Background

Historically, in addition to traditional community nursing teams, new services were commissioned to support specialist care in the community, such as heart failure services, respiratory teams and intermediate care services. Contrary to the structural changes brought about by the Health and Care Act 2022, which were characterised by collaboration and integration, these new services evolved based on contracted commissioning specifications and had an underlying transactional relationship. In the authors’ professional experience, this contributed to the development of a culture where teams were detached from each other, only delivering activities contained in service specifications. As a result, skills such as venepuncture and catheterisation were perceived to be procedures for the community nursing service and no longer recognised as requiring specialist services and intermediate care. Additionally, the growth of specialist services has led to greater depth of knowledge in specific clinical areas, for example Parkinson’s disease or diabetes mellitus, but with a narrower scope in skills and confidence in general community care.

The authors observed that there was a tolerance of task-oriented care in community nursing, with practitioners identifying that they were not allocated sufficient time to undertake comprehensive assessments for complex individuals, for example those with multiple long-term conditions or frailty. This local trend was reflected nationally in research that revealed an increasingly task-oriented care model, practitioners who were hurried and abrupt with patients, a decline in preventive care and a loss of continuity of care (Malbin et al 2016). In 2019, an analysis of what makes an outstanding community nursing service by The Queen’s Nursing Institute and the Royal College of Nursing (2019) found that district nurses were ‘compelled’ to work in a task-oriented way due to a lack of investment in community nursing.

As part of its role as one of ten accelerator sites for delivering a UCR service, the trust committed to investing in the expansion of its current workforce and skills rather than setting up a standalone service. The development of a UCR service as an integral part of a wider community offer was aligned with the move towards an integrated care model. It aimed to provide seamless access to a multidisciplinary team of professionals, optimising the efficiency and effectiveness of the workforce. This approach also reflected the emphasis in national guidance for a two-hour UCR service to use practitioners in an interdisciplinary way, whereby people from other disciplines agree to take on elements of others’ roles to best use their skills and knowledge as a team (NHS England 2022). This was particularly important for older people with frailty, many of whom had complex needs and/or multimorbidity, who would meet the clinical criteria for the UCR service and would be at high risk of hospital admission if they were experiencing a health crisis.

Rather than concentrating on specific roles, a ‘skills first’ strategy was used. The purpose of this was to identify the multifaceted abilities that all practitioners require to function efficiently and flexibly, not to formally redesign roles. The NHS England (2020) People Plan encouraged this shift towards versatility by emphasising the value of developing capabilities and adaptable skills rather than traditionally defined roles. It describes the importance of staff working and learning together in multi-professional teams as critical to keeping patients and staff safe. Figure 1 shows the theory used for developing a versatile workforce.

Figure 1.

Developing a versatile workforce

While the focus of the project at this stage was on skills and not structures or pathways, some of the challenges centred on out-of-date working practices and patterns that did not reflect the requirements of the current healthcare landscape. The project’s focus on skills acknowledged the workforce as the most important resource in the organisation. It was also a response to the widening gap between service demand and delivery that could not be filled by simply recruiting more staff.

Aim and initial steps

The aim of the project was to develop versatile and confident practitioners whose practice was evidence-based and who had the clinical competence to meet the complex needs of older people at home. The starting point was to gain an understanding of the skill mix required to achieve this aim and the current competencies of practitioners working in the community. A peer consultation involving community practitioners enabled the development of a skills matrix that identified the skills required to meet the complex needs of older people with multimorbidity and/or frailty. Between October 2021 and July 2022, practitioners were asked to complete the matrix and assess themselves as competent or not competent and to specify the reason if they were not competent or not using the skill.

The findings of this skills review, along with anecdotal observations in practice, were captured on a spreadsheet. A subsequent analysis of these data provided insight into trends relating to the competence and confidence levels of practitioners and these teams’ attitudes and cultural norms. The analysis produced some rich information on practitioners’ skills and capabilities and valuable insights into why they were not always using some of the skills they deemed themselves competent in. Reasons staff gave for not using their skills included:

The main issues identified from the skills review were:

Development of the Ageing Well programme

The findings from the skills review prompted the development of an education and coaching programme that emphasised clinical curiosity and learning throughout the entire clinical team, with an aim of empowering practitioners to optimise and value their skills. A core feature was registered and unregistered practitioners from nursing and allied health professions learning together, embracing Health Education England’s (2017) philosophy of lifelong, flexible, adaptive and interdisciplinary learning. Registered practitioners included nurses (community, ward, specialist and digital health nurses), nursing associates, occupational therapists, physiotherapists and dietitians. Unregistered practitioners included community support workers, generic therapy assistants, healthcare assistants, assistant practitioners and falls technicians.

Developing a curriculum where unregistered and registered practitioners from different professions would be learning together in a classroom setting required careful planning. To support this, two sets of learning objectives and competencies were developed that were informed by relevant capability frameworks, for example the frailty framework (Health Education England et al 2018), virtual ward and urgent community response (Skills for Health 2022) and the Nursing and Midwifery Council (2018) standards of proficiency for registered nurses.

While it was uncertain how effective this joint learning approach would be, interprofessional and multilevel learning was an important element that would encourage new ways of thinking and challenge norms and working practices in the context of a supportive learning environment.

Structure and content of the programme

The programme consisted of five face-to-face taught classroom days focused on increasing knowledge and skills in a range of subjects relevant to the healthcare of adults with complex needs in the community. All the sessions included the identification and interpretation of symptoms and clinical signs, underpinned by a structured model of clinical enquiry and strategies to promote clinical reasoning and decision-making. There was also an emphasis on skills to support the proactive management of long-term conditions, all with a focus on older people and how to support individuals to age well.

A holistic approach ensured that physical and mental health dimensions were included. Box 1 outlines the content of the Ageing Well programme.

The content took into account the needs of registered and unregistered practitioners and the differing levels of practice and proficiency they required. During the sessions, a clear distinction was made between the actions, behaviours and responsibilities that were within the scope of practice of all practitioners and those specifically relating to registered practitioners.

Following the taught days, participants received place-based one-to-one coaching to reinforce the transfer of knowledge into practice. The trust invested in three clinical facilitators, a new band 7 role that would work with practitioners in the workplace. The ethos was one of ‘being alongside’, characterised by an emphasis on coaching that also provided an opportunity for modelling professional behaviours and standards and challenging cultural norms.

Learning and competence were demonstrated by the completion of an online portfolio comprising ten sections (Box 1). Each section contained a list of learning objectives and competencies, along with content and a range of resources to develop and demonstrate competence. The portfolio was developed not simply as a record of competence, but as a comprehensive resource of learning materials. The online platform used for the competency portfolio enabled real-time editing and facilitated the sharing of further resources and support. Participants could continue to access their portfolio after programme completion, as a record of their competence and to encourage ongoing learning and professional development.

Evaluation of the programme

At the time of writing, 102 practitioners across three cohorts had completed the programme. Evaluation has focused on its effect on the clinical practice of individual practitioners who have completed the training, with interviews conducted with each participant from the first cohort (n=30). For subsequent cohorts, baseline data were also captured at the start of the programme via the questionnaire, which asked practitioners to self-report their levels of knowledge and confidence in relation to the programme’s aims and objectives. The same questionnaire was administered at the beginning of the programme and after the follow-up coaching to assess improvement in participants’ knowledge and confidence. All 102 practitioners completed these baseline and post-programme evaluation questionnaires. During the place-based coaching, further insights into the effect of the programme were gained from the clinical facilitators, who received informal feedback from managers, team leads and the wider teams in which participants worked.

Consistent feedback was received that, following completion of the programme, participants were less task-oriented when they visited patients, using new knowledge and skills that enabled them to identify subtle changes in patients’ conditions and provide timely preventive care and advice. One allied health professional who completed the programme said:

‘The programme gave me the knowledge and confidence to be able to support my patients to age well, regardless of their age. It has brought forward in me a different way of thinking, treating and assessing older people.’

The clinical facilitators who were accompanying practitioners on their visits identified that, after completing the programme, the practitioners were able to ‘do more’ for the patients they visited and were more confidently able to draw from a wider skills base. They also observed that a shift in mindset towards a more proactive and holistic response had taken place among those who had completed the programme. This was demonstrated primarily by their more thorough ‘top-to-toe’ assessment skills, which enabled practitioners to explore potential underlying causes for patients’ presenting signs and symptoms and to integrate elements of preventive healthcare.

When comparing baseline and post-programme evaluation questionnaires, registered practitioners demonstrated improvements in their levels of knowledge, skills and confidence, which enabled them to do more for patients and increased their job satisfaction:

‘I now have a better understanding of how medications can impact older people and always check whether a medication review would be beneficial to see if deprescribing may be an option.’ (Cardiac specialist nurse)

‘It has had a fantastic impact on my role. My assessments have improved tenfold. I provide more in-depth holistic care and have been sharing this within my team to ensure we are making the most of our visits and stopping the scattergun approach to referrals.’ (Community nurse)

Unregistered practitioners also demonstrated improvements in the questionnaires, with one community support worker stating:

‘It’s completely opened up how I work and how I look at things. Doing a top-to-toe assessment during each visit is really important. I’m now more aware of what to look for, picking up subtle changes in the patient’s condition and providing preventative care and advice.’

However, there were some differences in relation to specific components, for example malnutrition and falls assessments. Interviews with the participants identified that these differences were mainly due to inconsistencies regarding the skills that unregistered practitioners were permitted to undertake in different teams, rather than a lack of knowledge and confidence. One issue highlighted by the programme was discrepancies in the scope of roles, particularly for unregistered practitioners.

Many unregistered and registered practitioners expressed how the programme had reinvigorated their desire for learning. Observations by clinical facilitators in practice found that unregistered practitioners wanted to develop their skills and be able to do more for patients. Furthermore, team leads and managers said they had noticed a difference in members of their team who had completed the programme, specifically in relation to their holistic approach to patients and the move away from a task-oriented model.

Beyond the teams directly involved, other teams reported improvements in the quality of referrals they received. For example, practitioners described making fewer referrals to GPs and specialist teams, recognising an increase in their clinical autonomy. Post-programme interviews with participants identified that, overall, it had created ‘curious’ practitioners who wanted to enhance their learning and understanding. This was notable among the unregistered practitioners, many of whom reported feeling more valued as part of the team following the programme. Furthermore, it was identified that both registered and unregistered practitioners were sharing their learning and influencing the working practices and culture of the individuals and teams they worked with:

‘I am now more confidently able to apply evidence-based strategies in my practice. As part of the programme, we learned about the importance of nutrition. I used this knowledge to generate an evidence-based resource pack for patients, to promote the importance of protein in wound healing.’ (Nursing associate)

Costs and other resources

The initial start-up costs for this project were measured more in time than in direct financial input, as the design and development of the skills matrix and the curriculum were undertaken alongside existing roles. While it is challenging to determine exactly how much time this took, the overall timescale of this phase was approximately 12 months. The skills matrix and curriculum are now available as resources and may be adapted for any local context.

Three clinical facilitators were employed to provide place-based coaching as part of a wider role in facilitating learning and quality improvement in practice. The expertise of the programme clinical lead (MP) and trust-employed specialist practitioners was used together with the clinical facilitators to support the five taught classroom days. While new roles such as that of the clinical facilitator required investment, one of the main strengths of the ‘skills first’ approach is its focus on maximising the skills and potential of the existing workforce rather than recruitment of additional staff.

Finally, an emphasis on place-based learning minimises the number of days that practitioners need to be released from their duties to attend classroom-based learning.

Challenges during the project

The initial work of gathering baseline skills data via the skills matrix and review was time-consuming and took significantly longer than expected, primarily due to service pressures. In addition, it was challenging to engage some of the practitioners in a process that some approached with suspicion.

Accessing the online competency portfolio and resources was a challenge for some practitioners who were less familiar with the platform used and/or had limited information technology (IT) skills. Some practitioners had not undertaken any classroom-based learning for some time and needed support to complete the online competency portfolio. The importance of effective design, development and IT support should be recognised, and the success of the project was due in large part to the commitment and tenacity of the programme support manager (SB).

It is important to recognise that the challenges in using a ‘skills not roles’ strategy often related to the systems, cultures and practices in which the skills and capabilities were used. Therefore, it is not possible to undertake any meaningful skills and capability-based work without exploring these systems, cultures and practices.

The challenges that occurred during the project offered some insightful information for individuals and the organisation. Some practitioners were initially concerned about being expected to perform tasks they felt were outside of their scope of practice. Examples of this included nurses carrying out reablement, which they perceived to be a therapist’s role, or therapists undertaking clinical skills that they perceived to be nursing tasks. Other practitioners expressed concern that, due to their high workloads, they were learning new skills that they would not have time to use. As the curriculum progressed from the teaching days to the completion of the portfolio in practice, these anxieties lessened. Practitioners could see the advantages of learning new skills for their patients, and they reported an increase in job satisfaction because of their improved ability to take the initiative and act with more self-assurance. At an organisational level, areas were identified where the efficiency and effectiveness of teams could be improved, for example by ensuring consistency in the scope of skills in the same roles.

The clinical facilitators provided support in overcoming challenges that the individual or team encountered, whether these were practical issues, such as accessing the portfolio, or role-specific concerns. They were also able to support participants to apply and embed new knowledge and skills into their practice.

Next steps, sustainability and scaling

At the time of writing, the programme has been developed and tested in adult community services, in line with organisational priorities. This has demonstrated its potential and scalability. Future aspirations include extending the programme to primary care, social care and private providers of nursing and residential care.

An important next step will be to evaluate the effects of the programme from the patient perspective, ensuring that the measures used reflect what older people consider important. To do this, an evaluation will be conducted using a qualitative and appreciative enquiry approach, drawing on the findings from a report commissioned during the UCR accelerator phase (Healthwatch Cornwall 2023). Interviews with 20 older people who had received a UCR visit were conducted, in which they identified their healthcare priorities as (Healthwatch Cornwall 2023):

Learning points from the project

The primary aim of this article is to share knowledge with organisations who want to replicate the Ageing Well programme, or elements of it, in their services. The main learning points from the project are shown in Box 2 and may serve as a guide when considering its implementation. For further information about this project, please email: cft.ageingwelldevelopmentteam@nhs.net

Conclusion

The establishment of a community UCR service prompted the creation of the Ageing Well programme of learning. The programme was designed to equip multidisciplinary teams in adult community services with the knowledge, abilities and self-assurance they needed to maximise the health, happiness and independence of older people with a variety of complex needs. To meet this need, organisations should invest in the abilities and skills of their current workforce to reflect contemporary patient profiles and the move towards more community-based care. Workforce development strategies where the focus is ‘skills not roles’ are a necessary, practical and achievable response to this need.