Dr John Havard: Why we must support our vital district nurses
11:36 09 October 2014
Record numbers of experienced district nurses are leaving their jobs because it is all becoming too demanding and stressful. Nearly half of the senior district nurses in Ipswich have left in the last two years and replacing them is proving very difficult. However the staff situation in the west of the county has been more stable.
What is going on?
We are all aware that demand is increasing as the population ages but our nurses are not afraid of hard work. Many have spent decades looking after Suffolk people while going the extra mile to provide both competent clinical care but also compassion and understanding. Over the last couple of years the system has been centralised and organised into tasks that are distributed according to the grade of nurse. Clearly this affects continuity but also the electronic recording of every action through data entry has become paramount and seriously onerous when it should be simple. One might even go as far as to say it detracts from patient care and actually inhibits the delivery.
Is this about saving money?
Of course it is - but it is only right that every public pound is spent efficiently. Serco won the community services contract a couple of years ago and they have instituted some management changes that are at the root of this issue.
Why did it have to change?
We need to know how public money is spent and the former system did seem to be full of inefficiencies. Serco clearly saw that they needed to use their staff resource as efficiently as possible and wanted to minimise ‘wasted’ travel time. They reasonably thought that they could give nurses a series of visits appropriate to their skills early every morning which would save them needing to meet up in small practice-based teams before starting work. If they could drive from task to task on a scheduled route then they would spend more time in clinical work and less with colleagues and in their cars.
Did the plan work?
Not as hoped. Serco made every effort to try to be as efficient as possible and invested in laptops so the nurses could record their activity at the time of the visit. Unfortunately Suffolk 3G and broadband is poor and there were lots of problems. There was an imperative to record every single contact so that the workload could be demonstrated to the CCG so they could satisfy the contract and try to secure more funding. Nurses had to return to practices and found they were spending hours inputting data which was a great frustration – and paradoxically not an appropriate use of skill-mix. They also find that there is less time for informal discussions about patients with GPs which is a sad loss.
Why are the nurses throwing in the towel?
There is a massive divide between the technical skills and the all embracing nursing skills which are not recognised and cannot be counted. Patient assessment is a holistic whole-person affair and so much more than bean counting. If a terminal care patient dies then sitting down for a cup of tea with a spouse a week later is part of this immeasurable holistic care rather than an itemised task. Professional discretion is under too tight a leash although of course wide variation needs to be controlled. The satisfaction of the job and respect within a tight local community has been leached out by itemisation and this will not do. As the population ages and patients are discharged from hospital sooner, it is proving more difficult to fill the shoes of the nurses who are leaving.
What is to be done now?
We are in a mess and I certainly do not believe it is all Serco’s fault who took on the contract when morale was already low. They are under pressure to reduce costs via their NHS contract and, whilst they have introduced some imaginative solutions, they have fallen well short of the mark in the human resources skills required to keep the staff on board and motivated. They just did not seem to recognise that community services do not fit well into the management accounting strait jacket. Saving money requires desperate measures and this is happening all over the NHS but we must be much more careful not to throw out the nurses with the bathwater.
Changes afoot - Serco pulling out of NHS services.
Serco have just announced over the last few weeks that, following large financial losses, they are withdrawing from the NHS market across the country. Many in the NHS are delighted by the news as if this will mean ‘a return to the old service’. No way - we must not forget that the NHS can no longer throw money at services since accountability in tight times is never going to go away. The NHS is under the biggest financial squeeze ever, so every local organisation will feel just the same – there is no going back. We do however need to learn the lessons of this contract both good and bad. They started with scanty knowledge of the work activity and the complex contract required them to satisfy a record number of performance indicators as well as itemising the work actually being done. Laptops were introduced but technology failure meant that nurses had to enter the work manually back at base which took ages and was very frustrating for the less IT savvy ones. Many of the nurses who were really good at dressings and catheters found that their keyboard skills were less slick. Entering clinical information took hours every day and forced nurses away from patient care with ensuing discontent. We also need to return to district nurses working within practice teams and not in a generic way which makes the job task-orientated and not holistic. We all agree that the NHS has to be more efficient but we fail to recognise all the good work that is being done by dedicated nurses that is not itemised. We need to put a real value on goodwill and treasure the staff that make it all happen. This is down to all of us.