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Keywords:

  • community nursing;
  • primary care trusts;
  • provider organisations;
  • scoping study;
  • transforming community services

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

Aim(s)

To scope the provision of community nursing services in England after implementation of the Transforming Community Services Programme.

Background

Over the past decade, significant UK policy initiatives have shaped the structure, organisation and responsibilities of community nursing services. Understanding these organisational changes is important in the context of organisations seeking to deliver ‘care closer to home’.

Method(s)

A systematic mapping exercise to scope and categorise community nursing service organisation provider models.

Results

There are 102 provider organisations representing a range of organisational models. Two-thirds of these organisations have structurally integrated with another NHS Trust. Smaller numbers reorganised to form community trusts or community interest companies. Only a few services have been tendered to an accredited willing provider while a small number have yet to establish their new service model. Local discretion appears to have dominated the choice of organisational form.

Conclusion(s)

National policies have driven the reorganisation of community nursing services and we have been able to describe, for the first time, these ‘transformed’ structures and organisations.

Implications for nursing management

Providing detail of these ‘new’ models of service provision, and where these have been introduced, is new information for nurse managers, policy makers and organisational leaders, as well as researchers.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

In the UK, primary and community care services are the first point of contact for 90% of the population when seeking health care advice, support or intervention from the National Health Service (NHS) (NHS Confederation 2010). Public demand for these services is growing as a consequence of a range of factors, including demographic changes, increasing public expectations for quality and choice, the changing nature of disease and disease management, continuing advances in technology and treatments and the shifting focus from hospital to community-based services (Audit Commission 1999, Department of Health 2010a). The NHS Review (Department of Health 2008a,b) and the recent NHS reforms (Department of Health 2010b) have advocated primary and community care services that promote health, provide timely access for people experiencing ill health, are based on pathways of care, reflecting the needs of service users and focus on promoting quality and safety.

To meet these service demands, the skills of the entire healthcare team (both professionals and assistant staff) need to be supported, developed and, crucially, deployed in the most efficient way (Department of Health 2008c). Over the past decade, the NHS has sought to make better use of its human resource through role expansion and role redesign (Sibbald et al. 2004). Changes to the roles of health care professionals have created specific opportunities for reviewing developments in assistant roles (Benson et al. 2004). Assistants are a vital part of the primary and community care workforce and policies over the past decade have supported their growth in numbers and their increasing scope of practice (Saks & Allsop 2007).

‘Community nursing’ refers, in its broadest sense, to any nursing care delivered ‘outside’ the hospital setting, such as patients' homes, or residential care or health centres. There are many definitions of community health services but they all share a number of key functions and roles as summarised in Box 1. In addition, community nursing teams all work alongside the general practitioner and other health and social care professionals to provide patient care, support and management in the community. A wide variety of services and teams comes under this banner, for example district nursing, intermediate care, falls prevention, tissue viability or specialist nursing teams such as community-based respiratory teams. Importantly, the need for skilled ‘home’ nursing is rising as the population ages, as more people live with long-term conditions and as people are discharged home earlier from hospital (Department of Health 2004, Queen's Nursing Institute's 2009). It is estimated that district nurses visit more than 2.6 million people a year: one in four people over the age of 75, and one in two of those aged over 85, receive care from a district nurse (Audit Commission 1999).

Box 1. Key functions and roles of community nursing services

  • Delivering treatment in a community or home setting and where possible avoiding unnecessary admission to hospital
  • Supporting case management and disease management for those with complex long-term conditions and promoting independence
  • Supporting rehabilitation
  • Preventing disease and promoting health and healthy behaviours
  • Providing palliative care
  • Providing end-of-life care
  • Supporting the health and wellbeing of carers

Community nursing services are delivered by both registered nurses (Agenda for Change Band 5 and above) and their assistant staff (Agenda for Change Bands 2, 3 and 4) (Department of Health 2005a). Securing a sufficient number of nursing staff with the appropriate skills, across these levels, and deploying them effectively is a highly complex challenge. Staffing in community nursing teams has significantly changed over the past decade. The number of assistants in community nursing teams is reported to have increased by 118% to 16 968 over a 10-year period (1996–2006) (Queen's Nursing Institute's 2011). The number of qualified district nurses (that is registered nurses that hold a graduate level specialist community nursing qualification) has fallen 23%, from 12 350 to 10 008 and the number of registered (but not necessarily community specialist) nurses in community services increased by 38% to 35 179 (Queen's Nursing Institute's 2011). These changes in the composition of the community nursing workforce have created a ‘broader’ skill mix and this has generated wide ranging debates about role boundaries between registered nurses and assistant staff. In the past, much of the care delivered by nurses in the community may have been considered ‘routine’. However, the growing number of more dependent and complex patients and the unpredictability of caring for someone at home mean that there is a much wider range of complex and technical-based care. This requires nursing staff with the skills and abilities to deliver this range of care and has resulted in the current broader skill mix found in community nursing teams. Such a skill mix includes registered nurses and nurses with extended and specialist skills but also incorporates assistants working at different levels and with a range of skills to deliver the breadth of care once only delivered in hospitals.

Our main study aimed to develop understanding of assistant roles within community nursing teams in England by undertaking a scoping study to establish numbers, types and roles of assistant staff (Spilsbury et al. 2013). The starting point for the main study was to establish contact with a senior level manager (the Director of Nursing or equivalent). This was not a straightforward process owing to changes in the location of community nursing teams and the resulting varied models of service provision (Department of Health 2009a). These changes form the focus of this study.

Changes to the organisation of community nursing teams

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

Over the past decade, significant UK policy initiatives have been introduced which have shaped the structure, organisation and responsibilities of primary and community care services, including community nursing services. The main aim of these policies has been to deliver care closer to home for service users to better accommodate patient choice alongside the health and care needs of the changing population (Department of Health 2008d, 2009a). A summary of the key UK policies affecting the development of community nursing services is provided in Table 1, culminating in the Transforming Community Services Programme (Department of Health 2009a) which was incorporated in to the Coalition Government's plans for the NHS (Department of Health 2010b). This programme of restructuring the provision of community services has had a significant recent impact on the landscape of community nursing service provision.

Table 1. Key UK policies affecting the development of Community Nursing Services
YearPolicies
1999Primary Care Groups (PCG) formed to develop local primary and community care services (Department of Health 1999)
2000NHS Plan sets out measures to modernise the NHS with an emphasis on more choice and control for patients (Department of Health 2000)
2000Primary Care Trusts (PCT) launched to: purchase care for local communities from hospitals and other providers; provide community services engage with local people; and to tackle health inequalities and improve public health. There were initially 303 PCTs. Towards end of 2002, the role of PCT's expanded to improve the health of the community and secure provision of services that encourage local integration of health & social care (NHS Confederation 2011)
2002Payments by results led to remuneration for acute trusts for carrying out specific treatments (King's Fund's 2007)
2002Derek Wanless commissioned to evaluate NHS funding. He reported the that the NHS was under resourced by health care staff across hospital and community services (Wanless 2002)
2003New general practitioner (GP) contract introduced and resources were allocated according to workload and patient population. The GP had more autonomy to provide a wider range of services to meet the needs of their practice population (Department of Health 2003)
2004The first NHS (hospital) Foundation Trusts emerged (not community focused) (Department of Health 2005b)
2005Creating a Patient-Led NHS required PCTs to introduce a choice of elective care (Department of Health 2005c)
2006Commissioning a patient-led NHS identified a need for ‘step-change’ in the way services were commissioned. Under Practice Based Commissioning (PBC), GPs took on responsibility for commissioning of services to meet the needs of their local population (Department of Health 2006)
2006PCTs and Strategic Health Authorities (SHAs) were reconfigured to strengthen commissioning and establish closer relationships between health, social care and emergency services. The number of PCTs was reduced from 303 to 152. The number of SHAs was reduced from 28 to 10 (Department of Health 2009c)
2007Darzi sets out the Government's 10-year plan for the NHS. The emphasis was upon patient choice and the importance of services being provided close to the patient (Department of Health 2008b)
2008‘Our vision for primary and community care’ set out plans to expand non-acute services and acknowledged that there had been a lack of focus on community nursing services (Department of Health 2008a)
2009PCTs established a contractual relationship with their provider services leading to internal separation between PCT commissioner and provider arms (Department of Health 2008e)
2009‘Transforming community services’ suggested that all PCT community provider arms established as separate organisation with a deadline for April 2011 (Department of Health 2009a)
2010‘Liberating the NHS’ sets out the governments long-term vision with a focus on improving and innovating (Department of Health 2010b)

Transforming Community Services (Department of Health 2009a) recognised the lack of attention and years of underinvestment in community health services and required Primary Care Trusts (PCTs) to consider ways in which community health services could better meet the needs of the local populations, in particular those with long-term conditions. In 2009, PCTs started to identify strategies to split provider services from the commissioning functions of the PCT, with a Government imposed deadline of April 2011. A range of organisational models for community services were proposed (Department of Health 2009a, NHS Confederation 2009). Essentially, there were two main choices: the provider services could become a standalone organisation (community trust or social enterprise) or merge with another organisation (vertical integration with an acute or mental health trust). Alternatively, community services could be commissioned by the PCT to ‘any PCT accredited willing provider’ (named ‘any willing provider’ in earlier policies) to enable a ‘plurality of providers’ (Table 2).

Table 2. Main proposed organisational models for community services
Organisational modelDescription
Community foundation trustThe provider services from the Primary Care Trust separate from the commissioning arm and become an independent NHS organisation, called an Autonomous Provider Organisation
Social enterpriseA business model that aims to combine market efficiency with social and environmental justice. There are several legal organisational forms, for example a Community Interest Company (CIC)
Vertical integration with another NHS organisationThe provider services join another NHS organisation, such as a large acute hospital or mental health trust
Any willing PCT accredited provider (originally called ‘any willing provider’)Any provider accredited by the PCT commissioners who meet the specific requirements to meet needs of the local population, for example a private company

Local consultations, rather than any national guidance, were used to inform decision-making processes of which model provider services would adopt. This created a great deal of uncertainty for community healthcare workers and healthcare unions about who would be employing staff to deliver community services in the future (Department of Health 2009b). The processes by which provider services have been separating from the commissioning arm of PCTs (during 2010 to 2012), along with the change to PCTs themselves (being abolished in April 2013), coincided with the data collection for this study and created a number of practical challenges. We present here our understanding of the community nursing service provider organisations in England during our study period (January 2011 to June 2012).

Aims

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

The initial stages of our study required a clear understanding of new organisational structures and models for the provision of community nursing services in England. We required this information to enable us to make contact with a Senior Manager (Director of Nursing or equivalent) in the provider organisations and so that we appreciated the changing contexts in which community nursing assistants were deployed. We therefore identified that it was important to:

  • establish where community nursing services were located after the ‘split’ of the commissioning and provision of community nursing services; and
  • identify the emerging service models as a result of these changes in location.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

We adopted a systematic approach for mapping community nursing services. Our starting point was the list of 152 PCTs in four NHS clusters (North, South, Midlands and London) that we identified with Binleys (http://www.binleys.com/About/). Early 2011, we started making contact (by email or telephone) with the senior managers that had been identified. However, this list of contacts was not reliable and we were not making contact with the most appropriate senior manager: either the organisation no longer existed or the manager was no longer in the post. We were unable to locate a central source of the data we required (new organisational structures and their managers) and so we adopted a pragmatic approach: making contact with the ‘original’ PCT provider services and tracking how the services were being ‘transformed’ (including location, type of provider organisation and contact). These approaches were supplemented with web-based searches. Organisations were categorised according to provider models (outlined in Table 2).

This mapping exercise, to establish the national picture of community nursing service provision in England, has enabled us to describe the changing landscape of community nursing services: this was important in the context for our study of community nursing assistants (Spilsbury et al. 2013). The study was reviewed by the Proportionate Review Sub-Committee of a Multi-centre Research Ethics Committee (REC reference: 10/H0808/159) and progressed through research governance procedures as a National Institute for Health Research (NIHR) portfolio study.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

After the transformation of community services, 102 organisations providing community nursing services were identified and these represented a range of organisational models (Table 3). The majority of organisations (n = 67; 66%) integrated with another NHS organisation; either an acute trust (n = 44) or mental health trust (n = 23). Similar numbers of organisations made the transition to a community trust aspiring to achieve foundation status (n = 15) or a community interest company (n = 15). A small number of PCTs (n = 2) had tendered their community nursing services to an accredited willing provider/private company. We found a small number of organisations [all in the South Strategic Health Authority (SHA) cluster] described as ‘parked’ with the PCT as an ‘arms length’ provider (n = 3), with the future of these services still being debated (Table 3). The majority of organisations (82%) were making the transition during the period 1 April 2011 to 31 March 2012, with 11% doing so the year before (Table 4).

Table 3. Transforming community nursing services organisational models
Organisational modelNumber (%)
Community trust15 (14.5)
Social enterprise15 (14.5)
Vertical integration with another NHS organisation67 (66)
Any willing PCT accredited provider (originally called ‘any willing provider’)2 (2)
‘Parked’ with PCT3 (3)
Total number of organisations102 (100)
Table 4. Year of transition of Primary Care Trust (PCT) services to a new provider
YearNumber (%)
Pre- 31-03-092 (2)
01-04-09–31-03-101 (1)
01-04-10–31-03-1112 (11)
01-04-11–31-03-1283 (82)
Post 01-04-122 (2)
Not planned yet2 (2)
Total102 (100)

Table 5 presents the transitions by SHA cluster and shows that a higher proportion of PCTs in the North integrated with another NHS organisation rather than using an alternative model for providing services. Alternatively, PCTs in the Midlands were proportionately spilt between integration with a NHS organisation and stand-alone organisations (including both community trust or community interest companies). It is not possible to determine reasons for these choices within this study. Exploratory data analysis was conducted but no clear patterns emerged with regard to factors that predicted the type of organisation that was created. Local discretion appears to have dominated the choice of organisational form. When reading organisations' web pages, the choices were portrayed as promoting better services for the local populations as justification of their choice of transition.

Table 5. Transitions by Strategic Health Authority (SHA) Cluster
SHA ClusterIntegration (%)AcuteFTNon FTMental HealthFTNon FTCommunity Trust (%)CIC (%)Private Company (%)‘Parked’ (PCT) (%)Total
  1. CIC, Community Interest Company; PCT, Primary Care Trust.

London14 (21.2)9365412 (13.4)2 (13.3)0 (0)0 (0)18
North28 (42.4)211657614 (26.6)2 (13.3)0 (0)0 (0)34
Midlands14 (19.7)8256157 (46.6)5 (33.4)1 (50)0 (0)27
South11 (16.7)6335412 (13.4)6 (40)1 (50)3 (100)23
TOTAL67 (100)44  23  15 (100)15 (100)2 (100)3 (100)102 (100)

The reduction in numbers of organisations (from 152 to 102) is as a result of the merged delivery of services into one organisation, where they were delivered by a number of original PCTs. However, the services from one PCT could also be split across a number of new providers. Tables 6-11 provide detailed information about the original PCT and ‘new’ provider organisations for community nursing services in England at the point of reporting (December 2012). These are presented to represent the main organisational models.

Table 6. Vertical integration with acute trust (foundation and non-foundation status) (n = 44)
SHA ClusterPCTProvider organisation
  1. SHA, Strategic Health Authority; PCT, primary care trust.

North

North Yorkshire and York

Lancashire

Airedale NHS Foundation Trust
South

Berkshire East

Berkshire West

Berkshire Healthcare NHS Foundation Trust
North

Blackpool

North Lancashire

Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust
NorthBoltonBolton NHS Foundation Trust
NorthCalderdaleCalderdale & Huddersfield NHS Foundation Trust
NorthManchesterCentral Manchester University Hospital NHS Foundation Trust
North

County Durham

Darlington

County Durham & Darlington NHS Foundation Trust
MidlandsDudleyDudley Group NHS Foundation Trust
South

Wiltshire

Bath and North East Somerset

Great Western Hospitals NHS Foundation Trust
London

Lambeth

Southwark

Guys & St Thomas NHS Foundation Trust
NorthNorth Yorkshire and YorkHarrogate and District NHS Foundation Trust
MidlandsSolihullHeart of England NHS Foundation Trust
LondonCity & HackneyHomerton University Hospital Foundation Trust
NorthNewcastleNewcastle upon Tyne Hospitals NHS Foundation Trust
North

Hartlepool

North Tees

North Tees & Hartlepool Foundation Trust
North

Northumberland Care Trust

North Tyneside

Northumbria Healthcare NHS Foundation Trust
North

Rotherham

Doncaster

Bassetlaw

Rotherham, Doncaster & South Humber NHS Foundation Trust
LondonSutton and MertonRoyal Marsden NHS Foundation Trust
NorthSalfordSalford Royal NHS Foundation Trust
North

Middlesbrough

Redcar & Cleveland

South Tees Hospitals NHS Foundation Trust
North

South Tyneside

Sunderland

Gateshead

South Tyneside NHS Foundation Trust
MidlandsWarwickshireSouth Warwickshire NHS Foundation Trust
NorthStockport, Tameside and GlossopStockport NHS Foundation Trust
South

Torbay

Devon

Torbay and Sothern Devon Health and Care NHS Trust
NorthNorth Yorkshire and YorkYork Teaching Hospital NHS Foundation Trust
LondonTower HamletsBarts Health NHS Trust
SouthBuckinghamshireBuckinghamshire Healthcare NHS Trust
NorthCentral and Eastern CheshireEast Cheshire NHS Trust
LondonCroydonCroydon Health Services NHS Trust
London

Brent

Ealing

Harrow

Ealing Hospitals NHS Trust
NorthEast LancashireEast Lancashire Hospitals NHS Trust
Midlands

East Sussex Downs and Weald

Hastings and Rother

East Sussex NHS Trust
LondonLewishamLewisham Healthcare NHS trust
SouthMilton KeynesMilton Keynes Community Health/Bedford Hospitals NHS Trust
SouthSouth GloucestershireNorth Bristol NHS Trust
North

Bury

Oldham, Heywood Middleton and Rochdale

Manchester (north)

Pennine Acute Hospitals NHS Trust
MidlandsWolverhampton CityThe Royal Wolverhampton Hospitals NHS Trust
MidlandsSandwellSandwell & West Birmingham Hospitals NHS Trust
NorthSheffieldSheffield Teaching Hospitals NHS Trust
North

Sefton

West Lancashire

Southport and Ormskirk Hospital NHS Trust
LondonWandsworthSt George's Healthcare NHS Trust
MidlandsWalsallWalsall Healthcare NHS Trust
London

Haringey

Islington

The Whittington Hospital NHS Trust
MidlandsHerefordshireWye Valley NHS Trust
Table 7. Vertical integration with mental health trust (foundation and non-foundation status) (n = 23)
SHA ClusterPCTProvider organisation
  1. SHA, Strategic Health Authority; PCT, primary care trust.

London

Camden

Hillingdon

Central and North West London NHS Foundation Trust
NorthWestern CheshireCheshire and Wirral Partnership NHS Foundation Trust
NorthCumbriaCumbria Partnership NHS Foundation Trust
SouthBournemouth and Poole DorsetDorset Healthcare University NHS Foundation Trust
LondonNewhamEast London NHS Foundation Trust
North

Ashton, Leigh and Wigan Halton and St Helens Trafford

Warrington

Five Boroughs Partnership NHS Foundation Trust
NorthEast Riding of YorkshireHumber NHS Foundation Trust
North

Central Lancashire

Blackburn and Darwen

Lancashire Care NHS Foundation Trust
London

Waltham Forest Redbridge

Barking and Dagenham Havering SW Essex

North East London NHS Foundation Trust (NELFT)
SouthOxfordshireOxford Health NHS Foundation Trust
LondonBexley Care Trust GreenwichOxleas NHS Foundation Trust
SouthSomersetSomerset Partnership NHS Foundation Trust
Midlands

South East Essex

South West Essex

Bedfordshire

Luton

West Essex

South Essex Partnership University NHS Foundation Trust
North

Barnsley

Wakefield

South West Yorkshire Partnership NHS Foundation Trust
SouthHampshireSouthern Health NHS Foundation Trust
NorthBradford and AiredaleBradford District Care Trust
MidlandsCoventryCoventry and Warwickshire NHS Partnership Trust
LondonEnfieldBarnet, Enfield and Haringey Mental Health NHS Trust
MidlandsLeicester City, Leicestershire County and RutlandLeicestershire Partnership NHS Trust
MidlandsNorthamptonshireNorthamptonshire Healthcare NHS Foundation Trust
MidlandsNottinghamshire CountyNottinghamshire Healthcare NHS Trust
SouthSouthampton City, Portsmouth CitySolent NHS Trust
MidlandsWorcestershireWorcestershire Health and Care NHS Trust
Table 8. Community trusts (n = 15)
SHA ClusterPCTProvider organisation
  1. SHA, Strategic Health Authority; PCT, primary care trust.

Midlands

Birmingham East & North

Solihull

Heart of Birmingham

South Birmingham

Birmingham Community Healthcare NHS
London

Barnet

Hammersmith & Fulham

Kensington & Chelsea

Westminster

Central London Community Health Care Trust
Midlands

Cambridgeshire

Peterborough

Luton

Cambridgeshire Community Services NHS Trust
Midlands

Derby City

Derbyshire County

Derbyshire Community Health Services NHS Trust
Midlands

East and North Hertfordshire

West Hertfordshire

Hertfordshire Community NHS Trust
London

Hownslow

Richmond & Twickenham

Hounslow & Richmond Community Health Trust
South

Eastern and Coastal Kent

West Kent

Kent Community Health NHS Trust
NorthLeedsLeeds Community Healthcare NHS Trust
North

North Lincolnshire

North East Lincolnshire

Lincolnshire Community NHS Trust
North

Liverpool

Sefton

Liverpool Community Health Trust
MidlandsNorfolkNorfolk Community Healthcare NHS Trust
Midlands

Shropshire County

Telford and Wrekin

Shropshire Community Health NHS Trust
Midlands

North Staffordshire

Stoke on Trent

South Staffordshire

Staffordshire and Stoke-on-Trent Partnership NHS Trust
South

West Sussex

Brighton & Hove City

Sussex Community NHS Trust
NorthWirralWirral Community NHS Trust
Table 9. Community interest companies (n = 15)
SHA ClusterPCTProvider organisation
  1. SHA, Strategic Health Authority; PCT, primary care trust.

MidlandsNE EssexAnglian Community Enterprise (ACE)
SouthBristolBristol Community Health
LondonBromleyBromley Healthcare
NorthHullCity Health care Partnership
MidlandsMid EssexCentral Essex Community Health
MidlandsGreat Yarmouth and WaveneyEast Coast Community Healthcare
NorthKirkleesLocala Community Partnerships
LondonKingstonYour Healthcare
MidlandsMedwayMedway Community Healthcare
SouthNorth SomersetNorth Somerset Community Partnership
MidlandsNottinghamshire CityNottingham CityCare Partnership
SouthPlymouthPlymouth Community Healthcare
SouthCornwall and Isles of ScillyPeninsula Community Health
SouthSwindonSEQOL
SouthBath and NE SomersetSirona Care & Health
Table 10. Any Primary Care Trust (PCT) accredited willing provider (= 2)
SHA ClusterPCTProvider organisation (company name)
  1. SHA, Strategic Health Authority.

MidlandsSuffolkSuffolk Community Health care/SERCO
SouthSurreySurrey Community Health (Assura)
Table 11. Primary Care Trust (PCT) providers (arms length) or ‘parked’ (n = 3)
SHA ClusterPCTProvider organisation
  1. SHA, Strategic Health Authority.

SouthGloucestershireNHS Gloucestershire Care Services
SouthIsle of WightNHS Isle of Wight
SouthTorbay, DevonTorbay and Sothern Devon Health and Care NHS Trust

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

The community health care landscape is changing. This paper describes, for the first time, the current national picture of community nursing service provider organisations in England. The mapping study reported here was the first stage for a study of community nursing assistants (Spilsbury et al. 2013). While this was an important context for the sampling of the study, we believe that the findings of this mapping study will be of interest for policy makers, organisational leaders of community services and nurse managers, as well as those who plan, work or conduct research on community nursing services. There is a renewed focus on the importance of community health care provision across the UK, and the important role that community nursing teams will play in meeting emerging challenges. Understanding these organisational changes is important in the context of future roles and responsibilities of nursing teams. Nursing teams in the community provide the majority of locally delivered health care, treatment and support to patients in their homes. Each of the UK governments (England, Scotland, Wales and Northern Ireland) is pursuing policies to increase the amount of care delivered in the community.

Recent healthcare reforms and policy has placed an emphasis on the provision of care closer to home, with primary and community care services at the centre of health care delivery in the UK. Community nursing services are central to these reforms to provide high-quality and efficient services and to reduce unplanned (and unnecessary) hospital admissions, shorten the length of in-patient stay, promote self-care and prevent ill health. This mapping study sets the context for the main study of the community nursing workforce in England.

Nurses, and other professions, working in community settings have experienced approximately 7 years of uncertainty about their future and what type of organisation would be providing local health care. This uncertainty is far from over: changes set out in the Health & Social care Act 2012 (chapter 7) will introduce further transformations in the provision of care in the community. Regardless of their employing organisations, community nurses are key service providers and have to continue the operational delivery of care and respond to existing and future challenges in the politics of community healthcare. This state of flux will continue as ‘any Willing PCT Accredited Providers’ may secure other community contracts for care delivery in the future. The wider range of different providers promotes contestability and competition in the NHS and concerns have been raised that Transforming Community Services agenda will lead to an even greater fragmentation of services and an opportunity for the private sector to increase their involvement in the delivery of NHS services. Community nurses are increasingly required to find new ways of working and develop effective working relationships with other health and social care providers to deliver patient care, support and management within the community.

This study provides an insight into community nursing service provision at a point in time. It would appear that the choice of organisational reform was determined at a local, rather than national, level. After implementation of Transforming Community Services, two-thirds of community nursing services opted to structurally integrate with another NHS Trust. It is not clear whether these decisions were opportunistic, based on what service models existed locally, or strategically informed by a longer term vision of which model may provide the best community care for the local population in the longer term. Indeed the impact of the reorganisation of community services, including community nursing, on quality and efficiency requires future study (Ham & de Silva 2009). The findings presented in this paper provide an important platform for studying service delivery by these different provider organisations and the impacts of these local decisions on patient care and monitoring impacts of subsequent service transformation.

Study limitations

This is a cross-sectional mapping study providing data of the community nursing provider organisation in England. We recognise this is a snapshot and that these organisational structures may change over time. In addition, the study focuses on a UK workforce policy initiative which does not directly translate to international settings. Nonetheless, the findings will be of interest to policy makers, organisational leaders, nurse managers and researchers because we present in one place the current national picture: detail of which (to the best of our knowledge) is not available anywhere else.

Conclusion and implications for nursing management

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

This descriptive mapping study makes an important contribution to reports on changes in community nursing services provision in England. National policies have driven these reorganisations and we have been able to describe here the ways in which organisations have relocated and reorganised the provision of community nursing services. Providing detail of these ‘new’ models of service provision, and where these have been introduced, will be useful for policy makers, organisational leaders of community services and nurse managers, as well as researchers. However, further empirical evidence is required to ascertain the impact of these changes in service provision on patient care and service delivery and the potential effects of different models.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

We acknowledge the contributions of the research team to the main study and for discussions that have informed the development of this manuscript. The research team includes Karl Atkin, Karen Bloor, Rachel Borthwick, Dorothy McCaughan, Hugh McKenna, Una Adderley, Ann Wakefield and Ian Watt.

Source of funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

This paper presents findings from research funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 09/1801/1026). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

Ethical approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References

The study was reviewed by the Proportionate Review Sub-Committee of a Multi-centre Research Ethics Committee (REC reference: 10/H0808/159) and progressed through research governance procedures as a National Institute for Health Research (NIHR) portfolio study.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Changes to the organisation of community nursing teams
  5. Aims
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion and implications for nursing management
  10. Acknowledgements
  11. Source of funding
  12. Ethical approval
  13. References