The Ward Round: An untested theory

The NHS is experiencing winter in August. The latest performance data, published last week, highlighted the alarming pressure the acute care sector is under at the moment.

It showed demand for ambulances for the most serious cases reached a new high last month. Trust performance on the four-hour accident and emergency standard hit a new low — just over two-thirds of patients in A&E departments were treated, admitted or discharged within the target time.

Reasons for this deterioration in performance are complex, with July’s heatwave, school holidays, and untreated illnesses over the pandemic all contributing to the heightened acute workload.

Also, as reported in HSJ earlier this month, staff absences are rising, particularly those taking time off for mental health reasons. There are also serious concerns about staff burnout and retention as the long-term effects of the pandemic are felt.

But what’s going on in the acute sector is only a piece of the puzzle — there is arguably a relationship between acute pressure, hospital flow and the health of community services and the strength of its workforce.

Alison Leary, chair of healthcare and workforce modelling at London South Bank University, said modelling being done has shown covid has “driven up workloads for community teams”, as well as demand for end-of-life care in the community.

“We see more community work declared left undone than 2015,” Professor Leary said. “It could be reversed by innovative workforce initiatives, but it needs a significant cultural shift from employers and increasingly from nursing leaders.”

Queen’s Nursing Institute chief executive Crystal Oldman said there is an “underresearched potential correlation” between having insufficient resources in the community to meet demand, and more people needing to be cared for in the hospital through unplanned admissions.

”It’s a logical assumption but I am unsure whether there is any research which provides this data on correlation,” Dr Oldman said. 

Another signal is that many more deaths are taking place in people’s own homes, compared to before the pandemic, likely creating substantial end-of-life support needs.

Dr Oldman warned of the additional pressure more end-of-life care at home is putting on community services.

“[QNI members] are telling us the number of people being cared for at home hasn’t declined and is a message to the system that far more investment is needed into the community,” she said. “People choosing to die at home may end up in A&E unnecessarily if there are not people with extended skills to care for them.”

Dr Oldman added: “We know [district nurses] were under a tremendous amount of pressure pre-pandemic and the pandemic has magnified this. It is essential we understand the demand in the community in order to match the capacity needed to meet that demand.”

Unite’s lead professional officer Obi Amadi also stressed the need for the comprehensive spending review later this year to support growth in community services.

Referring specifically to health visitors and school nurses, Ms Amadi suggested these professionals could be better used to support parents in identifying whether A&E attendance is necessary.

“Community practitioners could be better used to support public health issues as they have wider experience than [just caring for] children aged between 0 and 19 years,” she said.

Earlier this year, community workforce experts warned key national ambitions around strengthening community services could be scuppered without more investment in the workforce.

Although the very recent uptick in district nurses is positive — the latest QNI workforce audit recorded an overall increase in nurses between 2019 and 2020 of around 20 per cent —  the frightening pressure on acute care again highlights the time for investment in community care is long overdue.