Wide variations in district nursing in Eastern region

Published: 18 March 2013

Research carried out by the Royal College of Nursing (RCN) show that in parts of East Anglia the number of district nurses has been cut by up to a third.

The Government’s health reforms and NHS savings plans are based on moving patient care out of acute hospitals and into the community. Information was provided by the NHS organisations to RCN Eastern through the Freedom of Information Act. The RCN represents more than 34,000 nurses across the Eastern region, covering Norfolk, Suffolk, Cambridgeshire, Essex, Hertfordshire and Bedfordshire.

In January this year, the Department of Health’s Director of Nursing for Public Health Professor Viv Bennett, published “Care in local communities – a new model for district nursing.” The paper sets out the need for “evidence-based workforce planning for district nursing and the use of appropriate skill mix”.

The DoH’s Director of Nursing paper makes it clear that a district nurse is defined as being a “qualified nurse with graduate level education and a specialist practitioner qualification”. Skill mix means getting the balance right between fully trained district nurses and the healthcare assistants who support their clinical work.

The NHS challenge to save £20 billion by 2015 does mean that NHS community service providers could increase the numbers of healthcare assistants and reduce trained district nurses to make a service cheaper but at the cost of quality of care.

Over a twelve-month period between October 2011 and October 2012 NHS organisations reported the following changes to registered district nursing staff (whole-time equivalents):

Registered district nurses

• Bedfordshire – a fall of 31 per cent from 160 nurses to 110.6
• North East Essex – a fall of 11 per cent from 97 nurses to 86.4
• Suffolk – a fall of 8 per cent from 216.6 nurses to 199.1
• Cambridgeshire – a fall of 2.8 per cent 154.8 nurses to 150.3
• South West Essex – a fall of 2.7 per cent from 113 nurses to 109.9
• South East Essex – a rise of 49 per cent from 133.7 nurses to 199.3
• Central Essex – a rise of 45.9 per cent from 116.1 nurses to 169.5
•  Norfolk – a rise of 36.7 per cent from 225.7 nurses to 308.8
• Hertfordshire - a rise of 3.7 per cent from 355.9 nurses to 369.3

Only one community provider in the region was unable to respond to the request for information – East Coast Community Healthcare which covers the Great Yarmouth and Waveney area.

Unregistered district nurses

• Bedfordshire – a fall of 33 per cent from 58 to 38.74
• South West Essex – a fall of 27.9 per cent from 115 to 82.85
• Norfolk – a fall of 15.8 per cent from 259.9 to 218.7
• Hertfordshire – a fall of 7.1 per cent from 115.37 to 107.16
• North East Essex – a rise of 0.85 per cent from 34 to 34.9
• Cambridgeshire – a rise of 19.3 per cent from 34.9 to 41.66
• South East Essex – a rise of 76.6 per cent from 41.22 to 72.8
• Suffolk – a rise of 200 per cent from 48.03 to 144.22 
• Central Essex – a rise of 205 per cent from 31.86 to 97.4

The information released under the Freedom of Information Act shows wide variations in the skill mix of district nursing staff. For example, in Cambridgeshire 79 per cent of the district nursing service is provided by registered nurses (with 21 per cent unregistered healthcare assistants) but in South West Essex the service is run with only 57% registered nurses and 43% unregistered healthcare assistants.

RCN Director for the Eastern region, Karen Webb, said: “We are concerned to see that in some areas, such as Suffolk, it appears the district nursing skill mix is being watered down with cuts to the numbers of registered nurses and a big rise in the number of healthcare assistants. Our concern would be that a service relying heavily on healthcare assistants is about cutting costs and not about high quality patient care. In other counties, such as Bedfordshire, both the numbers of registered and unregistered district nurses appear to have fallen dramatically.”

Skill mix

• South West Essex: 57% registered nurses, 43% unregistered healthcare assistants
• Suffolk: 58% registered nurses, 42% unregistered healthcare assistants
• Norfolk: 58% registered nurses, 42% unregistered healthcare assistants
• Central Essex: 64% registered nurses, 42% unregistered healthcare assistants
• North East Essex: 72% registered nurses, 28% unregistered healthcare assistants
• South East Essex: 73% registered nurses, 27% unregistered healthcare assistants
• Bedfordshire: 74% registered nurses, 26% unregistered healthcare assistants
• Hertfordshire: 77% registered nurses, 23% unregistered healthcare assistants
• Cambridgeshire: 79% registered nurses, 21% unregistered healthcare assistants

The RCN’s Frontline First campaign closely monitors the effects of measures being taken across the NHS to help meet the efficiency savings required and will identify trends that directly impact on the quality of care being delivered.

Karen Webb added: “Health reforms depend on a shift of patient care from acute hospitals and back into the community. Our research shows, however, that shift will be very difficult to achieve when district nursing is being cut and the skill mix of community nursing may mean that unregistered nursing staff are being left to cope on their own with little supervision from registered district nurses”.

“District nurses deserve the right training, the right staffing levels, and the right mix of skills to deliver high quality patient care. Our research does show that NHS commissioners and providers continue to need to grasp this problem.

“There is a desperate need for clinical commissioning groups to start purchasing specialist training courses for district nurses as some teams are operating with no qualified district nurses. Currently Bedfordshire, Essex and Cambridgeshire are reported as not having commissioned training for district nurses and this will create unnecessary risks to patient safety and quality.”