Hospitals dominate policymaking and media coverage of healthcare, while great developments in community and mental health services are going unnoticed, says Claire Murdoch
Oscar Wilde said there is only one thing in life worse than being talked about, and that is not being talked about. Billions of public pounds are spent on millions of patients, receiving tens of millions of interventions from hundreds of thousands of staff in community settings across the country − and no one seems to know about it. If they do, they are not talking about it.
‘The preoccupation with all things hospital perpetually dominates policies, politics, funding and the media’
This is how I felt having heard the eloquent, engaging and impressive speech given by the secretary of state at the Foundation Trust Network’s conference last month. It was all delivered to the audience in a manner that seemed to assume foundation trusts were hospital trusts, despite the fact that a third of us present were running large community facing trusts.
Care Quality Commission chief executive David Behan gave a similarly intelligent presentation on the aims and objectives of a new CQC. He did at least acknowledge community and mental health services in what he said, but nowhere was it visible in his structure chart, despite spending 10 minutes outlining it to us.
When asked about the fact that the structure has chief inspectors of hospitals, primary care and social care but no visible mental health or community services element, his response was that structures are not important − but what happens to patients is.
Who among us could disagree with that? Except it does matter when you do not appear in a structure that was important enough to be outlined at length as a key vehicle for delivering improvements in patient care.
Of course, the distinguished people in these two examples are in good company, as the preoccupation with all things hospital perpetually dominates policies, politics, funding and the media.
‘The skills of community services staff are the building blocks for a modern, sustainable and patient centred NHS of the future’
The good natured ribbing from my fellow acute trust chief executives about our invisibility and irrelevance made me laugh out loud on the train home from the conference. Except it is not funny and it is not acceptable to ignore the important and skilled work our staff do. Yes, of course it is irritating not to have our efforts recognised and appreciated. But in the grand scheme of things that couldn’t matter less.
What does matter, however, is the failure to see that community and mental health services have developed over the last two decades models of care, skills and competence that enable all manner of services to be delivered at home or in community settings.
These services might be provided to very ill people with complex needs who, for example, are dying at home, recovering from acute surgery or who have complex long term conditions such as mental illness or HIV.
Equally, our public health contributions to childhood immunisation, good parenting skills and one-stop-shop integrated sexual and reproductive health services play an important part in keeping communities healthy. We have recovery colleges, employment schemes, self-help groups, paid peer support workers, electronic CBT manuals for patients with conditions like COPD and so much more.
This year I celebrated my 30th year of working in the NHS, of which I am extremely proud. I began by training as a mental health nurse in a large Victorian asylum in north London. In my very first days I was confidently informed by an eminent consultant not to listen to wild rumours that the hospital would close and care would move into the community. Six years later I had the pleasure, as a ward sister, of being selected to speak at the closing ceremony.
I knew then that we were standing on the brink of a new era in how mental health services would be delivered. Two decades later, we have learned a great deal about community facing, recovery focused models of care.
Integration with local authorities and social care, partnership working with the third and other sectors, and the skills required to properly treat service users in the community have all been hard come by, with mistakes made along the way.
Making new models
We are still not there yet, of course, but there are many parallels with the challenges confronting acute trusts today. And we can be part of helping to develop models of care for the future.
The growing awareness, too, of the huge interplay between physical and psychological health is something that community and mental health trusts across the country are developing new and cost-effective models of care to more effectively respond to, with better outcomes, higher patient satisfaction and more cost effective care.
Behaviour change in populations, greater concordance with therapies in long term condition management and education programmes to enable truly expert self-management by patients… with all this it is hard to fathom why this work would not receive more attention by politicians and policymakers.
‘I object to the work of community nursing staff being perpetually airbrushed out of existence’
I have huge regard for the work of acute trust colleagues and great sympathy for many of the well documented pressures they are under. Winter pressures, A&E and marginal tariffs are but a few. I do not want to be divisive or downplay the challenges they face or the innovations in care they deliver. Community facing trusts have their own challenges such as block contracts, apparent disproportionate disinvestment in mental health services, increasing activity and a highly volatile market with high rates of competitive retendering.
The combined challenges of the acute and community sector have rightly been deemed as requiring a whole systems response and innovation. Community trusts are up for this and have much experience and expertise to share. How then is it we are so often overlooked? The sector itself must take some responsibility. That is why rather than simply venting my spleen over a glass of wine, I have put pen to paper.
Recently I spent time with a group of community nursing staff who were mourning the loss of a child they had helped to die at home two days earlier. They enabled the parents’ wishes to be realised because of their skill and dedication and I object to their work being perpetually airbrushed out of existence. Their skill, and that of their hundreds and thousands of community colleagues across the country, are the building blocks for a modern, sustainable and patient centred NHS of the future.
Claire Murdoch is chief executive at Central and North West London Foundation Trust