NHS crisis: Not a hospital problem but a community one

A relative of mine in Chesterfield received excellent care from both the NHS and social care at the height of the winter pressures earlier this year. She and her family were treated with expertise, compassion and dignity. It reminded me that these services require good organisation and adequate resources; but they also need good people.

I don’t imagine much more can be done to prepare for winter at this stage. Despite the best efforts, NHS friends predict that there will be a crisis in the next few months, its severity dependent mainly on what viruses are circulating. Once again, it will fall to the efforts of NHS and social services staff to get us through. Yet the health and care system is now under enormous pressure all year round. This is largely due to demographic changes, which mean that more elderly people need care, but face inadequate services. Too many people end up in hospital because there is no alternative.

This is not new. Problems with “bed blocking” in acute hospitals have been well publicised for years and apply equally in mental health. Three years ago I chaired a review of problems with admissions to mental hospitals for the Royal College of Psychiatrists. We found that many people were admitted because there was no alternative and there were difficulties in discharging people into community provision. It wasn’t a hospital problem but a community one.

There are three levels to the problem. First, there is inadequate provision of health and social care services in the community. Second, there are shortfalls in other public services such as housing that enable people to live in the community. Third, there has been a decline in the community infrastructure of voluntary organisations and self-help groups and in support for independent living. Austerity has made each of these problems worse. Bizarrely, there have been cuts in community services such as district nursing or community mental health teams just as demand expands. Part of the reason appears to be that it is politically easier to trim a few posts in community services than close far more visible hospital beds. Similarly, the lack of suitable housing is one of the main reasons why people are kept in mental hospitals unnecessarily.

Health is affected by many factors. The history of improving health globally has been a virtuous circle where scientific advances are reinforced by improved education, economic growth, improved pensions, better working conditions and much more. It can turn into a vicious downward spiral if any of these elements go into reverse.

There are choices to be made. The government has announced plans for improved community services. This is very welcome, but we will have to wait for the publication of the NHS Long Term Plan to see if they also address these wider cross-sectoral and informal sector issues.

Health care is about contacts between humans and government policy must also address the needs and development of health workers. Good health care is multi-disciplinary, but I suggest the government should particularly concentrate on nursing, half the professional workforce. A survey of nurses in 14 countries showed that they felt undervalued and unable to work to their full potential. All respondents talked about poor pay and conditions, but almost all referred to their frustration with not being able to do what they had been trained to do. This is an astonishing waste of talent and resources.

More needs to be done by government, the global Nursing Now campaign and others to raise the profile and status of nursing so that nurses are seen as the fully competent professionals they are—to the benefit of patients everywhere. Policies that strengthen cross-sectoral approaches to health and enable nurses and other health workers to work to their full potential are surely the best safeguard against future winter pressures.