A response to L. Kemp, E. Harris & E. Comino Changes in community nursing in Australia: 1995–2000. Journal of Advanced Nursing49(3), 307–314.

Abstract

In the United Kingdom (UK), as in Australia, there has been increasing emphasis on primary care-led health service and this presents huge challenges in terms of the redesign and delivery of community nursing services. Kemp et al. provide data which reflect Australian community nurses’ perceptions of changes in their workload and the nature of the work they undertake, but so far without the evidence to support this. There are many similarities between the systems of nursing care provision in the UK and Australia. First, the need for nursing care at home is increasing with population ageing – albeit less rapdily as yet in Australia compared with the UK – and so more and more patients with serious, chronic or terminal illnesses are being discharged from hospital earlier to be nursed at home. Second, there is increasing emphasis on a public health model of primary care, focusing on health promotion and prevention of illness, injury and disability – the essence of public health. However, there also are some notable differences between the provision of community nursing services in the UK and Australia, and this commentary concentrates on one of these. One of the main differences is the emphasis in the UK on collaboration between health and social care, which is seen to be essential in tackling inequalities in health, promoting social inclusion and improving people's lifestyles and circumstances [Department of Health (DoH) 1999, Scottish Office 1999]. Although Kemp et al. discuss the increasing collaboration between acute and primary care sectors in Australia, there is no mention of similar emphasis on cooperation with social service agencies; however, in the UK, this is increasingly regarded as the key to ensuring seamless provision of community care for people with complex needs. These people have needs that cross-traditional agency and professional boundaries (Hudson 1999, DoH 2001, Scottish Executive 2002), and the benefits of ‘joined up’ working are evident in better outcomes for service users and their carers, and better use of resources (Scottish Executive 2002). However, even in the UK there has been a history of a lack of concordance between health and social care organizations, especially between general practitioners and Social Services departments. The fundamental difference between health care under the National Health Service (NHS) that is ‘free at the point of delivery’ and means-tested Social Services provision underpins many of the ideological differences between the two sectors. The difficulties have been long recognized, with various attempts to break down the so-called ‘Berlin Wall’ between health and social care services. The challenge is to translate the visionary language of ‘co-operation’ into reality at strategic, organizational and practice levels. One of the tangible ways that this collaborative working has been promoted at a practice level in the UK is through the introduction in England and Wales of the Single Assessment Process (SAP) for older people (DoH 2001) and Single Shared Assessment in Scotland (Scottish Executive 2002). Thus, a common assessment tool is used by all community care staff whatever their professional background and, with the explicit consent of client or patient, the assessment information is shared across agencies. The aim is to reduce the duplication of questions asked by different professional groups and agencies, and to ease access to community services. The principles are sound but, in practice, significant difficulties need to be addressed if single assessment is to be wholly successful. Worth (1998), in her study of first assessment visits by district nurses and social workers, found a lack of confidence among health and social care practitioners in each others’ standards of assessment. Dickinson and Windle (2003), in their evaluation of a pilot site for the introduction of SAP, found that practitioners were uncertain about asking questions that they perceived lay beyond their professional knowledge. They felt that the SAP meant extending or changing their professional roles, and they often felt ill-prepared for this. As a result of these changes in practice, and alongside the wider re-shaping and re-organizing of the NHS, there have been corresponding changes in the nature of district nurses’ caseload. In the UK, these are broadly similar to the changes outlined by Kemp et al. in Australia, with shorter periods of intervention and a greater focus on more intensive forms of treatment, but without any corresponding increase in staffing numbers. Many community nurses consider that the unique and rewarding aspects of their role – which focus on building relationships (Kennedy 2004) – are being lost because of the constant policy drive to improve productivity, increase efficiency and measure outcomes (Scott 2004). As in Australia, the driver for change in the UK has come largely from high-level policy iniatives, and this has left many nurses feeling a sense of loss of control over their practice and of frustration about constantly responding reactively to situations rather than proactively developing the community nursing service as Kemp et al. describe. Similarly, district nursing in the UK has often lacked clinical and political leadership, both at local and national levels (CPHVA 2003), and this threatens to create a demoralized and demotivated workforce (Low & Hesketh 2002). As Kemp et al. argue, community nurses themselves need to take a stronger lead in developing future community nursing services. It would be interersting to know how Australian community nurses are being prepared to take on this challenging role when, as described in the paper, they are already feeling overwhelmed by day-to-day service demands. The Kemp et al. paper succinctly describes some of the unprecedented demands that community nursing is facing in Australia and to a certain extent the situation they describe is mirrored in the UK. It is clear that, in both countries, strong nursing leadership is vital in dealing with current and future challenges. Many of the changes outlined could provide greater opportunities for community nurses in the UK and Australia to develop more flexible and innovative approaches to the delivery of patient care, and there is also the potential to enhance clinical skills. On the other hand, there are concerns about the shift of responsibilities from acute to primary care sectors, and the increasing demands on primary care services as more patients with complex needs are cared for at home. The community nursing profession in both countries needs strong leadership to ensure that its core skills are recognized and the expertise of community nurses is utilized effectively.