Yvonne Sawbridge, Senior Fellow, Health Services Management Centre

As a staff nurse in hospital many years ago, during a particularly trying shift, I heard myself say to a relative who was late “well it isn’t actually visiting time - but alright then” and immediately thought, “who do you think you are to stop people visiting their loved ones? - what’s the matter with you?” This thought translated into a desire to move out of hospital care, where the needs of the patient could seem secondary to the smooth running of the organisation at times, despite all the kind and well-meaning staff working within the system

Outside of hospitals, professionals work with people and their daily lives, in their own homes/settings, with their rules. No banning of visitors – even four-legged ones. Indeed you might have to suspend your infection control procedures and try to work around the dog sniffing at the sterile dressings pack if that was the only way the patient would let you near - risk management at a whole new level!

Hospitals play a key role in the NHS and have moved considerably to develop more patient-centred approaches- with open visiting times one such example. At the same time the needs of patients in the community continues to evolve, and more and more complex patients are managed at home: Frail elderly patients with multiple long-term conditions; Intravenous therapies; people with dementia; and even ventilated patients.  And yet the narrative which positions hospital care as the most important aspect of the NHS persists. Compare the wholescale movement of district nursing services from PCTs and Community Trusts into a variety of organisations, with the changes or movement of services out of hospitals. Some were moved into private companies or social enterprises. I saw no headlines, petitions or public protests for the former but ubiquitous news coverage of the latter. Hospital pressures regular feature as newsworthy items – the rise in activity and “winter pressures” seem familiar terms to many of the general population (if my mum is the benchmark!). However, how many people could talk about the pressures which community services are facing? The Royal College of Nursing surveyed District Nurses (2011) and found that 90% DNs felt their workload had increased compared to 81% of all nursing staff, and 38% felt quality reduced compared to 30%. The Queen’s Nursing Institute survey 2014 (QNI) found a similar picture, as did the more recent Kings Fund report (2016), which also observed a  dissonance between numerous policy ambitions to offer more care closer to home and the continued neglect of the DN service. The Five Year Forward View (2014) laments the fact that there has only been 0.6% increase in community nurses in the past decade, despite them being an essential part of a transformed health service.

It is highly likely that the Sustainable Transformation Plans (STPs) currently being produced in England, will have a continued focus on providing care outside of hospital, and integrating care around the needs of patients, and not the organisations. This space is one in which the community nursing workforce already operates, and they would have much experience and expertise to share but any additional workload coming their way as a result of the Plans needs to be accommodated somehow.

Whilst HEE developed an education strategy (2015) and are beginning to redress the decrease in training places for DNs there is still much more work to do. There is a real sense of urgency that we need to find, nurture, develop and protect our district nurses - without this, the routine delivery of more services and care closer to home remains a fairy tale i.e.  “an incredible or misleading statement, account, or belief:”. Personally, I like my stories to have a happy ending but I’m still waiting for the hero of the story to be revealed.