Community Nursing Transformation Update
North Ayrshire Council · 9 May 2024
Back to Integration Joint Board — 9 May 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 9th May 2024 Subject : Community Nursing Transformation Update Purpose : • Awareness Recommendation : It is recommended that IJB Note the progress of the outputs from the Community Nursing Review whilst noting the current identified risks. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required X 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms NHS AA NHS Ayrshire and Arran HSCP Health and Social Care Partnership NMaHP Nursing, Midwifery and Health Professions CTAC Community Treatment and Care ICT Integrated Care Teams GPn General Practice Nursing ANPs Advanced Nurse Practitioners 1. EXECUTIVE SUMMARY The Community Nursing review, which took place late 2021/early 2022, reviewed the community nursing care models being delivered across Ayrshire and Arran with the aim to develop care models which meets the needs of the changing demographics. This review covered 24 hour/7 day per week community nursing services. Through the Pan Ayrshire Community Nursing Governance Group we have been progressing the work identified through the four main recommendations of the review: new models of care; workforce planning and workforce competence; IT and Digital; and governance. This update information was tabled at Ayrshire and Arran’s Health and Care Governance Group on 6 November 2023. It has already been shared with East IJBs and will be shared at a future South IJB meeting. 2. BACKGROUND
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2.1 Demand for our health and care services is ever-increasing as people live longer, often living with multiple long-term conditions, reduced independence and increasingly complex needs for health, care and social support. The “Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams” (2017) document outlines what is required to enable Community Nurses to support the shifting the balance of care from hospital to community and primary care settings. To deliver on the Transforming Nursing and Caring for Ayrshire agendas it requires new and innovative ways of working. This includes more joined-up, collaborative ways of working which provides seamless interfaces with other professionals and services. The Community Nursing review commenced in September 2021 with a focus on the current nursing care delivery models across Ayrshire and Arran with the aim to develop a model which better meets the changing needs of the people in our communities. Related to this, the review highlighted the need for improved workforce planning with clear career progression pathways for both registered and unregistered staff. The review included all levels of Community Nursing staff (in hours and out of hours) across teams within District Nursing, Primary Care, Community Treatment and Care (CTAC), Integrated Care Teams (ICT), General Practice Nursing (GPn) and Community Advanced Nurse Practitioners (ANPs) across NHS Ayrshire & Arran. There is a Pan Ayrshire and Arran Community Nursing Governance group with four main subgroups progressing the four main themes of the review: • New models of care; • Workforce planning and workforce competences; • IT and digital systems to support clinical care; • Improved governance. 2.2 Community Nursing Review Update Over the last year, not only have our front line clinicians explored new and innovative ways of designing and delivering our health and care services, but our administrative team members, Caring for Ayrshire Quality Improvement team and Programme Management have been key in supporting the rollout of the outputs from the review. Each of the four work streams have a work plan which feeds into the main Community Nursing Governance group, and the management representatives from the Health and Care Partnerships (HSCPs) are responsible for communicating this work into their governance arrangements.
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The main areas within each of the work plans will be summarised, with examples of developments and the impacts being reported for each of the four areas. Many of the developments are led by one sub group but will impact on others, for example ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) sits within the IT and Digital subgroup but will have implications for new models of care, workforce related to staff training and supervision and governance due to the need to audit the quality of the plans and measure the impact to patients and their families/carers. 2.3 New models of Care: The following is a summary of the main topics which short life working groups are progressing – Referral criteria to District Nursing document have been agreed; • The ratified lower leg wound Standard Operating Procedure with progression to audit development in partnership between Podiatry and Community Nursing; • Progressing the administration of IV antibiotics/ fluids by community nurses • within people’s homes; • Diabetes care – Short life working group is in place to improve processes, including when patients are admitted or discharged from acute hospital sites; • Continence Care – update training programmes being developed and referral data is being reviewed; • Catheter care – A short life working group has been set up with the aim of identifying the number of catheters in situ, reduction in cost and infection rates. They will also provide guidance on learning, supervision and standardising care; • Adherence to a wound formulae and electronic PECOS ordering of wound • dressings; • Advanced Nurse Practitioner role in Care Homes around team around the person and future care plans; • District Nurse Specialist Practitioner role; • Antimicrobial prescribing; • Further developing the role of Community Nursing in Palliative and End of Life Care. Example of New Models of Care work being progressed: PECOS A joint initiative, between Pharmacy and Community Nursing, is progressing the adherence to a wound formulae and electronic Professional Electronic Commerce Online System (PECOS) ordering of wound products. NHS Fife and NHS Tayside have been using PECOS to order both wound products and catheter supplies for a number of years. They have demonstrated cost efficiency and reduction in waste by
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changing the way that dressings are supplied to patients by district nurses, treatment room nurses in GP practices and Care homes by ordering through PECOS. Only formulary items are available via the PECOS system thus improving formulary compliance which promotes safe and effective care. The main staff advantages identified from the Fife experience included stock delivered to base, no prescription writing, no waiting for GPs to sign prescriptions, monitoring of dressing usage, improved budget control, right product right time. NHS Ayrshire & Arran spend in 2020/21 on these products was:- • Wound Management Dressings £1.695M. • Catheters/Bags/Sheaths/accessories spend £1.726M. Of this catheters spend is £1.208M. A small test of change with two District Nursing Teams in South HSCP commenced in October 2023. Since then this process of ordering wound products has been fully rolled out in South HSCP and underway in East Ayrhire. Roll out for North HSCP is planned from July 2024 (North Coast - July, Irvine - August, Kilwinning/Garnock Valley - September and Three Towns - October). This work is being supported by the recruitment of a band 7 nurse who has been funded from Pharmacy but managed within Community Nursing. Data has been gathered to show prescription spending over the last four years and PECOS spending will be added to this in order to identify any savings (see tables below).
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2.4 Workforce Planning/Competency The following is a summary of the main topics which short life working groups are progressing – • Job description and person specifications for all bands of staff have been reviewed and in draft form to ensure consistency. • The development of competency frameworks for all levels of staff using national frameworks are being progressed; • Piloting different shift patterns to support retainment of staff, skills mix, equitable training access and balance of workload. Changing the shift patterns also helps prevent delays in District Nurse responses to patients, especially those who are palliative, during the transition from “in hours” to “out of hours” teams and vice versa; • Exploring the use of recruitment videos to increase the pool of people applying for community posts; • Developing a range of supervision models to ensure safe and effective care; • Career pathways for both registered and unregistered staff; • Exploring a mentoring role for individuals transitioning into promoted posts by individuals leaving senior posts for retirement; • Reviewing the Community Treatment and Care (CTAC) Educator Role; • Workforce planning – a short life working group is in place. They are reviewing workforce profiles as well as public health population demographic information. In addition, the impact of the shorter working week on meeting the demands of the workload will be explored.
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Example of workforce planning/competency work being progressed: different shift patterns- The test of change commenced formally in September 2023 for a period of 3 months. Six staff from the clinical team agreed to be included in this initial test of change. Staffing ratios are being monitored on a daily basis. The outcomes of this test, including any benefits to both patients and staff, will be brought to the Community Nursing Governance group in early 2024 for agreement for next steps. The table above demonstrates that out of 26 data points, 13 of those were related to higher than average (n:3) staffing ratio at four staff per shift. Eight data points were related to lower than average staffing ratio however four of these specific data points were weekends when staffing levels typically drop to one staff member per shift. The initial feedback from the staff involved in this test of change is extremely positive and other areas are keen to review the outcome findings in early 2024. Example of workforce planning/competency work being progressed: introduction of band 7 District Nurse Specialist Practitioner (DNSP) posts- Workforce is one of them main work-streams of this programme to ensure we continue to deliver safe and effective care. One of our aims is to have clear career pathways for both registered and unregistered staff. From a registered nurse perspective, a direct outcome of the Community Nursing review was the introduction of band 7 District Nurse Specialist Practitioner (DNSP) posts to limit the number of people on the caseloads having to be admitted to acute hospitals for care and/or to
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promote quicker discharges: these specialist, generalist nurses have advanced skills to provide complex care at home. We recognised that the band 7 Clinical Team Leaders, whilst supporting clinical demands, also had large operational/staff management responsibilities which can impact on the time they have to support the most vulnerable/complex patients on the DN caseloads. This along with the changing demographics of our populations and the number of band 6 who had completed Specialist Practitioner course who then left their post for promoted band 7 posts out with the District Nursing teams influenced the introduction of the DNSPs. The DNSPs have been introduced in Out of Hours, East and South HSCP. 2.5 IT and Digital The following is a summary of the main topics which short life working groups are progressing – • The development of Single Point of Contacts in the HSCPs resulting in patient and their carers now speaking with a person instead of leaving voice messages; • A change to the management of referrals onto EMIS Web. • The use of Trakcare for receiving referrals from Acute and Community Hospital sites has been introduced; • Clinical photography Standard Operating Procedure (SOP) developed and ratified by all relevant stakeholders ahead of introduction of new wound management application to support clinical treatment plans; • Streamlining the process of information sharing between DN day services and out of hours teams; • Blood sampling labelling issues have been resolved; • Improved access to Community Nursing information for both public and staff – an AthenA site has been identified for staff and the Ayrshire and Arran public facing website will be used for members of the public; • GP Electronic Referrals (East) – test of change - Only 2 GP practices have not participated in testing referrals to DN service via e-form and email to clinical mailbox Example of IT/digital work being progressed: changes to management of referral process • The move from Netcall to admin colleagues providing a “live” call service has resulted in excellent feedback since both a service user and staff perspective. It has improved patient experience, with 12-15% of patients who have called in being dealt with at point of call and this has resulted in additional time being released for the nursing teams to provide care. The below table demonstrates the percentage of live calls taken by SPOC in the first 3 months.
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In early October 2023, positive feedback was received via a District Nurse from a palliative patient’s family about how the SPOC admin team supported them during a very challenging and upsetting time. The family member said “every single person she spoke to on the phone were very supportive, kind and made her feel at ease when she was looking to get in touch with the DN Team urgently (she mentioned ****** name a couple of times too). She wanted to pass on how greatly appreciative her and the family are.
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Example of IT/digital work being progressed: changes to management of referral process North HSCP have been piloting the management of referrals on EMIS Web. A staff survey was carried out which found an improvement in the quality of information contained within referrals and reduction in the number of tasks being responded to, which in turn have released time to care for nurses. The below table demonstrates the clinical time saved by admin colleagues changing the way they processed referrals. Example of IT/digital work being progressed: Trakcare South HSCP have rolled out the use of Trakcare for receiving referrals from Acute and Community Hospital sites. Time has been saved both for admin staff and District Nurses and is demonstrated in the below table. Beith/Dalry/Kil Saltcoats go live Cumbrae/Largs /Skelmorlie /West Kilbride go live Bourtreehill go live Ardrossan go live Ballot Road/Kilwinning go live 0 100 200 300 400 500 Minutes Time saved for District Nurses following introduction of new management of referral process time saved (4 mins per referral) Median NB: median is calculatedfrom 2/6/23
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A staff survey was carried out which found an improvement in the quality of information contained within referrals and reduction in the number of tasks being responded to, which in turn have released time to care for nurses. 2.6 Governance This sub group is focusing on the professional governance structure for community nursing, which ensures consistency of agenda, framework, report templates and frequency of reporting. The following is a summary of the main topics which short life working groups are progressing – • Development of Clinical Supervision - Plan to implement supervision along with the time lines and trajectories of NMAHP strategy and implementation of the National policy; • Aligned Budget Codes - to support Nursing leaders to align their Budgets to allow accurate workforce reports; • Monitoring Arrangements - Develop process for real time escalation of risk. Develop and agree reporting mechanisms and standardised reporting template. Agree our standards for audit, audit tool and how data will be recorded. Develop dashboard for community nursing; • Developing a process and Standard Operating Procedure for real time staff escalation needs; • Staff Governance and Support - Implementation of appropriate standards for team meetings. Appraisals, one to one meetings, Psychological safety
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questionnaires, NES safety cards Professional. Clinical and professional supervision. 3. PEOPLE WHO USE SERVICES AND CARERS IMPLICATIONS 3.1 With an increasing amount of health and social care being delivered at community level, we recognise that our community nurses are pivotal in providing health care services communities want and need. Staff recognise that change is necessary to meet ongoing changing health needs to ensure the right care is delivered in the right place at the right time. 3. PROPOSALS 3.1 For the IJB member to recognise the progress of the outputs resulting from the Community Nursing Review whilst noting the current identified risks. 3.2 Anticipated Outcomes With the complexity of health care needs in our communities, we are having to transform our nursing teams in order to meet these needs to promote people getting the right care, at the right time, by the right person. Also with the extended clinical skills of community nurses there should be a reduction in work for our primary care colleagues for patients on the district nursing caseloads. 3.3 Measuring Impact Impact measures have been identified in all community nurses developments and pilots following the Community Nursing review. Some of these have been illustrated earlier in this paper. Through the Community Nursing Governance sub group on going quality and care measures are being scoped in order assurance can be provided and reported on. It is the intention that as a minimum, a yearly Community Nursing governance paper will be shared with each of the IJBs through their Health Care governance arrangements. 4. IMPLICATIONS 4.1 Financial Currently there are no cost implications for the work from the community nursing review. To date, all the work has been done within existing budgets. However, as the balance of care continues to shift into community and homely settings there will be a future need for additional resources within community nursing. 4.2 Human Resources There are no direct Human Resource implications arising from this report. 4.3 Legal There are no direct legal implications arising from this report. However given the Community Nursing review was based on Caring for Ayrshire and the National Transforming Nursing roles papers, there are policy implications. The Pan Ayrshire
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Community Nursing Governance group oversees the outputs of the review and reports to each of the three HSCPs through the membership of the group and through formal IJB update reports. 4.4 Equality/Socio-Economic There are no direct Equality implications arising from the report. 4.5 Risk The risks identified as part of the current works are: i. Issues with staff recruitment and retention of staff; ii. Information related to prescribed medications by Community Nurses not always being available due to EMIS access issues; iii. Risk associated with the current ways Community Nurses have to record care and also connectivity issues. Associated to this IT risk relates to cost pressures, for example android phones supplied by the organisation are required for nurses to take clinical photographs; iv. Increased community nursing activity within an environment of reduction in NHS staffs’ working week. 4.6 Community Wealth Building Community Nurses are key in ensuring people are cared for within their own homes through the care they provide as also role within the multi-disciplinary team. Being aligned to GP surgeries allows the nurses to know what is available in community they work in therefore accessing local services, statutory and voluntary, to meet the holistic needs of their patients. 4.7 Key Priorities To continue to engage with our patients, families, the multi-disciplinary team, wider teams and local communities to promote the wellbeing of patients, including to ensure a good life and good death. 5. CONSULTATION Consultation for the Community Nursing review is detailed in the pages 17-24 in appendix 1. Consultation with HSCP community nurses is ongoing through the Pan Ayrshire Community Governance group and its subgroups with managers within each of the HSCPs linking in through their local governance and communication channels. Dalene Steele (Associate Nurse Director, EAST) and Kerry Logan (Head of Service, Health and Community Care – NORTH) dalene.steele@aapct.scot.nhs.uk and klogan@north-ayrshire.gov.uk Appendices • Appendix No1, Community Nursing Review
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1 of 33 Corporate Management Team (CMT) SBAR DATE Subject: Community Nursing Review Author(s): Dalene Steele, Associate Nurse Director Situation 1.1 A Community Nursing review (appendix 1) took place during September and October 2021 with a focus on the current nursing care delivery models across Ayrshire and Arran with the aim to develop a model which better meets the needs of our changing demographics and also to support improved workforce planning with clear career progression pathways. Background 2.1 Demand for our health and care services is ever-increasing as people live longer but are often now living with multiple long-term conditions, reduced independence,nd increasingly complex needs for health, care and social support. The “Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams” document outlines what is required to enable to Community Nurses to support the shifting the balance of care from hospital to community and primary care settings. To deliver on the transforming nursing and Caring for Ayrshire agendas it requires new and innovative ways of working. This includes more joined-up, collaborative way of working which provides seamless interfaces with other professionals and services. The age profile of our Community Nursing workforce and the high turnover of band 6 District Nurses, especially those who had been supported by NHS Ayrshire and Arran to complete the Specialist Practitioner Qualification (District Nurse) course, was observed by the author and was one of the main reasons for requesting this review to be commissioned. Assessment 3.1 Shifting the balance of care will allow more of our 65+ population to remain at home and receive care and treatment there and fits with Caring for Ayrshire. ‘Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams’ outlines the
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2 of 33 proposed District Nursing role in the wider transformational change agenda in health and social care in Scotland. Engagement with all levels of Community Nursing staff (in hours and out of hours) was facilitated through virtual focus groups and a questionnaire developed with support from NHS Ayrshire and Arran’s engagement team. The questionnaire was sent to staff working in District Nursing, Primary Care, Community Treatment and Care (CTAC), Integrated Care Teams (ICT) and Community Advanced Nurse Practitioners (ANPs) across Ayrshire & Arran. The findings of the review concluded the following four main themes: • Implement a new model of care; • Review of workforce planning and establishment of a 3 year workforce plan; • Establishment of robust governance structures; • IT and digital systems to support clinical care. Recommendation 4.1 For CMT to endorse the recommendations of the Community Nursing review; 4.2 To agree a support resource to take forward the findings of the review; 4.3 For the 2021/22 second increment of Scottish Government’s District Nurse uplift investment to be used across all areas (HSCPs and Out of Hours) for Band 7 Clinical posts; 4.4 To share the Community Nursing review with all stakeholders.
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3 of 33 Ayrshire & Arran Community Nursing Review September/October 2021
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4 of 33 Section Page number Aim and Methods 3 Timescale 3 Background 4-5 Current Workforce - Whole Time Equivalent Resource - Age Profile 5-6 Health Needs of the Population 6 Nursing Roles 7 Stakeholder Engagement 7-14 Recommendations 15-16 Reference documents • Appendix 1 - Workforce analysis • Appendix 2 - Agenda/questions virtual focus groups • Appendix 3 - Feedback from virtual focus groups 17-31
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5 of 33 Aim of the work:- To review current care models delivered in the community across Ayrshire to develop a model which meets the needs of the changing demographics. This will take into account District Nursing (DN), Advanced Nurse Practitioners (ANPs), Intermediate Care Teams (ICT), and Community Treatment and Care Teams (CTAC) spanning Ayrshire and Arran. Administration staff supporting these services will also be included. The review will consider all resources over the 24 hour period, i.e. in hours and out of hours services. With more and more health and social care being delivered at community level, it is vital that health and social care staff in the community are supported to provide the services communities want and need. Staff recognise that change is necessary to meet ongoing health needs. They also recognise that while change is often challenging, it presents opportunities. Caring for Ayrshire is an exciting and ambitious 10 year programme that will transform health and care services across Ayrshire and Arran. The vision is that care shall be delivered as close to home as possible, supported by a network of community services with safe, effective and timely access to high quality specialist services for those whose needs cannot be met in the community. The programme will explore new and innovative ways of designing and delivering health and care services. This review will propose a new service delivery model for communities of Ayrshire & Arran that aims to meet the challenges we face now, and will face in the future. Methods Stakeholder engagement is central to this review. Virtual focus groups were undertaken with over 50 staff members. In addition, a questionnaire survey was sent to all community nursing staff to allow them the opportunity to contribute. National guidance has been reviewed to offer a perspective on the national direction ensuring Ayrshire & Arran is aligned to that. Timescales Time period Activity 13/09/21 – 20/09/21 Collate details of all community nursing teams - DNs, CTAC, ICT, ANPs 20/09/21 – 20/10/21 Workforce analysis 27/09/21 – 11/10/21 Virtual focus groups with staff/discussions with staff regarding their ideas for improvement 08/10/21 – 22/10/21 Development of questionnaire to all staff/ distribution of questionnaire 11/10/21 – 18/10/21 Review CNO document ‘Transforming Roles’ considering new, innovative roles Write up findings and recommendations for comments Week beginning 25/10/21 Submission of findings
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6 of 33 Background The coming decades will see a rise in the number of older people, many of whom will have a long-term condition, and a fall in numbers of people of working age. Action is needed now to prepare a health care workforce to meet the challenges of delivering a community nursing service for people of all ages in the future. We have changing demographics - people are living longer but are more unwell for longer. Demand for our health and care services is ever-increasing as people live longer but are often now living with multiple long-term conditions, reduced independence, and increasingly complex needs for health, care and social support. The percentage of the population that is aged 65+ across Ayrshire (including each local authority areas) is higher than the national average. In recognition of this, there is a comprehensive Frailty programme spanning primary care, community and acute settings. Within Ayrshire and Arran we already offer a wide range of health and care services in our communities so that people have access to the healthcare they need as close to their home as possible. However, many people are still unaware of the wide range of health and care professionals they can seek help and support from. As a result, the demand on GP time and the number of people attending our Emergency Departments continues to increase, often resulting in waiting times that are longer than we would like. We need to look at how we can better support people to access the health and care services they need at the right time and in the right place. Hospital is not always the best place to provide care. Evidence shows that the best place for people to recover is at home or within a homely setting. Long stays in hospital negatively impact on a person’s ability to return to normal activity, particularly for older people. We know that all three local authority areas in Ayrshire have a significantly higher rate of multiple hospital admissions (65+) than other areas, with an increasing trend in admissions. We need to look at different ways to deliver care in the community so that long stays in hospital are the exception and not the norm. The pandemic has led us to use technical and digital solutions at times in order to continue delivering care within the constraints thrust upon us. These new ways of working will be considered during this review to ensure we are making full use of the technical and digital solutions available. Sustainable and vibrant services within communities is key to the future of health and social care delivery. At the same time, the needs of patients and families are changing as they become increasingly active participants in their own care or the care of loved ones. With this comes a need to ensure that all health and social services are planned and delivered with the needs of users, rather than providers, in mind. It also requires a move to re-focus all health and social care services on the enablement of patients and carers. The Public Bodies (Joint Working) (Scotland) Act 20141 sets out the policy and procedures for integrated services to improve the wellbeing of people in Ayrshire & Arran. The aim is to better support those who use health and social care services, particularly those whose needs are complex and involve support from health and social care at the same time. In addition the act seeks to develop further the provision of preventative and anticipatory approaches.
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7 of 33 Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams2 outlines what is required to shift the balance of care from hospital to community and primary care settings. Delivering on these aims requires new and innovative ways of working. A more joined-up, collaborative way of working is needed which provides seamless interfaces with other professionals and services. Community nursing services have much to offer in realising this vision and responding to the challenges associated with caring for an ageing population. However, new ways of working are highlighting the need for a wider range of skills and knowledge across district nursing teams, from appropriately prepared and supervised health care support workers and assistant practitioners to registered nurses working from level 5 through to advanced practice. Description of Current Workforce and Current Service Provision Workforce analysis for District Nursing, ANPs, CTAC, and ICT - all teams across each partnership has been undertaken by Linda McLaughlin, Workforce Staffing Lead. This is appended to this report. Appendix 1 outlines the compositions of all community teams along with all leave and sick leave for each team. Whole Time Equivalent (WTE) Resource There is a significant resource working in communities across Ayrshire & Arran. The total WTE across Ayrshire & Arran for registered nursing staff is in the region of 253.95 WTE. The total WTE across Ayrshire & Arran for non-registered nursing staff is in the region of 74.21 WTE. Figure 1 below outlines the WTE resource in each partnership across banding levels 2 - 8A. Figure 1 - WTE Resource WTE Band 8A Band 7 Band 6 Band 5 Band 4 Band 3 Band 2 East Ayrshire H&SCP 1.60 5.40 11.00 46.00 0 25.00 5.00 North Ayrshire H&SCP 1.00 8.00 11.00 73.00 0 22.00 0 South Ayrshire H&SCP 1.00 4.00 12.00 61.00 2.00 20.00 4.00 Total 3.60 17.40 34.00 180.00 2.00 67.00 9.00 Age Profile The age profile of staff highlights that, in some areas, the percentage of staff over 50 years old is high, i.e. 88% of band 7s in North Ayrshire are over 50; 67% of band 7s in South Ayrshire are over 50; 67% of band 8As are over 50 in East Ayrshire; 63% of band 3s are over 50 in both East and South Ayrshire.
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8 of 33 Figure 2 - Age profile of community nursing resource Please note that due to the inaccuracy of Cost Centre data, information required to be pulled manually In terms of registered staff, the forthcoming changes in pensions in March 2022 may have a bearing on some staff retiring earlier than expected. The age profile, and contingencies for an ageing workforce who are close to retirement age, should be taken into consideration in the development of a sustainable workforce plan. Health Needs of the Population When compared to national averages, we know that Ayrshire has an older population (aged 65 years and over) than Scotland. During the pandemic we have heard feedback from staff to indicate that older people have become frailer and have increased rehabilitation needs. A review of data also shows that the Ayrshire population of people aged 65 and over are more likely to have multiple hospital admissions than their counterparts across Scotland. Shifting the balance of care will allow more of our 65+ population to remain at home and receive care and treatment there. Population 65+ - The percentage of the population that is aged 65+ across Ayrshire (including each local authority areas) is higher than the national average. Multiple Hospital Admissions - All three local authority areas have a significantly higher rate of multiple hospital admissions (65+), with an increasing trend in admissions. East Ayrshire North Ayrshire South Ayrshire Scotland Time period Mid-year population estimate - aged 65+ (NRS**) 20.45% 22.66% 25.53% 19.11% 2019 Multiple emergency hospital admissions, aged 65+ (Public Health Scotland/ISD) 6812.87 per 100,000 6259.98 per 100,000 6705.65 per 100,000 5455.96 per 100,000 2017- 2019 For both of these reasons, it is acknowledged that changes are required in our ways of working. Nursing Roles Review of national guidance ‘Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams’ outlines the proposed District Nursing role in the wider transformational change agenda in health and social care in Scotland. It highlights that integrated community nursing teams will play a key role in planning, providing, managing, monitoring and reviewing care, building on current roles and best; practice to meet the requirements of people with more complex health and care needs in a range of community settings.
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9 of 33 The embedded document sets out responsibilities and roles in the wider community nursing team, with examples of levels of knowledge and skills from healthcare support worker level to advances practitioner. The framework is organised around the four pillars of practice - clinical practice, facilitation of learning, leadership, and evidence, research and development. Stakeholder Engagement Virtual focus groups were undertaken over a 2 week period. From staff working at band 3 level to Senior Nurses, over 50 staff members participated in a virtual focus group. The agenda and themes from each of these focus groups are appended in Appendix 2. A questionnaire was also developed with the support of our Engagement Team. The link to the questionnaire survey was sent to all staff working in District Nursing, CTAC, ICT, ANP services across Ayrshire & Arran. A total of 117 completed responses were received. The responses have been collated into a 60 page report. It is too lengthy to append to this report but is available to all should you wish to read it. Contributions from community staff have been fantastic - there is a strength of feeling which is palpable and a desire to ensure community services are the best they can be. What did stakeholders feedback? Firstly, staff taking part in the virtual focus groups reported that COVID had given the opportunity for the development of stronger working relationships between individuals and teams. There had been increased cross boundary working and good, collaborative links made between teams and services. Healthcare Support Workers indicated that they felt they were an integral part of the DN team, and very much trusted and valued by their nursing colleagues. They provided each other with a high level of support and were there for their team members, to listen and look after each other. The themes which emerged during the virtual focus groups were:- Communication - between individuals and different teams/services. Whilst there were some positive elements and examples offered regarding practice during the pandemic, there were some aspects which could be improved upon. “Lack of communication between teams and repetitive visits by more than one team could be more stream-lined, freeing up staff rather having more than one nurse visiting, share nursing duties / responsibilities instead of referring onto other nursing colleagues”. “There is inequity across the three partnerships and AUCS, due to the fact we are not one discipline and managed accordingly; there are differences across teams and information is not cascaded timeously to all staff”. CNO Transforming Nursing Roles.pdf
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10 of 33 Workload - excessive caseloads with a need for consistent ways of working, streamlining of current processes. “The DN service delivers best care, prioritises patient care over taking breaks, starting early and finishing late”. “We are very responsive/accessible, take referrals from anyone, we know our communities well and in my opinion, patients get a very good service”. “Huge lack of investment in district nursing, understaffed, poor skill mix”. “Poor management, lack of safe staffing, lack of time for training and documentation. Ongoing problems of this kind for more than 5 years so staff are burnt out and leaving because of this”. “On Arran, the service has been beset by chronic recruitment issues, limiting services and putting a great deal of pressure on the remaining team who are doing an excellent job with the time they have. There is no overnight nursing care on Arran, despite growing demand and an ageing demographic, and this is resulting in poor care or a lack of care particularly for palliative and terminal care. There are no trained staff to respond to, for instance, syringe driver problems overnight”. “Under resourcing and a lack of workforce planning has resulted in poor staffing levels. High use of bank staff, often without the clinical skills required to deliver quality, safe care. District Nurse teams are not able to attend training sessions to maintain skills due to workload”. “Increased demand on activity from GP Clinical Pharmacists requests - there has been impact on activity and frequency and duplication of task, BP, weight and height to be recorded frequently”. “INR Star machines could be in all GP surgeries, this varies currently - therefore reducing the need for community nursing to go out to Care Homes”. Systems - the functionality of current systems (EMIS-PC and EMIS-Web) was mentioned frequently. As systems are not compatible, there is duplication for staff inputting to these systems. “The EMIS system is very problematic and cumbersome, wastes a lot of time with data input rather than actual nursing”. “We need IT systems which speak to each other rather than the separate systems which are currently in place - GP / DN / OOHs”. Role definition - clarity is required for all roles and work undertaken to extend practice. “I feel that the services do not meet the changing needs of patients very well. For example, in the CTAC role you come across patients who may have some off days and are unable to attend for dressings. It would be useful, rather than adding to an already hectic workload, if we as CTAC staff members could visit these patients at home for the short time they may require a home visit”.
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11 of 33 “We need better role clarity - referral criteria needed too as there is huge variation in requests for support”. “Band 3 role definition is required and how it compares with other service areas/wards”. “We need definition of role - across the Bands - what each does and does not do”. Opportunities - there is a need for clear career progression and succession planning. “We have strong leadership and now we have one senior manager and Interim CNM in post this has been invaluable for the communication channels for all staff”. “Career progression routes should be defined (note that Care at Home staff are better paid than some Community Nursing Service jobs”. These themes were corroborated by feedback from the questionnaire survey. 95.4% of community staff felt that there is room for improvement in community nursing/healthcare services across Ayrshire & Arran. 50% of those who responded to the questionnaire work in District Nursing. 35.7% of respondents work in East Ayrshire. 32.1% of respondcents work in South Ayrshire. 28.6%of respondents work in North Ayrshire. 3.6% of respondents work pan-Ayrshire. The questionnaire asked respondents what currently works well, what could be improved, and how we could be better in delivering care across our communities. The breadth of comments over the next 6 pages shows the range of just some of the qualitative comments received from the questionnaire survey. What currently works well? Collaborative working between teams and services was highlighted, along with some changes in the ways of working which had been adopted during the pandemic. “The DN leading care when they have extended skills, prescribing - we can see the patient from diagnosis, during treatment, palliation ACP/DNACPR, medications, starting/adjusting syringe drivers to confirming death - complete holistic care driven and managed by the DN team”. “I feel that CTAC integrates well with other health services such as pharmacy, mental health practitioner, etc., and that there are good connections available such as lymphoedema services”. “In specific cases, we have shown the ability to provide excellent care. One instance was pulling together to get a hospital bed, walking aid, increased homecare and ongoing DN support for a palliative patient within one working day. Another instance was a DN raised a concern regarding function, ICT visited the same day, a stand aid was ordered and delivered promptly to ensure the safe transfer for a young patient at home”.
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12 of 33 “EMIS Web, however, it doesn't get used by the out of hours service”. “Fast response time from referral to initial assessment”. “I think having Mental Health Practitioners (MHP) and Physiotherapists within GP practices and within the community works well. I have had patients come to me due to being extremely stressed and anxious to the point it has been affecting their health and I have been able to refer the straight to the MHP for a chat as a starting point”. “The community nursing team on Arran meet twice weekly with the GP team to proactively review and plan care on active, complex and palliative community patients and this has greatly improved care but vitally is a chance for the teams to talk, reflect and support each other”. “Holistic care, not task orientated - using our experience to make advanced clinical judgements, and having the ability to recognise deteriorating patients”. “Link nurses within teams - nurses who have a special interest in a certain specialty and have the skills and knowledge to assist the wider team, e.g. palliative care, tissue viability, continence”. “ICT responds immediately to referrals. We also have good communication with other teams working in the community”. “The daily AM huddle - charge nurses, team leaders, managers from social work, mental health, East Ayrshire Community Hospital (EACH), CTAC, and service managers are all on the call - it last approximately 15 minutes with each service giving a brief status and overview and whether they need assistance that day. We can also address any issues and get an answer from the senior service manager on the call”. How could we improve? Similar themes of challenges with communication, excessive workload, incompatible IT systems, lack of clarity regarding role definition, and lack of opportunities for career progression were all highlighted. “Better communication between services in/out of hours”. “Easier access to services, less time trying to contact people”. “More staff, more equipment, more experienced staff, better training, better support and staff care”. “We could be more joined up with social services, it doesn’t feel like a partnership”. “Development of a leg ulcer service and community diabetic support”. “We need more extended skill, investing in experienced staff who do not wish to do SPQ but could become prescribers/undertake advanced assessment. We need to raise the DN profile as few services appreciate the extended role”. “Education for patients/families and carers in order to understand the role of the community nursing team as well as promoting self-management where appropriate”.
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13 of 33 “Inappropriate referrals, continence and equipment issues take up far too much of our time that we could be putting to better use”. “There are bureaucratic barriers to effective team working and communication within teams using separate note recording and IT systems which requires additional time and introduces the potential for patient safety issues when attempting to navigate them”. “EMIS Web is not fit for DN needs - too much duplication and time consuming”. “There needs to be clarity for the role of the District Nurse. The public and other professionals appear to view us as their ‘go to’ person, when no-one else will help”. “I think there should be more training and progressions of the Healthcare Support Workers (HCSW) as the District Nursing role becomes more complex”. “I think there is opportunity for development of the CTAC role. With appropriate training there is no reason why catheters, piccs cannot be done in clinic where mobile patients are able to attend”. “We need more skill mix to allow the right person to deliver the right skills for the patient/family”. “If an OT or physio undertakes an assessment for equipment, why does it fall to DN's to order equipment for a patient we have not met?” “There is an expectation for DNs to pick up all referrals no matter what. One of the main issues is regarding continence support. This is an entire job role in itself and there are several calls a day to the office where patients are expecting a DN to sort a pad order. Referrals come to DNs from practices whereby the GP has automatically said the 'DN will get you pads' there is no appreciation for the complexity of this as an 8-week assessment needs to be undertaken, followed by urine screening and ongoing support. It is an extremely time-consuming part of the job and should not fall under the remit of a DN”. How could we be better? “Introduction of band 7 for our charge nurses with a post graduate diploma - they are highly educated members of staff who are not paid according to their education or the management of teams, this would hopefully retain them in their roles and we would not lose them to primary care or ANP jobs”. “District Nursing has no waiting list and patients are seen instantly however recently we have had to triage and put off visits that are still essential. ICT and DN teams should be amalgamated into one team. Also - DN teams have no access to patient results portal and PMS which can, at times, hinder our assessment”. “Referrals from hospitals/GPs/AHPS to District Nursing - a new referral form should be devised to give appropriate information to the DNs regarding the patient. Phone numbers and clinical mailboxes should be given to all staff for DNs as some wards are still using old numbers. Ensuring any discharges home have an adequate supply of dressings/continence aids for at least 1 week”.
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14 of 33 “A robust referral system into the DN service to prevent it from being viewed and used as a default service when MDT colleagues are unsure where to sign post patients”. “Managers need to be more aware of constraints and complications when working with people who are ill, our online diaries are packed full, often running until 7pm some nights, which means breaks are reduced and writing up has to be done at home”. “ICT nurses could support DNs more if they had a budget for dressings, blood bottles, etc. ICT nurses should be able to request equipment such as hospital beds and hoists”. “Consistency - there is no consistency in what we do and what patients we see. Communication and support from management. We need guidelines for what patients are considered “housebound”. “Admin/band 4 clinical staff to have personal touch when patients make referral, signpost, triage. Admin support to keep eESS, SSTS, training calendars up to date”. “Ask GPs to stop and think who is being referred and for what reason. As nurses can we not share responsibilities? i.e. could ICT nurses not take on more of the hands on nursing tasks if visiting patients anyway to free up DNs? This would benefit patient and reduce footfall”. “I think we require a phlebotomy service attached to the DN bases due to the high increase of blood requests from GP surgeries, even more so since COVID and a lot of these patients are not on the DN caseload”. “Better use of CTAC service: CTAC and DNs could work more closely together - CTAC could help DN workload by doing housebound wound management, B12s. This will allow DNs more time with palliative patients. CTAC could take on more skills by doing training on catheter care. (Not all patients who have catheters are housebound, therefore they could attend the surgery), alongside picc line care and nephrostomy care. Make the CTAC service more uniform, all GP practices work differently, have clearer guidelines for CTAC so that we can work anywhere. Make CTAC more aware of the integrated team by providing information about what services are available for patients”. “Improved integration of teams in primary care, community, community hospitals and social care teams such as homecare and residential care would be hard but will be worthwhile”. “Patients could be empowered to take ownership of their care, i.e. being shown how to administer eye drops and Fragmin at pre-op appointments”. “If community stores deliver a hospital bed with a BiWave mattress why can it not be inflated by the delivery team? A District Nurse has to be phoned to come out and set up the mattress and inflate it”. “When I started in general practice there were 2 District Nurses aligned with our practice - they were in and out throughout the day, leading to a better understanding of what was happening to the patients and better and more effective communication. Since this was stopped (to improve the service) there has been a dramatic reduction in the relationship between DNs and the practice. This is a cause for concern. The change was made and as far as I am aware there was no review to establish if the change had improved the service or made it worse. At present the DNs seem to be working in isolation and this will cause increased stress for the nurses and health care assistants”.
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15 of 33 “There needs to be integration of all community nursing resource to a much better degree as, at present, we are working in silos with impact on service delivery palpable. Secondly, there needs to be investment and consideration of skill mix with increased numbers of bands 2/3/4 to support the community nursing teams”. “There is a need for admin staff to help with organisational tasks freeing up nursing time, and easier ways for GPs to communicate with the DNs”. “Support for SPQ candidates - prescribing time, backfill, and study leave to allow them to shadow other services and explore far reaching learning opportunities”. “I was due to finish at 5 and it is now 6.15pm but I wanted to fill this in before the deadline - I haven’t had a chance to do it before now. We are short-staffed and having to help another area. We have had a vacant post for nearly 2 years and no bank staff hardly to cover. Please fix this situation for me, for my colleagues and most of all, for my patients. They need us in full working order”. Ideas for improvement There were many ideas for improvement - a small number are highlighted below. The recommendations take into account a wider range of the ideas to improve community services. Provide adequate admin support to all community teams to allow them to focus on clinical skills and patient needs More training for HCSWs to free up time for registered staff to deliver more complex care Improve communication especially between day and out of hours - needs a dedicated nurse to nurse for complex handovers From a community ANP perspective I am in a good position to mentor and provide training to staff while working with all partners to prevent hospital With a SPOC we could reduce inbound referrals as we know many could be signposted elsewhere During the pandemic the DN service has been put under extreme pressure. As patients stopped being admitted to hospitals and hospices, the % of people dying at home increased by 43% - a specialist palliative care service is needed or we need other activities removed to allow us to deliver palliative care well Safety huddles each morning could be built upon but we need some clear escalation plans too when pressure is excessive More agile working, telephone consultations and Near Me consultations
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16 of 33 Recommendations Review of the workforce analysis, feedback from stakeholders, and national guidance have led to these recommendations below:- 1. Implement a new model of care • Staff feedback indicated that utilisation of all staff groups could be maximised by implementing a Community Hub model with a Single Point of Contact (SPOC) and robust triage of referrals. • Development of clear, robust referral criteria to services, e.g. a standardised definition of ‘housebound’ to ensure reduced variations in practice across Ayrshire. • Skill mix/maximum utilisation of registered workforce. Feedback from staff suggested that some activities could be undertaken by others to free registered and unregistered staff to focus on their key responsibilities. Activities which could be undertaken by others included:- Administrative support; Equipment ordering (currently this is undertaken via the District Nurse, even in instances where the DN is not involved in the person’s care); Phlebotomy (not all areas have phlebotomists); Care Home inreach, e.g. INRs for Care Home residents; some aspects of continence care and treatment. • Development of new pathways to maintain people at home for as long as possible, i.e. step-up to and step-down from Community Hospitals. • Advancement of clinical Band 7 posts to meet the growing complexities of care in our communities and retain experienced, skilled staff in community services. • Further clarity regarding staff roles and responsibilities. The development of a competency framework which outlines clearly all responsibilities in relation to each banding is required. • Development of clear pathways for patients which ensure smooth handover at transition points of care, i.e. patients being discharged from acute care, patients being signposted/referred onto Third Sector and other agencies/services. I have used Near Me consultations at patients’ homes when using specialist services - this has saved a lot of travel time for patients and nurse specialist
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17 of 33 • Management of public expectations in terms of care provision by community services, i.e. promotion of anticipatory care, palliative care, and raising the self-management/self- care agenda. 2. Review of workforce planning and establishment of a 3 year workforce plan • A robust workforce plan which takes into account an ageing workforce, and implications of changes in the pension scheme in March 2022. The COSLA document ‘An Integrated Health and Social Care Workforce Plan for Scotland’ highlights that a 3 year workforce plan is vital. National guidance will be issued to support local areas to develop their own plan. integrated-health-soc ial-care-workforce-pla • Development of competency frameworks for all levels of community staff. • Clear strategies for recruitment and retention of staff (We know that in one partnership area in Ayrshire, only 2 band 6 staff members out of 9 who have completed the Specialist Practitioner Qualification have remained in District Nursing - a retention rate of 22%). • Development of clear routes for career progression. • Development of Band 4 posts. This is being driven nationally with phase 1 due to be completed by 10 December 2021. 3. Establishment of robust governance structures • A clear management structure which promotes the professional identity of community nurses. • Further development of clinical supervision for all staff to ensure they are fully supported in their roles. • Aligned budget codes which accurately reflect workforce location. • Monitoring arrangements to support quality control and assurance of care delivery. 4. IT and digital systems to support clinical care • Review of IT systems such as EMIS-PC and EMIS Web to reduce/eliminate duplication. • A streamlined referral system fully supported by the IT system in place.
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18 of 33 • Further utilisation of digital solutions to deliver care, e.g. Near Me consultations Reference Documents 1. The Public Bodies (Joint Working) (Scotland) Act 2014 https://www.legislation.gov.uk/asp/2014/9/contents/enacted 2. Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland - The District Nursing role in integrated community nursing teams https://www.gov.scot/publications/transforming-nursing-midwifery-health- professionals-roles-district-nursing-role-integrated/ 3. An Integrated Health and social care: integrated workforce plan https://www.gov.scot/publications/national-health-social-care-integrated-workforce- plan/ Appendix 1 - Workforce analysis Appendix 2 - Virtual focus group template/questions Appendix 3 - Virtual focus groups feedback
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19 of 33 APPENDI X 1
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26 of 33 Virtual Focus Groups - Band 3 staff APPENDI X 3
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27 of 33 What currently works well? • Level of support we provide for each other, to listen, be there and look after each other • All working really hard • Good communication between staff • Care at Home services are pro-active and communicate well indicating early request for assistance • Team members feel part of a team, have a level of responsibility and involved in decision making process • Increased involvement in supporting palliative care individuals during COVID • Good relationships with patients and families/carers and other services e.g. Podiatry • Allocation of a duty nurse during the day to cover tasks (not all teams have this) • Recently covering other service areas which has created opportunities to work elsewhere eg. Prisons, other teams • COVID has given the opportunity for stronger working relationships across individuals and teams. Cross boundary working CTAC supporting DNs • HCSW/NA see as an integral part of the DN Team, trusted and valued by nursing colleagues What could be better? • A lot of time spent doing admin functions – duplication of tasks on numerous systems. Use of EMIS web and EMIS PCS (EMIS PCS GP system) to record the same patient information • Activity not recorded well on EMIS – does not translate into measure of time taken to undertake tasks – misrepresentation of activity • Need for experienced, dedicated admin support to ensure clinical tasks are the priority • Variation of practices – some Home Care Services dispense eye drops and apply creams whilst others don’t. Where Home Care services do not do these tasks HSCW/NA need to pick up – clarity and definition required around roles and responsibilities • GP Blood requests – consistent approach would help • Housebound patients – who takes their bloods? – variation again. Time pressure on house visits where patient not necessarily housebound • Increased demand on activity from GP Clinical Pharmacists requests – impact on activity and frequency and duplication of task, BP, weight and height recorded frequently • Constant multi-tasking • Care Homes – some homes have registered nurses however some nursing tasks are given to DN staff to undertake – bloods, INR etc. The purchase of an INR star machine would reduce the demand for community nursing staff to undertake these functions if they were supported in the Care Homes • Better level of respect for the role undertaken • Patients ask for a GP visit however the CNS is allocated the visit – patient and families wish a GP – managing expectations can be challenging • Although being done well – some additional support for the palliative care elements • Some communication is over reliant on IT systems and a phone call to staff is at times better and more efficient/effective and key to providing timeous patient care Opportunities for Change? • Same system across all areas – SOPs
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28 of 33 • Band 3 role definition and how it compares with other service areas/wards • Career progression routes defined (note that Care at Home staff better paid than some CNS jobs) Community Nursing Service (CNS) • INR Star machines to be in all GP surgeries , varies currently – therefore reducing the need for CNS to go out • INR blood vials? Issues with samples not being able to be processed by labs • Definition of role – across the Bands – what each does and does not do • Avoid numerous visits – if GP does a home visit then asks for the CNS to do bloods, another visit – why does the GP not take bloods there and then to avoid additional visit? Themes • Communication – positive elements however aspects which could be improved on • Systems – functionality of current systems and duplication for staff on a regular basis • Role definition – clarity required – expansion of the role, increased activity and demand • Opportunities – career progression and succession planning • Workload – need for consistent ways of working, streamlining of current processes Virtual Focus Groups - Band 5 staff What currently works well? • Good example of working alongside the Tissue Viability Nurse – patient on Arran was provided specialist support by nurse providing a photo and sending over to TVN with good outcome for patient • Good examples of working alongside the Hospice staff – Patricia Hood and GPs • Hospice provides 24/7 on call support and advice on medication/triage calls which stop crisis points • Diabetic Nurse support is also a good example • Podiatry services are now re-mobilised and provide support for wounds from the ankle down and support can be accessed by a phone call to the ICT number • CTAC came together as a cluster and shared vaccine vials which reduced the wastage of products. This could be spread by formalising clusters within CTAC to operate better vaccine campaigns • Good link with Social Worker colleagues e.g. Kilbirnie meet every two weeks and any other concerns between meetings are picked up and shared • CTAC nurse roles are very positive – October flu vaccine programme • Local Operational Meeting – an example of Housing, Police, SW, GP in Three Towns where patients are discussed to reduce risks. Largs also has benefits of being co-located with GP, SW and police next door which offers a quicker response • Community Store What could be better? • Employing dedicated Continence Nurse as a lot of time is taken up ordering of supplies, assessments and re-assessments. If one dedicated team were to focus on this it would
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29 of 33 mean that we had expert advice rather than each DN covering this with only the one day training course • Unrealistic expectation from GPs, SW, carers on what can be delivered – the DN pathway is outdated (2010) and GPs tend to pass the buck – hand everything over to the DN • Better role clarity – referral criteria needed as huge variation in requests for support • CTAC development – PICC lines. Could they provide housebound support with vaccines and wound care etc? This would allow the DNs to focus on more palliative care at home. Further training and role development for the CTAC staff • Professional development in the role – CTAC nurse better alignment with the roles which staff can undertake – clarity and definition • Development of the Band 3 role – INR and Nephrostomy care • ?? CTAC nurse in surgery in the morning and then out in Community in the afternoon to assist DNs?? • Care Homes to invest in INR machines – which would reduce the need for DNs to visit to carry out tasks • Ordering of equipment through the Community Stores – why does this have to come via DNs? The patient is not always known to services and the assessment information is best completed by the area where the patient is – in-patient ward area. Huge duplication of activity • Additional phlebotomist capacity • Lack of information when a patient is discharged from hospital where there is a request for DN support. Times when people come out without a Kardex, any information/details. Opportunities for Change? • Same system across all areas – SOPs • Group lifestyle advice and patient education would support early intervention and prevention of some conditions rather than waiting until a crisis and services having to be sent in. • INR Star machines to be in all GP surgeries and care homes – therefore reducing the need for CNS to go out • Definition of role – across the Bands – what each does and does not do • Admin tasks being done by qualified nursing staff – not a good skill mix • Concise triage process – prior notification of discharge • Signposting to other services rather than taking everything on • Integrated care is failing because it appears easier and quicker to pass the buck to the DN service • CTAC could support the Long Term Conditions in the community, wound care, urology, catheters, continence and provide training Themes Communication – positive elements however aspects which could be improved on Systems – functionality of current systems and duplication for staff on a regular basis
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30 of 33 Role definition – clarity required – expansion of the role, increased activity and demand Virtual Focus Groups - Band 6 staff What currently works well? • Good examples of working alongside the Hospice staff – very responsive outreach intervention • Hospice provides 24/7 on call support and advice on medication/triage calls which stop crisis points • MS Teams – Arran example of GPs now twice weekly calls with DNs which has improved communication, improved response times and better time management • MS Teams works well and can support some training • Services are very much patient focused rather than task focused • ‘We never say NO to a patient’ • Communication is good – very accessible and feel part of a bigger team • Good thinkers, problem solvers and excellent at spinning plates and co-ordinating plans • EMIS Web good at recording some data/activity which previously has not been captured What could be better? • Band 6 role doesn’t reflect that of other Band 6s in a ward environment – pay structure needs to be looked at • Job retention – turnover of staff is considered high • Referral document needs progressed to provide criteria, education particularly of discharge planning from wards. Better interface between Acute Services and Community • Gatekeeper of community store – needs revised and role – expectation that DNs will check equipment set up etc. • Enablement ethos to be applied across all services • Dedicated Continence Team/service • National Procurement Contract • Gap in service provision – OOHs and Weekends – 4.30-5.30pm gap – who covers? • Admin support Opportunities for Change? • Skill mix – each team to have dedicated Band 2 phlebotomist • IT system which speaks to each other rather than the separate systems which are currently in place – GP /DN / OOHs • Care Homes – requiring a lot of support and further education on syringe drivers, wound management • Peripatetic nursing staff – invest in the whole system rather than looking at fragments • Development of the Community Hub model • Invest in Staff governance and support • More visible leadership • Raise the profile of the profession – will be supported by a defined role/referral system
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31 of 33 • ‘Knock back some referrals’ • Signposting to other services rather than taking everything on Themes Communication – positive elements however aspects which could be improved on Systems – functionality of current systems and duplication for staff on a regular basis Role definition – clarity required – expansion of the role, increased activity and demand Skill mix Whole system approach rather than silo working Virtual Focus Groups - Band 7/8A staff What currently works well? • Provision of end of life/palliative and continence care across DM teams works well in EA, use of bladder scanners, managing patient in their localities, saving a trip and appointment within Secondary Care and staff having to travel. Huge commitment as patients need scanned twice a day • Clinical Nurse Manager Role (interim) in EA works well, supporting DN care home work working well re links to senior staff with social work background. Very valuable role supporting DMs to work as one team. Routes of communication, line management arrangement and escalation routes much better. Arrangement has worked well during COVID-19 • CNM role moving areas of work forward quicker now e.g. audits • ANPs working in COVID-19 Centre now working at EACH x 1 ANP currently • Opportunities to work as Community Team in future • Working alongside Professional Advisors with regular meetings required • ANP in General Practice, lots of positives, need to navigate across various roles What could be better? • DN Service would be better as a Pan Ayrshire model would give a consistent approach, currently different approached in different areas • Need to be united as a services as per previous structure • Most other nursing services managed by nurses • Looking at new model (CNM role) but impact of COVID - affecting this • Need to move forward with change when resources and time allow • Where there are operational leaders without district nursing background, senior nurses have to work hard to define professional roles and responsibilities • Links forming with Service Managers re input to operational issues • Community Hospital nursing input being reviewed (SAHSCP) bring MDT together • DN teams want to work to the top of their profession
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32 of 33 • Improvement needed re close working relationships with GPs, OT, Social Work Team leaders. Integration could have worked with professional leadership retained • 3 HSCPs have different opinions on DN service • Need for robust referral criteria • Informal working arrangements result in DNs “helping out” taking on work • Issues with retaining staff, work life balance and career progression Opportunities for Change? • Band 6 staff undertaking Post Grad Diploma, dissertation required to achieve Masters, not require for Band 6 role. Should be Band 7 role requiring this qualification. 2 year study period a hard slog. Staff join DN teams as they are dedicated to Community Nursing. • Band 6s should be developed to Band 7 role in different ways rather than Post Grad route would help with succession, contingency planning and retaining staff. Align with transforming nursing role paper • More Band 7 staff required at clinical level a team leaders bogged down with admin work • Other HB work in different way, services aligned to the specific needs of localities, works well in NHS Lanarkshire • Current volume of caseloads significant, caseloads need to be manageable. Increase in Band 7 workforce would help with this • Band 6 and 7s currently doing lower level work need for competency framework, this would release time for more appropriate work • Development of Band 4 posts, clarity of career structure and career progression • Teams swamped with blood test requests from GPs, challenging and need to push back work that keeps coming • Consistency needed in what is appropriate for DN services and what is not • Query Band 3 work – doing Band 4 tasks • Having professional identify and leadership would strengthen professional position • Historical budgets have not moved on? • Opportunity to work well as pan Ayrshire services as many staff very experienced, skilled and knowledgeable • Health Visiting service now standing strong, DN services has been left behind • Strong leadership declined when review of DN service and changes implemented in 2010 • Lots of anxiety re 2010 review and reduction in DN workforce • New referral processes written up for GP Sub Committee had not been progressed, concerns re feedback on this, need to move this forward • Other services have an opinion on what DN services should be doing • CTAC? – Practice Educator, Primary Care roles required – Band 6 to support learning and development of workforce, currently real gap in Band 6 role. Development lacking due to work pressures. • DN and Practice Nurses have been support work pressure but this is not sustainable • Support for HCSW development • Care at home and DN services required across the wider community nursing roles e.g. CTAC • New Band 6 roles would be attractive to Band 5 staff, without having to undertake 2 years study
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33 of 33 • Consider retiring and returner roles, would not be for everyone a balanced approach would be required • Approach being taken by NHS Borders