The default option for 'saving' the NHS seems to be putting money into secondary care. Yet a number of strategic documents have suggested new models of primary care with nurses front and centre are the likely solution.
Headline after headline has reported that A&E is buckling under the extreme volume of people accessing the services, that staff are overwhelmed and that the NHS will expire within the next five years, should this continue.
The DH invested an extra £700 million in 2014, to alleviate the pressure, yet this winter is thought to have been one of the worst on record, despite the cash injection.1 Wales and England recorded the worst outcomes relative to four-hour waiting-time targets over the past decade.2 The second week of January saw a dozen hospitals declare 'major incidents' to clear the backlog of A&E and discharge patients to free up beds. No statistics have been recorded for Scotland since September and none will become available until February, but the country is thought to be facing similar problems.
NHS England's Five Year Forward View3 looked at ways to make the NHS fit to last, not just through increased funding but by reworking the way primary care functions. Community and practice nurses were named as a vital resource for reducing A&E attendances.
In some areas, community nurses work alongside secondary care to assess whether patients can be treated in their homes or whether they need to be admitted to hospital.
They can be based in A&E wards to assess patients on site, go out with ambulances, or operate as a separate team to provide the care patients would receive in hospital out in the community. The benefit of this is that the healthcare professionals who work in the community can accurately assess which patients can safely stay in their homes and which would be better off in hospital.
The community rapid response team from Birmingham Community Healthcare Trust provides rapid assessment and treatment of unwell patients in community settings. The team offers a telephone triage service for patients over the age of 17 registered with a Birmingham GP, to assess whether they require hospitalisation, can be treated in a community hospital or by the rapid response nursing team.
Jo Drever, an advanced nurse practitioner, works in the A&E ward at Heartlands Hospital, Birmingham for four days a week. 'I assess patients as they come into A&E, and see how they can be kept in the community and in their own homes.'
'I work very closely with A&E consultants and nurses to see how we can provide the most appropriate care for our patients,' says Ms Drever. She says an important part of her job is working with other agencies to ensure that patients get the care that they require.
In a more rural area, North Somerset, the main purpose of the community nursing rapid response team is to respond to acute nursing needs to avoid hospital admissions. There are two teams, in the north and the south of the county, made up of registered nurses and healthcare assistants. The service is round the clock.
'Our work is split into two,' says Pauline Angell, clinical lead at the community nursing rapid response team for the North Somerset Community Partnership (NSCP). 'First we will go out to a patient and complete a full nursing assessment and put a management plan in place to prevent them turning up at A&E. Secondly, we respond to emergency situations, where people would otherwise have to go to A&E, such as for an acute infection or blocked catheter. We closely monitor them and mimic what would happen in the hospital, continue to do nursing observations, treat them with antibiotics and put the appropriate care in place to care for them at home and to prevent them being admitted to hospital.'
According to statistics from the NSCP, for the three weeks between 1 January 2015 and 21 January 2015 there were 31 referrals from the ambulance service to the rapid response team. This is in comparison to 14 referrals from the ambulance service in the same time period in 2014. In the majority of these cases the referral reason was 'prevention of acute admission.'
At the Birmingham Community Healthcare Trust, in April 2014, 1185 patients received urgent care from the rapid response service out of the 2517 who were referred to the Trust by the central phone system. These patients would have been referred to the hospital if the team did not exist. There was also a 58 per cent increase from April 2012 (up from 751 to 1185). The increase in referrals shows that ambulance services and rapid response teams can work side by side to reduce acute admissions. However, rapid response teams are only operating in certain pockets of the country.
Crystal Oldman, the chief executive of the QNI, says that the reason why this service is not used more extensively nationwide is down to CCGs wanting to see evidence of whether they can actually reduce A&E admissions.
'What CCGs will want to see before they commission these services are what the outcomes are for other areas, so they can base their decisions on investing in a new service if they don't already have something similar operating. Investing in a new service will mean savings elsewhere. These can be seen through rigorous evaluations on patient experience and economics,' she adds.
What community nurses can do to ease secondary care pressures will depend on local need.
Ms Drever says that in Birmingham they have seen a lot of patients with respiratory problems attending A&E, as there has been a virus that has been exacerbating their symptoms. 'Once we have taken the regular blood tests and done an x-ray and done a general check up and negotiated with the consultants, in A&E, the patient will then be sent home,' says Ms Drever.
Ms Angell says that working in a rural area, means that they may operate in a different way to nurses working in larger cities. 'It is not uncommon for a nurse on a shift to do up to 60-70 miles. Also adverse weather can really pose a threat to travelling around country roads. But we do have a 4x4 on standby to ensure that we can reach the people that need our care urgently. It's important being a rapid response team that we do get there quickly.'
Both of the nurses are confident that these teams can be replicated elsewhere with the local area in mind.
'This can absolutely be something that can be rolled out across the country,' says Ms Drever. 'I think work in the community needs to grow. I've been told that hospitals feel supported by having us there and recognise that it is making a difference. I can turn around up to nine patients a day and I work four days a week, so that slowly starts to add up.'
'Since we started functioning around six or seven years ago, there has been a drop in A&E admissions,' says Ms Drever.
In North Somerset, the team has been functioning for around 10 years with clinical leads coming into post two years ago. They were hired because the conditions the team was seeing were becoming more severe. This led NSCP to put clinical leads in place with advanced assessment skills and prescribing qualifications so they can carry out more detailed physical examination.
Ms Angell says that since these changes have been put in place, there has been a further drop in the number of patients being admitted to A&E. 'It is difficult to quantify, but just two weeks ago, we admitted 22 patients to safe haven beds (beds in nursing homes, looked after by the community rapid response team), when we usually have nine. Additionally it was reported that at Weston General Hospital, 100 per cent of patients were seen within four hours and the rapid response team and NSCP was thanked as having been a part of this,' she added.
In these cases increased funding was not the answer to providing quality patient care and reducing hospital admissions. Instead the trusts made the most of nursing skills and acknowledged that they noticeably reduced A&E attendances. The key to seeing these services replicated around the country will be services' ability to demonstrate value with outcome data.
1.The Telegraph. A&E crisis: soaring numbers of hospitals declare major incidents. 2015. http://www.telegraph.co.uk/news/politics/11327733/...
2. BBC News. A&E departments: More bad news. 2015. http://www.bbc.co.uk/news/health-30853342
3.NHS England. Five Year Forward View. 2014. http://www.england.nhs.uk/wp-content/uploads/2014/...
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