Item 5 on our agenda this afternoon is the debate on the Health, Social Care and Sport Committee's report: community and district nursing services. And I call on the Chair of the committee to move that motion—Dai Lloyd.

Motion NDM7210 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee: Community and district nursing services, which was laid in the Table Office on 21 August 2019.

Motion moved.

Thank you very much, Deputy Presiding Officer. I'm pleased to open the debate today on the Health, Social Care and Sport Committee's report on community and district nursing services This is the fourth in the series of spotlight inquiries recently undertaken by the committee.

The committee undertook a one-day inquiry into the activity of district nurse-led community nursing teams and the quality of nursing care provided to people in their own homes. At this point, I'd like to acknowledge the cross-party group on nursing and midwifery, as it was through their work that this inquiry came to fruition, and to acknowledge the leadership of David Rees.

The changing nature of healthcare provision and the move to provide more care outside the hospital setting means that the role of community nurses has become increasingly demanding. There is an acknowledgement that these community nursing teams can contribute to healthcare in the future, but the information about that is very scarce. There is no accurate picture of the number and skill mix of nursing teams. We don't know how many people are receiving care in their own homes or the level of care they need. It's also not clear how community nursing teams' activity is measured and reported, or how the quality and safety of services is monitored. Indeed, we were alarmed to hear community nurses describe themselves as the 'invisible service'.

The Royal College of Nursing told us that two thirds of its members work in the community, meeting the needs of elderly, disabled, and vulnerable patients who may otherwise struggle to visit a hospital. The move towards ever-greater delivery of health services in the community has increased people’s expectations of being able to access treatment in this way, and advances in medicine have made this a reality. Witnesses told us that people already expect to be able to receive extremely complex treatment in their own homes. Demand is likely to increase as a result of earlier discharge from hospital, keeping people at home to avoid unnecessary hospital admissions, and more people having complex and multiple conditions.

Community nursing teams act as a valuable link between acute services and primary care and promote independent living. It is therefore worrying to hear that nurses are finding it increasingly difficult to meet these increasing demands on them. The Welsh Government must therefore ensure that the crucial role of community nursing in the future delivery of healthcare is properly recognised in its workforce planning, nurse recruitment and training, and that's recommendation 1.

Turning to children's community nurses: the message from witnesses is that there must be an increase in the number of children's community nurses. According to the Royal College of Nursing, an average-sized district with a child population of 50,000 needs at least 20 full-time equivalent community children's nurses to provide a holistic children's community nursing service. This is partly due to the growing number of children with complex needs being cared for at home. It is worrying, therefore, to hear that we have no clear picture of the number of children's nurses currently working in the community. Further, it is extremely concerning to hear that children are less likely to be cared for at home at the end of life than adults because of shortages in appropriately skilled community nurses.

And, moving to palliative and end-of-life care, despite the crucial role community nurses play in enabling patients with palliative care needs to remain at home, we heard that the palliative and end-of-life care delivery plan makes little reference to them. Without a better understanding of who is being cared for where, and by whom, it is impossible to accurately determine the level of unmet need for palliative care. We believe that the Welsh Government must now publish an update on progress made in developing this action plan—that's recommendation 3—and I invite the Minister to update us on this point today.

Turning to district nursing staffing, the Welsh Government has said that it remains committed to extending the Nurse Staffing Levels (Wales) Act 2016 to additional settings. However, for district nursing, an appropriate workforce planning tool, required by the Act to calculate the nurse staffing level needed, is not likely to be ready for some years. We therefore recommended that the Welsh Government must produce and publish a strategy for extending the Nurse Staffing Levels (Wales) Act 2016 to all settings, including community and district nursing services, and that's recommendation 4.

And, turning to staff morale, some of the most stark evidence we received in committee came from nurses working in the community, who told us, and I quote:

'I left district nursing after 18 years as I could not cope any longer with the stress. The job workload increased more demand on paper work, and under staffed, and patients could not have the care they deserved.'

And another quote:

'The past five years has seen diminishing resources in front-line services. Nurses leaving and recruitment issues. We do not always look after our staff very well, we expect more and more from them.'

The RCN told us that morale is quite low, particularly at senior levels, because of the tremendous pressure community nurses have been under for a long time. Interestingly, this was not a picture that the health board representatives we spoke to recognised in their areas, and it was concerning to hear such conflicting views.

Finally, I'd like to turn to ICT infrastructure and technology, as one of the main issues raised by nurses working in the community was their inability to access the most appropriate technology to enable them to undertake their roles effectively. Half of the district and community nurses who were asked about their experiences of IT support reported using a variety of equipment, including laptops and Blackberries. The other half reported that they didn't have access to a mobile device at all. One witness told us:

'We have no computerised system for documentation. It's all paper.'

Another issue raised by the nurses was their inability to access office calendar and e-mails. The lack of appropriate technology is not only affecting nurses, but also patients who are trying to contact their community and district nursing services. If we are not providing nurses with the most up-to-date technology, how can we possibly expect them to communicate with and provide the best possible support to their patients?

Suzy Davies took the Chair.

It is unacceptable that nurses working in the community have limited access to patient information, appointments or e-mails via handheld devices and are instead reliant on paper-based systems and outdated technology. I will wait to hear other comments in this debate. Thank you.

I'm very grateful to take part in this debate on the committee report. And the first thing, actually, I'd like to do is pay an enormous tribute to all of the district nurses and community nurses out there in Wales. I speak from personal experience when I say that, after the arrival of No. 1 daughter, it was the district nurse that helped me keep my sanity, because I certainly had no idea what I was supposed to do once I arrived home. They are the unsung heroes, and, in fact, our report describes them as 'the invisible service'. And I think it's worth us all remembering that there's no accurate picture, at national level, of the number and skill mix of nursing teams, nor the numbers in our teams, the acuity levels of the patients that they're having to deal with. And this, of course, impacts on workforce planning, on recruitment and retention. And I think that the Chair of the committee has very, very clearly laid out, actually, the stress levels that district and community nurses face, and how this is driving people out of a profession that we so desperately need, particularly, Minister, if you are going to carry on a direction of travel that we all support, which is about treating people at home, in the community, in their homes, rather than sending them off to hospitals or to other facilities.

And I do find—. And I want to particularly speak to recommendations 6, 7 and 8. Six is about data, 7 and 8 are about training and recruitment. Because I find that the availability of data on nursing services is beyond poor. I recognise that health boards understand that, but not knowing for sure how many nurses in the community are district nurses, or not knowing how many district nurses are nurse practitioners, must seriously hamper the planning and delivery of services. And acknowledging that there are significant challenges in terms of data and the future development of the ICT infrastructure is a step forward. But I have to point out that this is a step that the Welsh Government and the health boards have been standing on for years. So, I'd like to know when will we see the roll-out of the Welsh community care information system. It's only in one health board, and that's Powys, at the moment.

And I just want to read out a couple of little highlighted segments from this report. This is what the people who work in our community services have to cope with—and you think about all the technology that we're surrounded with here to help us do our job—

'We have mobile phones without access to diary or email though colleagues in local authority have both and a functioning electronic system for health records.'

But district nurses, community nurses, don't.

'We have very little IT to support integration and CRT working. District Nurses are on paper; some therapy staff are on therapy manager; social care colleagues on WCCIS.'

'Most of the team have blackberry's, years old, that don't work sufficiently.... We have no computerised system for documentation—it’s all paper.'

And one of the concerns I have—and it runs, actually, across a wide variety of the health service—is I very often write to you, Minister, to ask for data on a range of topics, and you come back, in your written answer, and you say, 'No data held centrally'. Okay, I get that. I will then do an FOI on every single health board, following your answer, and guess what they come back and say? 'No data held centrally. No data recorded. This data isn't known; it's not cut, sliced and diced in this way.' If we don't have this essential data, how can we do workforce planning and management, how can we really target recruitment and retention? Are we not setting up Health Education and Improvement Wales to fail, because, if we can't access the data, and the Minister's obviously not got the data, I don't suppose for one moment HEIW have got the data either.

I would also like to know who will be evaluating the success of the Malinko software pilot at Cwm Taf. I'd be interested to know who's going to be evaluating it, when you expect the evaluation to happen. Because, as I understand it, if it does all that it says it does, then it would be a very good thing to roll out across all of our health boards. But I would like it independently evaluated, given Cwm Taf's current situation.

And my last and final point that I want to make, which is slightly in this report but it is an adjunct to it—we all know that primary care is based on the multidisciplinary team model. However, it is hampered at times by lines of reporting, and that does apply to district and community nurses, because, of course, most of them report back to health boards, rather than clusters or GP practices. Now, I've had a couple of cases where we've had seriously ill constituents—terminal cancer, GP has gone out, they need the support of a district nurse. But because there hasn't been a 13-page form filled in, their doctor, who says, 'This person must be nursed and looked at by a district nurse in their home', hasn't been able to do it, because they've got to go back to the health board and then follow a very convoluted way of being able to provide that service. So, can we just look at that and tightening it up? Because they're an integral part of the primary care team, and they need to be under the auspices of those who lead the primary care function.

I'd like to add my voice to what other speakers have already said—our gratitude to all those who contributed to the inquiry. I'd like to pay tribute to our Chair. I think these one-day, short, sharp inquiries are a really useful model and enable us to get to the heart of issues really quickly. I'm particularly grateful to the nursing staff who provided evidence.

The thing that was left in my head after this inquiry was the term 'the invisible service', and that's already been mentioned by others—the extent to which the work that these nurses do largely goes unseen unless it is not done or unless it goes wrong—and also the evidence that they gave about the level of responsibility of a nurse on her or his own in a family home, in a nursing home, perhaps, where they don't have the whole support network of nursing staff that's available to nursing staff who are working in hospital settings.

Now, like many others, I'm sure, I was very glad to see the Minister accept nine out of the 10 recommendations, until I read in detail what he was saying in response to those recommendations. And I'm afraid that what he was telling us was that much of what we were asking for, what the nursing staff were asking for, was already happening. Well, as Dai Lloyd has said, it's difficult sometimes when you have conflicting evidence, but, when I have nurses before me and I have senior managers before me, I am inclined to believe the front-line staff, who may know better what's going on on the ground.

I was particularly concerned that the Minister's response only highlights additional resourcing, or possible additional resourcing, for one of the recommendations that he accepts. Because if we are to meet his aspiration—an aspiration, I think, shared across this Chamber and across Wales—of moving more services into the community, we will have to have a larger, better supported, better resourced workforce, and that doesn't come for nothing.

I want to turn briefly to the recommendation that the Minister decided to reject, and that is recommendation 4, which is that the Welsh Government should produce and publish a strategy for extending the Nurse Staffing Levels (Wales) Act 2016 to all settings, including community and district nursing. Now, while I appreciate it's more difficult to do that—. It's relatively straightforward to know how many nurses at what level of skill are needed to support a particular set of patients in a particular ward because it's relatively easy to work out what their level of need is—the patients' level of need. And it's been difficult to do that, and this, of course, feeds into the points that Angela Burns has already made about the issues with information.

But if we are serious about treating community services with the same level of respect as we treat services that are provided in hospitals, if we are serious about providing community nursing staff with the same level of respect and the same level of support, then surely we must move to make those assessments, to work out the acuity, the sickness, of the patients that they're dealing with and the skills that they need and the time that they need, and, therefore, the level of community and district nursing that is safe for that particular population. And it is beyond me to understand why the Minister does not agree. I would have been perfectly happy to see him say that this will take a longer time, perhaps, than we as a committee were asking for, but simply to suggest that it's not necessary is a real matter of concern.

I want to highlight one particular aspect that I think the Minister may be taking moves towards addressing, and that is issues around terms and conditions for nurses employed by GP practices rather than directly by the health boards. It's very clear to me that the terms and conditions for some of those nurses have not kept pace with the terms of those nurses who are directly employed. A particular concern that's been raised with me by individual nurses in my own region is that they often don't have time for learning. Now we know that's a problem across the whole sector, but, if you're perhaps one nurse on your own, employed by a rural GP practice, it can be incredibly difficult for you to be released to increase your skills. I think the work the Minister highlighted the other day in terms of making sure that GP practices are reporting what levels of staffing they've got now may help with that, but I think it's really, really important that we protect the terms and conditions of that very important group of nursing staff.

I think there's an element of agreement about the issues that face us. The question now has to be how quickly and how effectively we can move to address those issues. It's a word I find myself using again and again, and not one that I particularly want to use, but I'm afraid that there are elements of the Government's response to this report that do appear complacent to me and, more seriously, appear complacent to the nursing workforce. Our nursing workforce staff deserve better than that. Our community nursing workforce deserve better than that from us all, and, very importantly, so do their patients.

I am sure that we all agree with the Minister that we need to grow our community services, but unless we properly resource and respect our community nursing workforce we won't be able to do that.

I thank the Health, Social Care and Sport Committee for their report into community and district nursing services. Community nursing is an essential service that helps keep patients out of hospital and remain in their own homes. As our demography changes, as we all live longer with increasingly complex chronic illness, the services provided by district and community nurses become more essential. 

Over the past two decades, we have lost over 5,000 NHS hospital beds, despite our population increasing by over 200,000. Without district and community nurses, our NHS would be overwhelmed. Despite this, the service continues to be undervalued. Giving evidence to the committee, community nurses described themselves as 'the invisible service', and this is very sad to hear. I therefore welcome the committee's recommendations, which are aimed at improving provision but, more importantly, recognise the absolutely vital role that our district and community nurses play in delivering health and social care in Wales. 

I am pleased that the Welsh Government have accepted nine out of 10 of the recommendations. What I don't understand is the Minister's rationale for rejecting recommendation 4. Extending the nurse staffing levels Act to all settings is the right thing to do. I accept that it won't be easy or doable overnight, but that is not a reason to reject the recommendation out of hand. Welsh Government should accept, at least in principle, that work needs to commence on achieving safe staffing levels now, not at some unspecified future date. 

The Welsh Government have to accept all 10 recommendations and act upon them swiftly if we are to ensure the future of the service. Morale is at an all-time low, yet we, as a nation, are becoming more reliant upon the services provided by our hardworking, dedicated district and community nurses. We have to demonstrate that we value our community nurses; accepting and implementing all 10 of those recommendations would be a good start. Thank you.  

Thank you very much. I call on the Minister for Health and Social Services, Vaughan Gething.   

Thank you, acting Deputy Presiding Officer. I want to thank the committee for their inquiry and report into community and district nursing services in Wales. I'm pleased to say that the recommendations do broadly reflect Welsh Government policy, as articulated in our 'A Healthier Wales' vision of more care being delivered closer to home. We know that, as part of a multidisciplinary approach to delivering this aim, registered nurses will continue to play a pivotal role. 

The majority of the recommendations relate directly to the community workforce in terms of planning, recruitment and training. Significant work has already been undertaken to increase the nursing workforce here in Wales with positive results. However, we are never complacent and recognise that there are challenges around the recruitment and retention of nurses in a number of settings. That is why I have again increased health education funding by 13 per cent for the next year, compared to the one that we are in. We went through the figures yesterday on the significant increases in nurse education and training here in Wales over the last six years. 

With the establishment of Health Education and Improvement Wales, we are now in a better position—a better position than ever—to ensure a national strategic approach to understanding our workforce and producing a sustainable supply of nursing staff for the future. The Welsh Government director of workforce and organisational development is liaising closely with Health Inspectorate Wales, as they develop their future workforce strategy, and that will ensure that recommendations 1 to 3 and 6 to 8 factor into that work. 

I recognise, of course, the crucial role that technology plays in community nursing, which was referred to by a number of Members in the debate. That is why the Welsh Government is working with all health boards in supporting investment in modern devices. I meet district nurses in my own constituency and around the country and they do describe some of the frustrations that some Members have referred to. It's again part of the challenge I regularly describe about catching up with what normal life is now like and our ability to do things on mobile devices. This does include the work that I've described within the Government—the prioritisation of mobile devices for community nurses and others who are not based in a hospital setting. We committed in 'A Healthier Wales' to significantly increase investment in digital as a key enabler of change, and that is supported by an increasing emphasis on common national standards across digital devices and applications.

Members will recall that I endorsed the chief nursing officer principles for district nursing in 2017. These are an essential step in the preparation for the further roll-out of the Nurse Staffing Levels (Wales) Act 2016. The intelligence provided from that, and the monitoring that my officials from the chief nurse's office regularly undertake, are an important step, and I understand that progress is being made on the ground.

In terms of further work on what the model should look like, we are undertaking an evaluation of the neighbourhood district nursing model. Subject to that being a successful evaluation, I will then consider options for commencing the roll-out of that right across Wales over the next financial year as part of our response to the forthcoming budget round.

I am sorry that I couldn't accept all of the committee's recommendations, and I understand that Members have referred in particular to the one that I didn't. That was specifically recommendation 4, which relates to the extension of the Nurse Staffing Levels (Wales) Act. Section 25A of the Nurse Staffing Levels (Wales) Act already applies to all settings where nursing care is either provided or commissioned. This duty sets out the overarching responsibility of health boards to ensure that there are sufficient nurses to care for patients sensitively, and health boards are committed to meeting that responsibility.

Regarding the extension of section 25B, C and E of the Act to all settings, the honest truth is that it wouldn't be possible at this time to articulate a strategic vision with any detail that could be considered valuable and worthwhile. There are significant and fundamental differences to the various settings in which nurses provide care, and it is too early to begin to understand the complexity around the variability across all settings.

A substantial piece of mapping will need to be undertaken by the all-Wales nurse staffing programme before a national strategy can be contemplated, but the programme manager has begun the early stages of that work. That's underscored by the reality of the work that is already ongoing that has underpinned the initial stage of roll-out, the pieces of work that are already in train at present, and, of course, the work that took place before my written statement today, where I confirmed that I had commenced the legislative process to extend the Act to paediatric inpatient wards, with the intention that the practical extension will be in place by April 2021. I will, of course, write to the committee setting out current progress across all nurse staffing programme workstreams.

There's a final point that I think is worth mentioning in terms of the debate, and that is that the publication of the committee's report was in August. The Nursing and Midwifery Council, the professional regulator, then announced that it intended to conduct a full review of post-registration recordable qualifications, and has explicitly identified specialist practice qualifications. That could potentially have significant ramifications for community-based roles and the way in which they are defined. Such roles include, specifically, general practice nurses, community children's nurses and, especially, district nurses. I will, though, keep the Assembly—through the committee—appraised of the outcome of that review and the ways that that might affect the practical implementation of Welsh Government policy.      

Thank you very much, and I call on Dai Lloyd to reply to the debate.

Thank you very much. In the few minutes that remain to me, I will summarise this debate by thanking everyone for their comments. Angela Burns told us about the challenges with regard to IT, technology and the lack of data. And Caroline Jones and Helen Mary Jones told us about the need to extend the staffing levels legislation to community nurses, and I heard the response from the Minister to that. But to summarise, it’s vital that the role and value of community nursing is acknowledged fully and that our community nurses and our district nurses do receive the support that they need to provide a service of the highest quality to our patients here in Wales today. Thank you.

The Deputy Presiding Officer took the Chair.

Diolch. The question is to note the committee's report. Does any Member object? No. Therefore, the motion is agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.