Exclusive: Plans revealed to integrate district and practice nursing

The project is the brainchild of Steph Lawrence, who is executive director of nursing and allied health professionals across both Leeds Community Healthcare NHS Trust and Leeds GP Confederation.

“It will absolutely help us with staffing shortages if we can do things more efficiently”

Steph Lawrence

She also has delegated responsibility for primary care nursing from the clinical commissioning group in the area, which means she is perfectly placed to lead the work.

While acknowledging that district and practice nurses were “very unique” roles, Ms Lawrence said there were lots of cross-over between the two.

“There are lots of patients in our systems and in our populations where both district nurses and practice nurses are seeing those patients,” highlighted Ms Lawrence, who is herself a district nurse.

She said sometimes patients were being seen by both nursing teams for the same problem.

For example, she noted that a housebound patient with diabetes may be reliant on a district nurse to administer their insulin but then be visited by a practice nurse for their long-term condition management.

She said: “In my head, why would you do that? Why couldn’t the district nurse just do all of that care?” 

steph lawrence

steph lawrence

Steph Lawrence

In other circumstances, decisions may be driven by team capacity rather patient need, she highlighted.

“For me, there’s a whole opportunity for us to do something differently,” Ms Lawrence told Nursing Times

Ms Lawrence said there were already examples of joint working in Leeds with the establishment of leg clubs, but she wanted to now take this further.

“Those are being led jointly by primary care and community nursing working together for the population,” said Ms Lawrence. “That’s what we want to build on.”

“If the nurse is the expert in wound care, why can’t they direct the patient straight to those services?”

Steph Lawrence

She has kicked off a project exploring a new model of wound care that brings district and general practice nurses together under one roof.

The aim is to establish around six or seven community hubs across Leeds, where patients can drop in to receive their wound care, and link these up with the new primary care networks being formed.

The nurses will have access to specialist wound care nurses and the vision is that they will also be able to refer directly into secondary care services, rather than patients having to go through a doctor.

Ms Lawrence said: “So vascular, plastics, dermatology, those types of things where at the moment a lot of those have to be a medical referral, but looking at actually if the nurse is the expert in wound care, why can’t they direct the patient straight to those services?”

For patients limited by transport issues, Ms Lawrence said conversations were being had with third sector partners about a possible minibus service to bring people to the wound care hub.

“The other benefit of doing that is it’s a socialisation opportunity for those people who may otherwise just spend all of their time at home isolated,” she added.

This new model of care could save staff time because district nurses would not have to travel between patients, and general practice nurses in the surgeries could concentrate on other duties, said Ms Lawrence.

She noted that, at the minute, wound care took up around 40% of practice nurses’ time, which “clearly is a significant amount of their workload”.

“Wound care is our starting point, our ambition is that we would build off that”

Steph Lawrence 

While insisting that improving patient care was the “ultimate motivation” behind the work, Ms Lawrence said staff shortages also played a part.

She estimated that Leeds Community Healthcare was running with a 10-12% nurse vacancy rate and general practices were collectively short of between 40 to 50 nurses.

“The ultimate motivation is for us to deliver a really great quality of care to our patients, that’s our first and foremost motivation, but also then to look at how we create efficiency and reduce variation,” said Ms Lawrence.

“It will absolutely help us with some of those staffing shortages as well, if we can do things more efficiently,” she said.

While stressing that it was “still early days”, she told Nursing Times that she hoped the first fully integrated wound hub will be up and running before the end of the year.

Ms Lawrence said wound care was just the beginning and the aim was to expand to deliver more services under the hub model.

For example, one idea being floated around was for patients to be able to get their flu vaccination at the hub while visiting for their wound care, she noted.

“Wound care is our starting point. Our ambition is that we would build off that with these hubs and that, actually, we could be delivering other services in a more integrated way,” she told Nursing Times.

Ms Lawrence said she hoped this venture would be a new and exciting pull to nurses and eventually help to address some of Leeds’ workforce challenges.

She added that jobs would be flexible and open to those who may have retired and looking to come back.

In addition, Ms Lawrence said she wanted to get students nurses going on placements in the hubs as part of their studies, in order to pique their interest in a career in the community.

“I have no intention of asking district nurses to do the job of practice nurses or vice versa”

Steph Lawrence 

“We are always looking at ways to try and create more community nurse experiences and I think this would be one option for some of that which would be great,” she told Nursing Times.

Looking further ahead, Ms Lawrence said her work around integration could even result in new rotational posts being created that allowed nurses to work across both community and primary care.

Asked about how this would work where general practices were outside the NHS, Ms Lawrence said a work around could be to have nurses employed by the trust but allow them to do stints in primary care under a “business arrangement”.

“We have just got some early conversations going about how could this work,” she said.

Outlining a potential model, Ms Lawrence said nurses would initially nurses be employed by the NHS trust, because that “gives them the stability and the Agenda for Change terms and conditions”.

However, she would then “look at how we have a business arrangement that enables them to rotate across different areas including primary care”, which she described as “almost an employ, deploy type model”.

On top of this, Ms Lawrence said plans were being formed to expand the internal nurse staff bank within Leeds Community Healthcare to include general practice as well.

Ms Lawrence highlighted that the project was not about merging the roles of the district and practice nurses, and also stated that no redundancies were planned.

“I have no intention of asking district nurses to do the job of practice nurses or vice versa, because they are both unique roles, I’m very clear about that,” she told Nursing Times.