Chapter Four: Planning and Developing the Multidisciplinary Workforce – Nursing and Midwifery
- Integrated community nursing teams will play a key role in planning, providing, managing, monitoring and reviewing care, building on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings.
- Nationally consistent approaches to roles and educational preparation for advanced nursing practice, district nurses, general practice nurses, health visitors and school nurses are supporting the development of these integrated teams.
- Programme for Government 2016-17 commits to invest £3 million to train an additional 500 advanced nurse practitioners across primary and secondary care. This will enable nurses across Scotland to maximise their leading role in integrated health and social care of the future.
- We have committed to an investment of £3 million over three years into training and education needs of general practice nursing.
- We will invest an additional £3.9 million over three years into training and education needs of district nurses to help sustain a 24/7 community nursing workforce.
- By September 2018, we will work alongside partners, including the Royal College of Nursing, to understand the requirements and investment necessary to grow the District Nursing workforce.
- An additional 2,600 additional nurse and midwife training places will be created over the life of this Parliament, with a 10.8% increase (sixth increase in a row) in nursing and midwifery student intake places for academic year 2018/19, as a further step to ensure we can recruit and train the next generation of staff.
- We will increase the number of health visitors by 500. This is being supported by funding which has increased over four years to £20 million annually (recurring).
- A marketing campaign will be developed to attract individuals into nursing and midwifery careers and ensure a sustainable workforce is available to meet Scotland's future requirements.
Nursing is the largest occupational group in community care, with approximately 12,000 nurses working in community settings (see Chapter two). As more people with increased complex needs receive care in their own homes and other community settings, the vital role of community nursing as expert nursing generalists is reinforced. Shifting the balance of care from hospital to community and primary care settings at or near people's homes aims to improve population health, increase quality and safety, and secure best value from health and social care services.
More Advanced Nurse Practitioners ( ANPs), District Nurses, Community Pharmacists and AHPs will be required to meet the evolving needs of individual communities and localities. This is in keeping with the National Clinical Strategy  and national health and social care workforce planning. The recent Improving health and social care service resilience over public holidays report  showed that workforce planning and development of extended professional roles within primary care recommended by the Primary Care OoH Review  is underway.
All those responsible for workforce planning should consider the full range of options at their disposal to deal with recruitment and retention issues within their nursing workforce to ensure sustainable 24/7 services. This Chapter sets out the national activity taking place to strengthen the nursing workforce in primary and community care settings, whilst recognising local challenges. Chapters five and six cover general practitioners and the wider clinical and non-clinical workforce.
Maximising the contribution of the nursing and midwifery workforce
The nursing and midwifery workforce will be enabled to work to its maximum capability; to do more or to work differently, reflecting changing population needs or service models irrespective of whether these staff are GP or Health Board employees. Part 1 of the National Health and Social Care Workforce Plan outlined the steps that the Scottish Government is undertaking to ensure that our supply of nurses and midwives meets anticipated future demands.
An additional 2,600 nursing and midwifery training places will be created over the lifetime of this Parliament. These will include a further expansion of training places to provide an additional 1,600 places, to build on the 1,000 extra places already committed to as part of the Programme for Government 2016/17  . This is expected to bring the total number of training places to over 12,000, an historic high which will strengthen the supply of qualified nurses and midwives across health and social care settings.
A further package of measures will extend and increase funding for Return to Practice programmes, enhance access programmes for support workers; improve recruitment, retention and completion rates particularly targeted at remote and rural areas; and support measures to retain and attract nurses and midwives to work in Scotland. These enhanced initiatives are expected to result in a further 1,300 nurses and midwives working in Scotland.
The package of measures will be targeted towards those practice and geographical areas where particular needs are identified, including primary care, mental health, midwifery, maternal and child health, and more remote and rural areas, particularly the North of Scotland. It will be closely aligned to the Chief Nursing Officer's Commission into Widening Participation in Nursing and Midwifery Education and Careers  and will help deliver its recommendations. The report – published in December 2017 – identified best practice and current barriers to nursing and midwifery careers, both in terms of ambition and access, and made recommendations to support and enhance access across the education and employment sectors.
The Commission report also concluded that further action is needed to celebrate the impact and opportunities of nursing and midwifery education and careers and recommended a national campaign to promote career opportunities. We will take forward a campaign later this year with the aims of:
- emphasising the professions' flexibility and extensive opportunities for personal and professional development;
- recognising nursing and midwifery career opportunities beyond the traditional boundaries of NHS Scotland, with a particular focus on care home nursing given increased workforce challenges in those settings;
- tackling stereotypical images of nurses and midwives, creating a more positive professional role model.
As noted in Chapter six, we anticipate that the campaign will be broadened to cover health care careers notably in Allied Health Professions and Health Care Science, given on-going recruitment challenges in these professions.
Good quality primary care workforce data is vital in planning for the future nursing and midwifery workforce. We are aware of the need to strengthen the data we currently collect and our approaches to developing more robust, integrated workforce data are set out in Chapter seven.
Integrated Community Nursing teams
Community nursing can be broadly described as any nursing care provided outside of an acute hospital. This includes healthcare provided in the home or other homely settings, and also in other settings, for example, General Practice, a community hospital, the custody suite of a police station, a school or care home and we acknowledge that not all roles have been covered in this chapter but all make a valuable contribution to improving the health and wellbeing of the people of Scotland.
Integrated community nursing teams will play a key role in planning, providing, managing, monitoring and reviewing care, building on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings. Delivering our aim of shifting the balance of care from hospital to primary and community care settings requires a different approach that enables community nursing staff to develop new and innovative ways of working to provide safe, effective, person-centred care and clinical interventions tailored to meet the needs of the individual.
District nurses, general practice nurses, ANPs and their wider teams working as an integrated community nursing team will provide a seamless interface and reduce any boundaries between their practice and place of care.
Integrated nursing teams are at the heart of the Buurtzorg model of neighbourhood care which has been so successful in the Netherlands. The model involves unhurried visits by community nurses who provide continuity of care and have freedom to work autonomously in small, self-organising teams to develop a flexible range of solutions to meet people's needs. A number of integrated community nursing and home care teams in Scotland are testing the Buurtzorg principles, using the learning to accelerate progress with integration as well as the development of the community health and social care workforce.
Sir Lewis Ritchie's independent review of Out Of Hours emphasised the essential role of district nurses to support 24/7 community healthcare. The review sought to underpin a consistent district nursing role, where nurses have the capacity, capability, infrastructural support and access to resources, enabling them to meet patient need.
In response, the Chief Nursing Officer's Transforming Roles programme has outlined a nationally consistent role for district nurses within integrated community nursing teams  . This emphasises district nurses' leadership role in areas such as anticipatory, palliative and end-of-life care; balancing their role in managing complexity alongside promoting self-care, independence, prevention and community engagement.
District nurses will play a pivotal role in integrated community teams. They will be at senior practitioner level within the career pathway and will be supported by the wider community team, including healthcare support workers, registered nurses and advanced nurse practitioners, to promote health and wellness, enable self-care and deliver personalised health outcomes in people's own homes or communities. Services will be integrated appropriately with social care and other partners and properly signposted to ensure a full range of locally led, co-ordinated, high quality, accessible and well-understood services are in place.
Refocused and nationally consistent core education provision has been developed to support a future-facing district nursing role, with guidance on caseload and resource-allocation agreed to complement the triangulated approach within the nursing and midwifery workload and workforce planning tools.
NHS Education for Scotland is managing a range of activities on behalf of the Scottish Government to support the implementation of the refocused District Nursing role. For example, NHS Boards are being funded to train District Nurses in nonmedical prescribing and Advanced Clinical Assessment modules with 95 training places in 2017/18. A Continuous Professional Development ( CPD) digital resource has also been developed which focuses on the skill required for the refreshed role. The resource has been developed in partnership with District Nurses to ensure the key areas for role development are addressed. In addition local projects within NHS Boards have been funded to support the implementation of the refocused role. For example, NHS Western Isles is testing implementation of the role in a remote and rural setting, and NHS Lothian has developed peer support groups to support roll out of the District Nursing CPD digital resource.
In total over £158,000 has been invested in District Nurse education and CPD in 2017/18. District Nurse education will continue to be a national priority and this is reflected in our investment of an additional £3.9 million over three years into training and education needs of district nurses to help sustain a 24/7 community nursing workforce.
In addition, recognising the importance of the District Nursing workforce in shifting the balance of care from hospitals to community settings, we will work alongside partners, including the Royal College of Nursing, to understand the requirements for sustaining and expanding this workforce. We are committed to undertaking this work at pace and will be in a position by September 2018 to better understand the requirements and investment necessary to grow the workforce. Integration Authorities and NHS Boards retain responsibility for planning and funding District Nurse vacancies and projected retirals from existing budgets.
General Practice Nursing
General Practice Nurses are essential to the future of general practice and are an integral part of the core practice team. They provide primary care services, mainly through direct employment by GPs, with general nursing skills and extended roles in health protection, urgent care and supporting people with long term conditions.
The numbers of consultations for GPNs relative to GPs increased from 28% in 2003/4 to 33% in 2013, illustrating the continued shift of chronic disease management from GPs to nurses  . With the growth in chronic disease prevalence, significant focus on the role of GPN is needed to reduce demand through more effective disease prevention and management including self-management and anticipatory care. The benefits of such an approach are set out in Chapter one.
With a dedicated Community Treatment and Care Service delivered through Integration Authorities, the 2018 GMS contract will support GPNs to focus on a refreshed role in general practice as expert nursing generalists providing acute and chronic disease management, enabling people to live safely and confidently at home and in their communities, supporting them and their carers to manage their own conditions whenever possible.
Over half (53%) of all nurses in general practice are aged 50 years and over. In order to support an enhanced role safely integrated into general practice and to grow the GPN workforce, making general practice an attractive career choice for nurses, under the Chief Nursing Officer's Transforming Roles programme, a short life working group was established in 2017 to refresh the role and educational requirements of GPNs. The overall aim of the General Practice Nursing Group is to scope the current GPN role across NHSScotland Boards and identify areas for developing a refreshed GPN role.
We are investing a further £3 million over a three year period for additional training to enhance the skills of GPNs so that they are better equipped to meet the needs of patients with multiple health conditions, making it easier for patients to access the right person at the right time.
Advanced Nurse Practitioners
ANPs are qualified to Masters level and are competent to work at advanced level as part of multidisciplinary teams across all clinical settings, dependent on their area of expertise. They are clinical leaders with the freedom and authority to act, and accept responsibility and accountability for those actions. The role is characterised by high-level autonomous decision-making, including assessing, diagnosing and treating (including prescribing for) patients with complex multidimensional problems. ANPs have the authority to refer, admit and discharge within defined clinical areas.
To ensure consistency and sustainability ANP roles need to be developed in a systematic way. The Chief Nursing Officer's Transforming Roles  programme has set out a nationally consistent approach to advanced nursing practice. To underpin this, NHS Education for Scotland has produced a Service and Education Needs Analysis Tool  to support NHS Boards/employers to plan, and evaluate the implementation of ANP roles and the education required to support them. NHS Boards/employers have been requested to complete an ANP Education Needs Analysis annually.
ANPs in primary care provide a high quality, responsive service within the MDT context, whilst encouraging career development within the nursing profession. Many of the Primary Care Transformation Fund projects have developed the role of ANPs; an evaluation report from the PCTF will be published later in 2018 setting out key learning from the programme.
The Scottish Government has commitment to investing £3 million to train an additional 500 advanced nurse practitioners across primary and secondary care. This will equip nurses across Scotland to maximise their leading role in integrated health care of the future.
We are also improving data on the availability on the size and profile of the ANP workforce. Statistics on the number of ANPs employed by NHS Boards were published by NHS National Services Scotland for the first time in September 2017  . These data will be published annually, providing a more comprehensive picture of this crucial workforce.
Case Study: Primary Care Advanced Nurse Practitioners
East Ayrshire HSCP is testing a process of development and implementation of Primary Care ANPs in four GP practices. All have completed a post graduate certificate in advanced clinical practice and are working towards completion of a Masters' degree. They have received positive feedback from GP partners and service users. Running in parallel, NHS Ayrshire and Arran have identified and supported a cohort of primary care practice nurses to develop their knowledge and skill set to advanced clinical practitioner, through academic study, supervision, competence frameworks and clinical practice.
ANPs will be developed with generic primary care expertise similar to that of a GP so that they can provide clinical sessions responding to undifferentiated conditions, make referrals, house calls and visit those in care homes, undertake reviews and care for those with long term conditions. Mentoring is provided by GPs in a similar way to that provided to trainee doctors. Competency frameworks and the processes for support and mentoring have been implemented for Primary Care ANPs in conjunction with The West of Scotland Advanced Practice Academy and in line with national guidance.
Children and Early Years
As part of the Transforming Roles programme, work has been completed to refocus the role and visiting pathway for Health Visitors. Focusing on family and child health, prevention, early identification and intervention, Health Visitors play a central role within early years services. They particularly focus on families with children under five years of age and offer universal services to all families whilst offering more targeted support to those families and children in greatest need.
To support and maximise the role and impact of Health Visitors within early years the Scottish Government has made a significant investment of £40 million (including over £3.4 million in health visitor training) over four years since 2014 to enable the number of Health Visitors in Scotland to increase by 500 by the end of 2018. When delivered, this will represent an unprecedented 50% increase in the number of Health Visitors. The Scottish Government will continue to support, develop and invest in career pathways for community nursing.
With a similar focus on prevention, early intervention and support for the most vulnerable, work has just completed to refocus the role of school nurses, increasing their capacity and competency and maximising their contribution as part of multiagency/multidisciplinary teams supporting health and wellbeing and raising attainment of the school age population. This future facing role centres around children, young people and families with additional needs, alongside a number of priority areas (looked after children, mental health and well-being, substance misuse, domestic abuse, youth justice, young carers, homeless families and children, transition periods and child protection).
The Transforming nursing, midwifery and health professionals roles paper on the refocused school nurse role is available at: https://beta.gov.scot/publications/school-nursing-role-integrated-community-nursing-teams/
Supporting the best start in life
The Best Start review  was published in January 2017 and sets out a vision for the future planning, design and safe delivery of high quality maternity and neonatal services in Scotland. It puts the family at the centre of decisions so that all women, babies and their families get the highest quality of care according to their needs. It signals a shift towards relationship based care, with a move towards a continuity of carer model and local delivery of care within community hubs. This will have implications for the midwifery workforce that we will consider carefully.
The role of the nursing and midwifery workforce in supporting and driving the reform of primary care in Scotland is vital. Through significant investment in expanding the workforce and enhanced support for education and training, we will support integrated community nursing teams address the needs of people across a range of community settings.
We are clear that shifting the balance of care will require growth and additional investment in district nurses as key members of integrated community nursing teams. The Scottish Government will lead work alongside partners to understand the on-going requirements and investment necessary to deliver the required expansion of this workforce. There is a need for robust evidence and reliable data on supply needs to support both current delivery and emerging models of care to ensure effective targeting of investment.