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?