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Proposals to integrate community services with acute and mental health trusts can be beneficial if nurses take advantage of the potential opportunities AUTHOR ROSEMARY COOK, CBE, HON D LETT,

MSC, PGDIP, RGN, PN CERT, is director at the Queen’s Nursing Institute, London. ABSTRACT Cook R, (2010) Liberating the NHS: what the White Paper means to community nurses. _Nursing

Times_;106: 38, early online publication _Liberating the NHS_ (Department of Health, 2010a), continues the previous administration’s policy of moving community services away from the

commissioning organisations in England. It also confirms the intention to create a diverse market of different providers, including “the largest social enterprise sector in the world”. The

white paper removes the possibility of community services remaining with primary care trusts since they are to be abolished, so it is likely that even more community services than originally

planned will merge with local hospital trusts or mental health trusts. This article looks at the potential impact of these moves. It also considers how nurses who are moving, and those who

will be working alongside new community colleagues, can ensure the best outcomes for patients from these changes. KEYWORDS Transformation, White Paper, community services * This article has

been double-blind peer reviewed PRACTICE POINTS * The Department of Health’s six transformational guides bring together evidence to improve services in all the main areas of practice, and

can be a useful guide for nurses. * Community nurses who are moving into employment by an acute or mental health trust should be prepared to explain how their service helps to achieve aims

such as preventing unnecessary admissions and helping patients to care for themselves where possible. * Hospital based nurses should explore the variety of community based services available

to their patients before admission and after discharge. * The Queen’s Nursing Institute’s ‘toolkit for implementation’ is available to help nurses improve services for patients at home and

in the community. BACKGROUND The Department of Health’s Transforming Community Services (TCS) programme was established to deliver the vision of the previous government’s NHS next stage

review final report (Department of Health, 2008). It makes the case for radically changing the way that services outside hospitals are organised and delivered, to meet the growing need for

community-based care. It aims to make care everywhere as good as the best. The programme’s transformational guides bring together the research evidence for good practice that will improve

care in six areas of practice: * Health, well-being and inequalities; * Children, young people and families; * Acute care closer to home; * Care of long-term conditions; * Rehabilitation and

neurological services; * End of life care. The Queen’s Nursing Institute (QNI) has produced a series of matrices that allow teams in the community to check themselves against these guides,

and identify areas that are priorities for change to improve services (QNI, 2010). The result should be better services, based on evidence, that achieve better outcomes for patients.

Alongside this practice improvement work, TCS addresses the organisation of community services, with guidance on the options for provider services to be based in, and commissioned from, a

wider range of organisations (Department of Health, 2010b). These include social enterprises, independent companies, community NHS foundation trusts, or other existing NHS organisations.

This is not a new idea: in 2005, the then chief executive of the NHS, Sir Nigel Crisp wrote to all PCTs to tell them that they should focus on their role as commissioners of services, and

divest themselves of their provider functions; that is employing and deploying community nurses, health visitors and therapists (Department of Health, 2005). The nurses and other

professionals who work in community services have therefore had five years of uncertainty about their future. This insecurity is now coming to an end with the proposed moves into other NHS

or non-NHS organisations. The decision about who should provide community services, if not PCTs, is not solely driven by policy developments. Factors such as the economic squeeze and the

need to find solutions in a reasonable timescale make mergers with existing NHS organisations more attractive than creating new organisations. Local plans suggest that there will be a small

number of new community foundation trusts, and some social enterprises or new integrated, community-based organisations. MOVING COMMUNITY SERVICES After nearly two decades apart from the

acute sector and mental health organisations, during which community services have changed and developed, many nurses have reservations about reintegrating with them. There are risks and

benefits to merging community services into hospital or mental health trusts. In anticipation of these moves, the QNI asked members of the All Wales District Nurse Forum for their views on

the issue, as community services in Wales have remained part of integrated hospital trusts. The Forum members identified the following benefits to integrated services: * It is an opportunity

for community nurses to demonstrate high quality care in the key areas of their expertise; * It improves working relationships between acute and primary care; * It allows for the sharing

and setting of joint priorities; * The transfer of care from acute to secondary care setting can be more seamless; * It is an opportunity to raise awareness of district nursing and what it

can do for patients; * All staff work to the same policies and procedures; * Training is integrated and shared; * The costs of specific treatments should not be an issue of dispute between

hospital and community services. Forum members felt that integration can lead to improved and co-ordinated patient pathways, for example, “a rapid discharge pathway for patients at the end

of life, which has been developed with in-patient and community services, has greatly enhanced patient choice in last days of life”. One note of caution was offered: “[Improvements happen]

sometimes, not always. Hospitals don’t always see further than their own role, that is when planning a change in service they often don’t consider impact on other services.” This comment

reflects the risks that the Forum anticipated from integrated services, which were that: * The priorities for an acute organisation might have a greater focus on acute areas and not across

the whole of the patient pathway.  The targets set by government will dictate the organisation’s priority; * The quality of community nursing could be difficult to maintain.  A

hospital-based organisation may not support the staffing numbers required to appropriately resource community teams due to the financial constraints of the organization; * Resources are

drawn into the acute area to meet targets, since none are set for community services these services are often seen as an easy way to save on costs. MAKING THE BEST OF THE MOVE Nurses and

their colleagues are not passive onlookers to these changes, and there are many things they can do to mitigate these risks, and help protect the quality and integrity of their services as

they settle in to new organisations. The Welsh Forum suggested using the move as an opportunity to raise awareness among the public, new colleagues and the Trust executives of the range,

complexity and importance of modern community services. Community nurses could invite acute colleagues and executives to visit their services in action, to see how good community services

prevent admissions, speed up discharges and contribute positively to the patient’s pathway of care. They could use audit to demonstrate the effectiveness of services, publicise their

innovative projects and celebrate achievements. Most importantly, one Forum respondent commented, nurses should try to “break down the artificial barriers between community and secondary

care: ‘them and us’ will not promote motivation and commitment”. ISSUES FOR HOSPITAL NURSES Many hospital nurses’ experience of community nursing will be confined to a brief placement during

their pre-registration education, and whatever encounters they themselves have had with their practice nurse or health visitor. They may not know that community services have expanded

significantly in the years since they split from hospitals (in England), and consequently there is a much greater variety and complexity of nursing work taking place outside of the hospital

walls. (Box 1 shows some of these developments.) BOX 1. DEVELOPMENTS IN COMMUNITY SERVICES * PRESCRIBING: district nurses and health visitors were the first nurse prescribers; community

nurses with appropriate training recorded with NMC can now prescribe from full British National Formulary. * ACUTE CARE IN THE HOME: procedures including blood transfusions, cancer

chemotherapy and ventilator support are carried out in patients’ homes in some areas. * AUTONOMOUS ROLES: advanced nurse practitioners see undifferentiated patients, assess, diagnose and

prescribe. Practice nurses are responsible for managing long term conditions. Nurses lead walk-in centres, urgent care units and community-based surgical units. * BUSINESS OPPORTUNITIES:

nurses are running general practices, nursing homes, social enterprises, charities and out-of-hours services, combining clinical and corporate management roles. Hospital staff need to be

familiar with local community-based services so they can integrate them with the acute care provided in the hospital. This will ensure the patient experiences a smooth transition along the

pathway of care. For example, a nurse working in an acute unit might need to ask: * Who will be there to answer my patient’s questions after discharge? * Are rehabilitation or support

services available in the home? * Who is going to check on the patient’s condition over the next 10 days? * Is specialist advice available to this family? * Who can they contact if they have

an urgent query at night? The answers to these questions will help the hospital team to develop a map of local services, including those of community nurses, wherever they are based. THE

FUTURE OF HEALTHCARE Numerous factors are already impacting on the demand for and supply of healthcare outside hospitals in the UK, and they are entirely separate from government policy or

ideology. These include demographic issues (see box 2), economic circumstances, technological advances and changes to people’s expectations. All of these are driving the move towards more

care in the home: both complex and acute care, and more routine care for long-term conditions (QNI, 2009). BOX 2. POPULATION CHANGES AFFECTING DEMAND FOR HEALTHCARE * 1 in 4 people aged over

75, and 1 in 2 aged over 85, need nursing at home (Audit Commission, 1999). * Since 1983, the number of people aged over 85 has more than doubled from 600,000 to 1.3m (Office for National

Statistics, 2009). * By 2025, there will be 42% more people aged 65 or over than today (Department of Health, 2010c). * 15.4m people in England live with a long-term condition by 2025

(Department of Health, 2010c). * Number of people with at least one long term condition will rise to 18 million (Department of Health, 2010c). Wherever nurses are employed in future – which

may well be in a mixed economy involving the NHS, independent sector, co-operatives and charities - the trend towards more integrated services which break down divisions between hospital and

community is likely to continue. Patients will expect more flexible, convenient, tailored and technologically-astute services than they have traditionally received. A health service with

financial pressures will need to be much smarter and more efficient in its delivery of care. It is essential that the transfer of community services into other organisations does not stall

the development of these services. The gains of recent years must not be swallowed up by acute sector priorities, if we are to create and sustain a community-based health service that can

meet the massive needs of the future population. * ACKNOWLEDGEMENT With thanks to the All Wales District Nurse Forum REFERENCES AUDIT COMMISSION(1999) _First Assessment – A Review of

District Nursing Services in England and Wales_. London: Audit Commission. DEPARTMENT OF HEALTH (2005) _Commissioning a Patient-Led NHS._ London: Department of Health. DEPARTMENT OF HEALTH

(2008) _High Quality Care for All – NHS Next Stage Review final report_. London: Department of Health. DEPARTMENT OF HEALTH (2010a) _Equity and Excellence: Liberating the NHS_. London:

Department of Health. DEPARTMENT OF HEALTH (2010b) _Transforming Community Services: The Assurance and Approvals Process for PCT-provided Community Services_. Department of Health: London.

DEPARTMENT OF HEALTH (2010c) _Improving the Health and Wellbeing of People with Long Term Conditions_. Department of Health: London OFFICE OF NATIONAL STATISTICS (2009): _Statistical

Bulletin: Older Peoples’ Day_. QUEEN’S NURSING INSTITUTE (2009) _2020 Vision – Focusing on the Future of District Nursing_. London: QNI. QUEEN’S NURSING INSTITUTE (2010) _Toolkit for

Implementation_. London: QNI.