At last, the NHS Long Term Plan (NHS England, 2019) promises significant investment in out-of-hospital care. This promise includes an expansion of community nursing services so that they can respond in a timely manner and provide adequate support to people in their own homes, thereby preventing avoidable hospital admissions. But the expansion will need to compensate for the additional nursing work likely to arise from the increasing number of urgent care centres providing same-day emergency care as well as shortened hospital stays through early discharges, in addition to the anticipated increase in proactive general practice care. This step change will require planning and careful implementation so that long waits in the home do not simply replace long waits for nursing care in hospital corridors or wards.
It has always struck me as ridiculous that acute hospital care has been able to command the largest claim on the NHS budget so that preventive action to avoid ill health has been largely neglected through underfunding and lack of media attention. The promise to address health inequalities and invest in prevention is therefore to be welcomed. But only time will tell whether the plan will address the medical and nursing hierarchies where hospital consultants and hospital nurses are accorded more prestige than general practitioners and community nurses, whose daily practice involves helping people to live as healthily as possible, self-manage their health issues and maximise their quality of life.
It is unclear why chapter four of the plan celebrates that the NHS is the largest employer in Europe and the world's largest employer of skilled professionals. Surely what matters is whether there are sufficient staff in the right place with the correct competencies to deliver the service required efficiently and effectively. Having too many highly educated staff with the wrong competencies for the service need is inefficient and a waste of the tax payers’ money, so numbers of staff on their own should not be the focus. It is to be hoped that nursing workforce planners have learnt from planning exercises over the last 40 years, where ‘feast and famine’ and numerous rebranding exercises, often labelled as ‘reforms’, have not ensured that there are sufficient nurses with the required competencies in the right place, including skilled nurses able to care for people with advanced diseases in their own homes. Addressing the shortfall of enthusiastic staff in less popular geographical locations is also an imperative.
The media has made much of the intention to make greater use of technology within healthcare, and inevitably concerns were expressed about those patients who are unable or unwilling to use Skype or other IT-enabled healthcare consultations. However, technology has wide applications including decision aids, self-management support in the home and improved communication across care teams. As time passes, more of the population, if not most of the population, will be increasingly technology savvy, and if not savvy, they will have sufficient IT skills to engage in IT-enabled health consultations in whatever form develops through testing. It must be remembered that healthcare in the Highlands and Islands of Scotland has used IT-enabled health consultations for some time to overcome geographical challenges and distance from Aberdeen Hospital, which is the tertiary care centre.
No doubt there will be much discussion and debate about the proposals and the adequacy of healthcare funding over the coming year. It is proposed that integrated care systems, that is, systems ensuring triple integration with seamless primary and specialist care, physical and mental health services, and health and social care, be established throughout England. It is important that district nurses contribute their perspective to local service redesign and the future shape of community health services if services are to be effective and meet local needs.
‘Planning and careful implementation will be required so that long waits in the home do not simply replace long waits for nursing care in hospital corridors or wards.’