4. Out-of-hours community nursing ― a challenge too far?
Matter for discussion submitted by the RCN Community Children’s Nursing Forum
With continuing public concern over out-of-hours GP cover, this meeting of RCN Congress considers the challenges and opportunities for nurses to provide out-of-hours care
Report on this discussion
Challenge of out of hours community nursing
The introduction of the new GP contract has allowed many general practitioners to opt out of offering out-of-hours cover, which is now the responsibility of primary care trusts.
In a wide ranging debate, Congress delegates considered the growing challenge to nurses and nursing to provide out-of-hours care. Mark Whiting, introducing this matter for discussion, said more and more community nurses had been providing out-of-hours care in the past few years – and increasingly, the out-of-hours agenda should and would be delivered by them.
Natalie Tidy cited nurses working for NHS Direct as already providing not just out-of-hours but 24/7 cover. Pat Bottrill warned delegates that we need to define what we mean by “out-of-hours cover” so as not to confuse the public.
Lisa Wood called for increased investment in primary care if such nurse-led developments were to succeed. Dave Dawes said increased emphasis on out-of-hours care offered real opportunities for nurse entrepreneurs – with many innovative examples already existing of nurses offering care for homeless people and workers in the sex industry, for example.
Bonnie Mitchell said there was a massive challenge for community learning disability nurses as a result of current policies. She was proud of the achievement of the pro-active out-of-hours service at East Lancashire PCT.
Summing up, Mark Whiting commented on what an excellent debate it had been.
Background
In 2004, the provision of out-of-hours general practice services in England became the responsibility of primary care trusts. Prior to this, many general practitioners provided out-of-hours care to patients registered with the practice. However, the introduction of the new GP contract allowed many to opt out of offering out-of-hours cover arrangements. Community nursing ― in particular district nursing ― has a long history of providing out-of hours care, including both ‘twilight’ nursing services and night time nursing. In recent years, nurses have played a crucial role in the development of 24-hour services, such as NHS Direct.
The provision of out-of-hours out-of-hospital care has rapidly taken centre stage in the debate about the future of the NHS. A National Audit Office review (2006) of out-of-hours provision across England reported that despite delivering a satisfactory standard of service, most out-of-hours providers were not meeting all the national quality requirements, particularly on speed of response. In 2007, figures released by the Department of Health revealed that 42 per cent of trusts failed to meet required quick response standards, while a further 32 per cent did not meet the standards for assessing patients over the phone to see if they have ‘life limiting conditions’. In his first major speech on the NHS, Prime Minister Gordon Brown challenged the NHS to provide ‘personalised services’ to patients, at times and in places where they want those services; a major focus of his speech was the need for GPs to deliver the out-of-hours care agenda.
Many nurses ― including district nurses, community midwives, community children’s nurses, and palliative care nurses ― already provide out-of-hours care in the community. This debate will provide an opportunity to celebrate the diversity of nursing roles that deliver out-of-hours care, and to consider opportunities for nurses to provide a more personalised NHS. There are, however, considerable concerns about the declining number of district nurses and health visitors.
In Wales, the Welsh Assembly Government has committed to move the focus of health care from the acute hospital to the community. In Northern Ireland, RCN activists in the Southern Trust area have been working in partnership with health professionals and local communities to help shape the design and delivery of out-of-hours services. The DHSSPS has also recently consulted on proposals to implement out-of-hours services on a cross-border basis with the Republic of Ireland in certain areas, and the RCN supports this initiative. The SNP government in Scotland is continuing to emphasise a shift in the balance of care to community-led services. In its strategic plan for NHS reform ― Better health, better care ― the Scottish Government (2007) has outlined plans to reform the GP contract, establishing five pilots to test and evaluate extended walk-in access to services ― including nurse-led treatments. However, the review of community nursing in Scotland ― due to be piloted between 2007 and 2009 ― means that the future national model of nursing in many community settings is still uncertain.
References and further reading
Community Practitioners and Health Visitors Association (2003) District nursing at the crossroads: a CPHVA perspective, London: CPHVA.
National Audit Office (2006) The provision of out-of-hours care in England, London: Stationery Office. Available from: www.nao.org.uk/publications
Scottish Government (2007) Better health, better care: action plan, Edinburgh: Scottish Government. Available from: www.scotland.gov.uk/publications