A discussion paper
Health and social care are delivered in and across complex systems which span the NHS, local authority, private, independent and voluntary organisations. There are a significant number of registered nurses working in social care roles and settings, however what we mean by social care setting, and social care nursing is hard to conceptualise. There is variation in service organisation, employment and contracts. This commentary raises some of the complexity faced when considering the social care nursing workforce, services, education, and how health and social care are inextricably linked.
Authors
Professor Claire Pryor*. RCN Foundation Chair in adult Social Care. Directorate of Nursing and Midwifery, University of Salford, UK *corresponding author: [email protected]
Professor Vanessa Heaslip. Professor of Nursing and Healthcare Equity. Directorate of Nursing and Midwifery, University of Salford, UK
Dr Melanie Stephenson. Associate Professor (Reader) in Adult Nursing. Directorate of Nursing and Midwifery, University of Salford, UK
Professor Deborah Sturdy. Chief Nurse for Adult Social Care. Department of Health and Social Care
Dr Sarah McGloin. Head of Grants and Impact. RCN Foundation
Conflicts of interest: None.
Contrary to popular belief, not all nursing happens within the National Health Service (NHS), in fact a vast proportion of nursing care is delivered outside NHS services. Gone are the days of the NHS providing ‘a bed for life’ for people who were chronically unwell1 or have long term conditions that need care. A significant amount of responsibility for care services is managed by local authorities, private or voluntary sectors. This is often delivered in partnership with NHS and Integrated Care Boards (England), Health and Social Care Integrated Partnerships (Scotland), Regional Partnership Boards (Wales) and Health and Social Care Trusts (Northern Ireland) reflecting the shift towards managing people’s needs in the community, supporting living well at home, and promoting healthy, individualised, proactive and preventative health care.
It is in this space that we find social care nursing.
In England there are approximately 18,500 separate organisations providing social care services. Between them, they employ around 34,000 registered nurses.2 With the NHS being responsible for ‘health’ and the social care system for ‘care’. You could be forgiven for thinking that as these care organisations employ registered nurses, they must be providing nursing services (which some are) and those services pertain to health (which they do) and that would be free – as is healthcare provided by the NHS. This is the sticking point: unlike NHS care, which is free at the point of need, social care is often means tested.
In England and Wales, people requiring nursing care within a social care setting, may undergo Local Authority, NHS continuing healthcare (CHC) assessments, or funded nursing care assessment. These aim to clarify if a person’s care needs are primarily healthcare, social care or mixed, and works out the proportion of fees to be paid for by the NHS, local authority or the individual. Scotland introduced free nursing care (FNC) and free personal care (FPC) through the Community Care and Health (Scotland) Act 2002. The Scottish legislation ensures that adults who have been assessed as requiring care provided by a nurse should receive FNC3 payments towards their total care costs. Similarly in Northern Ireland, care is supported by Health and Social Care (HSC) Trusts (which is the publicly funded healthcare system, and seen as part of the overarching UK NHS), however it is also responsible for providing social care services too under the Health and Social Care (Reform) Act (Northern Ireland) 2009.
Undoubtedly, the advent of Integrated Care Boards, and services, have made inroads into bringing the two facets of our care provision together, however, in some areas they remain separated and more akin to distant cousins rather than close siblings.
With funding, and place of care being seemingly separating factors, it poses the question of what, for the registered nurses may the difference be between ‘NHS’ and ‘social care’ nursing.
Skills for Care (2019)4 offer a narrative to the ethos of social care nursing, highlighting the enablement of people to live in their own homes, positively, despite complex health needs and/ or comorbidities. They identify that nurses in social care have cross sector working capabilities, and support health within a social model. Seeing not only the health need, but how that need interacts with their social and community wellbeing.
This is echoed by NHS England, who identify: ‘Nurses in social care have distinct expertise. They use their clinical skills to understand the variety of needs of patients, and also deliver relationship-centred support. They recognise the importance of giving each individual a sense of security, purpose, achievement and significance’ (NHS England, no date)5
What is common across both is the use of professional nursing skills to enable people to live well, focusing beyond that of a traditional illness or medical model, but rather a social model which is strength based, and includes health, independence, and wellbeing. Nurses in social care use their skills across a vast range of nursing specialisms, including working with people with a learning disability or autism spectrum disorder, drug and alcohol services, mental health, physical health and long-term condition care, complex domiciliary care, as well as care homes.
How do we define or distinguish between NHS and social care nursing? And should we?
Often social care nursing is defined as focusing on the building of lasting therapeutic relationships, however this and the skills noted above could also apply to many NHS nurses working in community or ongoing care provision. Questions then arise regarding how do we define or distinguish between NHS and social care nursing? And should we?
Reviewing the sector specific literature, government policy, and service models, it seems there is variation in what is seen as social care nursing, and social care nursing provision. We appear confused by the concept, organisation, and funding of adult social care nursing services, but trying to unpick it is perilous. On the one hand, it is distinct in employment contract; NHS services, vs non-NHS. This is purposefully a broad statement, and some NHS services use a social nursing ethos. Then comes the attempts to make distinctions of services including private hospitals, prison nursing, inclusion health, homelessness and outreach nursing services, and care and custody nursing. These may be included, or not, in reports of social care nursing depending on the nature of the organisation, the care provided, sub-contracting, or their ethos.
One distinction could be ‘acute’ health/nursing service requirements, and ongoing care as the remit of social care nursing, another could be location of care; hospital sites, or community settings (own homes, residential homes, care centres or charities), but what then about the NHS Trusts that provide home nursing services, or NHS employed nurses who deliver relationship focused care in the service users’ own home? For example, Dementia UK, a nursing charity, provide Admiral nurses who support families of people living with dementia navigate and manage complex needs of the person with dementia. Admiral nurses may work directly for the charity, or alternatively in a variety of host organisations such as the NHS, general practices, primary care, and hospices6 so may sit within NHS and social care nursing models and pathways.
Social care nurses are often undervalued, and at worst discriminated against by our very own registrants and professional peers
It is a shame to say that incivility has crept into the nursing discourse. Whether from other professions or indeed our own, it is well documented that nurses in adult social care, and particularly care homes can feel looked down upon, seen as ‘less of a nurse’, or devalued in other ways.7 This must stop. Professional snobbery has no place in the health and social care sector or with its registrants. Nurses working in the social sector are skilled, and professionally registered with the Nursing and Midwifery Council (NMC) the same as any nurse, but may take on a level of autonomy and professional responsibility that those working within NHS hospitals may not have encountered.
Consider being the only nurse in your department, building, or even organisation. You are the only nurse on duty for 12 hours, responsible for all your service users’ nursing care needs: if you are unsure, or need support who comes? Who can you talk to at 2am? And if you call someone, will they listen closely and recognise your knowledge of the person in concern, or will they be dismissive, rude or judgemental? Social care nurses are often undervalued, and at worst discriminated against by our very own registrants and professional peers. This appears to stem from a mainstream lack of understanding as to what social care nursing is, and the complex and vital role these nurses play within the totality of the health and care system.
There have been recent inroads into changing perceptions of social care nursing. Significantly the NMC and Queens Nursing Institute (QNI) have recognised the value of social care nursing and its distinct specialism. In 2023, the NMC published the standards of proficiency for community nursing specialist practice qualifications (SPQ)8 which has allowed Approved Education Institutes (AEIs) to design and present pathways for an adult social care nursing within a SPQ for NMC approval. The SPQ in specialist community nursing is one of only a few post-registration recordable qualifications on the NMC register, and as such carries a level of prestige and professional recognition. In tandem with the NMC, the QNI published field specific standards of education and practice for community specialist practitioner qualifications which included adult social care nursing.9 The QNI standards herald a levelling of the playing field for nurses in social care, by mapping the standards of proficiency achieved with in the SPQ to four pillars of advanced practice. In addition, both the NMC and QNI make clear that the programme of study must be post graduate master’s level. This puts adult social care nurse education and career development on the map. A robust and recognised career trajectory is being formed, equal to traditional NHS careers with the possibility for robust, approved, and professionally recognised development. We must strive to promote and celebrate these opportunities.
There are stories of student nurses being actively discouraged from applying for their first roles in social care settings as they will ‘deskill’
AEIs have a significant part to play in changing the narrative around social care nursing. Designing curricular and offering placement opportunities that represent the reality of health and care provision, outside the NHS acute sector, and fully showing the totality of nursing career opportunities. They must prepare students to be ready to enter the nursing workforce, not just the NHS. This though, all too often is not the case. Part of the issue here, is that most nurse academics working in AEIs are from NHS nursing backgrounds. This may negatively impact on curricular design, conceptualisation of nursing role, and perpetuate negative stereotyping. We hear learners being told that they are on their course to work for the NHS. To choose their last placement in the ‘Trust’ they want to work for- not area or environment. There are stories of student nurses being actively discouraged from applying for their first roles in social care settings as they will ‘deskill’. This must change; both for the students and the health and social care system.
We need to value the diversity of our workforce, in its totality. Nursing care is nursing care, different flavours, varieties, shapes and sizes. What remains is it is the care given by a registered nurse. This is all of us. We should be our own champions and champion our colleagues career pathways and choices, not undermine or devalue.
Key to effecting positive change is in understanding that our workforce operates within a health and social care system. Not Health, or Social Care.
We need to understand and champion specialist and advanced nursing roles in social care settings
Primarily, we need to understand and make clear what we mean when we talk about social care nursing, and all the many facets, and faces it has. Currently there is a lack of conceptual understanding in this which must be addressed moving forwards. More clarity should support a better understanding of the who, what, and where of social care nursing moving forward. In tandem with this, AEI’s must ensure that curricula prepare nurses to be workforce ready, to have exposure to, and experience meaningful practice learning in social care settings so they can make an informed choice around where their career paths may lie. We need to understand and champion specialist and advanced nursing roles in social care settings, placing them on a level footing with NHS career frameworks and access to education leading to Enhanced, Specialist, Advanced, and Consultant level nursing roles.
In an era where integration is key, there is a sense that NHS provides ‘health’ and everyone else provides ‘care’. But surely health is care, and care health. If it needs a registered nurse this is about health care (with a capital C), health and wellbeing, and healthy fulfilled lives – in all their shapes and forms. While there are technical divides between NHS and social care nursing in very real terms of contracts and commissioning, we need to push towards a care service where health and social care are siblings, family members around the dinner table: not distant cousins on other sides of the world.
Key points
- Nursing roles span a variety of settings including the NHS, Private, Voluntary, independent and charity sector
- Registered nurses within social care settings manage significant complexity of care needs
- There is a need to ensure social care nursing is seen as equal to NHS nursing
- Education and workforce development must ensure the nurses are ready to enter the nursing workforce, which may or may not include NHS employment.
References
1. Denham M. 2013. As we were in the early post war years – The 1941-1945 hospital surveys. [Accessed 20/09/2024].
2. Skills for Care. 2024. The size and structure of the adult social care sector and workforce in England. Workforce supply and demands trends 2023/24.
3. Scottish Government. 2019. Free Personal and Nursing Care Q & A. Edinburgh: Scottish Government.
4. Skills for Care. 2019. Registered nurses: Recognising the responsibilities and contribution of registered nurses within social care. Skills for Care.
5. NHS England. ND. Nursing in Social Care. Available from: https://www.hee.nhs.uk/our-work/nursing-social-care-0 [Accessed 20/09/2024].
6. Nursing Times. 2022. The journey from specialist dementia nurse to Admiral Nurse.
7. Thompson J. 2018. “I’m not sure I’m a nurse”: A hermeneutic phenomenological study of nursing home nurses’ work identity. Journal of Clinical Nursing, 27, 1049-1062.
8. Nursing and Midwifery Council. 2022. Standards of proficiency for community nursing specialist practice qualifications. London.
9. Queen’s Nursing Institute. 2022. Field specific standards of education and practice for community specialist practitioner qualifications. Raising the standards for people being cared for in the community. London.
