Addressing barriers
Our study identified various barriers to implementing DHA programmes, which are important to address.
Some have been addressed earlier, e.g. lack of joint health and social care leadership, resource constraints,
lack of adult social care commissioner capacity. Others are outlined below.
An important barrier to consider is district nurse capacity, and sometimes resistance. In GM, the DHA Programme lead role was important in building capacity. Together with senior nursing leadership, this also helped to address concerns around delegation and any risk to a district nurse’s registration.
It was very well managed by [lead DN], who’s the team leader, district nurse, but it was in the mix. [It was] an unforeseen issue that we encountered. So, we thought, or at least certainly I thought, social care, I guess, thought that it would hit resistance from the providers, but it actually hit resistance from the district nurses initially…. I think … it was about their professional role, and identity, and all that sort of stuff….as soon as we actually started figuring out how to do it, they didn’t want to do it. And we had to sort of work through that, which, as I say, I think [senior nurse], in a slightly different role to what she’s in now, and [lead DN] did that very successfully behind the scenes.
No district nurses opted out of the successful programmes, though their lack of engagement had been central to the failure of some boroughs to launch programmes. Engaging and supporting district nurses is a critical issue to consider.
Also consider how to engage providers, as their lack of engagement was a barrier. Leadership buy-in was particularly important and smaller, independent organisations were more likely to be involved. The DHA programmes ran mainly in care homes, which reflected their continuity of staffing, availability of peer support and that those requiring insulin administration were clustered there. Engaging larger organisations and homecare providers is essential to wider roll out of DHA. The engagement of larger providers may require additional funding and a national level system for both this and DHA policies may be needed as large providers work across many ICBs. Consideration is also needed to ensure that DHA models address the needs of homecare providers. Both are important to scaling up DHA.
Lack of care worker engagement was a notable barrier. In part, this related to the additional responsibility and lack of confidence, which could often be addressed by training. It also related to lack of increased pay and, sometimes, unfavourable comparisons to NHS pay rates, alongside concerns about delegation of increasing numbers of activities. Roll out of DHA relies on care worker engagement and it is important to address these concerns, particularly pay.
Some carers, initially, didn’t know anything at all about it. They were like, “No, we don’t get paid enough. It’s a nursing job.” I still get that now, but when I tell them more about it, they do understand more… It’s just about explaining it, I think, because they’re frightened initially that it’s a big responsibility
Consider adopting the Enhanced Care Worker role and increasing pay rates.
Care worker turnover also created a barrier in terms of the need for continuous retraining of care workers as existing ones left. Factored this into resource planning.
We have had a few cases where we trained care workers up and they’ve left. It is frustrating, it really is frustrating, but it’s just a consequence of that kind of workforce. So, we just keep going again, training the next ones that come in.
People who use services and their carers have a choice whether or not to accept DHA. While many were happy to do so, others were not. Reasons included: feeling a nurse should undertake the activity; having been told on discharge from hospital that a nurse would undertake the activity; and concerns around care worker skills. Ensure provision of clear and effective communication to build their confidence and understanding and secure their engagement. We provide a leaflet for people who use services and their carers on our project website which may support with this.
Consider how to manage adverse incidents: while these were rare, where they happened, providers tended to withdraw from DHA. However, it is not possible to totally eradicate errors. Support for providers and care workers to manage this risk and continue with DHA is vital.
