Anyone who thinks the front line of our healthcare lies in hospital wards or GP’s surgeries should spend a day with a district nurse. Looking after people in their own homes, they are the Cinderellas of the system. And yet many people do not even know they exist and new reports show that their work is at breaking point due to unmanageable caseloads, a growing gap between capacity and demand.
In the fierce debate about healthcare, how it is prioritised and funded, certain principles are broadly agreed. They include the fact that most people would like to be cared for and certainly to die at home – rather than in hospital. Enabling and expanding this would take pressure off hospitals and lower their costs. District nurses are emphatically proven to be able to do this. As a report by the King’s Fund this month ut it, “at its best district nursing offers an ideal model of person-centred preventative, community-based care.”
Yet in these times there is such intense strain on the district nursing system that many patients stay in hospital far longer than they need to. This so-called “bed-blocking”, in which patients occupy hospital beds because they cannot be discharged into the care system, has now reached its worst level on record.
Last week I spent a day with Liz Alderton, a district nurse, in Harold Hill on the London/Essex border, the largest housing estate, built for the Greater London Plan of 1944, to re-house people from the bombed out ruins of East London. Liz is a district nurse of 30 years experience, she is also a Queen’s Nurse, having achieving this special qualification from the Queen’s Nursing Institute, the charity which founded district nursing in the 19th century and which also set up my organisation, the National Gardens Scheme, to raise funds for district nurses.
Liz is a specialist in palliative care and qualified to prescribe drugs. The more severe a patient’s mental or physical ailments, or the more pronounced their poverty and social deprivation – both of which swathes of Harold Hill is blighted by – the more devoted Liz is. As she told me, the more difficult they are the more I love them. The patients we visited graphically bore this out; all were profoundly and terminally ill.
Even though visits are planned in advance district nurses never know what they are going to find in people’s homes and constantly have to make crisis-driven last-minute adjustments. We visited Peter who has late-stage oesophageal cancer and found that he had fallen out of bed onto the floor. Peter lives with his wife Emily who has been traumatised by his illness and is unable to offer real help. They are dependent on Liz and carers. Peter was critically ill and weak and suffering from exaggerated cachexia. We got him back into bed but Liz was concerned that it would happen again with fatal consequences so she phones for a replacement bed with sides.
The bed will arrive in the afternoon so we go on to Margaret, who Liz has not seen before. The local hospice rang her to say they were worried and could Liz call in, assess her and see Margaret’s niece who would be visiting. A crucial part of district nursing is caring for not only patients but also for their immediate families. When we arrive it is clear that Margaret is very depressed, she has had stomach cancer and now has metastases in her lung and bones. Liz crouches down to talk to Margaret and reassure her and her niece. While she is talking to them Margaret is violently sick as a result of bleeding caused by the stomach cancer.
Liz makes an instant decision; we will go to the local pharmacy for a prescription of morphine, anti-sickness pills and anti-depressants. Liz also addresses the serious issue that Margaret lives on her own and needs urgent care at home. She calls the hospice in the hope that, ideally, they will have bed or they can visit under their hospice at home programme. Neither are available. As a last resort Liz files a request for a Marie Curie nurse to be with Margaret overnight, but as it is now 4pm she is not hopeful. While we are driving Liz tells me, this is an old lady who is dying. I need to do the best for her. Of the options for Margaret, the worst would be to have to call an ambulance. Admittance into hospital would put her into a cycle of analysis and prognosis when all she needs is sensitive, knowledgeable end of life care.
Peter died peacefully that night. Margaret did get a Marie Curie nurse and two days later was admitted to the hospice where she died on Sunday.
The contrast between the day’s activity which conjured up images of being on a battlefield alongside a dedicated, experienced soldier, and district nursing’s place in our healthcare system was graphically summed up by Liz’s description of a recent visit from a CQC inspector. I wanted to wow her by taking her out and showing our work with patients, but she spent the day in the office asking me about the regularity of staff assessments and levels of diversity.
As so much of the National Health Service buckles under relentless pressure, district nurses remain a beacon of quality, efficiency and dedication. They are the lynchpin of care for thousands, managing people in and out of hospital, engaging with Marie Curie and hospices, or just executing their own formidable nursing skills.
And yet they are chronically undervalued. Two recent decisions; one to make trainee nurses pay tuition fees, the other by the Department of Health to scrap its nursing advisory board both confirm this. Sometimes GPs surgeries are not willing to properly engage with caring for patients in the community – which means visiting people at home. As Liz said to me with a wry smile as we parted at the station, GPs can do odd things and that’s why we have district nurses, to sort them out.
All patient names in this article have been changed.
George Plumptre is Chief Executive of the National Gardens Scheme, the most significant charitable funder of nursing in the UK.
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