Two reports on community health services were published last week. First, came that from NHS Providers on the current state of community services, based on a survey of more than half of community providers. It calls for three immediate actions: greater financial investment, prioritising community services at national and local levels, and addressing staff shortages in key roles.
The actions highlight the pervasive lack of understanding of community services in England, which could be improved with new benchmarking data recommended in the second report, which came from NHS Improvement. Focused on NHS operational productivity and unwarranted variations in community health and mental health services, Lord Carter’s report identifies where savings can be made, and recommends that productivity savings be reinvested in community and mental health services.
Standardisation and reducing unwarranted variation can be mitigated in at least two areas: by investment in new technology and software to support efficient and productive mobile working of staff in the community, and by investing in education and training of nursing staff in the community. This is a source of significant unwarranted variation so investment in the highly skilled nurse-led services in the community can help address it.
The missed opportunity of Lord Carter’s report is that there is no recommendation for a clinical community services director to be appointed at NHS England, alongside the clinical leads for mental health, primary care and hospital services. Such an appointment would be the perfect way to address the lack of understanding around community services.
The reason given for this omission was that it would further divide services and be at odds with the Department of Health’s integration agenda. For some, integration has been poor, feeling more like a hospital takeover of community services. A helpful change of mindset would prevent the hospital being seen as the ‘mothership’, with all other services somehow subsidiaries to it. It is not a competition between hospital, mental health, primary care and community-based services – they are different services equally deserving of understanding, funding and workforce planning. Having a lead in NHS England with a deep understanding of the complexities of community services would address the current inequity, and provide parity of esteem and intelligence to support the integration agenda.
Where NHS services have been successfully combined, patient focus has improved. To say a clinical director of community services would reinforce divisions is to misunderstand the critical nature of community services to the people served. Last week, I met a recently bereaved daughter who witnessed superb nursing care of her mother in the last weeks of her life. She was in disbelief when I told that, after this year, Health Education England would no longer support district nurse training. She had seen first hand the orchestration of care led by these specialist practitioners, who ensured that the needs and wishes of her mother and family were met at every step. Her mother had a good death; her family will always remember the skilled, holistic person-centred nursing care they received.
We should ask patients and their loved ones about their experiences of community services when we are seeking to reorganise, reconfigure and restructure – and making decisions to intentionally disinvest in the education of those expert nurses who are critical to delivering care in the home.
Crystal Oldman is chief executive, The Queen’s Nursing Institute.