Very often the solution to a problem can be so obvious that it is overlooked for something far more complicated. The problem in question here is bed blocking.
According to NHS England every day more than 6000 patients, well enough to leave hospital, are unable to do so because there is nowhere suitable for them to be discharged to. This costs the health service huge sums of money and is detrimental to the health of patients. An investigation by FullFact suggested the cost could be around £900million a year.1
While funding cuts to social care are indeed a contributor, a drastic decline in community nursing should be considered as a factor in delaying hospital discharges. Many patients no longer require hospital care but will still need follow-up care. Who else is going to provide that other than the community or district nurse?
These are not the patients without places in care homes or hospices, or those who are rendered homebound due to the reduction in taxi services for the elderly. These are patients who have homes and a support system, but require regular dressing changes or complex medication control. These are the patients that are forced to remain in hospital as there is no district nurse able to continue their care plan.
The community nurse workforce has shrunk by almost 50% in the past decade, falling from 12,620 to 6656.4 Fewer nurses in the community means fewer patients can be cared for in their own homes resulting in a backlog of patients being able to leave hospital for fear of exacerbating their illness/injury.
A petition urging the government to tackle the district nursing shortfall has been started and at the time of going to press had over 6000 signatories. The Royal College of Nursing (RCN) says that there needs to be 10,000 more district nurses in order to cope with patient demand.
‘I personally think [the fall in community nurses and pressure on the acute sector] could be linked,’ says Candice Pellett, a district nurse and transition manager at the Queen’s Nursing Institute (QNI). ‘You can’t look at anything in isolation. We need district nurses in the community to manage the highly complex needs that many older people have. People are living longer and we need the numbers and the right qualified staff to keep these patients at home.’
Looking further afield primary care as a whole could be a much-needed solution to alleviate the heavy pressures on hospital care and enable patients to be discharged.
The recent GP Forward View made many references to how integration of services and improving communication between primary care and secondary care could ameliorate the NHS. It reiterated the need for better integrated working and for hospitals to issue discharge summaries within
24 hours.
A report by Age UK identified four key problems linked to bed blocking:
- A lack of information and general confusion about what is available and who is responsible for paying for it.
- A marked shortage of good health and care services to help older people recover after they have had a spell in hospital.
- Poor co-ordination between different parts of the NHS and health and social services.
- Over-stretched professionals and administrators, struggling with clunky systems and insufficient resources.5
Care deficit
Danielle Tiplady, a trainee community nurse and key figure in the Bursary or Bust campaign, recently stated in an article for the Independent that bursary cuts, funding cuts and pay cuts, will do nothing to portray nursing as an attractive career.
She also stated that increasing levels of privatisation and outsourcing has disjointed the community nursing service instead of creating a seamless integrated pathway.
‘Take for example an elderly person who is discharged from hospital and needs a wound dressing after surgery. Community nurses can provide this care, but after the £1billion cut to elderly social care, we are often only allocated a 10-minute slot. As a result, we just can’t be there to help them have a nutritious meal, assist them to do exercise or simply to keep them company for a chat later in the day,’ she writes.6
According to the QNI’s discharge planning report, good discharge planning could reduce the rate of hospital readmission and older people frequently reported uncertainty, a lack of confidence and a lack of support following discharge from hospital.7
‘Time and time again, the issue of lack of care packages in the community comes up,’ says Ms Pellett. ‘This is a real issue. Getting adequate support systems is one of the main reasons that people are in hospital longer than they should be.’
Caroline Abrahams, charity director of Age UK, says that without investment in the sector, thousands of older people and their families and carers face a ‘bleak future living without basic daily needs being met’.
A solution on the horizon?
The government recently announced they would give local authorities access to up to £3.5billion of support for social care by 2019/20. In 2016/17, there is also a new Better Care Fund requirement for local areas to develop delay action plans.
‘The district nurse is key to keeping patients out of hospital,’ says Ms Pellett. ‘They do the whole package. They assess the patients needs, they will plan the care of that patient to keep them safely at home. They will constantly evaluate whether the care is appropriate.’
In some areas district nurses are being utilised to ensure that care is provided for patients who need it. Joanna Harry, deputy team leader on the district nursing team at Central London Community Healthcare Trust says the hospitals have discharge teams making sure that there are nurses and carers available. ‘Our level of care will often depend on what we are going in to do. If it’s a medication review or blood sugar testing we might just get a paper referral.’ For more complex conditions more detailed notes are required she adds.
This is a clear example where nurses are working with secondary care to ensure patients are in the right place.
A little bit of lateral thinking from those pulling the NHS pursestrings wouldn’t go amiss to plug the gaps in NHS care pathways. Investing in community nursing, advocating nursing as an attractive profession and reinforcing communication channels between settings are all steps that can and should be taken.
Simon Stevens, chief executive of NHS England, recently warned that the delays in discharge could continue for another five years.
With the current trend for Five Year Forward View’s, it could be time to develop a community nursing Five Year Forward View before the workforce disappears entirely and leaves the NHS bereft of an essential workforce.
References
1. Fullfact. 2016. No source yet for £6bn cost of ‘bed blocking’ claim. https://fullfact.org/health/no-source-yet-6bn-cost-bed-blocking-claim.
2. NHS Confederation. 2012. Papering over the cracks. http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/papering-over-cracks.pdf.
3. Kings Fund. 2013. How is the health and social care system performing? http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/quarterly-monitoring-report-feb2013.pdf#page=12.
4. Royal College of Nursing. 2014. District nurses face ‘extinction’ in 2025. https://www2.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025.
5. Age UK. 2016. Behind the headlines: are older people and families really to blame when their hospital discharges are delayed? http://www.ageuk.org.uk/Documents/EN-GB/Press%20re...
6. Danielle Tiplady. The Independent. 2016. http://www.independent.co.uk/voices/as-a-nurse-i-see-my-colleagues-go-to-food-banks-because-of-low-pay-without-corbyns-nhs-policies-our-a7209196.html.
7. Queen’s Nursing Institute. Discharge Planning. 2015. http://qni.org.uk/docs/Discharge%20Planning%20Report%202015.pdf.