General practice

The doctor’s surgery, health centre, medical centre and medical practice are all used to describe the General Practitioner’s (GP) base. GPs are medical practitioners who choose to work in the community setting with patients and their families, rather than in a hospital. GPs provide a wide spectrum of services from those offered by single handed or small group GP practices, some in remote and rural areas, to large Health Centres, where a number of practices and their practice teams share premises and provide a comprehensive range of services. Core general medical services include consultation, examination, diagnosis and treatment, family health advice, vaccinations, prescriptions and referrals.

GP health centres

The first GP health centres opened in England in 2008, as part of a wider programme to improve access to GP services, particularly in parts of the country that had fewer GPs and greater health challenges. Apart from the general medical services offered at most GP practices and health centres, GP health centres offer additional services that would normally be provided elsewhere such as maternity, dentistry, physiotherapy and minor surgery. Described in the press as ‘super surgeries’, GP health centres have a strong focus on promoting health, particularly for hard-to-reach groups, and on reducing health inequalities. Most centres open from 8 am to 8 pm, 7 days a week, and anyone can use the additional services and stay registered with their local family doctor. Appointments can be pre-booked or patients can walk in without an appointment. Health Trusts in England determine the types of services offered based on local needs and local health improvement plans.

Minor injuries units

Minor injuries units (MIU) are community-based facilities that provide an alternative to attending an accident and emergency (A&E) department, if the person’s injury is not serious. This frees up time for A&E staff to deal with more serious and life-threatening conditions. MIUs are usually nurse-led and attendees do not have to be registered with a particular GP. As appointments are not necessary and they are close to where people live, MIUs are convenient and save everyone time and unnecessary travel.

Treatment room services

Treatment room services are usually provided for people living and registered with a GP in a particular locality. The nurse completes a full and comprehensive assessment at the person’s first visit to the treatment room to ensure the most appropriate care and treatment is delivered. Treatment room nurses are usually qualified to prescribe a variety of products used in the delivery of care.

NHS walk-in centres

NHS walk-in centres have become well established in England, treating approximately 3 million patients a year, and offering a complementary service to traditional GP and A&E services. They are based in local communities and provide on-site treatment for people with minor illnesses or injuries. They may be run by independent companies but are managed by Primary Care Trusts and they provide an NHS service. Most centres are open long hours and for 365 days a year. Walk-in centres are available for everyone to use, regardless of where they live or the GP they are registered with. Appointments are not necessary. They are usually managed by nurses but in some centres there is also access to doctors. They are not designed for treating long-term conditions or immediately life-threatening problems but they offer convenient access to a range of treatments for the following types of minor conditions:

Community hospital

A community hospital is a local hospital, unit or centre providing healthcare facilities and resources that are accessible by the local community. GPs usually provide the medical care in liaison with hospital consultant, nursing and allied health professional colleagues as necessary.

Most of the original community hospitals pre-dated the NHS and provided inpatient beds for the people living in the locality. Often in small towns, they were funded by local benefactors and some were built as war memorials to commemorate local service men and funded by families and the local community. Consequently, there is often still a strong sense of local ownership, community pride and identity, which contributes to what can be described as ‘social capital’; the idea that communities working together create benefits for the whole community and for individuals. Community hospitals enable positive links and networks with and between carers and carer organisations, voluntary organisations, care providers in the social, private and care home sectors and local businesses, and are well placed to respond to new opportunities to work with and for the community. They are very well placed to promote a multidisciplinary, multisectoral approach to health care and have the potential to provide 24-hour, 7-days-a-week local access to a wide range of services. In most areas, nurses are employed to work specifically in the community hospital, although there are examples in some rural areas where district nurses are involved on a rotational basis.

The range of services that rural or urban community hospitals offer differs according to local arrangements for healthcare provision and depending on the needs of the locality. The following are some examples of the services that might be available at a community hospital, although most would focus on providing a selection of these:

The following are three examples of community-based centres in urban settings:

Hospice

A hospice can be defined as a place or setting but it is actually much more than that. Since Dame Cecily Saunders’ work in the 1950s and 1960s and the development of the modern hospice, it is more accurately defined as an approach to care. The aim of hospice care is to enhance the quality of life for the person who is dying and for their family. Care focuses on helping to control pain and relieve symptoms and to enable people to remain as positive, alert and active for as long as possible. Attention is given to meeting the person’s social, spiritual and emotional needs and care is delivered with compassion to maintain the person’s dignity, control and choice.

Hospice care teams include palliative medicine consultants and palliative care nurse specialists, together with a range of expertise provided by physiotherapists, occupational therapists, dieticians, pharmacists, complementary therapists, social workers and those able to give spiritual and psychological support.

Nurse-led services

Nurse-led services are a feature of the clinical settings described so far. In fact without the knowledge and skills of nurses in these settings and their competence to assess, diagnose, treat and prescribe, it is unlikely that services would have developed at all.

Laurent et al (2005) undertook a review of the substitution of doctors by nurses in primary care. Although there was limited research evidence, the review indicated that appropriately trained nurses can produce care of the same high quality and achieve equally good health outcomes for patients as doctors and at a lower cost. In many cases, it is not necessary to see a GP, so in areas where it is hard to recruit doctors or in some rural, remote and inner city areas where GP services are more difficult for people to access, nurse-led clinics and services offer a more accessible alternative. Not surprisingly, nurse-led services in primary care have flourished since the 1990s and tend to be either specialised and defined by the activities that are performed (there are some examples in Table 2.1) or more generalist in nature, such as nurse-led walk-in centres or minor injuries units.

Childcare and pre-school education

There is a wide range of provision in the community for both childcare and pre-school education. Private nurseries, registered child minders and workplace crèches offer day care for young children of working parents together with informal and family carers who look after children in their own homes. Local community playgroups, family centres and Sure Start children’s centres enable children and their parents and carers to meet together in a positive and informal environment. All 3–5-year-old children in the UK are entitled to free nursery education and this is provided in day nurseries, private nursery schools, nursery classes attached to primary schools and by accredited child minders. Members of the health visiting team have contact with the individual child and family wherever the child is cared for. They contribute to health promoting activities working alongside staff and offer services within settings such as children’s centres.

Sure Start children’s centres

Sure Start is a government initiative introduced in England in 1998. Sure Start children’s centres aim to provide a ‘one stop shop’ for children and their parents bringing together the different support agencies which offer a range of services and advice from pregnancy to school age. Each children’s centre is developed to meet the needs of the local community and, although core services must be offered at all centres, additional services vary according to local needs. Examples of core and additional services are shown in Table 2.2.

The different organisations offering these services work in partnership to offer the best support to all children and families in the community that the centre serves. The overall aim is to help children, especially those who may be disadvantaged in some way, get the best start in life. In Scotland, the aims of the Sure Start programme are now being used to take forward the Early Years Framework, which increases the focus on prevention, early identification and early intervention by agencies working together for the individual child and family.

School

School health services are provided in a range of education settings for school age children including mainstream primary and secondary schools, schools for children with special needs, independent and private schools and in the home for children who are home educated. Looked after children, children excluded from school and young people within the youth offending system, also receive school health services. Teams include school nurses, support workers and community medical officers and they are backed up by specialist services such as mental health, family planning, drug and alcohol services and specialist community children’s nurses supported by a range of services. All schools have a named school nurse who provides a first point of contact between the school and other services, and who is responsible for offering every child a programme of health assessment, screening, immunisations and health promotion. Most school nurses are based within health centres or clinics, with a small number based within schools, usually for children with special needs.

Day care centres for adults

Day care centres are run by local authorities, the NHS, voluntary organisations and private companies such as care homes. They can be in purpose built centres, community centres and halls, often in smaller towns and villages, and in residential care homes or in nursing homes. Based on the assessment of a person’s needs, day care aims to give people the skills they need to live as independently as possible, helps them to remain living safely at home rather than in a residential or nursing home and helps to minimise avoidable admission to hospital. It also enables carers to have a break from caring. Transport is usually available as part of the service and is often provided by volunteers from the local community. A range of services is offered at day care centres, including some or all of the following:

Community pharmacies

Community pharmacies are situated in cities, towns and villages across the UK. They include large chains with shops on every high street, premises in supermarkets and large retail outlets and small independently owned pharmacies in small communities. Many are open long hours when other healthcare professionals are unavailable. Consultation rooms are now available in many community pharmacies allowing pharmacy staff to undertake procedures such as blood pressure checks in private and discuss personal issues with people without being overheard by other customers.

They can be found in some of the most deprived communities, which offer very little else in terms of health care. Based in the heart of the community, community pharmacists are probably the most easily accessible of all healthcare providers and are consequently well placed to focus on the most hard-to-reach and vulnerable families in their community. (See more about the services that are offered in community pharmacies later in the chapter.)

The workplace

The workplace can be simply defined as a place where people work. Shops, factories and offices immediately spring to mind but the variety is endless. Later in the chapter, the role of the occupational health nurse is discussed but here, the workplace is discussed within the context of occupational health.

Occupational health is about the relationship between the workplace environment, the activities associated with the job and the health of the person who does the job. Occupational health is therefore important in all settings where people work, including industry, health and social care, education, retail and business, whether this is the public, private or voluntary sector. Employers have a legal duty to care for their employees.

Developments in occupational health and safety legislation have made a very positive impact on working conditions and many of the industrial diseases such as asbestosis in asbestos miners and industrial deafness in factory workers have practically disappeared. However, there are new challenges for workplace health resulting from new technology, societal change and changes in our expectations of work and the working environment. These make occupational health services as important as ever, as organisations strive to optimise staff performance and productivity, reduce sickness absence levels and help employers care for and understand the needs of their employees. There is a focus on enhancing staff morale and promoting a healthy working culture. The occupational health services provided cater to the needs of all employees in the organisation. The effect that a job has on an employee depends on the nature of the job and the individual’s personality and coping strategies. People who work in manual jobs are more at risk of injury resulting from accidents or musculoskeletal complaints such as back pain. Emotional and stress-related problems are more likely to be associated with more autonomous and managerial roles which carry a heavy burden of responsibility and where people are under pressure to meet tight deadlines.

In large organisations, most occupational health services are led by either an occupational health nurse, or an occupational health doctor, with other members of the team providing consultancy advice as needed. The day-to-day running of the occupational health service is often undertaken by a manager who is an occupational health nurse. Other members of the multidisciplinary occupational health team include physiotherapists; ergonomists, who specialise in the design of equipment and the workplace environment, toxicologists and clerical staff. Table 2.3 shows the types of services offered within occupational health.

Legal duties in relation to health and safety at work apply to all employers, including very small organisations. There is an occupational health advice service for small businesses and GPs provided by the Department of Work and Pensions, which focuses on physical and mental health issues that affect individual employees at work. The advice services provide small business owners and managers with early and easy access to high quality and professional occupational health advice, tailored to their needs.

Person’s own home

The setting which is most associated with the work of community nurses is the person’s home. ‘Home’ may be a flat, a house, a hostel, a room, permanent, temporary or mobile. For most of us, home is more than just a place. ‘A man’s home is his castle’; ‘Home is where the heart is’; ‘Home sweet home’, are all expressions that reflect the strength of feeling that people have about their home. Comfort, security, stability and familiarity are things that most of us want in a home and if we share it with others, we expect love, friendship and companionship.

But of course, home may not be associated with positive feelings and for some, it is the root of their health and social problems. Living conditions may be inappropriate for people’s needs or aspirations, uncomfortable, poorly maintained, cold, damp and remote from amenities, family and friends. People may feel isolated, vulnerable, subjected to abuse or neglect, overwhelmed by financial problems and feel unable to cope. The environment in which we live has a profound effect on our relationships, self-esteem and mental and physical health at all stages of our lives.

A research study looking at the environmental housing conditions on the health and wellbeing of children conducted by the Social Care Institute for Excellence (SCIE), in 2005, reported the following key messages:

Nursing home and residential care home

Nursing and residential care homes provide help and support for people unable to remain in their own home, even when a comprehensive support package is in place. The terms ‘residential care home’ and ‘nursing home’ are often used interchangeably and although there are similarities, they are not the same. Both settings provide accommodation, meals, care and support from staff 24 hours a day. The nursing home or residential care home may be owned and managed by the NHS, local authority, private company or voluntary organisation.

Residents are registered with a local GP who will visit them when they require medical care and advice. The main difference between the two is the complexity of the care needs of the individual. The care and services in residential care homes are provided by trained care staff. Qualified nurses are employed within some care homes often as managers but also may be part of the care team, providing nursing care and supervising care staff. However, district nurses have access to care homes and visit in response to referrals from the care home manager or GP. Nursing homes have qualified nursing staff on duty 24 hours a day to support needs that are too complex to be met within residential care homes.

All nursing homes and residential care homes must be inspected, registered and regulated by the national independent regulator of health and social care. Each country has its own regulator. In England, the regulator is the Care Quality Commission.

There are differences in the ways in which the four regulators are structured and discharge their duties. However, their overall aim is the same: to ensure the safety and wellbeing of vulnerable people who use services in local authorities, businesses, charities and voluntary organisations in the community. Regulation, inspection, review and support are methods used to encourage compliance with care standards and promote continuous quality improvement.

Sheltered housing

Sheltered housing provides older people and people with disabilities with safe, independent living. Usually sheltered housing consists of flats or small houses, supervised by a manager or warden and part of a complex with a communal area, where people can meet and socialise. The warden keeps regular contact with the residents and can be called through an alarm system in an emergency. People may own or rent their home in a sheltered housing complex, depending on whether it is provided by the local authority, housing association, voluntary organisation or private company. Generally, any personal care or services such as meals on wheels that residents require is provided by social services or community nurses but there are sheltered housing complexes that provide additional care services, for example, extra care housing, assisted living, very sheltered housing, close care and continuing care environments and care villages.

The clinical, community and home settings described here are just some examples of the places where people receive care and support in the community. You will come across many more during your period of practice learning in the community. However, the focus of your practice learning experience is the health needs of the individuals and the families that you meet, regardless of the setting. If you keep them at the centre, the providers and services fit into place around them and it becomes clear how their health needs are addressed.

Service provision

The way in which the settings and services have been described in this chapter could give the impression that they are separate entities. The fact is that the organisations that provide health and care services do not work in isolation but in partnership. NHS primary care services and community services work together as a primary care team and rely on partnerships, working with the local authority, independent and voluntary sector organisations, depending on the outcomes they want to achieve.

The complex care needs of older people in the community often require a package of care which involves all providers. Sure Start children’s centres are based on bringing a wide range of services and facilities together to offer a comprehensive service which has been shown to be much more effective than services delivered separately. For many, health and social care organisations such as Health Trusts and local authorities integration, rather than partnership, is the next step.

Many people live safely and independently at home managing the challenges associated with ageing or a long-term condition or disability with the support of a family member, neighbour or friend. Their medical care needs may be met by their GP and their contact with other health services such as community nursing may be minimal or not required. In many cases, it is the local authority social services departments that arrange the services which enable people to stay in their own home and avoid admission to hospital or a move to a care home.

Practical solutions such as providing equipment and home adaptations and help with daily tasks including, bathing and washing, getting in and out of bed, shopping, preparing meals, cleaning and transport, often make the most difference. Provision of services is based on assessment of need and where this is complex, a care plan will include a number of services provided by the NHS community services, such as home nursing, health promotion, continence advice, chiropody, occupational therapy, physiotherapy and the provision of equipment, such as wheelchairs and special beds. Other agencies can also provide cash for people to arrange their own services and manage care, e.g. employ a private carer to help with getting up and dressing, meals on wheels, a place at a day care centre run by a voluntary group.

Services differ in their characteristics because of the people they serve and also the type of provider organisation. Different solutions suit different service users, even within the same locality, and so reflect a personalised approach to care. The analysis of relevant and accurate information from local and national sources enables services to be planned at a strategic level. However, a local health needs assessment or a community profile builds up a picture of the health needs of the community in a particular area, often down to the level of the practice population and from there, services are adapted to meet the local needs. (Chapters 3 and 5 discuss health needs and assessment and community profiling in more detail.)