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How can we move care into the community if there are no nurses to provide it?

  • Comments (11)

If it feels like governments have been discussing the shift towards providing a greater proportion of healthcare outside of hospitals for years, that’s because they have.

When Labour came into power in 1997 it set out to give primary care a lead role in commissioning and providing services with Our Health, Our Care, Our Say. Nine years later it tried again with Transforming Community Services; like its predecessor, this initiative failed to achieve the government’s aims.

Fast forward to today and the latest government initiative, the Better Care Fund, is in trouble before it has even launched. The Cabinet Office has demanded more robust evidence on how the promised cost savings will be achieved.

I don’t underestimate the enormity of the task of shifting services out of hospitals – particularly if social care is also to be integrated, but it mustn’t be dropped because it’s too difficult.

We know hospital care is expensive, we know patients prefer to receive care at home where possible, and we know that the lines between health care and social care are often blurred. Properly integrated care provided wherever is most appropriate would be cost-effective and popular with patients and their families.

However, “cost-effective” doesn’t necessarily mean cheaper, particularly in the short term when new services need to be up and running before the old ones can be remodelled or dispensed with. And it’s not just about where you put the money – expanded community services need more staff to run them. So why did the district nursing workforce shrink by 40% in a decade while successive governments talked about expanding community services? Surely these nurses will be crucial, however new services might be configured?

The revision process for the Better Care Fund should include an investigation into how to rebuild community nursing services. If care really does transfer into the community, unless they have the support of these highly skilled practitioners patients with long-term conditions will simply end up needing hospital care that no longer exists.

  • Comments (11)

Readers' comments (11)

  • Of course the registered and specialist DN services were essential, especially those with proper DN qualifications. The training could've been improved with more attention to dementia and mental health issues in general, but it was cut back instead.

    Governments of both main parties were to blame. They opted for the local authority care services model of dressing unregistered staff up to look like they had enough nursing staff and counting them under the category of 'nursing team' when they knew little or nothing about how to provide effective care to patients.

    Managers in acute hospitals don't bother much with community services and they're hived off to other agencies whenever possible. As result, the services are now impoverished to the point where out of hours GP have only one choice with frail older patients and those with chronic conditions - admit or not admit.

    This means frail patients face repeated long waits in A&E and repeated failed discharges from acute hospitals. It's dangerous for them and desperate for their carers.

    It's time to recreate decent district nursing services throughout a NATIONAL health service.

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  • Anonymous

    While our local DN service hasn't grown much in a decade it has grown slightly but in terms of community nursing overall we have an increase of around 40%. Our community nursing service now includes community matrons, rapid response acute care nurses [24/7] and a multi disciplinicary team of which the biggest discipline is nursing [24/7].

    District nurses must ask themselves why these other services have come into being. What trick did they miss? Would it have been so bad for them to have incorporated advanced practice clinical skills into their practicc, or community administration of intravenous drugs and what of true case managment as opposed to case load holder?

    Practice nurses too must wonder whether they haven't missed something. In our area some never leave the practice. Have we fragmented care by them being heavily involved with chronic disease management up until the point the patient is housebound and their care transfers to district nurses.

    District nursing shines in so many ways, perhaps particularly in palliative care, but my point is has a trick been missed in service and practice development - and sadly so in emerging as leaders of community care.

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  • michael stone

    The title of this piece mirrors a comment I've made many times.

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  • Anonymous

    M. Stone

    perhaps in that case you can offer your services.

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  • michael stone

    Anonymous | 17-May-2014 9:47 pm

    The public is expected to offer opinions and feedback (see the NHS Constition) - it is the professionals who offer the services.

    Or in the case of DNs who aren't there to provide a service, do not offer their services.

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  • Anonymous

    michael stone | 18-May-2014 12:23 pm

    does that mean you suggest what others should do whilst refusing to offer your own services?

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  • michael stone

    Anonymous | 18-May-2014 5:22 pm

    It means what I wrote - what I wrote, is clear enough.

    Only a nurse, can offer services as a nurse - however, anyone who is a user of the NHS, is in principle encouraged to provide feedback about NHS services/behaviour. This is PARTLY because professional and lay 'perspectives' can differ (everyone is 'blinkered', but the 'bits of the scene blanked out from view' are different for different observers).

    Although as I 've just pointed out to the 'Public and Patient Engagement Officer' of my local CCB, it isn't always easy to work out to whom such feedback should be addressed, let alone to get it 'listened to'.

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  • Anonymous

    michael stone | 19-May-2014 11:21 am

    not sure what you wrote. it makes little sense.

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  • tinkerbell

    michael stone | 19-May-2014 11:21 am

    it's highly unlikely anyone is listening to anyone who knows what's going on, if they're not listening to frontline staff you can rest assured they are not listening to you. Whatever makes you think they would given the evidence to date? The listening exercise was a lip service, soundbite. Get real!

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  • tinkerbell

    P.S. Mike, sorry to sound so harsh but action is what we need!

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