Commissioning: further issues - Health Committee Contents

Written evidence from the Queen's Nursing Institute (CFI 35)


1.  The Queen's Nursing Institute (QNI) is the national charity concerned with the quality of nursing care patients receive in their own homes. We aim to improve care by funding nurse-led improvement projects, and inspiring nurses through the example of our Queen's Nurses. We also aim to influence policies that impact on the quality of care patients receive. The QNI does not have a membership base: this response reflects the expertise from our community nurse forum - which has more than 1,000 members.

2.  The QNI welcomes the opportunity to respond to the Health Committee's Commissioning: follow-up inquiry. Community nurses are vital to development of the best care pathways for patients in their homes - we believe a critical success factor for GP consortia. Community nurses have valuable insight into service delivery, including value for money, efficiency, and quality. They also know their communities - able to look above the clinical needs of individual patients - and support commissioners in the securing the right services for patients in their homes.

3.  Our submission responds specifically to paragraph 96 of the Committee's Commissioning Report - Integrating the full range of clinical expertise into the commissioning process. By way of illustration, we also showcase an example of commissioning innovation led by community nurses and detail our concerns about the continuing loss of nursing skills in the community. The QNI would of course be very pleased to meet with members of the Health Committee to discuss these issues further.


4.  The QNI supports the focus on "clinical" commissioning - that is, integrating the full range of clinical expertise into the commissioning process. However, we believe this must include clinical expertise that goes beyond the boundaries of general practice. For instance, the commissioning process must not focus solely on those nurses who are currently employed in general practice. It is true that nurses in general practice have contributed enormously to the achievement of quality outcome targets: that is because they are employed so to do. Meeting the health needs of the whole community cannot be achieved solely from within the general practice: it relies on the work of other nurses, and allied health professionals, who are employed by other organisations. Commissioners need to recognise and involve this workforce too. There is a huge opportunity, which has never been realised through any other re-organisation, to break down barriers between practices, and between practice-based and other teams, to provide a much richer, integrated workforce for care in the community. To support this process, we believe there is an urgent need to create realistic opportunities for community nurses in particular, to participate in the development of the new commissioning processes.

5.  The QNI agrees that the divide between commissioners and healthcare professionals is too great. Most frontline healthcare professionals (of all kinds) do not see how they can make a contribution to the new commissioning process. They feel they are powerless minions of the commissioners, rather than partners in the process. We believe there is an urgent need for a comprehensive development programme to empower and engage frontline healthcare professional in the new commissioning process. Healthcare professionals need to understand how their experience, expertise and knowledge can contribute to the commissioning functions - assessment, patient involvement, quality assurance, evaluation and service redesign. It is not enough for a national leadership and development programme to focus solely on GPs at this time. This initiative would provide professionals with the confidence to lead on commissioning.


6.  Modern healthcare services are increasingly nurse-led in response to changing healthcare needs. Accordingly, some solutions to commissioning will inevitably be nurse-led.

7.  In 2008, the QNI funded (as part of the our Innovation Fund) a nurse-led project which set up a non-judgemental drop-in wound care clinic for injecting drug users in Dewsbury - a partnership initiative between NHS Kirklees, The Mid Yorkshire Hospitals NHS Trust and the charity, Lifeline. The clinic offered specialist advice and treatment in a non judgmental clean environment, so preventing associated risks of infection that untreated wounds can develop. The clinic was run by a fully qualified District Nurse and a Tissue Viability Nurse Specialist. Project lead Jackie Hatfield said: "Drug users who get a sore, abscess or open wound in an injecting site tend to treat themselves at home in sometimes difficult circumstances. Earlier treatment will be better for users and more cost effective for local health services because it will mean fewer people being admitted to hospital or visiting A&E inappropriately."

8.  The project successfully:

—  reduced associated health risks to service users from untreated wounds. In particular, clients who attended for regular wound care had their pain controlled by better management, which in turn led to better compliance with their drug treatment programme and improved their general health ie nutrition, mobility and a reduction in illicit drug use;

—  reduced accident and emergency attendance for wound care in IV drug users. This also included an awareness of the clinic in the injecting drug user population and other healthcare professionals sign posting the clients to the clinic; and

—  enabled service users to engage in treatment programs. For instance many clients return to the clinic for follow up treatment linking their visit with their planned Lifeline appointment. It is an added value to the client and has helped to improve patient outcome.

9.  The clinic also enabled increased productivity within a short time frame with clients in one place rather than two nurses travelling to a client's home in what can sometimes be a risky and unhygienic environment.

10.  This project responded to a community health need identified by community nurses. As a result of its success, the clinic was commissioned by NHS Kirklees, with funding for two afternoon clinics at Lifeline Dewsbury per week.


11.  The need for skilled home nursing is rising as the population ages, more people live with long term conditions, and people are discharged earlier from hospital. One in four people over the age of 75 need a district nurse's care at home, rising to one in two people over 85. In total they visit more than 2.6 million people a year. Yet the number of trained district nurses has been falling for more than a decade, to fewer than 10,000 in England. At the same time, the number of health care assistants - trained to do specific tasks but who are not qualified nurses - has more than doubled.

12.  Current changes to the NHS will introduce further alterations to the provision of community care. The QNI is already receiving regular reports from community nurses about reductions in staff numbers, down-grading of posts, ending of innovative projects and a rush to retirement amongst colleagues who are eligible. Morale is undoubtedly very low, and practitioners are very concerned about their ability to sustain high quality services and care.

13.  The QNI believes that the skills, knowledge and engagement of community nurses will be vital in the successful implementation of the new commissioning framework. There is no alternative workforce to help commission and deliver nursing care services in the home. So it is essential that the workforce issues are addressed early on - including the falling numbers of community specialists, highly diluted skill mix, rapidly-increasing use of health care assistants to do nursing tasks, and exclusion of all but GPs from input into planning, commissioning and designing services.

14.  In response to the current challenges, the QNI launched a campaign last October, Right Nurse, Right Skills. The campaign draws attention to the continuing loss of nursing skills in the community, and the impact this is having on the quality of care for elderly and vulnerable people in their own homes. We are not campaigning "'against" healthcare assistants. We are campaigning for a properly skilled and trained home nursing workforce, so that patients receive the care that they need. To date we have more than 1400 supporters.

February 2011

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Prepared 5 April 2011