1.  SUMMARY

  1.1  Changes in medicine and technology are taking healthcare provision out of the hospital building and into the community resulting in community and district nurses taking on far more work and responsibility. And yet the NHS has reached crisis point in the recruitment and retention of nurses. Poor working conditions, status and pay do not attract new recruits not help to keep staff.

  1.2  The CDNA welcomes the initiatives outlined in The New NHS which seek to improve conditions for nurses and enhance their status. We are concerned, however, that these plans do not go far enough and that, without increasing the overall number of nurses, they will result in more work for already overworked nurses. The CDNA believes that improved conditions and increased status are not enough; pay must also be improved.

2.  INTRODUCTION

  2.1  The Community and District Nursing Association (CDNA) is pleased to offer the following evidence to the Health Select Committee inquiry into the Future NHS Staffing Requirements.

  2.2  The CDNA is a Professional Body and Trade Union with members working primary and community care. Our membership includes: district nurses and their teams; practice nurses; those working in nursing homes; school nurses; health visitors; indeed, any nurses working in the community environment. Ninety nine per cent of our members are women with an average age of forty five. Our evidence is illustrated with our members' own experiences.

  2.3  Community nurses work alongside GP's, social workers, Trust management and Professions Allied to Medicine.

 3.   FUTURE STAFFING REQUIREMENTS OF NHS

  3.1  Changes in science and medicine and the potential of modern information and communication systems mean that healthcare is moving out of the hospital building and into the community. People with short or long term disabilities and very complex healthcare needs are now cared for in their own home. We see a much greater role for our members in the future provision of healthcare; this we welcome.

  3.2  Community nurses are now able to provide many of the treatments which previously required hospital visits, such as blood transfusions and chemotherapy. Furthermore nurses are now able to prescribe drugs for patients. However there is an inequity of provision and such initiatives should be extended nationally as soon as possible. Community nurses are best placed to assess the quality of care and requirements of patients as they visit and care for the patient regularly; sometimes on a daily basis.

  3.3  The CDNA looks forward to the publication of the Audit Commission Survey into District Nursing in early 1999 which will hopefully reveal the true potential of district nursing.

  3.4  Over the next decade the NHS expects to provide services for an extra 100,000 people aged 85 and over. The CDNA believes that elderly people are best cared for in the community. Once admitted to hospital older people can develop unnecessary complications (eg incontinence) which increase their hospital stay and make their return home more difficult. There is also a significant reduction in the percentage of 18 to 25 year olds which produces nurses, hence reducing the potential for recruitment.

  3.5  Community nurses are well placed to take account of the special health needs of their locality and it is only right that they will now be able to have an input into healthcare planning through their involvement in Primary Care Groups.

  3.6  Taking on a leadership role, monitoring and educating nurses and other staff, managing care and commissioning health services. Community and District nurses are becoming an ever more valuable asset to the NHS. Their responsibilities and commitments are increasing. The need for more nurses is therefore evident with the development of consultant nurses taking on a new role.

  3.7  The UKCC statistical analysis of the register for the year 1 April 1997 to 31 March 1998, published in July 1998 states that 27,173 practitioners did not renew their registration in 1997-98. Furthermore for the eighth year running the percentage of practitioners under 30 has fallen; over the last three years the percentage of practitioners between 30 and 39 has also fallen with the largest percentage increase within the 40 to 49 age group.

 4.  RECRUITMENT

  4.1  The nursing profession is currently in the midst of a serious recruitment crisis. A significant number of qualified District Nurses and Health Visitors will reach retirement age in the next 10 years and yet 38,000 student nurse places remain unfilled. CDNA believes that the Government's announcement in March to commit £2.15 million on an ongoing national advertising campaign to recruit nurses is a step in the right direction. However, the CDNA argues that recruitment of nurses is dependent on working conditions, status and pay. At the moment working conditions, status and pay are all perceived as being poor.

  4.2  Nurses are perceived as overworked, undervalued and working in difficult conditions.

  4.3  CDNA welcomes initiatives such as PCGs and the recent "supernurse" initiative and believes that they will help recruit new nurses. We do not, however, believe that such measures will be sufficient to fulfill the government's targets; or to prevent the shortage of staff impacting badly on our members in terms of extra work.

  4.4  The low starting pay is off-putting to many potential nurses. They often find the starting salaries for other jobs more attractive.

  4.5  The CDNA believes that more effort should be put into encouraging nurses who have taken time out to return to nursing. Flexible, family friendly policies and childcare facilities would help encourage mothers back to work.

  4.6  We need to urgently consider why 27,173 practitioners did not re-register in 1997-98. Where are they? The qualified nurses are out there but they need to be encouraged back into the NHS.

  4.7  Increased responsibility will help increase the status of community and district nurses and so increase more people into the profession. However, the NHS will not attract people of sufficient quality and skill if it does not pay a fair and equitable amount for work of great value.

 5.  RETENTION

  5.1  The most recently published figures by the Institute of Employment Studies (1997) and the UKCC show that the number of nurses employed as district nurses has fallen every year over the last three years indicating that District Nurses are leaving the NHS. The CDNA believes that, as with recruitment, the factors causing nurses to leave are conditions, status and pay.

  5.2  Resources—The shift in care out of hospitals and into the community is not being matched by a shift of resources. There are increasing pressures on staff to provide increasingly complex care with the same/or reduced resources. It is worth remembering that within the community ward space is not limited; community nurses work in wards without walls.

  5.3  Overwork—Often CDNA supports individual members who have received disciplinary warnings for not completing paperwork thoroughly enough. Our members tell us that they were unable to do the paperwork more thoroughly due to overwork. In such instances our members find management unsympathetic. Our members compare their situation with that of doctors, who they perceive as doing as they please with nobody checking on their quality or competence (as evidenced by the recent Bristol incident).

  5.4  Bullying—The CDNA is not happy with the way in which possibly legitimate management concerns about performance are dealt with. Ministers talk about performance management, staff development and valuing staff contribution; NHS Trust publications announce that staff are their most valued asset; and yet minor issues are dealt with by heavy-handed management that is not conducive to the development of nursing practice and the enhanced role of nursing in the new NHS. The following examples illustrate our members' experiences:

—  A community nurse, under increasing pressure for months, cuts corners whilst delivering excellent patient care; is disciplined and now off sick with depression—a loss to the NHS.

—  A district nurse, abused and trapped by patient; no action taken by management, except to send in another district nurse, no police.

—  Senior clinical nurse, work problem during pregnancy, off sick then Maternity Leave. Management insisting on disciplinary action on her return in spite of her having already giving an adequate response; now they are unwilling to co-operate with her return to part-time work.

—  District nurse, receives a complaint; management response is to bully and intimidate her without following agreed procedures. Proper investigation finds no substance to complaint.

  5.5  We are aware that when our staff are unfairly criticised in this way they are tempted to seek redundancy or early retirement on the grounds of ill health. The CDNA endorses the findings of the Nuffield Report Improving the Health of the NHS Workforce which lists damning statistics about the mental and physical health of NHS employees linking to, among other things, workload pressures and management style.

  5.6  Family Friendly Policies—Our members are predominantly women with families. Consequently our members would be more likely to remain in their jobs if they were offered flexible, family-friendly hours and childcare facilities.

  5.7  Best Practice—The CDNA welcomes the human resource priorities outlined in The New NHS including measures to promote health at work through strategies to minimise accidents, avoid violence, and address stress; to recognise and deal with racism. The CDNA is aware of Trusts already implementing excellent working conditions and would like to see these extended. The South Downs Health NHS Trust Personnel Department has been brought to our attention as interpreting policies in an innovative manner. Childcare is available (although there is a problem in this area for bank staff). And staff have access to free eye checks, chiropody, dental treatment, accelerated hospital appointments. There is also a £250 fund for work environment improvements (eg microwaves, clock, picture etc) and free swimming and local discount cards. Furthermore, Personal Development Programmes are well monitored and a harassment policy staff handbook has been worked out by staff and management. With such innovative policies in place South Downs Health NHS Trust has no recruitment problems in District Nursing. The Government's recent announcement regarding Nye Bevan awards which will help to promote areas of good practice is a step in the right direction.

  5.8  Our members are highly skilled healthcare professionals. Community Nurses are senior clinicians who have completed basic nurse registration and often have many years experience in hospital work as ward sisters and managers. Preparation for practice as a District Nurse entails a BSc degree course in Community Specialist Nursing taken at a College of Higher Education. In our view nurses are not used to their full knowledge level/potential; however we believe that this is changing. There continues to be a major status differential between medicine and nursing/doctors and nurses. Nursing continues to have a major image problem—although it is hoped that this will be somewhat alleviated by the "Super Nurse" initiative. The CDNA hope that it will become widely recognised that nurses are able to handle more responsibilities—without the desire to become GPs. CDNA believe that their members would like to continue with their training. We are concerned that some nurses face obstacles in gaining funding and time for study. Our members are often mothers with children and study outside work proves difficult. Innovative ways must be found to help staff to continue with development.

  5.9  Differentials of c.£6K between nursing and comparable professions are too large to retain staff. A former CDNA member recently left nursing to work in Waitrose to get paid more. Furthermore, many of our members have children in their teens and early 20's who are earning more at the very beginning of their careers.

6.  IMPLICATIONS OF RECENT NHS SPENDING ANNOUNCEMENTS

  6.1  Whilst welcoming the CSR announcements of extra money for the NHS we are anxious that not all this money should go into hospitals but also into community nursing.

  6.2  The CDNA is concerned that the recent announcements on public sector pay mean that increased pay for nurses is unlikely. We believe that failure to increase nurses pay is very short sighted. As we have outlined above, district nursing saves NHS money in the long run by reducing hospital admissions and complications resulting from admissions.

 7.  TAKING STEPS TO DEAL WITH FORECAST SHORTAGES

  7.1  Pay is the root problem when trying to attract individuals into nursing; however, prospective candidates often take an holistic view. If local conditions are good they may be more likely to apply for a job.

  7.2  Recent figures state that the cost of taking staff from nursing agencies to work in NHS Hospitals and health clinics across Britain was £191.5 million last year. Reallocating funds into nurses pay would help alleviate this problem.

8.  CONCLUSIONS

  8.1  Healthcare provision is changing; moving out of the hospital and into the community. Funding must follow. Money should no longer be poured into the bottomless pit of draughty, expensive old buildings. Instead it should provide sufficient staffing with back up resources in the community.

  8.2  Whilst welcoming the extra work and responsibility for community nurses CDNA believes it is essential that there are sufficient community nurses there to do the work. We are concerned that whilst workload and responsibility are increasing the number of new recruits is actually dropping. Workload increasing due to shortage of nurses and low pay are causing a crisis in morale amongst our members.

  8.3  Retention and employment are dependent upon improved conditions, status and pay.