Health: Primary and Community Care

Baroness Emerton Excerpts

Thursday 24th June 2010 Lords Chamber

[Baroness Emerton]

My Lords, I, too, warmly congratulate my noble friend Lord Mawson on, first, introducing the debate but, more importantly, on demonstrating through his entrepreneurial approach what has been achieved in managing change of this magnitude in what at first sight must have seemed an impossible task.

We have had put before us lessons taught in managing change through people to provide a community service in every sense of the word. Like many other noble Lords, I found my visit to Bromley by Bow Centre a manifestation of real entrepreneurial skill— second to none in demonstrating holistic care in the most imaginative ways—which became not only productive in outcome but engaged the patients and community members in a non-conventional way. The emergence of a true community was evident. I found my noble friend’s book very gripping, for no punches were spared in the description of both the barriers and the successes.

I declare an interest as a retired nurse. Over the past 10 years, much progress has been made in community services to encompass a wide range of services, including public health and prevention services, but despite many primary care and community initiatives we still have a long way to go on early identification of disease, risk factors, reduction of health inequalities and the promotion of child health. In the development of urgent care, acute care at home and end of life care services, community services work in close partnership with the GPs, hospital services and social services to support the independent living of older people and the safeguarding of vulnerable adults. They also work with children’s trust partnerships. Currently, 200,000 staff are employed to meet these services, requiring £10 billion from the NHS budget. There is considerable evidence of widespread variation in productivity, which, if addressed, could generate a substantial direct improvement in service quality and sustainable efficiency, thereby reducing costs.

During the past 10 years, attempts had been made by the previous Administration to improve services through the recommendations in the NHS Plan, published in 2001, the general medical contracts in 2004, and the White Papers, Our Health, Our Care, Our Say in 2006 and Transforming Community Services, published last year. The Nursing and Midwifery Council, its regulator and its predecessor, the UKCC—of which I declare an interest as a former chair—have long supported the provision of healthcare in the community. During the previous decade, they introduced specialist community practice awards and created a specialist community health nursing part of the register. These measures acknowledged the shift in expertise needed to ensure safe community practice. While not yet enforced, the emerging standards for pre-nurse education will require pre-registration students to spend 50 per cent of training in practice-based settings, which will increasingly be within the community as services are reconfigured. This represents a sea change in nurse education and will herald a major improvement in healthcare delivery at the point of registration. The planned 4,200 increase in the number of health visitors is admirable. They play an important cross-professional, co-ordinating role, leading skill mix teams in delivery, postnatal, early-years and family healthcare.

However, it is important that health visitors retain a grounding in basic nursing and/or midwifery skills. Knowledge of diabetes, associated obesity, childhood ailments, immunisation, prescribing and disease management are all essential to ensuring safe delivery of patient care pathways. The Nursing and Midwifery Council is looking for the best way to take forward the preparation of health visitors. Will the Government support this initiative?

The introduction of matrons, advanced practitioners, specialist nurses and consultant nurses in the community has resulted in many patients with complex, long-term conditions being expertly cared for without the need to frequent their local hospital. Community matrons in particular are striving to help people with long-term conditions become more self-reliant and better informed about their health and how to improve it. This reflects a shift in emphasis towards nurses helping to empower patients to look after themselves and manage their conditions better.

The programme to support practitioners to transform services and deliver high- quality care and productivity set out evidence for best-practice care within community services through a series of six transformational reference guides entitled, Health, Well-Being and Reducing Inequalities; Services for Children, Young People and Families; Acute Care Nearer to Home; People with Long-Term Conditions; Rehabilitation Services and End of Life Care. All of them provide a guide to high-impact changes and are intended to enable practitioners to give high-quality care.

The continuing work is looking particularly at the needs of frail, elderly patients with complex health conditions. They are the main service users of community healthcare and now occupy the majority of acute hospital beds. Increasing evidence points towards a wide variation in the care offered to the elderly. Studies indicate that up to 30 per cent of people in hospital at any one time, many of them frail and elderly, could be safely cared for in the community with the right access to community services and appropriate support. There are efforts to mobilise staff using evidence to create a “social movement” among front-line staff and empowering clinicians to lead change and innovation. This leads to the use of care pathways to increase care co-ordination and best practice for patients. Combining primary, community, hospital and social care to increase efficiency and provide high-quality care, it is best described as “care without walls”.

At present, a high proportion of residential nursing homes employ healthcare support workers and social care workers. Evidence from a study conducted by Ian Kessler at Oxford University shows that many undertake aspects of care traditionally done by nurses but that they are not trained to do it safely. If there is to be an increase in community care, increasing the level of social carers and healthcare support workers, there must be an increase in safeguards on the roles undertaken by those staff. With no form of regulation in place, it is difficult to track and prevent those unable to provide safe levels of care. The move to community-based care poses a significant risk to patient safety.

Against a background of the demographic growth of the elderly population—requiring an increase in both long-term and acute home care—of the care of vulnerable children in pre- and post-natal care and of changes in the pattern of commissioning services, it will be important to ensure that at every level a nursing voice will be able to ensure the safety of patients as well as the delivery of high-quality care in the most cost-effective way. It is imperative that the new systems of commissioning primary and community services enable the voice of an experienced nurse to ensure that the resources and training facilities in clinical placements are sufficient to meet the need.

The Royal College of Nursing continues to express its concern over the lack of investment made into the community nursing workforce. A particular concern is the problem of the ageing nursing workforce, as 27 per cent of nurses working in community services within the UK are aged over 50. Over the next 10 years around 180,000 nurses will be eligible for retirement, leaving a huge hole in the workforce which, at current levels of commissioning, will not be met by future recruits. There are concerns that the problem will be magnified through the current period of financial constraints by recruitment freezes and the deletion of posts as a result of efficiency savings. There has also been evidence of an active reduction in student places being commissioned, despite a record number of applications to enter the nursing profession. This, it says, is a great disappointment and a blow to all that has been done to improve the attractiveness of nursing as a career.

The leadership skills required are of paramount importance and it is through people rather than policies that change can be effected. The challenges of overcoming the barriers between various services are enormous but the opportunity to grow community services must not be lost. Just as my noble friend mentioned, it takes time to break through the barriers and that cannot be rushed. Certainly, in my experience of leading and managing a project relocating 1,500 and then a further 1,200 learning disability patients from two large hospitals, it took 10 years to ensure that every patient was individually assessed, relocated according to their needs and placed into the most appropriate accommodation. That involved seven London boroughs and two county councils—none of which was keen to take back its residents—while ensuring that staff were appropriately trained to care for residents in the community, which was completely different from being within the large hospital and a big culture change for them. There were relatives reluctant about their relatives transferring from the safe environment provided by the large hospital to an open community and there was the receiving communities’ reluctance to receive learning disability clients.

While there was an overall strategy accompanied by a critical path analysis setting target dates, that project really required hours of careful negotiation through the barriers to result in a changed culture—one providing a more meaningful style of life for clients in a safe environment, while delivering high-quality care and management. Managing such an innovative project, as with those that we have heard described this afternoon, was certainly a huge learning curve for me—and, I am sure, for others. I believe that there is an urgent need for nurses and all healthcare professionals to gain the necessary leadership skills to be equipped to meet the challenges and opportunities of the future’s reconfigured community services.