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Comment: Growing the community

With the number of district nurses falling, it is vital that minimum staffing ratios are set out and adhered to for community nurses.

In this column six months ago I applauded the fact that the national chronic shortage of nurses was getting some high-level attention. Since that time hospitals have been recruiting at home and abroad to meet ward staffing targets first recommended in the Francis Report.  

From June 2014 every hospital must publish, by ward, their nursing status every month, indicating the number of nursing hours planned against the actual number. Evidence for safer staffing levels has now finally been published by the National Institute for Health and Care Excellence (NICE). This official guidance will hold hospital management to account for the capacity of the nursing team in acute in-patient units. In a nutshell, red flags of concern will be raised where poor staffing impacts on patient safety. These will include where patients have delayed planned medication, missed vital signs monitoring and any delay over 30 minutes for pain relief. Two registered nurses are required for each shift and no nurse on a day shift should be caring for more than eight patients. This final point has not been made mandatory. Interestingly, Australia and California have patient/staff ratios prescribed in law.

Still, it is a good start - but is only a start. Nurses have long recognised the positive impact of sufficient staffing ratios, patient safety and efficient care provided by engaged and compassionate nurses. The negative cycle experienced by many - and revealed in public inquiries, might now be broken. 

The NICE staffing guidance is one of a series planned for different healthcare settings. For me, the community one cannot come soon enough. The recent RCN congress revealed there has been a 47% drop in qualified district nurses (DNs) in England over the past decade; this is only expected to get worst with the aging DN workforce retiring. Community nursing teams increasingly report struggling to give sufficient time and care, combined with transport challenges and working in isolation. More of the population are living longer with complex care requirements and the government's commitment to more care in the community cannot be realised without appropriate staffing. 

The media have exposed the scandal of home care providers rationing the time and services they give to housebound clients attended by untrained staff, generally on minimum wage and often with poor English language skills, where a daily 20 minute visit must suffice. 

Many of these patients are on the DN caseload with their health and social needs increasingly blurred and fragmented by different service providers. So who is accountable for ensuring the safety of these vulnerable adults? Is there a community equivalent of Mid Staffs waiting to happen?

Nursing ratios would be much easier to implement in general practice. Practice list sizes are relatively stable and matched to the age profile, screening regimes, chronic disease registers and the housebound, provide the calculation for an appropriate nursing team. Though this has been a need since the 1990 General Medical Services (GMS) contract, a lack of consistent practice nursing leadership coupled with the business model of general practice means there is still a huge variety in nurse/patient ratios and rationality.

Nursing home (NH) staffing ratios should be reviewed: with clarity on qualified nursing competencies and those of healthcare assistants. The ability, capacity and willingness of qualified nurses, district/community nursing teams and practice nursing to work together, regardless of their employer, should be addressed by clinical commissioning groups (CCGs) in a bid to utilise the diminishing numbers and training of nurses working outside of hospitals.

We need to work together better. Workforce intelligence indicates there are around 12,000 whole-time equivalent nursing posts vacant in England and a predicted national shortfall of 48,000 nurses by 2016. This poses a risk to the national targets for moving care into the community, reducing A&E attendance and improving patient safety.   

Staffing levels do matter. Lord Willis is presently undertaking a review of future (5-15 years) nursing training for pre and post registration and healthcare assistants - with an emphasis on community and domiciliary settings.

I wish Lord Willis luck. Crucially, NHS funding should follow his recommendations and not be highjacked by cost savings, NHS reorganisations or a change of government as has happened in the past.