An article in the Guardian a few days ago caught my eye. In it Dr Michael Dixon suggests that much of the care currently provided in hospital could be provided at home, or much closer to it. That hospitals should be slimmed down, and that Clinical Commissioning Groups (CCG), should and will want to move services away from acute Trusts and into the community. The political rhetoric for years now has been to shift care ‘closer to home’, to consider if certain services should be provided outside of an acute hospital setting. More than 10 years ago, when I was a specialist nurse, we discussed how outpatient clinics could be provided in community hospitals and clinics. In theory the idea was a good one, but the provision of rheumatology services involves the need for additional support (pathology, radiology, therapy services) and also for some patients to be admitted to hospital. Perhaps those making the decisions were more easily reassured that the current practice was best, that it would be too costly to move them, that services would be disrupted. Certainly we never actually asked the patients. GPs locally weren’t worried that our service took place in the hospital, they were more concerned that we kept on providing it and didn’t give them more to do.
Redirecting services to new places, shifting care into a community setting requires the will to do so, and it requires people to be willing to shift their working practices. It requires the accommodation for clinics to take place, it requires inpatient facilities if that is what is needed or a great many community staff if care is to be provided in the home. Each time there is a suggestion that hospital services are cut back, changed or heaven forbid closed, there is an outcry within the local community and the political leaders of that area. It is hard for people to imagine the change that needs to happen to allow services to move. It is hard to see how taking the money away from one place can in turn be utilised elsewhere. Often the amount of money released might be insufficient to set up something new somewhere else.
There is also the issue of people’s attitude to healthcare, the days when everyone accepted ill-health as an inevitable outcome of life and expected to die in their 70′s has quite rightly gone. But now people expect the best and most high-tech input, they expect to have access to specialist services and they expect it as soon as possible.
I am at heart a district nurse, so my instinct is that patients should be cared for in their homes or close to them, where possible. But I have witnessed failed attempts to persuade people that is exactly what they want or need. Yesterday, I drove past my local hospital. Currently its A&E and acute services are being expanded, pretty much rebuilt. This is partly due to the downgrading of services at another hospital. But it is also because people are using acute services much more. They are bypassing primary and community services and turning up at the Emergency room. This increase in unplanned care has been going on for a few years. the way Trusts are funded contributes to this increase, since being paid for each time a patient attends increases their income. Commissioners can try to cap this activity, but no one seems yet to have informed the patients.
In my two most recent jobs, I have learned that if you want to find out what people using your services think then you need to ask them. If you want to develop the best services, you need to work with patients in developing them and if you want to change policy you should actually consider what real people think about it. If the CCGs would like to significantly change the face of healthcare provision then they will need to weather a serious political storm (previously endured by managers) and the views of the people who will use those services.