There has never been a better opportunity for community health services to demonstrate and evidence the significant contribution it can make to the transformation of healthcare across the system, writes Tracy Taylor.
By its very essence, community healthcare is fully engaged with each patient’s life; fully focussed on that individual, their home, their family. The relationship that develops is different, wider, deeper to that in the hospital environment where, necessarily, the needs of the patient must compete with the practice and routine of the institution to be the key driver of care.
The majority of NHS care is provided in people’s homes and communities. More than 250,000 people are employed to deliver those services in England. Yet the profile of community healthcare does not reflect the reality of this position of strength, particularly when compared with the relative intensity of the emotions invested in hospital buildings and services.
Community health services are provided for everyone; wherever and whenever they are most needed. From hospital to home; from health centre to high school; from shopping precinct to prison. The way they are delivered in each case is determined by the individual – their circumstances, their lifestyle, their choices.
We hear a lot of well-meaning talk about ‘empowering’ patients – focussing on the individual, responding flexibly to their needs and offering them real choice. Community healthcare, by definition, enables patients and service users to determine the what, how, where and when of their own healthcare.
But now is the time that community healthcare providers must really step up to the plate. The perception, and often misconception, that community services are rigid, Monday to Friday, 9am to 5pm operations needs challenging and changing forever.
There needs to be challenge not only to the public’s perceptions but to its own culture and sense of self-belief. Where needed, they must be urgent responders, with flexible models of care accessible at all times of the day and night. No longer the ‘Cinderella service’; rather, the holders of the key that will unlock the benefits of a reformed health service.
The task for community healthcare providers is to seize this opportunity and to go toe-to-toe with competitors and prove their worth. Historically, community services have developed models with prescribed, and often limiting, access and referral criteria. This means from the moment of first engaging with a new patient, we have embarked on a process of trying to squeeze them into the best fit out of a set of pre-designed boxes.
Everything we know about co-morbidity shows that individual circumstances are very often too complex to be simply categorised in this way and exposes an overly prescriptive system that too often fails to meet both individual and system needs. Our responsibility is to create the flexibility and responsiveness to addresses this.
Community healthcare providers are in a prime position to integrate and co-ordinate services across disciplines and levels of health and social care. They are best placed to act as the interface where care pathways intersect and traditional boundaries are breached. This is the elusive extra ingredient the whole health economy seeks – the ‘personal touch’ that adds up to genuine patient-led care.
Five years ago, across the city of Birmingham, there were three different models of intermediate care, three different models of community hospital inpatient care, different access criteria to different levels of service provision for the same condition and what was accessible depending on which part of the city you lived in. It was little wonder that patients, GPs and carers couldn’t find their way through the system. And little wonder then that they would often resort to the easiest alternatives – dialling 999 or attending A&E.
For the last three years, a lot of time and hard work has been invested to implement an alternative – a single point of access for community services and urgent care, offering a clinician-to-clinician conversation where necessary to determine the most appropriate place of care.
If it is determined that acute hospital intervention is not clinically necessary then the community services take the responsibility and – if required – that can mean rapid response in the patient’s own home within two hours of the initial call.
The district nursing service as it has long existed is not suitable for this new delivery model. The community nurses are now part of integrated multidisciplinary teams - working closely and flexibly with therapists, social workers and case managers to provide the seamless care that allows patients, particularly frail elderly people, to retain their independence at home and reducing pressure on acute services.
Obviously, when acute care is agreed as the best clinical option for a patient then this is the route immediately taken but the new model ensures that need is determined by clinician-to-clinician dialogue rather than hospital admission serving as a default because the alternatives are not adequate.
With over 16 community healthcare providers progressing towards Foundation Trust status, and a large percentage of community services being provided by a range of other providers, the collective challenge over the next two years is to seize the opportunities of the new, competitive environment. That means addressing historic restrictions in contracting and innovation but remaining proud and building on our core values - being receptive to the wider determinants of health, aware of changes in lifestyles and family circumstances; and creating membership recruitment mechanisms that allow us to understand our public as individuals – allowing each to define their personalised terms of engagement so that our services derive a genuine boost from this new energy source.
Sir David Nicholson has described community healthcare as “mission critical” to the NHS, presenting opportunities to improve quality and productivity across the system. We are already part of community life, embedded in the routines. That traditional local engagement, allied with a new dynamism in service delivery and management, places community providers at the heart of reform and gives our service users and carers a more audible voice than ever.
What are we waiting for?