Visiting your local hospital could be a far rarer event as NHS England plan healthcare much closer to home. However, turning this vision into reality hangs on NHS leaders overcoming a big crisis in  staffing.

 

Traditionally the next step on from your GP is the local hospital, whether it is to help diagnose or to start treatment. But NHS England has concluded that many of these trips are unnecessary and clog up an already over whelmed hospital service.

 

NHS leaders are working on plans to treat more of us in community settings. Instead of going to your local hospital for tests, treatment or check-ups you will be sent to a community-based facility, part of a Primary Care Network which will house multi-disciplinary teams of health professionals.

 

Jargon aside, this means GPs, community nurses, therapists and technicians all working together from large, souped-up health centres connected with other core services like social care. At least that’s the vision, but can it be delivered?

 

The size of the challenge is significant. It means a huge investment in extra buildings, community staff and technology. The government have pledged an extra £4.5bn for primary care over the next five years, but health economists are already agreed that this is not enough and will mean some tough choices.

 

NHS leaders have set a dizzying target to reduce the number of outpatient trips by 30 million a year, a goal they explain in their 10-year plan for the NHS published earlier in the year.

 

Our hospitals contend with very high demand, outpatient care has been rising at around 3% a year and this new policy aims to put a brake on this by rerouting an army of patients towards community facilities. However, as yet these services don’t exist in anything like the scale they need to.

 

Who will treat take on this extra work? General practitioners will lead the community teams, but they are wincing at the prospect. The number of GPs has actually fallen over the last five years.

 

There are now 1784 fewer GPs than there were in 2013 (full time equivalent) according to figures published by NHS Digital.

 

The health secretary promised 5000 more by 2020. After missing their recruitment target for two years more young GPs are finally joining, but most areas are still understaffed, particularly as older GPs are retiring at twice the rate that they were in 2010.

 

All this explains why many of us are finding it hard to get a GP appointment. One in five patients now has to wait at least 15 days to see a GP in England, NHS figures have revealed. Meanwhile our need for healthcare has grown, the number of GP patients has risen by 16% in the last 7 years.

 

There is a yawning capacity gap, which has widened throughout the recent years of austerity. The problem for NHS leaders is that community services are already struggling, but the gap must be bridged if they are to have any hope of redirecting thousands of hospital patients towards community services.

 

Health visitors have seen their numbers fall by nearly 10% in the last five years. Many are dealing with perilously high caseloads to manage. A recent study found that some health visitors are responsible for up to 830 children – when the recognised safe limit is 250.

 

Staff are running the risk of being too busy to spot domestic violence or child abuse or to have too little time to catch the signs of a mother with postnatal depression.

 

The same pressures are evident for district nurses, who also know that their patients are getting a worse service.

 

“When you have a big list of patients to see in the day, if you want to get through that list, you really need to rush… you end up going and doing whatever you’re there to do, but fail, sometimes, to notice that that person is actually not herself today, or something’s wrong. The workload is the main enemy for the patient centred care.”

 

Shockingly district nurse numbers have fallen by 46% since 2010, although part of this can be accounted to the transfer of staff to other providers.

 

Private providers like Virgin have won large contracts to provide a wide range of community health services to the NHS in Somerset, Devon and Essex and often NHS staff have transferred to work for these providers. It is unclear how this part of the market will develop, although the NHS will be in a much stronger position if it expands its own community staffing.

 

Whilst there is apprehension about the new plans, other NHS staff are more positive, as to some they about promise more cohesion and a more appropriate community-based model. There is no doubt that NHS England’s vision has been powerfully painted, but even so there are worries about what is achievable.

 

Helen Stokes Lampard, a GP and Chair of the Royal College of GPs is supportive of the aims but has yet to see a difference on the ground

 

“There are workforce shortages right across the board. In the first year, the only additional employees PCNs (Primary Care Networks) are looking to take on is more pharmacists and social prescribers.” (source: NHS Providers website)

 

Siobhan Melia – Chief Executive of Sussex Community NHS Foundation Trust commented,

“The targets in the Long Term Plan don’t feel particularly realistic at the moment because of the absence of any clarity about investment”

 

When will the extra staff arrive and how? The government avoided this crucial question when it published the Long Term Plan in January. Commentators noticed the hole in the plan immediately. A workforce plan would follow later the government reassured us. But getting the right level of staffing is fundamental.

 

One of the reasons for the delay is the extra cost that it will entail. The issue is now caught up in the wider Autumn spending review. All departments are vying for extra cash and the NHS is seen to have already done well. However, the reality is that the £20.5bn already announced is not enough to fuel improvement, economists agree on this. So why leave the job half done? The NHS needs the investment to support a new plan to expand the NHS workforce, the whole plan hangs on it and without it the vision of community-based healthcare lacks credibility.

 

 

 

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Paul Evans
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director of the NHS Support Federation

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