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Community matrons and district nurses visiting patients in their homes should be an ideal antidote to the NHS crisis. They can help people avoid becoming trapped in overcrowded hospitals by spotting and treating illnesses at early stages. When patients come out of hospital, they can monitor them and offer reassurance, while making certain they receive the social care they need, so they aren’t quickly calling 999 again.
By easing “bed blocking”, they should relieve the demands on paramedics and A&E doctors. The problem is short staffing – the same issue affecting so many parts of the NHS. There simply aren’t enough people doing these jobs, nurses argue.
Under pressure from increasing demands on their services, nursing staff in teams low on numbers get asked to carry out procedures they may not be “competent” to do, one community matron with 25 years of experience in the NHS tells i. They are duty-bound to say no – but with nobody else available, that means patients can go days, weeks or even months without the treatments they need.
“They’ve been overloaded,” says Esther, whose name we have changed to protect her identity and that of her patients. “They end up seeing people they’re not competent to see. They’re scared of making errors.”
She adds: “Nurses come to me to say: they want me to do this, I can’t do this. They want me to do that, I can’t do that. I say: don’t do it. If you’re not competent to do it, if you make any errors, your pin [a nurse’s professional registration] is at stake.”
She is confident her colleagues reject tasks they are unsuitable for, because “there’s a lot of education going around about this, and I keep referring to their nursing code”, and she says managers are understanding.
But what happens when there is nobody else to carry out a procedure instead? Inevitably appointments are postponed, says Esther. “Some of our patients that we needed to have seen, we haven’t seen. The next call I get is, ‘Mr so and so is in hospital,’ which is something I could have avoided.”
One of the worst cases she can think of involved a man who needed his urinary catheter to be changed. This should be done at least every three months – but he ended up waiting six months because nobody with the necessary training was available, says Esther, raising the risk of him developing an infection and even sepsis.
Other potential examples she cites include staff being unable to use a syringe driver – a small, battery-powered pump that gives a patient medication constantly – or inserting the tube of a PICC line into a vein to provide someone with drugs or fluids.
Although they are never placed under duress, exhausted and demoralised staff sometimes feel they shouldn’t say no to jobs, claims Esther. “If you’re not competent to do something, you need to say it out loud. But to some people, it feels like you’re refusing.”
But continually being allocated to patients they can’t help can add to mounting stress levels, and staff may feel their caseload is too heavy for them to take time out for further training.
Esther is “fed up” with this facing this situation. “Nurses are breaking. People are going on long-term sick leave due to stress. They are frustrated, angry, disgruntled.”
Her account correlates with warnings from other nursing staff who worry they are being forced to care for an unsafe number of patients. “If we are doing it in the right way, one person can see only three to four or five patients,” community nurse Gurpreet Kaur told i last week, “but unfortunately we are seeing 14 to 15 patients a day.”
Lisa Elliott, a deputy director at the Royal College of Nursing, the leading union for the profession, says Esther’s concerns are “extremely worrying”.
“This account goes right to the heart of what nursing has been warning Government about for years,” says Elliott. “This is the reality of short staffing. It puts both patients and nursing staff at risk.”
She says the RCN’s national standards, published in 2021, “were created to explicitly set out what must happen within workplaces to ensure services are safe, but they’ll never be safe if there aren’t enough nursing staff to care for patients.”
The Government encourages any NHS staff who feel they are being asked to act beyond their competency to raise this with their employer or regulator.
Esther says heavy workloads can also result in the reverse situation: they end up covering gaps in social care when they should be focusing on people’s health. “They’re not allowed to do what they are supposed to do, what they know how to do. They’ve been pushed here and there, pillar to post.”
It isn’t meant to be like this.
‘The Government needs to buckle up’
Community nursing has been an important part of British healthcare since the Victorian era, with the first district nurse appointed in 1859. Today there are 86,000 community nurses in England, some covering general health issues, some specialising in fields such as frailty, neurology, children, mental health and palliative care.
The NHS calls them an “integral part” of its workforce, providing “invaluable care to people in their own homes, care homes, or close to where they live, in clinics and GP practices across every village, town and city in the country”.
Esther has been working in nursing for several decades now, serving in the UK for 25 years after being recruited from abroad. Seven years ago she became a community matron, a role created for the NHS in 2001.
Matrons share many duties with nurses but have added prescribing powers, plus a focus on avoiding unnecessary hospital admissions by caring for people at home. Although they do not manage staff and have separate caseloads of patients – hence Esther calling herself “a lone ranger within a team” – they provide authority and leadership as role models, offering advice while ensuring standards are upheld.
“I bridge the gap between the GPs and the patient, in case the GPs are not able to visit them,” says Esther. “We’re there to manage their long-term conditions like heart problems, breathing difficulties and diabetes.” GPs, hospital medics and ambulance staff can all refer patients to her.
“I can provide them with a rescue pack with antibiotics and steroids to make sure they’re stable. They can have them at home while being monitored there on a daily basis, rather than being in hospital.”
“Most of our patients are older people,” she says. With them, a crucial part of her job goes beyond the monitoring, the diagnosing, the prescribing. It’s about the caring part of healthcare, especially for patients who often find it hard to get their inundated GP’s receptionist on the phone, let alone the doctor themselves.
“When I go to see a patient for an initial assessment, I will get to know them totally. I’ll give them my number, they can call me anytime,” says Esther.
“The moment they get to know you, they feel comfortable relating to you. They can see their case is being attended to. They feel happy and they trust you. They tell you a lot of stuff that you can work with – mentally, physically, socially as well. We can refer them to care services if they need a package – anything that will keep them away from the hospital, we’ll do that.”
She adds: “Patients are very grateful for my input. That’s the only joy I take home, when I look at everything happening right now. All I rely on is when I visit a patient and they say to me: ‘Thank you so much for your help, you’ve been wonderful’. A patient told me last week: ‘You’re the only person I’ve been seeing in the last year.’”
Some patients offer her gifts to show their appreciation. “That is how much they appreciate you. Even with the strike action, some of them keep telling me: ‘We appreciate you guys are doing a lot, the Government needs to buckle up and look after you nurses.’ This is from somebody who has missed a few visits from community nurses and is still very grateful for everything we are doing for them.
“I keep telling my colleagues: when you get a ‘thank you’ from your patient, it goes a long way. Do not expect it from any manager.”
Growing demand but falling numbers
The problems experienced by Esther and her colleagues are probably best explained by national staffing figures.
In 2003, there were 12,620 district nurses in England. By 2013, the number had dropped to 6,656. In 2019, it was down to just 4,000 according to the Royal College of Nursing and the Queen’s Nursing Institute – a reduction of two thirds in 16 years.
That left only one district nurse for every 14,000 people, compared to one GP for every 1,600 people, despite government recognising the importance of providing more treatment in people’s homes.
The number has since increased only marginally, to the equivalent of 4,409 full-time posts in the latest figures from March last year.
Miriam Deakin, director of policy at NHS Providers, tells i the long-term decline has been “exacerbated by the pandemic and the cost-of-living crisis” and is “deeply troubling”.
There are 47,000 NHS nursing vacancies right now, equivalent to 12 per cent of the workforce, but there is no breakdown available of how many unfilled roles are community jobs.
“Boosting the number of community nurses is challenging in part because overseas recruitment to the sector is limited and roles in the sector can be less visible to graduates,” says Deakin.
This is despite their importance in innovations such as virtual wards, where patients are monitored at home to free up hospital beds, and urgent community response teams, which aim to further ease pressure on the system by providing prescriptions, therapy and help with food and drink to elderly people at home within two hours.
Matthew Taylor, chief executive of the NHS Confederation, says: “Community providers are working incredibly hard to ensure there are sufficient community nurses, and the right skills mix within teams, to deliver safe and effective care in the community.
“But there’s no question they’re facing significant staff shortages at a time of increased demand for community services and higher acuity in the care needs of patients. This means community nurses are seeing increased caseloads and risk being over-burdened, contributing to existing issues with staff morale and retention.”
Asked about concerns over vacancies, a Department of Health and Care spokesperson says: “District nurses play a hugely important role in communities and patients value the care they provide. We are committed to developing this vital workforce having increased funding for training year-on-year since 2017.
“There are record numbers of staff working in NHS with over 10,500 more nurses working in the NHS compared to October 2021 and we are on track to deliver 50,000 more nurses by 2024. This year we will also publish a comprehensive workforce strategy to help recruit and retain more nurses and make the NHS the best place to work.”
Taylor says this long-term plan “must include a central focus on developing the pipeline of community nurses.”
Wes Streeting, Labour’s Shadow Health Secretary, told i: “The future of healthcare needs to be focused in the community, with more people cared for in the comfort of their own home. The Conservatives have failed to grasp this.
“Cuts to community care causes more patients to end up in hospital and more still are stuck there after their treatment, which is worse for patients and more expensive for the taxpayer.
“Labour will double the number of district nurses qualifying every year, paid for by abolishing the non-dom tax status. We want new entrants to the profession to see community nursing as the place to be for a rewarding career.”
‘I cry inside’
In her time working as a community matron, Esther has seen a “rapid drop” in standards, staffing and the viability of the system. The situation is “tearing me apart”, she says.
Her team currently numbers around 20, including healthcare assistants and staff “borrowed” from other teams to cover five vacancies after colleagues moved to other trusts, she explains.
“They put a vacancy out there, but people are not applying,” she says. “They need to start looking at the root causes… It’s because the workload is getting too much and they’re not able to provide good care for their patients.
“In the middle of all this, you have sick absences, you have annual leave, and you’re left with nothing. In the last two weeks, I’ve been helping district nurses with their caseload – and my patients are still there but I can’t see them.
“Because they’re long-term patients and they know me, I try to call them to explain to them. They’re very understanding, because we need to see diabetes patients – who are very high priority, they need to have their insulin injections – and there are patients on palliative care.”
“I came in today and I’ve been given a lady for insulin, I’ve got a lady for another injection, and I’ve got another one for dressings. I told them: you didn’t even ask me whether I’ve got my own patients, I’ve still got two of them and I’ve got meetings as well.”
The cost-of-living crisis is worsening staff retention and recruitment troubles. Increased fuel costs have had a particular impact on community medics who travel throughout the day for their roles, says Esther – especially when they’re being asked to see more patients, meaning greater distances being covered.
An NHS survey last summer found that some staff were paying an extra £200 a month to visit patients. “We’re subsidising the NHS,” says Esther. “When we travel to see our patients in their house, we buy our own petrol, we maintain our own car.”
Following a small increase this month, NHS staff in England can now claim taxable expenses of 59p per mile driven for work for up to 3,500 miles per year and 24p per mile beyond that – compared to basic rates of 60p in Scotland and 50p in Wales.
But Esther points out: “We don’t get this money until the following month. Some people cannot afford this… Without our cars, there’s no way we can achieve all these visits.”
On top of all the stress from her job, Esther is still dealing with the effects of long Covid, which she believes she caught from a patient who later died.
“I had it in April 2020 the first time around. It was really bad,” she says. “This patient was admitted to hospital with Covid, and I thought, oh my goodness, I hope I haven’t caught anything from this man. At that time, there was no PPE. All I had on was my apron and gloves and I was there for about an hour.
“I started phoning around the other patients that I had visited within a week or two to make sure they hadn’t got it. Thankfully, nobody else got it, which means I probably got it from that patient or his wife.”
“I refused to go into the hospital, GPs were monitoring me on the phone because my oxygen was desaturating, but I got a fear from seeing my colleagues dropping on the telly. That scared me. I was always crying.
“The patient I thought I had it from, his wife called me three weeks into me having it, to say her husband had died… I felt really low because that person died when he wasn’t supposed to.”
She adds: “When I went back, I started feeling fatigue and other problems. I didn’t realise what was going on. I was tired. My bones, my body just would drop…
“Throughout that year, I worked, went back, worked, went back, I kept pushing myself – and then I was on long-term sick leave for almost two months. I started working from home.”
She was vaccinated twice but caught Covid again before her booster jab. “I was very, very down. Mentally, I was really affected. I thought: what is going on? I can’t do this anymore. I was frustrated, I was mentally low.”
Thankfully, her health improved, and with it her mood. She feels much better now, though is still unable to perform certain physical tasks she would normally do in her job.
“Hey ho, I’m all right, I’m here, I’m still alive, which is a joy,” she says. “Some of our patients knew I had long Covid and were ringing and texting me to say: ‘We’re just checking up on you, we’re not asking you to come and see us, we just want to make sure you’re right.’ That made me feel good, that my patients missed me.”
“I don’t want to sit at home, I want to be out there. Any time I’m in my patients’ houses, I feel different. We have a laugh together, we talk together. I manage them and I feel there’s a result. I feel the joy.”
The experience of becoming ill from her job, however, makes her feel all the more frustrated by a below-inflation pay increase of 4.5 per cent from the Government. This has seen the average basic pay for nurses rise to around £37,000, or just over £27,000 for those who are newly qualified.
Lisa Elliott of the RCN says short staffing “has been caused by years of under investment in our pay and in the NHS, with nurses now earning 20 per cent less in real terms than in 2010.” She adds: “It is the Government’s responsibility, after a decade of cutting nurses’ pay, to fix the record NHS nursing vacancies across the NHS. This should start with fair pay.”
The union has been calling for a rise of 5 per cent above inflation – amounting to more than 19 per cent.
The Government says that increasing pay by that rate for nurses and all other NHS staff on the same contract would cost more than £9bn extra, more than 6 per cent of the total NHS budget of £152.6bn.
There have been reports recently that nursing leaders would accept a 10 per cent deal. But together with other health unions, the RCN also argues “the lengthy pay review body process is currently not fit for purpose” and is calling for it to be made more independent.
After four days of strikes so far this winter, nurses at 73 trusts in England as well as 12 health boards and organisations in Wales are planning to walk out again on 6 and 7 February. Industrial action remains paused in Scotland pending further negotiations, while no action is scheduled in Northern Ireland.
Esther hopes her patients will not suffer, but campaigned and voted for strike action with the RCN and has taken part in picketing. For her, this union defiance is not just about pay but about conditions in her local service being driven into the ground.
“When I come to work and I see everything so shattered, so messy, I cry inside,” she says. “I go into our office with the district nursing team and I just say: what is going on?”