Community is key: Invest in health outside hospitals

"Too many people end up in hospital, because too little is spent in the community" ~ Lord Darzi

Lord Darzi’s recent independent investigation into the state of the NHS report screams for a radical change in how we think about healthcare. But, I would go further and say it’s healthcare outside of the clinic walls that we need to invest in if we want a healthier society. Health promotion and education is the bread and butter of nursing. As a community nurse, this is something my colleagues and I have been asking for years as we see the cost of its loss through our day-to-day work.

Under-investing in the community healthcare workforce and services has led to staff burnout and acute care services being clogged up. The over-focus on hospitals and secondary care has skewed our understanding of health too, as we then tend to focus more on acute health needs and run the risk of neglecting early intervention.

So often, the question I get asked when I say I’m a nurse is “Which hospital do you work at?” Yet, all of us will have come across a nurse or other healthcare worker based in the community at some stage of our lives:

The Community Midwife that met with your mum when she was carrying you; the Practice Nurse who gave you your childhood and travel vaccinations; the Health Visitor who visited your mum at home soon after you were born; the School Nurse you went to see when you were sick at school; the District Nurse who visits your gran for her insulin, or orders a specialist mattress for her due to her bed sores; the Community Mental Health Nurse checking in on their patient over a coffee; the Palliative Care Nurse who collects and administers pain relief medications. And then there are the community nurses and services in more hidden places like nurses working in the prison service, nurses working in hostels for people experiencing homelessness, nurses working with asylum seekers; nurses doing street outreach with people with people at times of real distress…the list can go on.

~ Nurses based in the community are the eyes and ears of the people they serve

Nurses based in the community are the eyes and ears of the people they serve and unsurprisingly, the decrease in their numbers correlates with an increase in health concerns. The Institute of Health Visiting’s report out earlier this year, “The State of Health Visiting” highlights that since 2015, there has been a cut of over 40% of the Health Visiting workforce. As a result, Health Visiting teams have been prioritising child protection and child in need cases, but have not been able to carry out their other preventative and early intervention work as much as they would like to. The Health Visitors questioned as part of the report shared their concerns over an increase in the number of children with developmental difficulties, the number of babies and children referred for safeguarding concerns, and the number of families struggling due to the cost of living crisis. Could a shrinking workforce be missing opportunities to detect issues early on?

In the adult population too, nurses are seeing those at the margins of society, sometimes unaware of their rights to healthcare services, but at other times disengaged with it altogether due to difficulty accessing it or having negative experiences with it. We’ve all had personal experiences of having difficulty getting through to the GP by phone or spending hours in A&E to be seen. Numerous studies from around the world show how well-planned community care teams can prevent hospital readmissions or inappropriate A&E visits. But, a stretched service will end up operating in a streamlined way, fire-fighting, and in doing so, it misses vulnerability, and we then end up sending people to A&E or going through a series of root causes analyses to look at where we went wrong.

The thing is, we know what the answer is. We can keep carrying out serious case reviews, root cause analyses, commissioning reports and research to look into the causes. But, the truth is, it’s understaffed and underinvested. For care to be provided locally, the scales need to be tipped so that community services are not only valued for their role, but are capable of carrying them out safely. By investing in preventative healthcare, early intervention services, and health promotion at its basic level, we can:

• ensure that our communities feel confident in recognising concerns early on

• make healthcare workers visible and accessible in the places that people use the most

• support healthy behaviours for a healthier society

Despite an increase in health needs with a greater demand on GP services, and repeated government promises, the figures show that investment in community health services just isn’t growing. The Office for National Statistics (ONS) publish yearly UK healthcare expenditure figures. Around 8.2% of the total UK healthcare expenditure in 2022-2023 was spent on preventative care. This is divided between immunisation programmes, early detection screening services, surveillance, and information. However, prevention is much more than just disease control and screening. It’s supporting people to take care of themselves to prevent disease in the first place.

~ Around 8.2% of the total UK healthcare expenditure in 2022-2023 was spent on preventative care

In the 11 years that I have worked in community health care services, I have seen the erosion of grassroots health promotion. The kind where I would go to day centres, church halls, Healthy Start centres, and schools to talk about all sorts of topics with parents, students and the general public. Instead, we’ve seen more and more managerial roles or roles that are more clinic-based appear. Long-term funding for health promotion work in the community just isn’t available.

~ For the majority of us, we are more likely to meet a healthcare worker in a community setting than in hospital

Spending on early health promotion and care in the community for all ages makes financial sense and common sense. For the majority of us, we are more likely to meet a healthcare worker in a community setting than in hospital, we have an ageing population, as well as a population with growing chronic health conditions and mental health needs. So, investing in health upstream will save expensive hospital visits, support people with living healthier lives in their communities, and make the NHS an attractive employer to work for.

Lord Darzi’s report does a great job of highlighting this issue. The next few years will show us if this call to action will be brought to reality, because investment in community healthcare services has been a fixture on government promises for years.

References:

Gorham and Wood (2023) Unlocking the power of health beyond the hospital: supporting communities to prosper.

Office for National Statistics (2024) Healthcare expenditure, UK Health Accounts: 2022-2023

The Institute of Health Visiting (2024) State of Health Visiting, UK Survey Report.