23 January, 2019
Staffing the NHS: Why we need to invest in the community workforce
In a time of rising demand in healthcare it’s unsurprising that the perennial issue of winter pressures comes onto the radar. The recent publication of the NHS Long Term Plan tried to tackle many different subjects but included relatively little on demand and no concerted effort to understand it.
One of the areas that it did focus on was keeping people out of hospital. The Long Term Plan offers an ambitious aim: to integrate GP, community and health and social care with increased investment. This idea is not new but it is often seen as the answer to the overloading of the acute sector. One of the reasons it never quite seems to work out is because of the challenge of providing acute care outside of hospital.
The workforce supply issues we currently face in the acute sector pale in the light of the decline of the community workforce, and there is no better example than district nursing. In England district nurses have almost halved in just a few years. They provide a range of services such as palliative care and the management of long term conditions in the community - the kind of care that, if unmanaged, means the default is hospital.
District nursing is some of the most complex work we have ever observed. Not only does it consist of complex case management but the effective network and brokering ability of this group is extensive. They seem to conjure up solutions to problems and have many alternative strategies to the emergency department. They are also a salutary example of the decline of the expert front line decision maker.
Community nursing is a good example of this decline. Disinvestment in the specialist district nursing qualification, a division of labour model of task delivery, the rise of “tick box care” which nurses find frustrating, inflexible employment models and an ageing workforce have all contributed to their decline. The Queens Nursing Institute which researches the community workforce, found that there had been a 10 per cent drop between 2016 and 2017 of those taking the specialist qualification.
In order to meet increasing demand in both acute and community, the policy response to workforce is to develop a cheaper, less qualified, more flexible worker. More hands for less money. Various types of assistive personnel, such as associate professionals, are being introduced whilst the experienced, expert, decision-making workforce declines.
A workforce of low cost interchangeable widgets has long been the holy grail of workforce planners. A less qualified workforce is a very risky proposition in healthcare. The panacea of a “widget workforce”-worker who can fill any gap, in an increasingly high risk, high expectation, complex safety critical field is an illusion if good outcomes such as admission avoidance are key. Other safety critical industries have tried and then reverted back to the valuing of front-line expert decision makers.
If we want to solve the issue of winter pressures in the acute sector then sustainable and safe alternatives need to be found. Investing in the community workforce could be a significant part of that solution.