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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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’?