Facing the Future as One Service

Margaret Devonald-Morris, Service Delivery Manager

Hywel Dda University Health Board


Hywel Dda's Children’s Community Integrated Nursing Service has been a pilot project bringing together two small nursing workforces, generic and continuing care into one community team. It has also allowed a separated assessment capability which focuses on needs assessment & care provision recommendations from care package management.


Hywel Dda University Health Board is the second sparsely populated Local Health Board in Wales serving a 0-18 years population of 71,058 across the counties of Carmarthenshire, Ceredigion and Pembrokeshire.

Starting Position, February 2016

Children’s Continuing Care Nurses x 3 managed by one team leader:

  • 1 based in Ceredigion

  • 1 based in Pembrokeshire

  • 1 based in Carmarthenshire

The nurses undertook the continuing care assessment process and managed a total of 16 packages averaging 800 care hours/week delivered by the third sector. Seven packages located in Carmarthenshire, six packages in Pembrokeshire and three in Ceredigion resulting in the Ceredigion nurse having to travel from North Ceredigion to manage a package in both Pembrokeshire and Carmarthenshire. In addition there was one WellChild Transitional Care Nurse based in Carmarthenshire working across both services.

Generic Children’s Community Nurses x 6.5:

  • 3 based in Pembrokeshire of which 0.8 was the Team Leader

  • 3 based in Carmarthenshire of which 0.2 is the Practice Teacher

  • 0.5 based in Ceredigion

A caseload of 270 children and young people (CYP) across the three counties with varying health needs including long term, life limiting and complex health needs. A number of the CYP were defined as being inactive i.e. no nurse contact for 4 weeks. In Pembrokeshire there is an additional 0.48 nursing post funded by education-based in specialist school. Due to the Children’s Continuing Care Team Leader securing another post led to a review of how the workforce continues to meet its service demand.

It provided the opportunity to pilot the integration of the two small nursing workforces and funding to recruit 1.26 WTE Band 5 nurses and additional 5 hours for the Team Leader post. Agreement from the nursing workforce and planning for the pilot began in February 2016 with the start of a six-month pilot from March 1, 2017. Participatory action research approach was applied as a reflective process of progressive problem solving.


The planning process involved the team undertaking an analysis of the strengths, weaknesses, opportunities and threats, barriers and counter measures leading to the development of pilot objectives, education programmes, a review and development to the teaching library resource and the implementation of a single nurse assessor role for the continuing care process. Nurse bases were reviewed with two sites in Ceredigion-north and south, two sites in Carmarthenshire-east and west, and two sites in Pembrokeshire-mid and south.

The development of a traffic light system provided a risk framework to support the delivery of an equitable, safe and sustainable children’s community nursing service.


  • The risk framework facilitated implementation of the centralised referral system;

  • Initiated the pilot of a nurse led clinic service for CYP requiring overnight oxygen saturation monitoring Instead of receiving home visit by a nurse, the CYP attends the clinic to collect and return saturation monitor the next day for the nurse to download their recordings for review by the prescribing doctor.

At the end of the six months, there was agreement that we cannot return to being two teams, maintain the nurse assessor role and review in 3 months.


  • The pilot facilitated the development of an in-house education programme, mentoring/buddy system to support the development/updating of nursing knowledge and skills;

  • The integration of two small nursing workforces maximises clinical capacity by having nurses based across six sites;

  • The risk framework promotes the identification for the right practitioner, providing the right care at the right time and right place, acknowledging the need for further service mapping.

Part of cohort Bevan Exemplar Projects 2016-17