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In this chapter we introduce the background and rationale for our historical review of community nursing services through the lens of health policy. We provide the research questions the review is based on and detail the topic themes used to structure our answers to these questions. We have considered policy relating to community nursing services over seven eras from 1948 to the present day and each subsequent chapter details this. A definition of community/district nursing used for the purposes of the review is provided, as well as an outline of the structure of the chapters and the book. Each chapter will follow a consistent format: Historical context The role and function of community/district nursing services The management of community/district nursing services and the population covered Financing community/district nursing services Summary

In this chapter, we detail the first major re-organisation of the NHS since its inception and the consequences for community nursing. The 1974 wholesale re-organisation was born out of frustrations with the management and fragmentation of services resulting from the tripartite system. Services were bought together in a unitary model, centrally controlled but geographically organised. Local Authorities (LAs) were divested of many of their healthcare responsibilities including community nursing, which was transferred under the responsibility of newly created Area Health Authorities (AHAs). There was optimism that bringing community nursing under the NHS umbrella would foster a new era of co-ordinated working between all disciplines in the system, such as hospital nursing. Unfortunately, many of these intended aspirations were not realised despite the importance of the service to policy agendas emphasising integration, out-of-hospital care and prevention of ill health. In terms of managing and financing the district nursing service, this was not simplified by the re-organisation and population coverage continued as a mix of geographical and attachment to GP services. We conclude this chapter by emphasising the increasing demand for community and district nursing services. It became apparent in this era that the re-organisation did not bring any significant improvements and thus the attention shifted again towards organisational and management solutions to the NHS’ problems.

This chapter centres on the publishing of the NHS Long Term Plan in 2019 and subsequent revised Health and Social Care Act (2022), both of which focus on integrated, out-of-hospital approaches to health service delivery. The creation of a layered system across geographical levels is advocated, with nested levels of ‘place’ and ‘neighbourhood’ intended to be the building blocks of Integrated Care Systems (ICS), which replaced CCGs in July 2022. We introduce the concept of newly created, ‘neighbourhood level’, Primary Care Networks (PCNs) of general practices and how district nurses fit into them, especially with regard to their organisation around geographical versus GP registered lists. Whilst not explicitly mentioned in the H&SC Act, it is clear that the Act situates community-based services as essential in the context of the desire to reduce the amount of hospital care, which has implications for district nursing services in particular. This mode of care delivery will require multi-disciplinary team working across all levels of the new system whereby community nurses will be required to liaise and co-ordinate with primary and social care to deliver services. Continuance of case management approaches for patients with complex needs and lack of funding in the social care system, means that we discuss in this chapter, the further strain on already pressured community nursing teams.

The National Health Service and Community Care Act 1990, set in motion by the publication of the 1989 White Papers—Working for Patients and Caring for People, saw an intense time of policy change which would profoundly impact community and district nursing services. These papers ushered in the introduction of the internal market with purchaser/provider split between commissioners and providers of services, aiming for better services, better patient choice and to reduce costs. This chapter focuses on how the NHS was re-structured to facilitate this quasi-market organisation with Health Authorities (HAs), once pivotal, replaced by Primary Care Groups (PCGs) at the end of the decade. We document here the impact of these changes on the district nursing service as well as bringing to the fore that it was a service in crisis and in need of attention. Heavy caseloads coupled with a diminishing workforce led to a review of the grading system and an increasing use of ‘skill-mix’. We also highlight that aligned with internal marketisation ideals, funding of community services was based on a crude count of average number of contacts rather than based on the complexities of the role. As ever, there was a need for district nurses to ‘deliver more for less’ (Audit Commission, 1999, p. 94) at the end of the era.

In this final chapter of the book, we return to our original research questions and draw together our findings, looking across the eras to illustrate how the policy changes of the past have defined the services of today and the future. We show how, over time, there has been a consistent pattern in policy by which community nursing services are rarely the focus of policy. Rather, changes have occurred in policy which have had a knock-on effect on Community Health Services (CHS), and these effects have often been to their detriment. In the conclusion, we offer observations on the incoming policy changes in 2022 (H&CA, 2022) and suggestions for future research. Proposals for the development of Integrated Care Systems (ICS) offer both opportunities and threats to the provision of community nursing/health services—the former from more investment or the latter from being dominated by larger acute services. Our main concern is there is a danger that the voice and needs of CHS will yet again remain unheard and un-regarded.

Taking the first era from the inception of the NHS through to 1974, this chapter documents the establishment of the service as a home nursing service. Known as the ‘tripartite era’ because of the way provision of health services were divided between three types of bodies—Local Authorities (LA), Executive Councils of the Ministry of Health and Hospital Boards—this era would see a split enshrined between LA-provided community nursing services and medical services provided by the others. This split has been a feature of the NHS ever since, despite successive unifying re-organisations of the health service, and has come to define the way community nursing is perceived by policy apparent in this review. In line with the format of the chapters, we start to look at the role and function of district nurses (DNs) and begin to see how the role was focused on home care for the sick, management of infectious diseases and supporting doctors. We also begin to examine how DNs were managed and paid for and identify the enduring tensions in how they are organised—either geographically or attached to GP practices. We conclude this chapter with a brief paragraph summing up that for this era the role of district nurse services, despite becoming a national requirement, is rarely fully set out in policy. In other words, the district nursing service was largely invisible in policy terms.

The new millennium saw the publication of The NHS Plan in 2000, which bought a welcome focus to community health services (CHS) and the role of community nursing. We outline the proposals contained in the plan which furthered the quasi-marketisation of the NHS and increased commissioning of health care at the local level of Primary Care Trusts (PCTs)—replacing Health Authorities (HAs) and Primary Care Groups (PCGs). A further review by Lord Darzi and subsequent policy, Transforming Community Services: Enabling new patterns of provision (DoH, 2009) instigated the separation of commissioning/provision and laid out timetables for how PCTs were to do this. The long held roles of the district nursing service continues in this era, although not always clearly defined, understood or acknowledged and policy attempts to expand their remit feature heavily. This included more clinical tasks as well as focusing on such things as public health/health protection and promotion programmes that improve health and reduce inequalities. This chapter also describes the uncertainty for frontline nurses that the Transforming Community Services (TCS) brought in terms of who their employer would be or what management arrangements they would work under given the establishment of some standalone Trusts, some third sector and some combined acute/community Trusts. The aims of the TCS programme were bold but in reality achieved little by the end of the era.

A change of government in 2010 brought fresh NHS reforms and a new Health and Social Care Act (HSCA, 2012). Both, along with the 2014, Five Year Forward View (NHSE) set the tone for this Chapter. We discuss how the continued emphasis on competition between providers, and the introduction of Clinical Commissioning Groups (CCGs) which replaced Primary Care Trusts (PCTs) as commissioners of community services, impacted on community nursing service management and delivery. Policy shifted in favour of a more co-operative approach to service provision and familiar agendas were set out for keeping people out of hospital with reform based around integration between health care sectors and between health and social care services. There was little change on the ground for district nurses in this era despite increasing emphasis on integrated care, collaborative, cross-sector working (i.e. with LA social care) and multi-disciplinary team management of complex patients. The HSCA 2012 began to unravel almost as soon as it was enacted, with the emphasis on competition undermined by the Five Year Forward View shift towards integration between sectors as a dominant organising principle. Community Health Services (CHS) were, to some extent, protected from the fragmentation associated with the Act, and in terms of district nursing practice, this era generated little change with patterns of service provision remaining very much as they were following the upheaval generated by the Transforming Community Services agenda.

This was another period of churn for the NHS. First, the service endured another restructuring exercise, reducing hierarchical layers to 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 influential Griffiths Report in 1983. This marked an important phase in the NHS in which a clearly defined management function was implemented to improve efficiency, planning and accountability but bought shifting sands to the way community nursing services were managed. A review of community nursing services in a similar vein, The Cumberlege Report (1986), also proved significant. We focus on the recommendations of this report for improving the role and function of district nursing services and their geographical deployment to strengthen the concept of a localised, neighbourhood nursing structure. Whilst this was a period of change in terms of the organisation and management of Community Health Services and indeed the NHS as a whole, the core role of community or district nurses remained as one of care in the community but with an emphasis on greater multi-disciplinary team working.

Chapter 8 reports research on the changing role of commissioning in the restructured public health system. The chapter will discuss how public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. It will focus on discussing how the re-organisation substantially changed the way public health commissioning is done, who is doing it, and what is commissioned, since the reforms. There have been significant changes in commissioning processes, with important consequences for what health improvement services are ultimately commissioned. Also new opportunities for creativity and joining public health with wider determinants of health (e.g. housing and leisure).

Chapter 5 reports research on the more recent policy of allowing CCGs to commission primary care services. In 2014 CCGs were invited to volunteer to take on responsibility for commissioning services from their member GP practices in addition to their wider responsibilities for commissioning acute and community services. In this chapter we explore the history of primary care commissioning and financing in England, and discuss the broad policy objectives which underpinned this significant change in CCGs role and scope. These objectives include the need to move to a ‘place-based’ approach to commissioning, and the need for a more effective linkage between the commissioning of primary and secondary care services in order to support movement of services into the community. Over time, most CCGs have moved to take on full delegated responsibility for commissioning GP services, and have established functioning primary care commissioning committees, with little evidence of significant problems associated with conflicts of interest. The development of local additional ‘quality contracts’ and investment in infrastructure and premises have been important issues, with few CCGs seeking to establish larger scale contractual changes. There have been significant local legacy issues in some areas relating to unclear contracts and poor handover of responsibilities from NHS England. The current legislation, under which statutory responsibility for commissioning primary care services remains with NHS England and is delegated rather than transferred to CCGs, presented some problems, particularly for those CCGs who wished to work together across a broader geographical footprint.

High quality primary care services are an essential part of a successful health service. However, the planning and management of such services is complex. Using evidence from a study of recent extensive changes in the English NHS we highlight the need for local service oversight by managers who understand local conditions and needs. We also suggest that the recent English experience supports an incremental policy adjustment approach rather than wholesale organisational change.

ObjectivesFrom April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.DesignWe carried out two telephone surveys using a sample of CCGs. We also used a qualitative case study approach and collected data using interviews and meeting observations in four sites (CCGs).Setting/participantsWe conducted 57 telephone interviews and 42 face-to-face interviews with general practitioners (GPs) and CCG staff involved in primary care co-commissioning and observed 74 meetings of CCG committees responsible for primary care co-commissioning.ResultsConflicts of interest were seen as an inevitable consequence of CCGs commissioning primary care. Particular problems arose with obtaining unbiased clinical input for new incentive schemes and providing support to GP provider federations. Participants in meetings concerning primary care co-commissioning declared conflicts of interest at the outset of meetings. Different approaches were pursued regarding GPs involvement in subsequent discussions and decisions with inconsistency in the exclusion of GPs from meetings. CCG senior management felt confident that the new governance structures and policies dealt adequately with conflicts of interest, but we found these arrangements face limitations. While the revised NHSE statutory guidance on managing conflicts of interest (2016) was seen as an improvement on the original (2014), there still remained some confusion over various terms and concepts contained therein.ConclusionsDevolving responsibility for primary care co-commissioning to CCGs created a structural conflict of interest. The NHSE statutory guidance should be refined and clarified so that CCGs can properly manage conflicts of interest. Non-clinician members of committees involved in commissioning primary care require training in order to make decisions requiring clinical input in the absence of GPs.

Background The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.Methods We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two timepoints, and in-depth case studies in five purposively selected geographical areas.Results Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint. Conclusions Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

On 23 October 2014, NHS England Chief Executive Simon Stevens published a new 5-year plan for the NHS. Highlighting the challenges facing the NHS associated with an ageing population, the document argues: ‘The traditional divide between primary care, community services, and hospitals — largely unaltered since the birth of the NHS — is increasingly a barrier to the personalised and coordinated health services patients need .’1 It then goes on to discuss what models of care might look like under the plan. The focus is on integration and collaboration, eschewing further structural change but highlighting the potential of new service models which bring GPs together with a wide range of other providers, including community, social, and acute care services. Moving care closer to patients’ homes is highlighted, with vulnerable patients cared for proactively by multidisciplinary teams. None of this is new. GP fundholders pioneered better access to diagnostic tests and outreach by hospital consultants in the 1990s,2 while the 2000s brought Community Matrons, Virtual Wards, and Models of Case Management.3 However, integration between primary and community health services (CHS) has not been easy to achieve,4 and it is far from clear that such service models can, in fact, reduce costs.5 Against this background, an extensive review of existing literature was conducted to explore what factors should be taken into account in planning for primary care and CHS to work more effectively together. Starting with interdisciplinary healthcare teamworking (the micro-level), evidence was examined across all levels of the current care system to account for the diversity of the services. At the meso level (that is, …

Background Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013.\ud \ud Methods Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent.\ud \ud Results The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services.\ud \ud Conclusions There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective.