Community Nursing 2008 Lambeth PCT Catherine Caulfield Senior Practitioner Team Leader South West Locality

Service overview Current model structured around housebound patients with very limited clinic based activities Care delivered by teams of qualified nurses and non qualified staff. Teams are linked to GP Practices and work in partnership Each team is led by a qualified district nurse We also see patients in residential homes and have a duty to patients registered with Lambeth GP’s although not resident in the borough. That means we may have to visit patients resident in other boroughs if no recipricol agreement in place. At present agreements in place with Wandsworth and parts of Southwark but not with Croydon

Service overview Operates 7 days a week & 365 days a year. Service offered from 8.00am to 11.00pm with staff working over three shifts Open referral, reactive service, demand led. Operates no waiting list. Increasingly managing more complex patients. Five large teams across the PCT with subdivisions of between 3 and five teams in each locality. We are not an emergency service. Though we don’t have a waiting list we do have referral criteria, one of which is that we are given 48 hours notice of discharges. However this often doesn’t happen

A community team Senior practitioners are Specialist practitioners with a recordable degree level professional qualification in addition to their nursing qualification. They manage a caseload of patients and lead team of qualified and non qualified staff Skill mix Band 7 – Senior practitioner Team leaders Band 7 - Community Matron Band 7 - Specialist Practice Teachers Band 6 - Senior Practitioners Band 5 – Community staff nurses Band 4 – Primary Care assistant practitioners Band 3 – Health care assistant Band 3 – Admin support Nurses increasingly takoing on extended roles and services Prescribing Case management Phlebotomy IV’s Palliative care

Current issues On an average Monday approx 350 patients will receive home visits from approx 60 staff. Very complex to manage this efficiently Planning can be difficult as we have little control over referrals and patients conditions can change rapidly Practices taking on increasing numbers of patients not local to the surgery. Community nursing often seen as a catch all service Poor sickness and morale issues. Band 6 vacancies hard to fill. PCT not sponsoring nurses to undertake the course Again boundaries an issue Inappropriate referrals include patients referred who are not truly housebound patients Non house bound patients whose practices don’t have practice nurses Patients with mental health issues Patients with social care problems

Current issues Poor data collection systems resulting in inaccurate and ad hoc data collection and no standardisation of systems across the trust. SAP is not shared with social services IT systems implemented which not compatible with DN work (Rio) With increasing workload more unskilled practitioners being used and difficulties found in embedding these new roles. This has been identified through recent caseload reviews and we are in the process of implementing standard systems of record keeping and data collection Nurses are not particularly computer literate which is causing some problems with implementing new systems like Rio. Still running pretty much a paper system Need to develop unqualified staff like primary care assistant practitioners and health care assistants

The future People living longer. Burden of long term illness rising. More complex and acute patients. Increasing number of people wishing to die at home Demand management will remain a priority Greater need for technical intervention with patients requiring complicated IV’s, drains, ventilators etc Practice based commissioning Greater need for health promotion and surveillance- whose responsibility will this be? Development of new roles and skill mix Workforce issues-Older staff/less qualified Movement of staff and budgets from acute to community Demand management- role out of case management to all staff Reducing visits to A&E and admissions to hospital Reducing lengths of stays in hospital Supporting patients to self manage Supporting patients to manage their own long terms conditions better Practice based commissioning. Need to be more businesslike in collecting data to support the marketing of the service to commissioners. Our service will be competing with others. Need to market the service effectively. Community nurses need to engage with GP’s to influence the commissioning process as they work closely with the service users.

Action required Develop a more focused service with clear service description and stricter referral guidelines Identify data that proves that the service delivered meets local needs and is of high quality Develop data collection systems and processes Develop clear quality indicators that will support this Identify training and development around future workforce needs Build on existing working relationships with GPs, social workers, local mental health teams Stop being the catch all service. Practitioners need clear guidance about what the service is able to offer and need support to implement this. Quality indicators need to be looked at Increasingly nursing service asked to contribute to Qof data Maybe we need our own Qof’s Quality indicators such as healing times of venous leg ulcers Information on pressure sores, diabetic patients managed and reviewed regularly Numbers of people enabled to spend their last days at home Need to look at expected outcomes and measure ourselves against them. Bench marking Unfortunately community nurses not good at discharging people from their care Whole lot of work around how we measure quality Can be hard to quantify/measure a therapeutic intervention that may be no more than listening. Nursing is not always about doing!!!! Need patient satisfaction surveys Input from user groups These are crucial. What about a ‘team around the person’?