Over the years, community nurses and others have aspired to deliver person-centred care, where the wishes of the client and their family are respected and acted upon. However, time pressures together with limited cultural change have sometimes prevented personalised care becoming a reality of practice. Universal Personalised Care (NHS England (NHSE), 2019a) reminds us that, while much progress has been made with more than 200 000 individuals benefitting from a personalised care approach in 2018, mainstreaming personalised care as usual practice across the health and care system will require commitment to shared decision-making with social prescribing, if the 2.5 million people with long-term and complex needs are all to receive personalised care by 2023/24. Reskilling and increasing the community and primary care workforce will be essential prerequisites.
A particular challenge facing district nursing (DN) services has been the fall in the number of nurses holding the District Nurse Specialist Practice qualification (DNSPQ) since 2010, compounded by poor recruitment to community staff nurse roles (Queen's Nursing Institute (QNI) and Royal College of Nursing (RCN), 2019). Indeed, the limited capacity of the DN services may underpin the rise in the number of older people being hospitalised (QNI and RCN, 2019). Further, it is difficult to identify DN services that are well-led and delivering excellent care, because many are part of acute hospital or mental health NHS trusts, although there is evidence that new care models with good integration reduce hospital admissions with GPs, particularly valuing the contribution of DN services if the services were not struggling with insufficient staff to meet demand (QNI and RCN, 2019). Unfortunately, uncertainty around funding for the DNSPQ and the introduction of an apprenticeship programme may mean there will be no new district nurses qualifying in 2021 (QNI and RCN, 2019).
Against this background, NHSE (2019b) has recently published the NHS Long Term Plan Implementation Framework, which sets out the Government's determination to see service transformation and system development nationally to reduce health inequalities and unwarranted variations. The strategic priorities for community health services include improved crisis response and re-enablement care, providing ‘anticipatory care’, enhanced care in care homes and using digital innovation. The Implementation Framework notes the importance of staff, including community nurses, as clinical leaders who can respond to local priorities and who are crucial for the new model of care delivery. However, while additional funding is heralded, it is unclear how the DN workforce will be expanded to ensure that these services are adequately staffed to meet the growing demands for nursing care in the home and extend their practice to include more preventative care. Indeed, the GPs and district nurses who contributed data to the QNI and RCN (2019) report noted that many DN services were struggling with diminishing workforces. But despite the pressure upon DN services, patients and carers universally praised their district nurses for their knowledge, clinical expertise and interpersonal skills and acknowledged their confidence in the care being delivered (QNI and RCN, 2019).
The immediate challenge facing the NHS is population health management, so that both the health of the population and care experience improve alongside enhanced workforce wellbeing and reduced overall costs (Deloitte, 2019). Echoing the Implementation Framework (NHSE, 2019b), Deloitte (2019) emphasised the criticality of improved use of information technology, including electronic healthcare records, linking previously disparate datasets and digital and remote care delivery, so that new care models and associated patterns of service delivery develop with scrutiny of their effectiveness. District nursing cannot eschew the digital age.
‘The strategic priorities for community health services include improved crisis response and re-enablement care, providing ‘anticipatory care’, enhanced care in care homes and using digital innovation.’