Embargoed until date of meeting
Renfrewshire Community Health Partnership Committee
Date: 08 October 2009 (Paper No 09/35)
Author: Sylvia Morrison, Head of Health and Community Care
Agenda Item; Developing District Nursing Services in Renfrewshire – Service Review
1. Introduction and Background
1.1 The purpose of this report is to inform the CHP Committee on the recently completed review of District Nursing Services in Renfrewshire CHP. A copy of the full report is attached.
2. Background
2.1 Following the inception of Renfrewshire Community Health Partnership in August 2006, the need to review a range of services was identified. A key driver in this was to ensure services were best placed to deliver against the stated aims of the CHP i.e. to target inequalities and meet the needs of our population. The district nursing service was identified as one service that would benefit from review.
2.2 The purpose of this review was to provide a detailed analysis of our current service, building on existing strengths and identifying opportunities for improvement which optimise outcomes for our patients and also to continue to develop our workforce. Any recommendations require to demonstrate both value for money and to be deliverable within available resources.
2.3 The review commenced in 2008 following a successful engagement event involving staff, GPs and their staff, local authority managers, voluntary organisations and members of our staff and patient partnership forum. The review has taken place within the context of our CHP priorities, with a focus on targeting inequalities and improving health. An important feature has been staff engagement, promoting a focus on their professional and personal development needs as we move forward.
3. Review Process
3.1 The review took place between September 2008 and June 2009 under the auspices of a steering group that included representation from our district nursing staff, a range of services within the CHP, acute services, social work services, Public Partnership Forum and Staff Partnership Forum.
The following five key thematic work streams emerged from; our initial stakeholder event in May 2008, early analysis of national and local strategies and staff personal development plans.
1. Continence Services
2. Governance
3. Health Information and Technology
4. Partnership Working
5. Workforce Planning & Development
4. Vision
Our vision for our future service is to provide high quality, patient centred care by a community nursing service shaped by and responding flexibly to the needs of our communities and people of Renfrewshire. Working collaboratively, we will develop and maintain mutual trust and respect with our service users, carers and partner agencies.
5. Policy Context
Current national and local policy recognises the need to plan and deliver change to better meet the future needs of our population. Key policies include:
§ Caring for Scotland – The Strategy for Nursing and Midwifery (2001)
§ Nursing for Health (2001)
§ Visible, Accessible and Integrated Care: Review of Nursing in the Community (2006)
§ Leading Better Care – The Report if the Senior Charge Nurse Review (2008)
§ NHS GGC Long Term Conditions Strategic Framework 2009 – 2015
§ NHS GGC Community Rehabilitation and Enablement Framework (2007)
§ NHS GGC The Primary Care Strategy Refresh – currently under development
6. Current District Nursing Profile
6.1 Our current staffing profile comprises 123 people equating to 94.15 whole time equivalent. Our core district nursing teams are attached to GP practices. There are 30 GP practices within the CHP, however some practices are small and as such some nursing teams are attached to more than one practice.
6.2 At present the 30 practices are supported by 25 teams comprised of 1.6 to 6.7 whole time equivalent staff and covering practice populations ranging from 3,370 and 14,822.
6.3 The total budget for district nursing services is £3.17m. During the time frame of the implementation plan arising from this review, the CHP is required to deliver cost efficiency savings across all services.
7. Service Model Options and Option Appraisal
7.1 The literature search and policy framework were used to identify criteria against which service models could be appraised. Four models were developed based on current practice and best available evidence. The models considered are summarised in the table below:
SERVICE MODEL OPTIONSModel / Outline
A Status Quo / GP attached, flat distribution of staffing, open referral system without criteria, some gaps in hours of service.
B Evercare / USA model, based on private healthcare for older people. Care management approach, includes nurse practitioner roles as new and additional roles.
C Virtual Ward / In use in parts of England and Wales. Relies on GP practices working collaboratively to care manage 100 virtual beds. Community Matron has responsibility for virtual ward working closely with attached teams.
D Renfrewshire Model / Hybrid model. GP attached, Includes adults of all ages, based on need, larger teams, change in band and skill mix , optimises role of band 6 as team leader and care management with focus on rehabilitation and enablement and LTCs.
7.2 Following a detailed option appraisal model D was determined to be the preferred option. (Full details can be accessed in section 10 of the full report).
7.3 Our proposed future structure is described below:
7.4 This model proposes a significant shift from 25 small teams to 3 geographical teams, comprised of a total of 10 district nursing teams. Research within the human resources field provides evidence of improved capacity, capability, flexibility and overall effectiveness in larger teams. In addition Band 6 staff will ensure protected time to fulfil their professional leadership and management responsibilities. This will focus on development of all staff and teams and promote improved engagement with, and delivery of, local and national policy to ensure practice development. This model is affordable within available resources and offers the opportunity to introduce an improved band mix and optimise the skills of all staff within the service.
8. Review Recommendations
8.1 The review produced a total of 41 recommendations across the five thematic work streams. In line with the terms of reference, opportunities to make service improvements during the review period were progressed with the approval of the steering group. Examples include development and implementation of a clinical audit cycle; development of referral criteria and prioritisation framework, currently in pilot phase and joint working with home care services to support people with palliative and terminal care needs. (A summary table is available in section 15 of the full report).
9. Communication and Engagement
9.1 Involving people has been a key feature of the review since May 2008. A communication and engagement plan was developed as part of the project initiation document. This plan detailed the diverse range of people who required early and ongoing communication, engagement and participation to develop the recommendations and promote ownership of the planned improvement programme.
9.2 Regular reports have been provided to the Professional Executive Group, Senior Management Team and GP Forum. The approach taken promoted two way communication and discussion and allowed representatives to keep their constituents advised of progress and plans. An electronic bulletin was issued on a quarterly basis providing a summary of work to date and contact details for further information.
10. Implementation
The full review report and recommendations were approved by the Steering Group, and subsequently by the Professional Executive Group, Staff Partnership Forum and Senior Management Team. Our implementation Group is now in place Co Chaired by Marian McGhee Rehabilitation and Enablement Manager and Dorothy Duffy Senior Nurse Adult Services.
Recommendations
The Committee is asked to:
§ Note the content of the report and progress to date
§ Receive future reports on the implementation process
Embargoed until date of meeting
Developing District Nursing Services in Renfrewshire
Review Report
June 2009
Project Sponsor Sylvia J Morrison
Head of Health and Community Care
Project Manager Dorothy Duffy
Senior Nurse Adult Services
Final Draft 20th July 2009: Subject to Professional Executive Group (PEG) Approval - 13 July 2009
Executive Summary
The review of District Nursing Services in Renfrewshire commenced in 2008 following a successful engagement event involving staff, GPs and their staff, local authority services, voluntary organisations and members of our staff and patient partnership forums. The review has taken place within the context of our CHP priorities with a focus on targeting inequalities and improving health. An important feature has been staff engagement promoting a focus on their professional and personal development needs as we move forward.
During the period of the review, some work streams have moved to implementation with the approval of the steering group. Early success include: improved clinical governance, including a focus on patient safety; joint learning and education with partner agencies, introduction of single point of contact as part of our work on rehabilitation and enablement; pilot of user defined evaluation, funding and project nurse support secured to introduce the community nursing system and improvement to continence services.
This report describes the review process, outlines the issues and outcomes from our work to date and makes recommendations for a planned way forward over the next 1- 3 years. The recommendations build on the existing strengths of the service, build on the achievements to date and signal changes required to meet the future needs of our service users, wider population and staff. The local and national policy context and impact has been considered. It is important that we are able to target need, focus on rehabilitation and enablement and improve the health and well being of people with long term conditions. This will require change for service users and staff alike as we develop knowledge and skills to support self care and improve pathways and outcomes for patients and carers. The recommendations within this review provide a starting point to achieve a comprehensive assessment, rehabilitation and care management service model for older people, older people with mental illness and adults with a physical disability. We will ensure an integrated approach with our specialist rehabilitation and enablement services and our mainstream physiotherapy, podiatry and dietetic services.
The shift in balance of care from hospital to community care coupled with the changing demographics in Renfrewshire will continue to challenge all statutory and voluntary agencies. Real improvement will require multi agency and partnership approaches focused on the needs of our communities. The recommendations in this report will be taken forward in partnership with staff, GPs, partner agencies and our public partnership forum. This is with the aim of building commitment to achieve our vision for District Nursing Services in Renfrewshire.
Sylvia J Morrison
Head of Health & Community Care
Renfrewshire CHP
Contents Page
Executive Summary 2
1. Introduction 4
2. Purpose and Scope of the Review 4
3. Vision and Guiding Principals 5
4. Policy Context 6
5. Current Structure and Service Provision 9
6. Current Roles and Responsibilities 11
7. Current Service Activity 13
8. Finance 14
9. Communication and Engagement 15
10. Service Model and Option Appraisal 16
11. The Proposed Renfrewshire District Nursing Model 18
12. Thematic Work Streams and Groups 20
13. Conclusions 31
14. Acknowledgements 31
15. Report Recommendations 31
16. Summary of Recommendations 32
1. / Introduction1.1 / This is the final report from the District Nursing Review Steering Group. This report:
· Makes recommendations for service improvement for consideration by the Senior Management Team and Professional Executive Group.
· In addition proposes that, subject to approval, the implementation phase commences with immediate effect supported by an implementation group and plan.
1.2 / The steering group includes representation from our district nursing staff, a range of services within the CHP, acute services, social work services, Public Partnership Forum and Staff Partnership Forum. (Membership is detailed in appendix A)
Key work streams emerged from our early analysis of national and local strategies and staff personal development plans. In addition the issues raised at the initial stakeholder event in May 2008 informed the established of five thematic working groups, namely:
· Continence Services
· Governance
· Health Information and Technology
· Partnership Working
· Workforce Planning & Development
Details of the sub group membership can be found in appendix B.
1.3 / In line with the terms of reference agreed by the steering group, opportunities to make service improvements during the review period were progressed with the approval of the steering group. Examples include development and implementation of a clinical audit cycle; development of referral criteria and prioritisation framework, currently in pilot phase and joint working with home care services to support people with palliative and terminal care needs. These are described in more detail in paragraphs 14 and 15 later in the report.
2. Purpose and Scope of the Review
2.1 / Following the inception of Renfrewshire Community Health Partnership (CHP) in August 2006, the need to review a range of services was identified, in order to ensure consistency with the stated aims of the CHP Development Plan i.e. to target inequalities and meet the needs of our population. The district nursing service was identified as one service that would benefit from review.2.2 / The purpose of this review was to provide a detailed analysis of our current service, building on existing strengths and identifying opportunities for improvement which optimise outcomes for our patients and also to continue to develop our workforce. Any recommendations require to demonstrate both value for money and to be deliverable within available resources.
Our District Nursing Staff and the services they provide are greatly valued by patients, carers and General Practitioners. This review has offered the opportunity recognise these strengths whilst at the same time developing proposals for short and longer term improvements which better meet the needs of our communities and further develop our staff.
Sylvia Morrison
Head of Health and Community Care
2.3 / The parameters of the review were shaped by the outputs of the stakeholder event Working Together to Develop District Nursing Services in Renfrewshire which took place on 29 May 2008.
A clear message from the participants was that the existing service has many strengths which should be built upon and not lost. However a number of issues emerged which were taken forward as key elements of the review process:
§ Changing demographics of our population and impact
on services
§ Changing the balance of care from hospital to community
§ Governance
§ Information Management and Technology
§ Partnership working
§ Public involvement
§ Service improvement
§ Workload
§ Workforce development and education
2.4 / The scope of the review included; core district nursing services (including weekend service), specialist community nursing services i.e. intensive care management, gerontology, tissue viability, palliative care, respiratory and continence. Although the evening and overnight services had previously been reviewed in 2007, they were included within the scope to ensure a whole systems approach.
3. Our Vision and Guiding Principles