Community nursing will 'blow’ as discharge threshold is reduced

Both the Royal College of Nursing and the Queen’s Nursing Institute — the charity for community nursing — told HSJ that district nurses were now having to prioritise patients more than normal, as staffing numbers have become “extremely stretched”.

The demands on nursing care in people’s homes has worsened due to instructions from NHS England and the government to discharge people from hospital more quickly, and when their health is “medically optimised” but not yet “back to baseline”, freeing up tens of thousands of beds for acute covid-19 admissions.

One GP, who asked not to be named, told HSJ: “The skill base in community nursing is high, but before covid19 we didn’t have [enough] staff, and that is without the increase in early discharge, complex patients [moving out of hospital] and the slower consultations that having to wear personal protective equipment will also cause. The NHS is really going to struggle, it is going to blow.”

HSJ understands that NHS England is concerned about community capacity, and has asked its regions to investigate what level of referrals are being received, and each area’s ability to meet that demand.

Carolyn Doyle, the RCN’s professional lead for community and end of life care, told HSJ some royal colleges and national organisations are looking into guidance to help community nurses “make difficult ethical decisions” — about treatment of people with severe illness who may die — although she added: “We are hoping it doesn’t get to that point.”

The latest guidance from NHS England for community health services said district nurses need to “clinically prioritise urgent care needs” and must use “segmentation” to decide which patients are most in need. It said nursing teams should also “monitor [the] rising risk of deferred visits”.

Ms Doyle said: “District nurses are a lifeline for so many vulnerable groups of people. Unlike acute [services] we can’t close the ‘ward’ or drop our caseloads, but we need to be mindful we will only be providing care to those that have critical needs. We will be looking at other measures to support those without critical needs.”

She said this included considering whether families could carry out some functions delegating ”what can be handed over to other people, such as social care and care home staff”. She said they might be asked to provide care such as catherization and insulin administration, which “maybe in the previous world they weren’t doing”.

She also said lots of work was ongoing to train up healthcare assitants to provide more nursing care.

Crystal Oldman, chief executive at the QNI, told HSJ: “When the NHS announced they had emptied the equivalent of 50 district general hospitals [worth of beds], was any thought given on where those patients have gone?

“Those discharges have put an enormous pressure on the community. It’s manageable but I do think it’s changing from one day to the next because of sickness of staff and the volume of referrals into community.

“It may be there would be a crisis point at which we look at domiciliary carers and teach them how to do insulin for example. We do this with families, so this might be an occasion when it seems like an enormous ask but it may be a reasonable one. At the very extreme end, we could ask what are volunteers doing, but only if we are at absolute crisis point.”

The number of district nurses in England has fallen by 43 per cent in the last ten years, with 7,055 reported in September 2009 compared to 4,031 in January 2019.

A spokesman for NHS England said: “The NHS is pulling out all the stops to respond to the biggest global health threat in a century including freeing up thousands of beds, while also ensuring that people can still access the services they need in as safe a way as possible.

“We are working with regional colleagues to ensure that community services can support discharged patients in other NHS and social care settings and at home, making sure that people are safe and supported, and as part of a comprehensive assessment of people’s needs, we always consider what role families can play as part of an overall care plan.”