For any newcomer to Wales, understanding its healthcare system offers valuable insight, particularly in exploring the provision of district and community nursing. The author explores this essential aspect, offering a concise overview.
Wales is a beautiful, mountainous country on the western side of England and is the smallest of the four countries of the UK. Wales is 170 miles from north to south and has a population of 3.13 million (Office for National Statistics (ONS), 2021). The most notable urban areas are in the south of Wales (Cardiff, Swansea, Newport), with rural areas across mid and west Wales. These areas are sparsely populated, which creates challenges for healthcare service delivery and infrastructure. Around 30% of the population of Wales and up to 77% of Gwynedd, Anglesey and Ceredigion speak Welsh (Welsh Government, 2021). The government's aim is to increase the number of Welsh speakers to 1million by 2050 (Welsh Government, 2024).
The population of Wales is predominantly of White, British descent, with areas of mixed ethnic backgrounds primarily in urban areas. The key industries are public sector employment, healthcare and education, manufacturing, public administration, agriculture and tourism. The unemployment rate in Wales, at between 3% and 4%, is slightly higher than in England. Over 62% of the population of Wales is of working age and 22% is aged 65 years and over. The over 65 years old are the fastest growing population group in Wales, with many retirees relocating to Wales, particularly to rural and coastal areas, to enjoy its natural beauty and lower cost of living. This presents significant implications for healthcare demand and service delivery, exacerbating the challenges posed by an ageing population in Wales. Wales has one of the highest poverty rates in the UK, with 23% of the population living in poverty. Life expectancy is cited as 82 years for women and 78 years for men; slightly lower than the rest of the UK. Unsurprisingly, because of this demographic profile, Wales reports higher rates of chronic conditions and disabilities than England, with 23% of adults living with a long-term condition. Cardiovascular disease and cancer are the leading causes of death in Wales (ONS, 2021).
In 1998, Wales became a devolved nation of the UK (Senedd Cymru, 2024). The Government of Wales Act of 1998 transferred legislative and self-governance powers from the Government of the UK to the Welsh Government. In 2020, the Welsh Government was renamed Senedd Cymru and was awarded law-making powers for over 20 specified areas. Similar processes to devolution have taken place for Scotland and Northern Ireland, defining the four countries of the UK. The National Health Service (NHS) in Wales, like the NHS across the rest of the UK, is publicly funded from taxation and a block grant from the UK Government. The Barnett Formula is used to determine the level of the block grant that His Majesty's Treasury allocates to Wales (National Confederation, 2024).
‘The delivery of care for community patients falls within the remit of the seven local health boards in Wales. Health boards deliver district and community nursing in their region, which is an integral part of healthcare delivery, ensuring care is delivered close to patients’ homes (Health Education and Improvement Wales, 2020).
The Welsh Government allocates its funding for the NHS across Wales via a draft budget that is approved by Senedd. Around 49% of the Welsh office budget is spent on health services across a range of NHS in Wales organisations. The NHS in Wales comprises seven local health boards, three NHS Trusts and two special health authorities; unlike England, there is no NHS Wales. Each local health board is responsible for planning, commissioning and delivering local healthcare to address local needs. With an ageing estate, substantial funds are required year on year, across Wales, to support the maintenance of premises.
The delivery of care for community patients falls within the remit of the seven local health boards in Wales. Health boards deliver district and community nursing in their region, which is an integral part of healthcare delivery, ensuring care is delivered close to patients’ homes (Health Education and Improvement Wales, 2020).
Services are delivered in alignment with the national policies set by the Welsh Government, with aims to improve access, integration and responsiveness. Services are delivered within primary care clusters, with groups of GP practices working together with community teams, pharmacists, therapists and social care to address local healthcare needs. District and community teams provide a range of services that include chronic disease management, wound care, palliative care, post-hospital discharge care, preventative care and the provision of specialist support.
‘District and community nursing services in Wales face challenges and opportunities that are like the rest of the UK. Challenges in recruiting and retaining community nursing staff impact on workforce shortages. There are growing demand for services because of an ageing population, the increased prevalence of chronic conditions and the challenges of rural life. Opportunities include the use of telehealth and mobile working solutions to enhance care delivery and ensure equitable care in remote areas.’
District and community teams in Wales are led by qualified district nurses, who hold a specialist practice qualification, leading a team of staff nurses and healthcare support workers. They provide care in patients’ homes, care homes or community clinics with an aim to reduce hospital admissions and maintain patient independence. Community nurses work closely with GPs, social services, therapists and voluntary organisations to provide holistic care. Regional Partnership Boards bring together health, social care and third-sector organisations to ensure the services offered are seamless.
Integrated health and social care are embedded with initiatives such as the Wales long-term plan, A healthier Wales: our plan for health and social care (Welsh Government, 2021), which focuses on prevention, reducing inequalities and delivering care closer to home. The National Community Nursing Specification (Strategic Programme for Primary Care, 2022) outlines a vision for community nursing that emphasises workforce development, technological support, and patient-centred care. With such a diverse and rural geography, digital technologies are essential to support district and community nursing. To support the implementation of technology, the Welsh Community Care Information System, a single system of shared electronic records, enables better record keeping, communication and coordination among professionals.
District and community nursing services in Wales face challenges and opportunities that are like the rest of the UK. Challenges in recruiting and retaining community nursing staff impact on workforce shortages. There are growing demand for services because of an ageing population, the increased prevalence of chronic conditions and the challenges of rural life. Opportunities include the use of telehealth and mobile working solutions to enhance care delivery and ensure equitable care in remote areas. District and community nursing in Wales plays a vital role, emphasising collaboration, integration, and patient-centred care. This service is central to achieving a healthier and more equitable healthcare system across the nation (Strategic Programme for Primary Care, 2022).
Care for patients in the community is person-centred, tailored to meet the specific needs of patients and supports physical, emotional, psychological health and the patients’ social needs. Patients and their families are involved in all decision making, with care that respects the patients’ language, culture and values. Care aligns with the Wales bilingual policy (Public Health Wales, 2024) and is available in both Welsh and English to support the cultural and linguistic needs of patients. Nurses coordinate complex, holistic care, particularly for individuals with multiple conditions.
Services are designed to be accessible, particularly in rural areas, using virtual wards, mobile clinics, home visits and telehealth technologies. Community nursing teams are responsive to feedback, which is routinely collected to improve service delivery. Metrics such as patient satisfaction, hospital admission avoidance and wound care outcomes are routinely collected with quality improvement at the heart of community nursing.