skill mix to properly care for the increasing numbers of older people in hospitals.

9.4 In addition to the increasing ageing population, it is important to note the significant number of younger people who have multi-morbidities and have additional needs in terms of accessing work, education and housing services. Integration, in this sense, requires cross-departmental working from the Department of Health, Department of Work and Pensions, Department for Communities and Local Government and Department for Education to effectively provide for those with long term conditions so that they can lead fulfilling and healthier lives, both mentally and physically.

10.0 The interaction between mental health conditions and long term physical health conditions

10.1 The RCN supports efforts to achieve integrated care between mental and physical health. Much of what has already been said above is relevant to this particular point. A single point of contact for those with mental health conditions and long term conditions can be beneficial in providing seamless care between services. Additionally, patient held records and clear care pathways managed by an integrated team can also be used to improve the integration of services.

10.2 For those with long term and mental health conditions, access to primary care services is vitally important in diagnosing and continually assessing often fluctuating conditions. The flexibility and sensitivity of primary care services is crucial to being able to manage mental health conditions. For example, the length of appointments at GP surgeries with doctors or nurses must be long enough to properly assess the physical and mental condition of a patient.

10.3 Patients must feel able to disclose information about their mental health and seek care and support for all physical and mental conditions. For this to happen, health and care professionals must be appropriately trained and educated to deal with both mental and health conditions, this is not often the case and patients experience different levels of care from different people. The RCN encourages approaches to train and educate nursing staff to manage both the mental and physical health of patients so that a more integrated approach could be achieved.

10.4 Often the simple reason for disjointed services is the geographical location of professionals and resources. To achieve a more integrated approach, the RCN would like to see mental health professionals and resources located in primary care settings, resulting in a co-location of mental and physical services.

10.5 Social isolation is often a factor for those living with long term conditions. Variables such as employment and education are known to have an impact on mental health and effective integration of local public services can be beneficial to the overall whole-person health outcomes.

11.0 The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes)

11.1 The RCN strongly supports the delivery of personalised care, with 88% of respondents to an RCN member survey on social care stating that individuals should be able to tailor their care to their own preferences and needs.7 Members also stated that personalised services and care are crucial to preventing health and care needs from developing or deteriorating, and hence represent an invest to save approach. Members identified personalised care plans, support to help make choices and regular reviews of care needs from appropriately trained staff, as critical to an individual’s experience and outcomes.

11.2 Personal health budgets (PHBs) are one tool which can help deliver personalised care for some patients. In the same RCN survey, 58% of respondents agreed that PHBs improve choice and control. Almost the same percentages were reflected in members’ responses to whether everyone should be entitled to a personal health budget with 57% concurring that PHBs improve choice and control.

11.3 However, even with appropriate resourcing and safeguarding in place, the RCN does not believe that PHBs will be an appropriate way to deliver personalised care for all patient groups and individuals. Different methods to personalise care will be required. Therefore, the RCN believes that PHBs must be optional. To maximise choice and personalisation, the Government will have to look how it will resource and deliver existing “traditional” services alongside additional services that personal budget-holders commission.

9 May 2013