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NHS Benchmarking Network June 2020 Raising standards through sharing excellence Community Services benchmarking Deep dive report for Community / District Nursing
NHS Benchmarking NetworkJune 2020
Raising standards through sharing excellence
Community Services benchmarking Deep dive report for Community / District Nursing
Raising standards through sharing excellence
© NHS Benchmarking Network (NHSBN)
Citation for this document: NHS Benchmarking NetworkDeep dive report for Community / District Nursing. June 2020
Community Services benchmarking - Deep dive report for Community / District Nursing
ContentsSection 1: Introduction Content of this report Executive summary Community / District Nursing
Section 2: National policy context Community Services Community / District Nursing
Section 3: Key Findings - Community / District Nursing Service model Access Activity Workforce Finance Quality and outcomes
Section 4: Time series analysis
Section 5: References
Appendix 1: The Community Services benchmarking project
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Community Services benchmarking - Deep dive report for Community / District Nursing
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 1: Introduction
Section 1: IntroductionWhen reviewing this document, please note:
the 2019 Community Services project collected and analysed data for the NHS financial year 2018/19. The “2018 project” refers to 2017/18 data
any reference to the “national average” within this document refers to the mean average of 2019 project participants
all charts and data in this report refer to the overall UK position. Peer group profiling is available in the online toolkit
on bar charts, each blue bar represents an individual service. The orange horizontal line represents the mean average value of all services
this report is an overview national report and therefore the charts in this report do not show the position of any one organisation in particular. Member organisations who participated in the Community Services project can check their individual positions in the online toolkit, which is issued to members once the dataset has been finalised. This allows individual comparison of every metric collected against the sample position.
Content of this report
NHSBN Community Services 2019 - Community / District Nursing
Face to face contacts per 100,000 population
Face to face contacts per clinical WTE in post Patient facing time
Average length of a contact
Clinical WTE per 100,000 population Average waiting time
Referrals received per 100,000 population
Unique service users per clinical WTE in post
Face to face contacts per service user
55,962 1,656 60%
31 mins
43 6 days
5,416
75
24
5
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 1: Introduction
Executive summary Community / District NursingInvestment in Community / District Nursing services has seen a general decline since 2013. On average, these services have a mean average clinical staff pay budget of £1.56 million per 100,000 registered population. With additional investment for community services outlined in the NHS Long Term Plan, it is important to track investment in these services in the coming years.
In line with investment levels, staffing levels have not seen any growth, with a 2019 position of 43 clinical WTE per 100,000 population.
Despite lack on investment in services, productivity has risen, with Community / District Nurses delivering, on average, 1,656 face to face contacts per clinical WTE in post. This figure is 26% higher than the number of face to face contacts per clinical WTE reported in 2013. In 2019, 58,962 face to face contacts were delivered per 100,000 population per annum.
Vacancy rates remain high in Community / District Nursing services at 10%, suggesting increasing pressure on teams. Spend on bank and agency staff, used to fill workforce vacancies, represent 5.9% and 4.7% of pay budget respectively.
Despite many Community / District Nursing staff reporting that the complexity of their caseload is increasing, the average time on caseload has decreased in recent years, highlighting a faster turnaround of service users. In 2019, patients were on the caseload for 123 days, on average.
On average, the Community / District Nursing teams spend 60% of their time in patient facing settings. Community / District Nursing staff deliver a variety of functions, with wound care taking up the highest proportion of patient facing time (37%).
Average time on caseload (days)
2018
2017
2019
2016
2015
100
50
250
200
0
150
6
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
National policy contextCommunity ServicesEngland
The NHS Long Term Plan, published in January 2019, highlights the importance of community services in supporting service users in the community and reducing unnecessary hospital admissions. The Long Term Plan sets out to:
boost ‘out-of-hospital’ care, and dissolve the historic divide between primary and community health services
increase investment in primary medical and community health services, which will equate to an extra £4.5 billion a year by 2023/24. Extra money will start to flow to community via Sustainability and Transformation Partnership (STP)/ Integrated Care Systems (ICS) and Primary Care Networks (PCN) via Directed Enhanced Service (DES) contracts in 2020/21. The Long Term Plan Implementation Framework outlines funding allocations, with funding for Primary Care flowing more quickly than funding for Community Services
increase the capacity and responsiveness of community and intermediate care services via a new offer of urgent community response and recovery support. These services will aim to prevent unnecessary admissions to hospitals and residential care, as well as ensure a timely transfer from hospital to community
expand community multidisciplinary teams aligned with new Primary Care Networks based on neighbouring GP practices. Expanded neighbourhood teams will comprise a range of staff such as GPs, Pharmacists, District Nurses, Community Geriatricians, Dementia workers and AHPs.
Yes
No
Does your organisation operate with any Primary Care Networks (PCNs)?
0% 60%
40%
20%
100%80%
69% 31%
7
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
Although the focus of community services within the NHS Long Term Plan is on adult services, wider children’s services and providing a strong start in life for children and young people is also highlighted in the plan. The Long Term Plan sets out to:
bring together the NHS, Local Authorities and other local partners through local maternity systems, with the aim of ensuring women and their families receive seamless care, including when moving between maternity or neonatal services or to other services such as primary care or health visiting
expand and invest in mental health services for children and young people
design and implement models of care that are age appropriate, closer to home and bring together physical and mental health services. These models will support health development by providing holistic care across Local Authority and NHS services, including primary care, community services, speech and language therapy, school nursing, oral health, acute and specialised services
roll out clinical networks to ensure improvement in the quality of care for children with long-term conditions such as asthma, epilepsy and diabetes.
Wales
Community services strategy in Wales is contained within the document A Healthier Wales: Our Plan for Health and Social Care and sets a clear ambition to bring health and social care services together for the benefit of service users. This is not a new vision, but is supported by clear expectations, milestones and design principles to establish new models of care in every part of Wales.
The overall aim is to provide services that are designed and delivered around the needs and preferences of individuals, with greater emphasis on sustaining a healthy population and preventing ill health. To achieve this ambition, Wales must continue to break down the barriers that prevent health and social care services and their wider partners from operating across the whole system, delivering seamless care to the people of Wales.
Good planning arrangements are critical to bring together multiple providers and allow the system to be pre-emptive and anticipatory, ensuring that the right level of care is provided at the right time, from the right source and in the right setting.
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
A Healthier Wales outlines the following strategies, all of which relate to the provision of community services:
services which support people to stay well, not just treat them when they become ill when people need help, health and social care services will work with them and their loved ones
to find out what is best for them and agree how to make those things happen. This is the basis of the ‘person-centred approach’
more services will be provided outside of hospitals, closer to home, or at home, and people will only go into hospital for treatment that cannot be provided safely anywhere else. This ‘community-based approach’ will help take pressure off the Welsh hospitals, reduce the time people have to wait to be treated, and the time they spend in hospital when they have to go there
health and social care services will use the latest technology and medicines to help people get better, or to live the best life possible if they aren’t able to get better.
Northern Ireland
Northern Ireland have a strategy which, in tandem with the modernisation of acute hospitals, seeks to expand the range of services that can be delivered in the community and is described in A Healthier Future. This encompasses the following:
the key aim is to support an increasing number of people to live independent lives, preferably in their own homes
to do this, the Health and Social Care Board and the Public Health Agency in Northern Ireland need to develop effective alternatives to hospital care, which are designed to reduce inappropriate admissions and unnecessary lengths of stay
there also needs to be a strong focus on rehabilitation in tandem with assessment of long term care needs to avoid unnecessary reliance on residential and nursing home care.
To deliver on this vision, the following strategies are being pursued in relation to community services provision in Northern Ireland:
secure an appropriate balance between hospital and community based services within local health economies
continue the expansion and evaluation of intermediate care as a way of working that is designed to prevent unnecessary hospital admission, promote faster recovery from illness, support timely discharge, maximise independent living and improve the quality of assessment of long-term health and social care needs
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
Scotland
The newly created Public Health Scotland’s strategy around community services is embodied in A Fairer Healthier Scotland 2017-22. There are five strategic priorities that have been developed in partnership with stakeholders, including providers of community services. These are as follows:
Fairer and healthier policy - ensure that knowledge and evidence is used by policy and decision makers. This is so that strategies focus on fairness and influence the social determinants of health and wellbeing.Children, young people and families - ensure the knowledge and evidence provided is used to implement strategies focused on improving the health and wellbeing of children, young people and families.A fair and inclusive economy - providing knowledge and evidence on socio-economic factors and their impact on health inequalities. This is to contribute to more informed and evidence-based social and economic policy reform.Healthy and sustainable places - ensure the knowledge and evidence provided is used to improve the quality and sustainability of places. This will increase their positive effect on health and wellbeing.Transforming public services - working in partnership with and support public sector organisations to design and deliver services that have fairer health improvement and the protection of human rights at their core.
in co-operation with the independent sector, expand the use of supported living, domiciliary care, day care and assistive technologies as alternatives to residential accommodation, focusing on rehabilitation and independent living
develop a range of housing and care options for different levels of support, offering a continuum of care as people’s needs change
contribute to the development of a region-wide single assessment process, focused upon the person and designed to streamline and improve decision making about long-term health and social care needs and simplify access to services
expand the range of flexible and responsive respite and support services for carers increase the take up of Direct Payments engage actively with users and the voluntary and community sector in the design and delivery
of services.
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
Community / District Nursing services play a key role in supporting service users with long term conditions in their own homes and in the community, and support the movement of care from acute hospitals.
NICE guidelines Emergency and acute medical care in over 16s: service delivery and organisation (NG94) recommend that nurse-led support is provided in the community for people at increased risk of hospital admission or readmission. Condition-specific clinical knowledge, as well as knowledge of the individual patient, enables teams to provide personalised and effective care. It is also noted that community nurse-led care can be cost effective.
The NHS Long Term Plan sets out plans to care for increased numbers of patients in a community setting, outside of an acute hospital, to free up acute bed capacity and reduce pressure on acute services. Through additional £4.5 billion funding for primary care and community services, expanded community multidisciplinary teams aligned with Primary Care Networks will be funded. Community/District Nursing services will play a vital role in these teams, delivering integrated community based care.
Community / District Nursing
The NHS Long Term Plan also sets out plans for expanded Urgent Community Response and intermediate care teams, taking a multi-disciplinary team approach to providing short term support for older people to prevent an unnecessary hospital admission, or help support timely discharge from hospital following an episode of care. Nursing staff make up a notable proportion of the intermediate care workforce. Findings from the National Audit of Intermediate Care 2018 show that, across England, Wales and Northern Ireland, nurses make up 23% of home based teams, 39% of bed based teams and 33% of crisis response services. As part of their episode of care, typically 46% patients in home based intermediate care services will see a nurse. Within bed based services, 92% of services users will come in contact with a nurse.
Does your Community / District nursing service have links with acute services?
Does this service provide in-reach into the acute services?
Is this service managerially and
functionally integrated with acute services?
0% 60%
40%
20%
100%80%
26%
26%
74%
74%
11
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
High vacancy rates within the NHS workforce highlight increasing pressure on services. The Interim NHS People Plan highlights nursing as a particular area for concern, with addressing nursing workforce shortages being a priority. Community nursing is cited as one of the areas with the most significant shortages. The Queen’s Nursing Institute estimates that the number of District Nurses has decreased by almost 43% in England in the last ten years (Outstanding Models of District Nursing). A Retention Programme, launched by NHS Improvement with NHS Employers in June 2017, focused on nursing turnover, with a reduction in turnover rates reported nationally from 12.5% to 11.9%. Through the Programme, Trusts are supported in developing interventions that are known to have the biggest impact on improving retention, such as ensuring new staff are well supported, developing flexible working and providing career development opportunities. The Programme also encourages sharing of good practice between Trusts.
The NHS Interim People Plan also highlights routes into the profession as a possible barrier for nursing. Applications for nursing courses fell by 31% between 2016 and 2018, with education funding reforms cited as a contributing factor. Two national campaigns, ‘We are the NHS’ campaign and ‘Transforming Perceptions of Nursing and Midwifery’ have both been set up to publicise the professions and promote nursing in schools and communities.
Increases in capacity for undergraduate nursing qualifications aims to address this issue. An increase in placement capacity for those on undergraduate nursing courses is also promised. This includes community nursing, to provide a high quality learning experience within community settings, and increase understanding of the community nurse role amongst the profession.
Combined with high vacancy rates, the Royal College of Nursing (RCN) finds that community nurses have a higher age profile than the nursing workforce in general, with 38% of nurses in the community being over 50, compared to 24% of the general nursing workforce, which may cause further strain on services as nurses chose to retire (The Community Nursing Workforce in England).
Community / District Nursing teams are made up of a highly skilled workforce, delivering care to patients with a range of complex conditions. The RCN found that 86% of nurses agreed that patients are being discharged from hospitals more quickly than before, and 92% agreed that they are now caring for patients with more complex needs compared to a year ago.
NHS Improvement outline recommendations for safe, sustainable and productive staffing in Community / District Nursing services. Although there are not set quantitative guidelines for community nursing caseloads, NHS Improvement outline guidance in Safe, sustainable and productive staffing – An improvement resource for the district nursing service. Factors that should be considered when
12
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
reviewing caseloads include patient safety, geography and staff safety. Regular staffing reviews, monitoring of patient outcomes, monitoring staff experience and planning the multiprofessional workforce should all be considered to provide safe caseload management.
In a survey of district and community nurses, carried out by the RCN, many nursing staff reported noticing an increase in their caseloads, resulting in less time to spend with patients.
On average, respondents saw nine patients on their last shift (mean and median both 9) with 25% of respondents reporting that they saw 12 or more patients. Across all respondents, three quarters reported that they had left necessary activities undone. However, despite this, 19% said they had provided ‘excellent’ care to their patients on their last shift while 61% said they had provided ‘good’ care, 18% ‘fair’ care and 1% ‘poor’ care. The number of patients seen by a Community / District Nurse negatively correlated with the quality of care reported.
Expanded use of digital technology has been promised for community services within the NHS Long Term Plan, with increased access to mobile digital services, with an aim to increase patient facing time. However, 85% of community nurses cite poor connectivity in patient’s homes as a barrier to using digital technology. One third of community nurses highlight that using multiple systems can lead to duplication of data entry. The Queen’s Nursing Institute (Nursing in the Digital Age) recommends appropriate levels of funding need to be ringfenced to help improve digital technology access. They also advise that systems used should be specifically developed for staff who work in the community setting, to ensure they are fit for purpose.
The Outstanding Models of District Nursing Report (Queen’s Nursing Institute) sets out key recommendations for District Nursing services to fully meet the needs of patients, families and carer in the community:
District Nurses continue to gain a post qualifying District Nurse Specialist Practice Qualification (DNSPQ)
develop a strategy which will expand commissioners’, providers’ and the public’s understanding and knowledge of the District Nurse role
promote the population health element of the District Nurse role
develop a national standardised data collection system and data set within England
develop a national standardised approach to the assessment of quality support safe staffing and safe caseloads actively explore the co-location of District Nursing teams within Primary Care Networks.
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 2: National Policy Context
The Northern Ireland Department of Health launched a District Nursing framework in 2018, outlining an eight year plan to develop a world class district nursing services, available 24 hours a day, seven days a week. The framework aims to help deliver person centred care, where services are integrated and population based around GP Practice. This will be achieved through collective leadership, access to new technologies and a skilled workforce aligned to support new service models.
The Scottish Government Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: The district nursing role in integrated community nursing teams, highlights the importance of District Nurses in shifting the balance of care from acute hospitals to community services and primary care settings. The aim is for integrated community nursing teams to play a key role in planning, providing, managing, monitoring and reviewing care, building on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings.
Patient centred goals met (Community / District Nursing, 2019)
62%21%
16%
Fully met
Partially met
Not met
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - service model Community / District Nursing services provide nursing care to housebound patients in a particular
geographic area. Core Community / District Nursing functions include initial, holistic assessment of patient’s needs, referrals to social care, referrals for equipment, prescription of medication or referrals for medication, continence care, follow up care for patients recently discharged from hospital, long term care for chronically ill patients, end of life care, wound care and support for families and carers
all Community / District Nursing services included in the project deliver care in a service user’s own home. Most services (97%) also provide care in residential homes. 64% of services provide care in clinics and health centres and 53% in nursing homes
26% of Community / District Nursing services included in the project provide in-reach into acute services. 26% of services report being managerially and functionally integrated with acute services
the majority of services (91%) report being an adult service for those aged 18+. Some services report being available to those aged 16 or older
the chart on the next page highlights the range of functions that are delivered by Community / District Nursing Teams.
Key findings
What is the age group served by this service?
Adults - aged 18+
Children - aged 0-18
Children - aged 5-19
Children - aged 0-19
All ages - no restriction
Other
7.7%
91.0%
0%1.3%0% 0%
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Services provided
Support for self care
Advice and support managing long-term conditions
Urinary catheterisation and ongoing care
Bowel care
End of Life care
Wound care
Injections
Skincare
Continence management
0% 60%
40%
20%
100%80%
Yes No
Health education
Pressure ulcer care/ pressure area care
Pain control
Falls prevention and management
Phlebotomy
Equipment checks
Medication prescribing
PEG feeding
IV therapy
Verification of death
Nasogastric tube feeding
IV therapy, including chemotherapy
100%
100%
100%
100%
100%
100%
100%
99%
99%
99%
96%
96%
96%
94%
92%
91%
71%
69%
64%
44%
28% 72%
56%
36%
31%
29%
9%
8%
6%
4%
4%
4%
1%
1%
1%
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Access
Average waiting time (days)
0
15
10
5
25
20
30 Generally, Community / District Nursing teams are able to respond quickly upon receipt of referral, offering some of the shortest waiting times across all community services.
The mean average waiting time from referral to first appointment for Community / District Nursing services was 6 days. This is a decrease from the figure of 7 days reported in 2018.
DNA rate (%)
0%
3%
2%
1%
5%
4%
6%
Reducing the DNA rate across services can have a number of positive benefits including; reducing costs, improving service efficiency and increasing productivity.
The average DNA rate for Community / District Nursing services was 1.4%. Community/District Nursing services report some of the lowest DNA rates across services, which is likely to be a reflection of many
appointments taking place in a service user’s own home, and fewer clinic based appointments. Within the Good Practice Compendium, many services provided information on initiatives to help reduce their DNA rates. Examples include the introduction of a text reminder service and a flexible appointment booking option.
7%
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Access7 day services
The majority of Community / District Nursing teams operate 7 day services, with almost all services reporting some staff on shift during the weekend. However the NHS Long Term Plan does not specifically mention 7 day services within a community setting.
As expected, a higher number of staff are on shift during weekday daytime with, on average, 79 staff available during this time period. Although staff are available during the weekend daytime, staffing levels are just 46% of those during the week. Of all community service provision, Community / District Nursing Services have most evening and weekend provision.
Evening and night time staffing levels are similar during the week and at weekends.
Weekend staffing levels as a % of weekday staffing levels
46%
97%
98%
Community / District Nursing - ActivityReferrals received per
100,000 registered population
0
6,000
4,000
2,000
10,000
8,000
12,000
Demand for Community / District Nursing services is high, with on average 5,416 referrals received per 100,000 population in 2018/19.
Referrals to Community / District Nursing services are generally appropriate, with 95% of referrals accepted.
23% of services report that all referrals received are accepted, assessed and seen within 28 days of receipt of referral.
14,000
18,000
16,000
20,000
18
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - ActivityAverage time on caseload
(days)
0
150
100
50
250
200
300
The average time spent on a Community / District Nursing caseload was 123 days. This is the shortest time reported in the project to date, showing a faster turnover of service users.
Despite the Community Nursing Workforce in England report (Royal College of Nursing) highlighting that nurses feel they are providing care to more complex patients than previously, this suggests that services are under pressure to discharge service users from the caseload more quickly.
350
450
400
500
Caseload turnover in 2019 was 4.8, an increase on the 2018 figure of 3.7.
Unique service users per clinical WTE
0
150
100
50
250
200
300 The number of unique service users per clinical WTE gives an indication of caseload.
On average, 66 unique service users were seen per year per clinical WTE in establishment. This is a decrease on the 2018 position reported of 72 unique service users per clinical WTE.
350
19
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - ActivityFace to face contacts per
100,000 registered population
0
60,000
40,000
20,000
100,000
80,000
120,000
Community / District Nursing is the highest volume community service, delivering the highest number of contacts per 100,000 population across all community services.
The mean average number of face to face contacts was 58,962 per 100,000 population in 2019.
The mean number of non-face to face contacts delivered by Community / District Nursing services per 100,000 population was 4,489, with a median position of 2,367.
140,000
As community services have rapidly adapted to more virtual working, in response to Covid-19, the proportion of non face to face contacts may increase in future iterations of the project. The NHSBN project will continue to track the switch to more virtual working.
The average number of face to face contacts per clinical WTE in post was 1,656, the highest figure recorded in the project to date.
The number of face to face contacts reported in 2019 was 26% higher than the 2013 figure.
Service users typically receive 24 face to face contacts during their episode of care. This figure has also risen in recent years, suggesting a higher intensity of input for service users, despite reduced time on caseload. This may be representative of the complexity of patients on the caseload.
The average length of a contact is 31 minutes.
Face to face contacts
1,656 per clinical WTE in post
24 per service user
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - ActivityPatient facing time
8%
11%60%
8%
13%
Patient facing time Patient non-facing timeIndirect patient specific activity
Non patient specific activity Travel time
Patient facing time is an important measure of efficiency. The chart displays the nationally reported position for the proportion of time spend on patient facing time, patient non-facing time, indirect patient specific activity, non-patient specific activity and travel time.
Patient facing time accounts for 60% of clinical time. Travel time represents 13% of Community / District Nursing time. The Survey of District and Community Nurses (Royal College of Nursing) reports that some services deliver services across large geographical areas. The average furthest distance travelled was 13 miles. In rural areas, the furthest distance travelled was 17 miles.
Analysis of clinical time by service user condition
6%
8%
6%
3%
17%
Administration of medication Bladder management Bowel management
Ear care Eye care
For the Community / District Nursing service, analysis of clinical time by service user condition is provided.
Consistent with previous years, the greatest proportion of time is spent on wound management (37%). For the 2019 project, the category of ‘prevention treatment & management of pressure ulcers’ was combined with the ‘wound management’ category. 17% of clinical time was spent on administration of medication and 19% of time was spent on ‘other’ activities.
19%
37%
1%
2%
Long term conditions and holistic planning Palliative care
Tracheostomy care (<1%) Wound management Other
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Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Workforce
Clinical WTE in establishment per 100,000 registered population
0
20
40
60
Community / District Nursing staffing levels have increased slightly from 2018, with an average of 43 clinical WTE in establishment per 100,000 population reported in 2019. However, the value is still below that reported in 2013 (45 clinical WTE), suggesting a lack of investment in Community/District Nursing.
Community / District Nursing services typically have 3 non clinical staff members per 100,000 population.
80
Clinical staff skill mix
Almost half of the Community / District Nursing workforce is comprised band 5 staff. 17% of the clinical workforce is made up of band 6 staff and unregistered staff make up 27% of the workforce.
100
120
49%
6%
18%17%
Band 2 Band 3 Band 4 Band 5
Band 6 Band 7 Band 8a Band 8b / 8c / 8d / 9 (<1%)
7%
3%1%
22
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Workforce
HR KPIs (%)
0
14
4
16
Workforce metrics (staff turnover, vacancy rates and sickness rates) can give an indication of pressure that the workforce is under.
Vacancy rates showed an increase across all services in 2018. Although the 2019 vacancy rate position for Community / District Nursing appears to have improved slightly, vacancy rates and staff turnover rates still remain high.
The average vacancy rate for Community / District Nursing services in 2019 was 10%, with a staff turnover rate of 14%. Sickness rates have stayed consistent between years at 6%.
The Interim NHS People Plan outlines strategies to improve retention of nursing staff, noting particular shortages of nursing staff within community settings.
8
18
12
Vacancy rate (%) Sickness rate (%) Turnover rate (%)
20182017 2019
10
6
2
10%
6%
15%
13%
6%
17%
10%
6%
14%
23
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Finance
Bank spend as % of total budget
Agency spend as % of total budget
With high vacancy rates reported in many Community / District Nursing services, spend on bank and agency staff can make up a high proportion of the pay budget. On average, bank spend makes up 5.9% of the pay budget, with agency spend making up 4.7% of the pay budget.
0%
15%
10%
5%
25%
20%
0%
15%
10%
5%
25%
20%
Clinical staff pay budget per 100,000 registered population
£0
£0.5m
£1.0m
£1.5m
For Community / District Nursing services, total pay costs make up, on average, around 69% of the total cost of the service.
The mean average clinical staff pay budget per 100,000 population for Community / District Nursing is £1.56 million.
£2.0m
£2.5m
£3.0m
£3.5m
30%
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Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Budget vs Spend per 100,000 registered population
In the 2019 iteration of the project, spend, as well as budget, was collected for Community / District Nursing services.
This chart shows the mean average budget for Community / District Nursing services for 2018/19 (blue bar), against the actual spend for 2018/19 (orange bar).
£0.2m£0
£0.6m£0.4m
£1.2m£1.0m£0.8m
£1.4m
Clinical staff pay cost
Non-clinical staff pay cost
Non-pay cost
Indirect costs & overheads
Budget 2018/19 Spend 2018/19
Year/Cost
Budget 2018/19
Spend 2018/19
1.56m
1.5m
Clinical staff pay cost (£)
0.10m
0.10m
Non-clinical staff pay cost (£)
0.15m
0.16m
Non-pay cost (£)
0.54m
0.55m
Indirect costs and overheads (£)
Many services report an underspend, compared to budget, for clinical staff pay costs, which could suggest that some vacancies are left unfilled by bank or agency staff.
On average, budget and actual spend are reported at similar levels for non clinical staff pay costs, non pay costs and indirect costs & overheads.
Community / District Nursing - Finance
£1.6m£1.8m
25
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Quality and outcomes
Friends & Family Test results - average score
0%
20%
40%
60%
The Friends and Family Test score indicates the percentage of people who are ‘likely’ or ‘extremely likely’ to recommend the service to others. Since the Friends and Family Test was launched in 2013, millions of service users have submitted feedback across community, acute and mental health services.
Service users continue to be satisfied with the care received, with an average Friends and Family Test score of 97%, consistent with previous years.
80%
100%
Complaints per 100 WTE staff
0
10
20
30
In 2018/19, Community / District Nursing services received a mean average of 7 complaints per 100 WTE staff, with a median position of 3 complaints.
Services reported that, on average, 89% of complaints were responded to within the target time frame. The majority of services reported a target time in which to respond to complaints of 25-35 days.
40
50
60
26
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 3: Key Findings - Community / District Nursing
Community / District Nursing - Quality and outcomes
PREM / PCOM usage
58% 15% 87%
In 58% of Community / District Nursing services who responded, a Patient Reported Experience Measure was in use, to capture the patient or carer reported experience of service delivery. Only 15% of services utilise a Patient Centred Outcome Measure, to identify, measure and track what matters to the individual patient.
Services report that, on average, 87% of service users have patient centred goals set. Where goals are set, 62% of service users fully meet their goals, 21% partially meet their goals and 16% do not meet their goals.
58% of services use a Patient Reported Experience
Measure (PREM)
15% of services use a Patient Centred Outcome
Measure (PCOM)
87% of patients have patient centred goals set
27
Community Services benchmarking - Deep dive report for Community / District Nursing
Section 4: Time series analysis
Community / District Nursing Time series analysis
% change from 2013
The time series analysis illustrates that the clinical staff pay budget for Community / District Nursing services (a proxy for investment in the service) is now 1.1% below 2013 levels. This investment figure has not been adjusted for inflation, so has fallen in real terms.
Not surprisingly, given the falling investment in Community / District Nursing services, the overall workforce is 5.0% below 2013 levels.
And finally, as a measure of productivity with service users, face to face contacts were reported as 0.5% below 2013 levels.
Clinical staff cost per 100,000 population
Clinical WTE per 100,000 population
Face to face contacts per 100,000 population
20172015 201920162014 20182013-12%
-10%
-8%
-6%
-4%
-2%
0%
8%
6%
4%
2%
28
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Section 5: References
ReferencesDepartment of Health (Northern Ireland). A District Nursing Framework 2018-2026. February 2018Department of Health (Northern Ireland). A Healthier Future: a Twenty Year Vision for Health and Wellbeing in Northern Ireland 2005-2025. 2004The Health Foundation/Nuffield Trust. Community Services. What do we know about quality? November 2017National Institute for Health and Care Excellence. Emergency and acute medical care in over 16s: service delivery and organisation (NG94). March 2018NHS England. Next Steps on the NHS Five Year Forward View. March 2017NHS England. The NHS Long Term Plan. January 2019 NHS England. NHS Long Term Plan Implementation Framework. June 2019NHS Health Scotland. A Fairer Healthier Scotland. A strategic framework for action 2017–2022. 2017NHS Improvement. Interim NHS People Plan. June 2019NHS Improvement. Safe, sustainable and productive staffing in district nursing services. March 2017The Queen’s Nursing Institute. Outstanding Models of District Nursing. 2019The Queen’s Nursing Institute. Nursing in the Digital Age. 2018Royal College of Nursing. Community nursing workforce in England. May 2012Royal College of Nursing. Survey of district and community nurses in 2013. June 2014Scottish Government. Transforming nursing, midwifery and health professionals roles: district nursing. December 2017Welsh Government. A Healthier Wales: Our Plan for Health and Social Care. June 2018
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Appendix 1 29
Community Services benchmarking projectThe Community Services project is one of the NHS Benchmarking Network’s longest standing projects, being a key area for members to want to benchmark, given the lack of national data available in this area. Community services represent over £10 billion of NHS expenditure and they play a key role in supporting service users at home and reducing unnecessary hospital admissions. The Next Steps on the NHS Five Year Forward View highlights the importance of close working with community services, with an aim to free up capacity in 2,000-3,000 hospital beds over the next two years. Despite this policy intention, The Nuffield Trust reports that funding given to NHS Trusts for community services fell by 4% last year. An NHS priority over the next 10 years is to help older people stay healthy and live independently in their communities, with a move towards more integrated care for this cohort. Community services provision is expected to play an important part in the NHS Long Term Plan.
National data on community services is currently limited and the Network’s Community Services project aims to fill this information gap, taking a view across all aspects of service provision including access, activity, workforce, finance and quality metrics. The project provides a detailed view of 25
different community services, and there is a series of case study reports for every single service benchmarked.
Appendix 1
Cardiac Community Team
Wheelchairs
Speech & Language Therapy (Child)
Speech & Language Therapy (Adult)
School Nursing
Respiratory Community Team
Podiatry
Physiotherapy (Child)
Physiotherapy (Adult)
Occupational Therapy (Child)
Occupational Therapy (Adult)
MSK
Integrated Sexual Health Service
Health Visiting
End of Life Community Team
Continence Community Team
Dietetics (Child)
Dietetics (Adult)
Diabetes Community Team (Adult)
Community Paediatrics
Community Matrons
Community Integrated Care Teams
Community Dental
Community / District Nursing
Children’s Community Nursing Team
Community Services benchmarking - Deep dive report for Community / District Nursing
Appendix 130
The Community Services benchmarking project runs on an annual cycle; project scoping taking place with the Community Reference Group from January through to April; data collection from May through to June; data analysis and validation in September and October, with the national event and other outputs being made available in November and December. There may be some changes to the community services where data is collected between the years the project has been operating.
The Community Services benchmarking project collects provider level data on access, activity, workforce, finance and quality and outcomes at aggregated organisational level for the whole year. Some organisations may chose to make multiple submissions, often where service models differ between different geographic areas or their service covers multiple CCG areas. The metrics are agreed with the Network’s Community Reference Group and definitions are provided for every metric to ensure consistency of interpretation of metrics. The Network provides a Helpline to help with interpretation and give advice on data collection. Metrics are reviewed at the end of each cycle, with a view to refining data collection, and ensure that metrics and definitions utilised are relevant and up-to-date. Metrics with a poor response rate tend to be discarded for the next year’s benchmarking. Within the membership, participants take part in the Community Services benchmarking project from all four UK countries. The project provides the most comprehensive dataset available in the NHS on Community Services.
Data is collected via an online data collection tool, input via the online data collection pages in the Network website members’ area. The project collects data for subsequent NHS financial years, running from 1st April to 31st March, so the 2019 iteration of the Community Services project collected data from 1st April 2018 to 31st March 2019. As the project has run for many iterations, time series analysis is available, through toggling between the years on the online toolkit.
During the data validation phase, all submissions are reviewed and participants are given the opportunity to amend or update their data where any outlier positions are identified. These are checked following the production of a draft online benchmarking toolkit, which shows the draft benchmarked findings for the whole sample against every metric collected. All outputs are anonymised, and provider organisations can see their own position(s) only.
Jan DecNovOctSepAugJulJunMayAprMarFeb
Project scoping Data collection ValidationValidation
& Draft toolkit
EventOther
outputs published
Community Services benchmarking - Deep dive report for Community / District Nursing
Appendix 1 31
Next cycle
Project outputs
Networking and sharing good practice
The Community Services project will feature in the Network’s 2020/21 work programme, collecting 2019/20 outturn data. In response to member requests, the data specifications have been cut down and the number of community services being benchmarked in this year’s cycle has been cut down, to enable members to have the capacity to complete the benchmarking, following the coronavirus pandemic.
NEW Community Services Covid-19 trackerThe Network is also offering a NEW Community Services Covid-19 tracker dashboard project which reports on a monthly basis on a limited set of metrics to track the impact of the pandemic upon community services provision.
Every participant in the Community Services benchmarking project receives a suite of outputs. All of the outputs from the Community Services project are available via the members’ area of the NHS Benchmarking Network’s website. Log-in details are required to access the member’s area. To request new, or to be sent a reminder of existing log-in details, please email [email protected].
Once logged-in to the members’ area, each of the Network’s projects is listed on the home page. The following outputs can be accessed: Online toolkit Project reports Good Practice Compendium Presentations from the Network’s 2019 Community Services national conference
In addition to the project outputs, organisations who participated in the project are still able to view their data submission via the online data collection pages in a read-only format. Please contact Lucy Atherton if you need any assistance accessing the project outputs.
The Network is keen to facilitate networking and sharing good practice examples between project participants. If your organisation is interested in contacting other project participations, please email Lucy Atherton and, providing consent is granted, the relevant project lead contact details can be passed on. Please note, although some organisations choose to share their organisation’s identifier codes between each other, the Network keeps all data supplied to the benchmarking projects anonymous. The Network will never pass on identifier codes to colleagues outside your organisation.
