Trusts providing community services need to have the right staff with the right skills to deliver high-quality care for patients. However, the supply of community staff has not kept pace with increases in demand and trusts delivering community services now face considerable workforce challenges. In addition, trusts providing community services face recruitment and retention issues as they struggle to attract staff in to the community. This set of workforce challenges has led to mounting pressures across community services, which mirrors the experience of the wider NHS.
There are ongoing workforce shortages in various professions, particularly in district nursing and health visitors, which need to be addressed rapidly and effectively. While the number of nurses in the acute sector has increased since the Francis report (Francis R., Feb 2013) and the subsequent drive to improve safety through staffing ratios, the community nursing workforce has decreased. Since May 2010, the community nursing workforce has contracted by 14%, which amounts to a loss of 6,000 posts. Over the same period, the workforce has grown in acute adult settings by 6%, representing over 10,000 posts (NHS Digital).
Within the community nursing workforce, the specialist role of the 'district nurse' is vital, but the number of district nurses has reduced by 44% since May 2010 (NHS Digital).The current community nursing vacancy rate is estimated at 9.5% and there is some evidence that these nursing shortages are risking the quality of patient care in community settings (House of Commons health committee, January 2018) as they put pressure on staff and their caseloads (The King’s Fund, September 2016a).
Our survey showed that 45% of trusts that provide community services are "worried" or "very worried" about their current ability to maintain the right numbers, quality and mix of (clinical and non-clinical) staff to deliver high-quality care (see figure 13). When asked what the picture would look like in one year, their level of confidence decreased and 62% were "worried" or "very worried".
District nurses play a vital role in supporting people with long-term conditions, helping older people often with complex co-morbidities, and caring for those who are recently discharged from hospital or near end of life. In a patient’s eyes, they are often the linchpin between primary and social care, hospital teams and care homes.
However, there are not enough district nurses to meet current or future demand, and district nursing has an ageing workforce making supply an even more pressing issue. National policy has had some impact in increasing the supply of community staff in the past. The national target to boost the number of health visitors by 4,200 between 2011-15 was missed, but did cause numbers to rise (Department of Health, October 2012). Since the target was not renewed in 2015, the number of health visitors has fallen by 19%, showing how when the national impetus falls away, so do the results (NHS Digital).
Health Education England began a review into community nursing training in February 2018, after struggling to fill post-registration courses, and has increased the number of school and district nursing training places commissioned for 2018/19. However, the wider workforce strategy will need to consider the workforce in social care alongside community services as staff often move between the two and the capacity and capability of staff in both sectors is vital for supporting patients in the community.
There are not enough district nurses to meet current or future demand, and district nursing has an ageing workforce making supply an even more pressing issue.
In addition to district nursing, trusts providing community services are facing other issues and are particularly struggling to recruit and retain the staff they need. The community sector has a nursing staff turnover of 14.6%, which is 3% worse than acute trusts (Health Education England, December 2017).The trust leaders that we interviewed report that it is difficult to attract staff to work in the community as working in a hospital is still considered to be more 'glamorous'. It is also difficult to promote community services as an attractive career option.
There is some innovative work underway across the country to address the continued professional development needs of community staff, such as offering rotational posts that span organisational boundaries, and to deliver care more effectively, such as new care models redesigning the skill mix in multidisciplinary teams. However, these measures need to be supported to roll out across the country.
The imminent national workforce strategy needs to deliver the appropriate number of community staff and raise the profile of careers in the community sector. Across all types of trust, levels of confidence in national workforce planning are low. As figure 14 shows, 86% of trust leaders are worried or very worried that national strategic workforce planning will not deliver appropriate numbers of community nurses.
It is particularly concerning that 59% of respondents stated demand was not being met in adult community services (figure 10) and 45% are very worried about having the appropriate numbers of staff for these services (figure 14). One trust leader that we interviewed commented that the changes to nursing education were concerning, especially as they happened at the same time as medical training being protected and expanded.
The mismatch between the inadequate supply of core community health staff and the national policy ambition to move more care into the community will need to be resolved in future. To make this ambition a reality, it is crucial to increase workforce capacity before strengthening and expanding the provision of care in the community, so Health Education England’s national workforce strategy must ensure appropriate priority is given to the supply of community nurses. Staff will need to be redesigned, upskilled and supported to work according to different models of care and a population health approach, if this is not already happening. The community sector needs a more flexible workforce that can take a holistic approach to care.
STPs and ICSs provide an opportunity for strategic system-wide workforce planning to address shortages in the health and care workforce (including social care staff). This will ensure organisations are not competing for the same limited pool of staff, and enable development opportunities across the footprint.
Workforce capacity in the community needs to be strengthened in line with the expansion of community services. The gap between the current supply of community staff and the demand for services means that staff are already working flat out to provide high-quality care. Trust leaders are increasingly concerned about having the right staff with the right skills in the future. In addition to worrying staff shortages, trusts are also grappling with recruitment and retention issues. There needs to be appropriate priority given to the supply of community staff at a national level, as well as a focus on the community workforce at local system level.