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Community nursing needs a new prescription

Nurses know how to make people better, but with a little extra support we are also able to keep people well

Professor Field, Chief Inspector of Primary Care, recently highlighted the importance of primary and community nursing, and the role that they could play in helping to manage demand and deal with long-term conditions more effectively in the community.

He identified that the solution lies in workforce planning and skill-mixing the nursing and medical workforce, and offering further education to nurses in the management of long-term conditions.

In my view, this is just a repeat prescription - although a focus on falling district nursing numbers does need urgent attention, just as health visitor numbers did before that. Support to practice nurses is still unacceptably variable. We need a new prescription entirely, which will not engender more dependency on us as clinicians to 'fix' people, thus fuelling demand. 

The prescription for managing demand needs to be balanced with one which helps stem the very flow of that demand, otherwise the patient will remain sick. In terms of long-term conditions, a review of community nurse education should have an evidence-based focus on wellbeing, and how to create 'health', as much as how we manage illness. We need to share knowledge of how we support and enable our residents to help themselves. I believe that community nurses are ideally placed to embrace this way of working because we have an excellent understanding of how family and community works.

Most nurses are aware of the five ways to wellbeing, published by the New Economics Foundation. But there is now a range of knowledge about what 'makes' us healthy (in contrast to what 'keeps' us healthy: our lifestyle, health protection and the social determinants of health). This knowledge of health creation, known as salutogenesis, is relatively little-known to nurses but could be the key to how we might help halt the rising tide of demand. If you search 'What makes us healthy' by my esteemed colleague Jane Foot, you will have the whole evidence base at your fingertips.

The psychiatrist Victor Frankl, having reflected on who lived and who died alongside him in German concentration camps, told us that everyone needs a reason for living. Nurses will know this from their own experience: for example, we observe what happens when a much-loved pet dies or someone whose clear purpose was to tend their garden becomes too frail to do it. We also know from the work of the Joseph Rowntree Foundation that loneliness profoundly affects wellbeing, and indeed in health terms is the equivalent of smoking 15 cigarettes a day. Nurses can enable patients to have a reason for living, not just via social prescribing (which is excellent) but by becoming entrepreneurs and innovators. The example I give is of district nurse Mike Palmer in the Shetlands, who in an effort to avoid older people drinking alone at home, now accompanies a group of older residents to the pub for a wee dram. Nurses can be enabled to use initiatives like this, and entrepreneurship programmes like the Queens Nursing Institute (QNI) Nurse First programme, need to be extended. Nurses need to signpost routinely to start up entrepreneurship awards from organisations like UnLtd as well as nursing sources like the Burdett Trust.

Clinicians alone will not solve the problem of managing long-term conditions. Only when we embrace communities, carers and patients themselves as partners - not just as 'expert patients', people who tell us their 'experience' or (massively unsupported) carers, but as assets with complementary gifts of their own. In a now-famous animated online video, 'The Parable of the Blobs and Squares', Edgar Cahn, the founder of timebanking, describes organisations as 'squares' whose measure-and-tick-box approach misses the point of what really happens in communities. Likewise the 'blobs' in communities lack the clout to change their own destinies. The point Cahn makes is that we can't change the blobs into squares as it changes their very strengths, and that in fact the blobs and the squares need each other to make a real difference. But sometimes residents don't have the confidence early on to shape their own communities and it is us - nurses - who can be there to guide them through the early stages. It is time we said no to more of the same. Nurses do not need fixing again. We know what to do, trust us. We just need liberating.