Do the Dutch have the answer to Britain’s district nursing crisis?

In October 2019 the district nursing teams in Dundee were hit by a staffing crisis. While staffing crises are not uncommon in district nursing, the situation in Dundee was unusual because the local press found out about it. One nurse, speaking anonymously to the local newspaper, The Courier, explained what was happening: “There are not enough staff to cover everything we need to do. People come back from holiday for one day and are ready to walk out because of what they face. There are a lot of people off with stress. People need to understand how bad it is for us. This is the worst I’ve seen it by far.”

So how did local NHS managers deal with this situation? They simply instructed the nurses only to visit patients with the most urgent needs at home. Everything else was put on hold. Flu vaccines, patient reviews and meetings all fell by the wayside in an attempt to fix the problem.

But Scotland is not alone in having a district nursing problem. In November 2019, the Queen’s Nursing Institute, the national nursing charity covering all parts of the UK, except Scotland and which promotes the work of district nurses, published a report setting out the scale of the crisis in the profession in the other parts of the UK. This report sets out how rising demand for district nursing care has led to unmanageable caseloads, which in turn leads to poor working conditions and lack of training and development. End result? Increasing numbers of district nurses are leaving the profession, putting even more pressure on those who stay.

So what’s the solution? Sadly the NHS doesn’t have one. In the NHS long term plan  district and community nurses get just six mentions and one of those is to highlight the current staffing difficulties.

The Queen’s Nursing Institute, on the other hand, does have some answers. Crystal Oldman, chief executive, launching its report, said: “To stem this crisis, what is needed now is a significant programme of investment by government into the training, education and development of a new generation of highly skilled district nurses, who will become the leaders of community services.  We need to return the numbers in the workforce to what they were in 2011, or better.”

What about district nurses themselves? How do they think this could be resolved? A survey of district nursing team leaders sees additional staffing as the top priority. But, even if the NHS had the additional money, this still doesn’t solve the problem because there is a national shortage of nurses. A recent Nursing Times report said there are  about 40,000 nursing vacancies across the UK. The government is recruiting 50,000 new nurses but these will take five years to train. If you are a nurse right now you are in a seller’s market. Why would any nurse want to join a district nursing team if all they can be offered is overwork and a lack of training and development?

In December 2015 a district nurse manager, Linda Fairhall, formally recorded a risk in the systems of North Tees and Hartlepool NHS Foundation Trust. A recent change in policy by the local authority meant that its carers no longer visited patients to ensure they took their medication. So instead the decision was taken that district nurses would do this instead. This change in policy added an additional 1,000 visits per month to the caseload and caused the team to go into crisis. Throughout 2016 Linda Fairhall escalated these concerns formally to senior management. Their response? Linda Fairhall was first suspended and then sacked. The world only found out about this when an employment tribunal ruled in Linda Fairhall’s favour in February 2020.

This shocking story illustrates an uncomfortable truth about caseloads. District nursing teams, uniquely in the NHS, have evolved into a universal healthcare service, doing things which no other health and care team either can or wants to do. Medication visits in North Tees and Hartlepool is a case in point. 

So what exactly should a district nursing team be doing? Crystal Oldman of the Queen’s Nursing Institute says: “Most people probably do not realise exactly what the daily work entails. They are the key co-ordinators of multiple services and manage the treatment for complex conditions, preventing patients from needing hospital admission. They provide end of life care for the dying, and they administer a range of complex, clinical treatments at home to patients of all ages and abilities, supporting their families and carers too.”

What does this mean in practice with staff shortages and overwhelming demand? One nurse, speaking anonymously to BBC Radio Ulster, described her job. “The service is slipping, and slipping, and slipping. You cannot dilute care, you cannot dilute people. We are being abused and patients are losing out big time. We are visiting palliative care, terminal patients, very complex patients that are being discharged earlier and earlier from hospitals, vulnerable cases, dressings and insulin. Time is so limited we are racing from patient to patient….we are in with patients who are dying and as we are holding their hands we are are clock-watching.”

Because hospital wards operate on a one in and one out basis they need to discharge patients as soon as they are medically fit to accommodate the next patient who needs a bed. These incoming patients typically come from Accident & Emergency departments (with patients often in corridors on trolleys awaiting beds) or from GPs admitting their patients directly into hospital. To discharge a patient a hospital needs to ensure that the right nursing care is in place in the community. 

One district nurse, interviewed by the Kings Fund in 2017, put it like this: “If a ward is full, a ward is full, but within district nursing caseloads there’s no way of doing that. The referrals keep coming, and providing they are appropriate in terms of clinical requirements, then those patients will be accepted... The demands increase exponentially and it’s not easy to control.”

We all know about our ageing population and the rising demand for healthcare. In 2018 one in five of us was over 65, by 2050 the Office for National Statistics predicts it will be one in four.

But since 2010 the number of general and acute beds in English hospitals has reduced by about 8,000 or 7.3 per cent. Logically as the number of hospital beds reduces the number of district nurses should increase to care for these additional patients at home. But district nursing numbers have reduced by 3,000 or 43 per cent over the same period.

Away from the NHS district nursing team there are carers employed by local councils and private agencies who visit patients and provide help with dressing, washing, meals and basic care. This means that a patient might have both in the house at the same time. 

In a typical district nursing team caseload management is carried out by a senior qualified district nurse. It is a process of continual review of individual patients. For a typical team of 20 to 30 district nurses with a couple of hundred patients on the caseload this will take time.

Patients are very perceptive about what happens when district nurses are under pressure.  One patient told a Healthwatch survey of the service across Wigan: “The district nurses only really saw the wound they were dressing, they didn't ask anything about it or what had happened and yet it was the result of a serious operation, as a result of an emergency admission with suspected pneumonia, but on investigation an abscess was found in his leg. We were warned that he could lose the leg and the whole episode was very frightening.” Other comments were equally damming: “Their enthusiasm for my care was non existent.  Luckily I am good at finding out information for myself. God help the ones that aren't! (They were) only focussed on the reason for the visit.”

As the teams go into task mode continuity of care is no longer provided by one nurse and instead different nurses start to visit the same patient to perform a single task at each visit. As another Wigan patient said: “It was always a different nurse turning up – actually that's if they did turn up at all as they often didn't and we would have to telephone to find out where they where, but because you only reach an answerphone you then have to leave a message and wait until somebody phones you back, which could be the next day and then you have missed that day's visit.”

As pressure mounts nurses start to make mistakes. Nurses no longer have time to fill in the paperwork and  complaints from patients start to increase.

District nurse team leaders will be alerting senior managers to the unfolding crisis as the situation worsens. Entries will be made into risk registers. Risks will be escalated. And then it’s up to senior managers to find a solution. In North Tees and Hartlepool NHS Foundation Trust the solution was simple. They sacked the messenger. Other wiser managers will draw up a plan. A key element of any recovery plan will be to bring in additional help from outside.

But fixing a local problem doesn’t help with the national problem of unmanageable caseloads and an unhappy workforce. So where can we look in order to find solutions?

The answer lies in the Netherlands where a crisis in district nursing in the 1990s and early 2000s led to radical changes in the way the service was  organised and delivered. So far reaching were the changes that other countries now beat a path to the Netherlands to find out how they did it and how it could help them.

In the 1990s the Dutch government introduced a series of reforms  designed to standardise practice, reduce costs and drive up standards. Regional organisations were introduced, which drew up  detailed contracts for each patient specifying which task should be carried out and by which healthcare professional in a specified number of minutes.

Unfortunately these reforms had the  opposite effect to that which was intended. Decision making was taken away from frontline staff and handed instead to regional organisations. As a result some patients saw as many as 30 different nurses, carers and other professionals for just one element of that patient’s care. The government was faced with rising costs because the system incentivised intervention instead of prevention and it was in the care providers’ financial interest to keep providing care.

Then in 2007, Jos de Blok left his job as a district nurse and, together with three other nurses, set up a new provider service. He called this new organisation Buurtzorg (which means “Neighbourhood Care”). The homepage of their website says “Welcome to Buurtzorg – Humanity over Bureaucracy”.

There are three elements which originally distinguished Buurzorg from other organisations providing care. First, instead of a traditional hierarchy, as the organisation grew, De Blok organised the nurses into self-managing teams. Without managers it is up to the nurses themselves to organise themselves to deliver the care. There is a small central support office which looks after the paperwork. Second, everything is digital and the IT system allows nurses to monitor their own performance and ensures that bureaucracy is kept to a minimum. Third, there is a regional network of coaches to support the nursing teams.

With this radically different structure Buurtzorg then turned district nursing upside down. Instead of lots of different professionals visiting a single patient to carry out different tasks, a Buurtzorg nurse does everything for their patient covering nursing care and the non-nursing care (eg assistance with showering and meals). Buurtzorg only employs registered nurses. They do not wear uniforms and all the nurses in the team have an equal voice so there is no hierarchy.

Providing all care to patients, including non-nursing care, is popular with nurses. Interviewed by the BBC in 2013, Buurtzorg nurse Cora Duinkerken, said: “We choose to work under our level but with that we can give the client complete care. That's better for the client, but it also makes our job a lot more diverse. You get a much closer relationship with the client because you spend a lot more time with them so they eventually will share a lot more with you.”  

Another key innovation was to think about caseload management differently. Buurzorg nurses actively consider how their patients might move off the team caseload into self-care or the care of family, neighbours and friends.

To support this further Buurtzorg is currently transforming itself into what it calls Buurtzorg Plus. Borrowing from the model in the UK where therapists work closely with district nurses, Buurtzorg is bringing physiotherapists and occupational therapists  on to its teams.

A KPMG report into the Buurtzorg model in 2016 said: “One of the keys to the programme’s success is that Buurtzorg’s nurses organise their work themselves. Moreover, rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem to help them become more self-sufficient. Simply put, Buurtzorg nurses aim is to make themselves superfluous as soon as possible.

Buurtzorg’s model is popular with nurses and patients and this fuelled growth. One patient, interviewed on the BBC, said of the Buurtzorg nurses: “They treat me well, they take care of me. You are a human with them and they don't start saying, we only have X amount of hours or so many minutes to change my support stockings or shower me.”

From the initial four friends in 2007, Buurtzorg grew to 9,500 nurses and 850 teams seeing 70,000 patients across the Netherlands within 10 years. To support them there is a central office of 45 staff plus 16 coaches and 2 directors.  

One of the surprising results of the Buurtzorg model was the effect on costs. They went down. This process of reducing costs was helped by the Dutch nursing providers’ stipulation that their nurses spent at least 60 per cent of their time on direct patient care.

The impact of this was so great that other Dutch district nursing providers followed their lead. Amstelring and Zorgaccent both moved their nurses in self-managing teams and moved to putting the relationship between the patient and the nurse at the centre of their organisations’ ethos. But this wasn’t always an easy process.

Both organisations had employed large numbers of lower-paid nursing assistants who could deliver tasks such as assisting with showering but who weren’t qualified to provide higher levels of nursing care. Changing to a Buurtzorg model meant these nursing assistants were given a choice, either obtain the qualifications required to nurse or leave the organisation. However once qualified their outlook changed – instead of delivering a task these nurses were now seeing their patients in a more holistic way.

Amstelring also noticed that as they changed their model to the Buurtzorg one then quality went up and costs went down. 

KPMG had more warm words for Buurtztorg in their 2016 report. They said: “Essentially, the programme empowers nurses (rather than nursing assistants or cleaners) to deliver all the care that patients need. And while this has meant higher costs per hour, the result has been fewer hours in total. Indeed, by changing the model of care, Buurtzorg has accomplished a 50 per cent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.”

Sounds good? So why don’t we try a Buurtzorg model here in the UK? There has certainly been lots of interest from the UK and a number of pilots have taken place. In 2016 the NHS even sent a team to the Netherlands to study the model.

The problem is that De Blok could never have set up Buurtzorg in the UK. This is because the Dutch healthcare system is very different to the UK’s. In the Netherlands healthcare services are not provided by the state. It’s private and individuals have to buy healthcare insurance, which then pays for the private care.  The insurance companies are virtually all not for profit co-operatives. Buurtzorg, Amsteling and Zorgaccent are all private providers of district nursing care.

This means the money follows the patient whereas in the UK it doesn’t. In the UK hospital and district nursing care is paid for by block funding and contracts. Starting a new small scale nursing service in the UK is therefore next to impossible. 

However these potential barriers have not stopped parts of the NHS bringing in the Buurtzorg model into existing NHS organisations. The results have been mixed. In Suffolk where there was a small-scale pilot to set up a single team the King’s Fund review highlighted staff and patient satisfaction with the new way of delivering nursing care but also identified the challenges involved in operating a self-managing team within the existing NHS hierarchy. In the end problems with recruitment and retention of staff led to a situation where only two full-time equivalent nurses were left.

The only way to test the Buurtzorg model properly is to convert an existing district nursing function within a big NHS Trust into the model. And this is exactly what is happening at Guys and St Thomas’ NHS Foundation Trust after a positive initial evaluation of their pilot. The new Buurtzorg nurses organised their own work with a smaller caseload.

The change from the previous system was noticed by patients who highlighted continuity of care and more time for patients being key benefits. One patient told Kingston University, who carried out the evaluation of the pilot scheme: “This new system has picked that up {a potentially serious new physical symptom}. Whereas in the old system that  would never have happened at all, because they {district nurses} didn't want to stay in the place more than five minutes if they could help it.”

And the nurses themselves really like working in the Dutch system, principally because they could see the benefits for their patients. One nurse told the reviewers: “There was a patient who was happy to see the (Buurtzorg) neighbourhood nurses and this was the first time she had been ‘happy’ to see any health-care professionals because we had helped make a difference for her."

 GPs also noticed a difference with comments such as, “the feedback we've had from patients is that they'll do anything for them…..they have  made such a  difference with some of the most difficult to engage people with mental health problems and other long term conditions."

These London Buurtzorg teams do still have to operate within a big NHS Trust with its NHS hierarchy and ponderous bureaucracy. One nurse in the pilot reported that: “I’m surprised after all these months that GSTT (Guys and St Thomas) are still trying to manage us, tell us what to do.” Another said the Buurtzorg nurses needed, “more buy-in from the trust to the concept of self-management to help break the barriers and challenge the way many processes are done now". 

The Buurtzorg model, for all its apparent benefits, does not solve the problem of overwhelming demand. It doesn’t matter how motivated, well organised and efficient a team is, if there is still an unmanageable list of patients needing care.

The good news is that another element of the Dutch healthcare system does offer a way to help district nursing teams in the UK. And this element is a structured process of clinical reasoning – an assessment.  

According to guidance published by the Dutch Healthcare Institute the assessing nurse has to consider if a patient is going to be able to look after their own care and how can the patient’s own network of family, friends or local community support that person?  If this is not possible or appropriate then the assessing nurse decides on the nursing care needed, the length of the care and the outcomes.

This process of assessment and clinical reasoning does take place here, but without being mandated in the way that it is in the Netherlands. In the UK the assessment often takes place only after the patient has been referred and taken on by the district nursing team. Hospitals, which are under their own intense bed pressures, often discharge patients  without applying a robust process of clinical reasoning. If hospitals applied the Dutch assessment criteria to patients they could reduce the number that need to be referred to community care.

This lack of clinical reasoning and robust assessment in hospitals can lead to real problems. The fact that the money does not follow the individual patient in the UK does have the advantage that it gives the NHS flexibility in a crisis. But in the recent Covid-19 that flexibility was used by the NHS to tragic effect when nearly 20,000 patients were discharged with Covid-19 into care and nursing homes. If a system of structured clinical reasoning had been operating this might have resulted in these care-home residents being transferred to the newly built Nightingale or independent hospitals for their hospital care.

In April this year Crystal Oldman told the Health Services Journal: “When the NHS announced they had emptied the equivalent of 50 district general hospitals [worth of beds], was any thought given to where those patients have gone? Those discharges have put an enormous pressure on the community. It’s manageable but I do think it’s changing from one day to the next because of sickness of staff and the volume of referrals into community.”  

It makes sense for the NHS to follow the Netherlands model and create dedicated community provider organisations which include district nurses.  Another reason for removing district nurses from the power structures of acute hospitals is their relationships with GPs. Whenever anyone goes into hospital then they are under the care of an NHS consultant, who is a senior doctor and who leads the team of hospital doctors and hospital nurses. Patients at home are all under the care of a GP, who works with district nurses to deliver care to patients in the community. So why have district nurses working in an organisation run by hospital doctors and managers?

So, what next? The good news is that the very first step towards improving district nursing in the UK is easy. Someone at the very top of the Department of Health and Social Care in England and the equivalent in each of the devolved administrations just needs to pick up the telephone to their counterparts in the Dutch Health Service and ask if a team could visit to find out what the NHS in the UK could learn from the Dutch way nursing.