What’s really going on with nursing outside hospital?

Mark Dayan and Billy Palmer argue that we should treat figures appearing to show a plummeting community nursing workforce with caution. While a real problem exists, the statistics only count a subset of the workforce, and we can’t fully see what is happening with some other staff.

Blog post

Published: 19/10/2018

Last week’s State of Care report from the CQC warned about the patchy progress we have seen in moving to a model where more patients can be helped outside hospital. It repeated some alarming figures on the number of nurses working in the community services who support people at home or in neighbourhood clinics:

“From 2009 to 2017 there was a 40% fall in the number of full-time equivalent community matrons and a 44% drop in the number of district nurses. At the same time, the number of nurses caring for adults in hospitals increased by 8%.”

While the underlying problem in community nursing is very real, these numbers don’t quite tell the whole story.

Comparing like with like

The quote compares the trend in community matrons and district nurses to the trend for all nurses in hospital. But community matrons and district nurses are particular, relatively senior roles. They account for 3% and 13% of the workforce respectively.

The data on workers employed by the English NHS classes three quarters of the community nursing workforce as “other 1st level” or “other 2nd level” nurses. This covers all nurses except managers and those with certain special roles and qualifications like district nurses and community matrons. The different levels relate to whether nurses qualified under the full three-year course required nowadays, or shorter courses in the past.

The numbers in these broader categories of the rank and file have also fallen, but by far less – only 6%. Overall the number of nurses in community services in the data fell by 14%.

We should perhaps treat the figure of a 40% fall for community matrons with particular caution. As well as being a small slice of the workforce, the role is also a job title that could be used differently from place to place, rather than being a qualified class like district nurses. We can’t be sure whether a drop in numbers means that there are fewer people doing the job, or just fewer people doing it under that particular name.

Community nurses employed by NHS as a proportion of 2009 total (FTE) 19/10/2018

Chart

Source:  

NHS Digital

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Lost in privatisation?

And there’s another complication too: the data presented include only staff directly employed in NHS trusts and CCGs. But over the last decade, quite a lot of community services have been taken over either by private companies like Virgin Care or by “community interest companies” – a type of local social enterprise that reinvests profits in patient care.

It’s difficult to be exact. Recent data suggests around 12% of NHS referrals to community services go to charities, companies and other organisations that are not NHS trusts. And our analysis suggests even this data set is still missing many appointments and contacts.

So could it be that staff are simply being transferred to providers outside the NHS, rather than there actually being fewer of them? Unfortunately, it is very difficult to be sure because non-NHS providers have not provided the same level of information over this period.

Data shows a significant number of community nurses in the private sector, equivalent to more than 4,000 full-time workers, compared to 33,000 in the NHS. As the chart below shows, there hasn’t been much change over the last two years. Not all companies and charities have sent in their figures, so the true figure is unknown but probably higher. Some of the staff captured won’t have been working for NHS-funded services. Crucially, the data doesn’t go back far enough to show what happened at the start of the decade, when the fall in NHS community nurses was steepest.

Independent health provider workforce (FTEs) 19/10/2018

Chart

Source:  

NHS Digital

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Trimming from the top?

Although it isn’t quite right to compare the drop in district nurses and community matrons to all hospital nurses, it does tell us something troubling. There has been a sharp drop in the number of the most senior nurses who work outside hospital. The figures are so large, and so disproportionate to the rest of the community nursing workforce, that it seems unlikely this is accounted for just by the holes in the data around the private sector. If we look at the number of “modern matrons” in the hospital sector, although it has also fallen by 13% there is no similarly dramatic drop.

This is something nursing groups have been warning about for some time. One factor may be the relatively old age profile of district nurses, with many close to retirement age.

Given the aspiration to do more outside hospital, this apparent loss of the staff most able to take responsibility autonomously for patients is a cause for concern. Exactly why and how this has happened should be looked into.

A patchwork problem

The data also suggests another discrepancy in community nursing numbers – based on areas of the country. Over the last two years, while the number of these nurses has actually risen in some areas of the country, like London and the West Midlands, in others it has fallen dramatically. The East of England has seen a fall of more than 8%.

Community nurses and health visitors, June 2016 to June 2018 19/10/2018

Chart

Source:  

NHS Digital

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Again, what we cannot be sure of is what proportion of this might reflect staff moving to the private sector, rather than actually no longer treating patients. Unfortunately, there is no readily available data that records how many staff independent providers have in each region. But it seems there may be issues that echo the CQC’s concerns about an uneven level of pressure and resources on services outside hospital.

The bottom line is that we have good reason to worry about what is happening in community nursing. But rather than being a simple, certain problem of plummeting numbers, the drop in these vital workers is much more uneven – and we still can’t quite be sure exactly what’s going on.

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