Keywords

4.1 Historical Context

This was another period of churn for the NHS following two significant developments which came to characterise the era. First, the structure in place since the 1974 re-organisation was again under scrutiny and the NHS endured another restructuring exercise. This saw a pruning of the hierarchical layers to one of a less rigid bureaucratic structure. Area Health Authorities (AHAs) were abolished in 1982 and replaced by 192 District Health Authorities (DHAs). Second, there was a move away from ‘consensus’ style management towards ‘general management’ following the publication of the Griffiths Report in 1983. The Griffiths Report (DHSS, 1983) marked an important phase in the NHS in which ‘general management’ defined as ‘the responsibility, drawn together in one person, at different levels of the organisation, for planning, implementation and control of performance’ (p. 11) was implemented. In short, the review concluded that management by consensus slowed up the NHS’ decision making and change processes, making it inefficient and that it lacked a ‘clearly defined management function’ (p. 9) resulting in little accountability for action (Ottewill & Wall, 1990). In order to reverse this, people in charge were needed to make things happen, whether recruited internally, or external to, the NHS—managers were required from the top to the bottom of the organisation (Klein, 2010, p. 118).

Implications for community nursing were to be seen therefore in the way they were managed resulting from both another re-organisation and through Griffiths’ recommendations. Whilst CHS was not a direct focus of the review, Griffiths recognised the importance of their role in the delivery of health care and suggested that the tenets of the review were equally applicable to all aspects of health service delivery. In his recommendations to the Secretary of State for Health in 1983 (NHS Management Inquiry), Griffiths admitted that the report lacked detail on CHS due to on-going discussions with the DHSS. However, several key white papers and a review (The Cumberlege Report, DHSS, 1986) were published in the latter half of the decade, which were influential in shaping the CHS and community nursing landscapes. Not least of these was another review by Griffiths in 1988, Community Care: Agenda for Action, which when taken in combination with the White Paper—Promoting Better Health—1987, amounted to further reform for community nursing going forward.

4.1.1 The Role and Function of Community/District Nursing Services

One of the conclusions from the Cumberlege Report;‘Neighbourhood nursing, a focus for care’ (DHSS, 1986) was that community nursing services ‘are in a rut’ (p. 2)—which the authors felt was a succinct summation of the state of affairs for community/district nursing at the time. Commissioned by the government in 1985 to examine—‘nursing services provided outside hospital by HAs and to report back to the Secretary of State on how resources could be used more effectively so as to improve the services available to client groups’ (DHSS, 1986, p. 2)—the Community Nursing Review Team, led by Julia Cumberlege, produced recommendations which would prove contentious but significant to the service.

The report focused on community nursing within, and attached to, primary care. District nurses were treated as holistic practitioners but it was suggested that they had become set in their roles, resulting in professional skills being under and/or unused (Ottewill & Wall, 1990). Thus, the role and function of district nurses continued to be aligned with the policy priorities of the era with little change save for a greater demand on their skills. Here, the review did not focus on the specifics of district nurses’ tasks nor what they did, except to say that the focus should be on (DHSS, 1986, p. 8):

  • Caring for old/disabled/frail to enable them to stay in own home

  • Professional nursing help for sick people/people discharged early

  • Health education, illness prevention

Instead, the report outlined recommendations intended to improve the role and function of the district nurse service by offering proposals for improving the organisation of services, training and making better use of nursing skills. The proposals were rooted in focusing on local need, ‘knowing communities and individuals’ (ibid., p. 11), better linkage with community resources and better primary healthcare team working. The authors argued for mitigating overlap, duplication and lack of co-ordination of skills, workloads and caseloads, especially with other services such as health visitors by proposing a Neighbourhood Nursing (NNT) service based on geographical zones (outlined in next section). The review team also recommended enhanced training—a 1-year, diploma, with opportunities to add on specialist models or a masters. It suggested invention of nurse practitioners as more highly skilled nurses within the team and that nurses should be able to prescribe from a limited list whilst also emphasising nurse’s ability to diagnose and manage minor ailments (ibid., p. 31/33). The authors also suggested that GP practices should no longer be subsidised to employ practice nurses. The roles being taken by practice nurses could be done by district nurses working in clinics, under the agreement between a NNT and each practice. A skill mix model was advocated, with enrolled nurses and auxiliaries to do tasks under the direction of district nurses (ibid., p. 21).

The recommendations of The Cumberlege Report were incorporated into the 1987 White Paper—Promoting Better Health which was the product of the first ever review of Primary Care Services in the UK. As such, it would prove pivotal in shaping community nursing services going forward since, on the whole, the recommendations of Cumberlege were accepted, in particular the emphasis on effective primary healthcare team working. The review of primary care had been conducted with a view to improving services, raising standards of care, promoting health and prevention of illness, giving patients wider choice and improving value for money. Cumberlege espoused the view that the basis of many improvements was a strong, multi-disciplinary primary health care team, for which roles and objectives were documented and agreed. This was not a new concept as can be seen from previous sections of this report. In conclusion, to the 1987 White Paper, HAs were invited to review:

the organisation of their community nursing services in the light of the proposals in the Report, and make suggestions about possible developments in the range of activities carried out by nurses working in the community. The strengthening of primary health care teamwork is essential if nurses are to be able to maximise their contribution to the provision of better primary health care services. (ibid., p. 58)

At the same time, a working party was also initiated—The Whitley Council—tasked with reviewing nurse’s pay in an attempt to identify a fairer framework for rewarding nurses based on level of clinical expertise and tasks performed, rather than qualifications or level of management responsibility (Gavin, 1995). The outcome was radical and controversial. In April 1988, a clinical grading system was introduced for nurses with grades starting from A up to I. District nurses would start at a minimum of Grade G rising to H and I based on the number of staff managed at Grade G (DHSS, 1988). This would prove an unpopular policy which provoked industrial action and thousands of nurses appealing the grades they believed they were wrongly assigned to (O’Dowd, 2008). However, this was not to be the only time nurses took industrial action. Proposals contained in the White Paper—Working for Patients (1989a)—introducing the idea of marketisation for the NHS (see Chap. 5), also prompted action.

4.1.2 The Management of Community/District Nursing and Population Covered

What of community nursing and the organisational changes? From a re-structuring perspective following the 1982 changes, the responsibility for district nursing often came under Community Units where implemented in DHAs. These were discreet ‘Units of Management’ with their own District Management Teams (DMT) with responsibility for the community services of the district. According to Lorne et al. (2019), existing DMTs District were reshaped and covered what was described as ‘the smallest possible geographical area within which it is possible to carry out the integrated planning, provision and development of health services’ (ibid., p. 35). Nurses held important, senior leadership roles within the unit. Nursing officers reported to Directors of Nursing Services responsible for the overall management and planning of community nursing within available resources.

However, DMTs were subsequently reformed following the 1983 Griffiths inquiry, and the status for senior nurses was lost (Rivett, 1998, p. 355). There was a reduction in the number of District Nursing Officers at the District Health Authority (DHA) level, with the role transformed into a general advisory position and the introduction of general management at the unit level (DHSS, 1983, p. 5). Under the Griffiths proposals, the system of a professional hierarchy for nurses established by the Salmon Report (1966) was effectively superseded by a general management structure with few nurses appointed to these roles.

The Cumberlege Report bought attention to the importance of locally based planning and delivery and the role of community nursing services (DHSS, 1986). The report proposed that nursing services should be organised around specific geographical, neighbourhood patches rather than managed on a district-wide basis claiming that the latter was too large for meaningful interactions to take place (ibid., p. 17). At the same time, the report warned against organising nursing services solely around general practices, as these were not related to a specific geographical area unlike community nursing services that had a responsibility for all residents of a defined area. The argument for geographical coverage was made on grounds of:

  • Nurses would get to know their local patch, including needs and available voluntary/community services and be able to work with them to promote health

  • Same geography as social workers where the report recommended linking to social workers to Neighbourhood Nursing Teams

  • GPs do not cover everyone—there are unregistered patients

  • GPs do not link with local community groups and are not linked to LA

  • Time is wasted in travel

To prevent ‘a wasteful criss-crossing of community health workers’, the report recommended that each District Health Authority would identify within its boundaries an area (or locality) to be used for planning, organising and provision of nursing and primary care services (DHSS, 1986, p. 14). In specifying what this meant, the Cumberlege Report defined an area comprising at the minimum of 10,000, and the maximum 25,000 people. This was to be organised via newly established Neighbourhood Nursing teams (NNTs), covering a defined geographical patch (or Zone) and managed by a nurse manager who was herself district nurse trained (DHSS, 1986, p. 16). The nurse manager would coordinate a wide range of teams most notably specialist care teams, district nurses, health visitors, social services, as well as local voluntary groups, school nurses and other specialist nurses to be attached in some way. Cumberledge was strongly against attachment to general practice and suggested that NNTs have formal written agreements with GP surgeries agreeing the composition and goals of teams and the number of hours nurses are available to provide services in practices. The authors suggested GPs who did not enter into such an agreement would only receive nursing services at the discretion of the NNT manager, and then without any guarantees. As per page 41, ‘We have great sympathy with the view expressed to us by the RCN that as a matter of professional principle, nurses should not be subject to control and direction by doctors over their professional work’. Needless to say, the recommendations of the report proved unpopular with GPs who were vehement in their opposition to it.

The report received mixed reviews prompting some to question to what extent community nursing could be equated with primary care and whether the potential of community nurse manager was overstated (Allsop, 1986). Holmes et al. (1986) proposed that the changes ignored difficulties arising from a need to provide continuity of care to patients who might not easily map onto the neighbourhood boundaries. For Williams and Wilson (1987), on the other hand, the recommendations were unnecessarily introducing another layer of management albeit at the community level. They also pointed out that the neighbourhood units were not coterminous with general practice and likely to overlap with other services, suggesting that contracts rather than a common agreement would need to be in place to manage these interactions. The lack of clear definition of what constitutes neighbourhood and a community is also problematic but tends to be considered as a priori positive thing. Kivell et al. (1990, p. 710) for instance, drew attention to political expediency of the terms with policy makers at the time pursuing decentralisation and ‘localisation of many services with “neighbourhood” as the key unit for service management and delivery’. From a British Journal of General Practice commentary on Cumberledge (Williams & Wilson, 1987), ‘management problems also emerge when considering the proposed agreement or contract between neighbourhood units and practices. The number of agreements necessary with overlapping units and practices would be a bureaucratic nightmare’ (ibid., p. 507).

Despite all of these issues, the concept of a localised, neighbourhood nursing structure appears to have been embraced by those providing services at the ground level and many District Health Authorities had, by 1988, plans to, or had, implemented them (Ottewill & Wall, 1990, p. 433).

4.1.3 Financing Community/District Nursing Services

As a result of the proposals of the 1983 Griffiths Report, there was a change to the way CHS were funded. Instead of receiving budgets apportioned per function (such as for catering, supplies, nursing), they received budgets for the entirety of their operations (Greengross et al., 1999). These ‘fixed-sum’ payments were paid through their DHAs and were increasingly finessed with the introduction of computer-based financial information systems. The increasing cost of financing CHS was, however, a concern for the government, and Griffiths was tasked with a second review as mentioned earlier: Community Care: Agenda for Action—1988 (Griffiths, 1988). This aimed to examine and provide options on both how public funds were being used to support and increase the effectiveness of the policy of increased care in the community (Ottewill & Wall, 1990). Griffiths’ key recommendations predominately focused on the role of Local Authorities in funding, providing and organising personal packages of care in the community using community services. These recommendations did not include medical care, which was to be the responsibility of health authorities. However, as Wing (1988) commented, the two are not divisible. Interestingly, the recommendations of the review were not taken forward into the Working for patients—1989 White Paper which focused on the organisation of hospital and general practice, yet variants were included in the Caring for People—1989b White Paper (DHSS, 1989a—see next chapter).

As for Cumberledge (DHSS, 1986), this report did not make concrete recommendations about levels of resources as ‘it is a matter for individual health authorities to decide what should or should not be the correct balance of resources between community and hospital services and between nursing and other community services’ (p2). Cumberledge was more concerned with the development, management and organisation of the service rather than how it was to be funded, however, the report does go on to suggest that money could be ‘vired’ from hospital budgets and that the additional resources would be found by: (ibid., p56).

  • Saving money by keeping people out of hospital—the money saved by no longer keeping people in hospital unnecessarily could be vired to community budgets such that it is community nurses supporting earlier discharges.

  • Stopping paying GPs to employ practice nurses and shifting resources into community nursing.

  • Better organisation of the service—reduced duplication within NNTs, reduced paperwork and reduced travelling time.

4.1.4 Summary

A period of change in terms of the organisation and management of CHS and indeed the NHS as a whole, but not necessarily for the role of community or district nurses. The emphasis is still very much on care in the community and the role of district nurses in providing this. Greater multi-disciplinary team working between social services and community services was advocated in this era and as a means to reduce costs, and although Griffiths (1988) advocated greater separation between social and health care because of the cost implications—the latter being free at the point of use whilst the former being subject to means testing—this was not taken forward into the subsequent policies of the 1990s.