By April 2022, anyone in England over 18 years of age whose health or wellbeing suddenly deteriorates at home will have access to an urgent community response team within 2 hours. At a minimum, those services are expected to operate 12 hours a day, typically between 8am–8pm, 7 days a week.
Urgent community response (UCR) teams may not be particularly new, but it is the first time that the NHS has adopted a national standard for community healthcare in its history. Accelerating the rollout of UCR was triggered by NHS England's Long-Term Plan (2019), which committed to increase investment in primary medical and community services by £4.5 billion in real terms by 2023/24. It stated: ‘Extra investment and productivity reforms in community health services will mean that, within 5 years, all parts of the country will be expected to have improved the responsiveness of community health crisis response services to deliver the services within 2 hours of referral.’
This is in line with the National Institute for Health and Care Excellence's (NICE) (2017) recommendations that there should be a crisis response within 2 hours if the patient has experienced an urgent increase in health or social care needs, the cause of the deterioration has been identified and their support can be safely managed in their own home or care home. Community crisis response represents a clear opportunity to prevent hospitals admissions, cut emergency department attendances, reduce ambulance conveyances and, by providing care at home within 2 hours, improve patient experiences and outcomes.
The original timeline set out in the NHS Long Term Plan (2019) was accelerated by 2 years to support the COVID-19 pandemic recovery effort (NHS England, 2021a). Now, 26 of the 42 integrated care systems (ICSs) in England are delivering a 2-hour crisis response. Other ICSs are on track for full geographical coverage over the coming months.
Seven accelerator sites were launched in 2021, which included:
- Warrington Together (Warrington Integrated Care Partnership)
- West Yorkshire and Harrogate Health and Care Partnership (Kirklees)
- Leicester, Leicestershire and Rutland Health and Social Care
- Cornwall and Isles of Scilly Health and Care Partnership
- Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System
- South East London Integrated Care System
- Norfolk and Waveney Health and Care Partnership.
This was followed in July by national guidance (NHS England, 2021b) on the 2-hour crisis response.
Community nursing: a core service model
A question arises: are we creating new services, rather than building on existing community health care?
The operational requirements in the national guidance (NHS England, 2021b) highlighted: ‘Community and district nursing services may well provide the core service model to provide crisis response services. These services could be enhanced to become multidisciplinary to respond to all 2-hour community crises. However, organised locally, district nursing teams will be an important service to provide ongoing planned care after the urgent community response service has ended.’
Some locations, such as Kirklees and Warrington, have created new UCR teams. Other areas are building on existing rapid response teams, and still others, such as Cornwall, are redesigning care teams with community nursing at the centre. The model is determined locally and in line with the national guidance to achieve service consistency. It is, after all, important that any adult in a health crisis can expect the same response from UCR teams, whether they live in Brighton, Bracknell or Blackpool.
In Kirklees, West Yorkshire, where 21% of the population is expected to be over the age of 65 years by 2030, compared to 16% in 2015, a provider alliance was established to deliver community crisis response. Referrals are made through a central point (or single point of access) hosted by a social enterprise, Local Care Direct. Initially, these are handled by non-clinical care navigators. If the referral meets the required criteria, it is passed to the clinical triage team, which consists of GPs, advanced clinical practitioners (ACPs)and physician associates.
If accepted, the referral proceeds to the visiting clinicians, currently provided by Locala Health and Wellbeing and Curo Health. There are eight ACPs and two trainee ACPs on the team. They have backgrounds in primary and secondary care (medical and surgical), emergency medicine, community care and the ambulance service.
Visiting clinicians see the patient in their own home or care home and carry out a full clinical history and advanced clinical assessment to diagnose and treat all presentations of ill health. Any on-the-day urgent diagnostics can be referred to the Same Day Emergency Care team. The UCR refer patients to the community Short-Term Assessment Response Team for ongoing clinical monitoring and therapy input. There are other strong links to the Hospital Frailty Team and the Care Home Support Team, with whom they are developing a falls pathway to prevent long lies while waiting for a full assessment. The team is also building links with district nurses for ongoing wound management, pressure area care, long-term catheter management or end-of-life care and support.
Kirsty Robb, the lead advanced nurse practitioner at Curo Health in Kirklees, commented:
‘Despite the service being in its infancy, we have had a positive impact on reducing pressures in primary and secondary care, and the ambulance service decreasing avoidable conveyances to hospital and other services locally.
‘We have delivered over 1400 face-to-face visits, with 96% of these being within 2 hours. Some 81% of the people we have seen have not had an A&E attendance or an emergency admission within 2 days of the visit.’
In Warrington, the crisis response team includes 14 nurses with a variety of backgrounds in community nursing, GP practice, prison service, intensive care, A&E and urgent care centres.
Both Kirklees and Warrington are building links with their ambulance services to access category 3 and 4 calls from the waiting stack.
Lead matron at Warrington, Gemma Barber, said:
‘During the referral triage, we often find ourselves providing reassurance. The referrer can themselves be in a crisis as well as the patient, whether it is a carer or another professional in need of advice and resources.
‘We believe there is no wrong front door. We help the referrer in the best way we can. If we do not think our service is the most appropriate for the patient, we will signpost and find the correct service to help that patient.
‘If we take on the referral, our clinicians carry out baseline observations to enhanced clinical assessments. Our advanced nurses have the enhanced clinical skills qualification and the non-medical prescribing qualification. This means we can assess, diagnose and treat patients at home.
‘For high-risk patients, we will work with the patient to avoid hospital admission and refer on to the patient's key worker such as their GP, a community matron or a specialist team.’
The UCR team at Warrington, which is handling up to 60 referrals a week, meets regularly with the hospital rapid response team and wider intermediate care services and is building strong links with district nurses, whose large caseloads often make it difficult for them to deal with complex, unexpected problems.
‘I predict that, in 90–95% of cases, we handle will keep the patient at home,’ said Barber. ‘We hope the team will grow with demand. There are many services that we can support. As we increase our capacity, we will have a critical role in supporting the flow of patients and working with high-risk patients to offset potential complications, such as falls, infection and safeguarding risks.’
In Bromley, one of the providers within the South East London accelerator site, the crisis response team has the capacity to handle 27 referrals a day and is currently keeping nearly 80% of patients out of hospital. The team has five advanced nurse practitioners (ANPs).
Farah Mohedeen, the clinical lead and ANP at Bromley, commented:
‘Our clinicians have advanced assessment skills and offer domiciliary consultations to patients who are acutely unwell.
‘We liaise with GPs after consultations to discuss the best treatment or management for the patient. We are encouraging district nurses in Bromley, who have a huge demand, to call our crisis response team for support, particularly to deal with blocked catheters and with any intravenous therapy.
‘Overall, we are highly valued by unwell patients, and GPs are recognising that our clinicians are professional, reliable and have good clinical skills.’
Most referrals in Bromley are from GPs, which is reflected nationally, but there are many other sources of referral, such as the ambulance service, NHS111, local hospices and care homes.
‘We're known for being “the team in Bromley” that is readily available for any urgent, on-the-day home visit. It is not without its challenges,’ says Mohedeen. ‘It can feel overwhelming at times for the team, and we would like to build our capacity to meet the demand. The team is fulfilled; it is hugely rewarding and is extending the role and scope of community nursing.’
Expanding the scope of community nursing in UCR
Gemma Barber of Warrington believes UCR offers nursing a real opportunity to grow: ‘We do work with blurred responsibilities and recognise that we have the ability to upskill ourselves and the team. I am a trained nurse and I would not expect to be able to do the work of a social worker or a therapist. We can, however, upskill our responsibilities to do the upmost for the patient,’ she said, citing a recent example. ‘I was dispatched to a patient with a suspected chest infection. While at the patient's home, I provided hygiene care and identified the need for a commode, a bed lever and a raised chair that I was able to order, as well as completing a comprehensive capacity assessment.’ This kind of variety has widened her professional horizons:
‘I have found my place in nursing and feel honoured to work with a fantastic team of clinicians every day. We face challenges, and it can feel daunting, but we reflect and learn, and we have a culture of being open and honest. Nurses are dynamic and conscientious of the needs of the patients we see. We do our baseline role, but we always strive to do better and improve the experiences for our patients.’
Kirsty Robb of Kirklees states that building the UCR team, bringing together the expertise of each and every provider in their alliance, has been a ‘very positive experience’. ‘One of the biggest challenges has been improving the understanding of and confidence in the UCR team across all health services,’ she says. ‘We meet on a regular basis with primary care networks, community teams, care homes, hospitals and the ambulance service to build understanding of what we do.’
This has included roadshows and attending other education events in primary care, community services and the ambulance services. The team at Kirklees have even created a QR code in order for other colleagues to find quick referral details. They are planning to introduce self-referrals for patients and carers, which will further expand the service and continue to evolve the UCR team to meet the needs of the community they serve.
The 100-day challenge
A nationwide 100-day challenge was launched in October 2021 to drive collaboration between UCR teams and ambulance providers, resulting in most of these realising the potential to work in a closer and more cohesive way. Warrington is particularly spearheading the drive to divert category 3 and 4 calls into the UCR team, which is significantly reducing waiting times for those needing to be seen by a clinician. Warrington has also linked in with the local council's CareCall service, which responds to people with pendant alarms. Regarding this, Gemma Barber commented: ‘We are now picking up cases where patients are having to wait a long time for an ambulance. We had one report where an older lady had fallen and could not get up. We have also intervened quickly to handle 999 calls involving attempted suicide, dementia and chest pains, making patients safe and medically stable while linking to other services to ensure appropriate care management in place.’ Robb believes the overall impact of the 2-hour crisis response initiative is positive for both patients and professionals. Here, nursing will play a pivotal role:
‘Nurses are involved in every aspect of our alliance, from commissioning, operational management, service development, clinical input and delivery of the service.
‘Our nurses are very forward-thinking and making waves of change for the better with their clinical skills, building key relationships with other health services, undertaking clinical auditing, research and development, and through their drive and leadership. The team continue to shape advanced practice and push the limits to what we can achieve in a community setting. It is truly inspiring to see.’
Key points
- Community crisis response represents a clear opportunity to prevent hospital admissions, cut emergency department attendances, reduce ambulance conveyances and, by providing care at home within 2 hours, improve patient experiences and outcomes
- Community and district nursing services may provide the core crisis response service model, which can be enhanced to become multidisciplinary to respond to all 2-hour community crises. District nursing teams will be an important service to provide ongoing planned care after the crisis
- Nurses are making waves of change for the better with their clinical skills and key relationships with other health services, alongside undertaking clinical auditing and research and development.