Care in the community will ease nursing pressures and help patients but it is not going to happen by accident, says Peter Carter

It has long been heralded as the future of our NHS: moving care into the community. On paper, you can understand why ministers and managers have found the premise so compelling. A more comfortable patient experience, fewer readmissions to hospital and a more efficient model of care delivery are just three reasons to shift care from the hospital bed to the living room.

We have been told by government after government that it must be a priority, and the Royal College of Nursing has always agreed. In fact, I have been quoted in this journal and others as fully supporting the principle.

As with any changes in the NHS, despite the fact that the idea may be a good one, the execution is often flawed. The shift of non-urgent care into the community has never really happened. The nationwide transforming community services scheme was ambitious, and achieved some good results. However, the programme has now concluded and we are left with the original problem.

Far too many patients arrive at our accident and emergency departments when, in reality, they really do not need to be there. For our older patients, the problem is often more serious. Often alone, with little or no support at home, they spend extended stays in our acute settings because the systems are just not in place to care for them closer to home. The sad reality is that we know they would often rather be in their own home receiving care where they feel comfortable.

Furthermore, the problem is getting worse. Despite continuous governments failing to properly invest in our communities, the availability of beds in our acute settings has fallen – by 20 per cent in England in the last decade alone. The latter would not pose a problem if the investment in our communities was there, but it isn’t and patients are quite simply left with nowhere to go.

The Royal College of Nursing revealed recently just how much pressure our community nurses are facing, given caseloads that are increasing and budgets that are doing the opposite. Fewer than one in 10 said they always had the time to meet the needs of their patients. Confirming our fears, nearly nine in ten said their caseload had gone up in last year and six in 10 said they were spending less time with their patients than they did 12 months ago.

Be bold

Nurses in our communities are being stretched to breaking point as more and more patients require their attention but the level of support around them dwindles. More than two thirds of community nurses told us that staffing levels had fallen where they work in the last year.

Community care is indeed the future of the NHS, but a good future requires a good level of investment. If this government is serious about saving money and making the NHS budget sustainable, it needs to be bold.

It needs to invest like no government has ever invested before: promoting telehealth, recruiting more community practitioners and helping staff prevent illness.

History has shown us that in times of hardship, the governments with the greatest foresight invest in infrastructure like roads, bridges and train lines. These guarantee a nation’s prosperity and ensure that, in years to come, they are better, more effective places to live.

We need the same attitude towards our health service. Care delivered in the community can indeed lead the way in excellence and efficiency, but it cannot happen by accident. Despite a pledge by the Department of Health to increase the number of health visitors (a move the RCN supports), we need to do more.

Our nursing staff should not have to feel like they need to cut down on the time a patient receives, in order to undertake every visit that day. Instead, patients deserve enough nurses working in their communities so that the care they receive is tailored to them. It may sound radical and indeed impossible, but the best ideas often are.

Also online: designing staff policy based on needs

Howard Catton, head of policy and international, talks to Ruslan Zinchenko about designing staffing policies that are based on the fundamentals of patients’ needs and why changes to postgraduate training could be the key to shifting care to the community.