Coronavirus: Community nursing faces ‘rehabilitation disaster’ as Covid leaves thousands in need

Tens of thousands of coronavirus survivors needing long-term care are heaping pressure on Britain’s stretched community services, threatening a crisis that experts warn could dwarf that seen in hospitals over the past 12 months.

As many as 100,000 intensive care patients, including up to 15,000 Covid-19 survivors, will need long-term community nursing care after being discharged from hospitals during the past 12 months, The Independent has been told.

This will be on top of an as yet unknown number of Covid patients from the 350,000 treated on general wards since the pandemic began, as well as tens of thousands of people who were sick without going to hospital but have been left with debilitating symptoms of long Covid.

Labour’s shadow health minister Liz Kendall warned: “There will be huge pressures on community services as people who need long-term support are discharged back into their own homes.

“Ministers have got to put in place a proper workforce strategy for the NHS and community care otherwise we will see people struggling to recover and the burden of care could also fall on their families.

“This is one of the long-term consequences of Covid that we haven’t begun to even think through yet.”

NHS community services have already started reporting big increases in demand with some services reporting a 50 per cent or more increase in referrals for community nursing, with staff having to work longer shifts and extra days to cope with demand. Some less critical services are being stopped.

Despite the recovery needs of intensive care patients being recognised by the National Institute for Health and Care Excellence in guidelines now more than 10 years old, NHS England still doesn’t commission post-ICU rehabilitation services.

Without a substantial investment in the coming weeks and months, patients could see vital community services being rationed.

Zudin Puthucheary, an intensive care consultant at the Royal London Hospital and chair of the Intensive Care Society’s national rehabilitation collaborative, has been lobbying for urgent investment.

He warned: “The rehabilitation disaster is going to be our next pandemic. The full scale of this needs to be understood.

“We need to get going today, the clock is ticking.”

Before the coronavirus pandemic community services were already overstretched, with the numbers of district nurses who work in people’s homes and lead community care teams falling from more than 7,000 to just over 4,000 in the 10 years to 2019. Three-quarters of teams had vacancies and recruitment freezes before the pandemic.

With tens of thousands of hospital surgeries delayed or cancelled, and more than 2 million patients shielding at home, the demand for home care has increased substantially.

Community teams are also picking up increased demand for blood tests and other routine care as well as having to look after sicker patients discharged from hospitals earlier to free up beds. There has also been an increase in patients needing end of life care at home.

With nurses having to wear full protective clothing before entering a patient’s home, this has to be changed after each visit. For a caseload of between 10 and 15 patients a day this means an hour in lost time if changing takes only five minutes per visit.

At the same time community services are building up their own backlogs, as staff such as physiotherapists and speech and language therapists have been redeployed to help hospitals during the Covid surge.

Many community services are paid for with lump sum, or block, contracts, meaning increases in demand have to be met from existing budgets.

One hospital trust delivering community services told The Independent it had seen increases of more than 50 per cent in referrals for district nursing care. Another in the north of England warned some clinics and appointments were already being rationed and scaled back to free up staff.

Separately, directors at the Walsall Healthcare Trust were warned this month that the “financial envelope and resourcing for community services as a result of the Covid-19 legacy” was a major risk.

A report to the trust board warned: “The extent to which pressures on community services have increased during January cannot be overstated,” adding: “Backlogs in therapy pathways, demand way above forecast in Covid pathways and suspension of less urgent appointments has been an unavoidable position.”

The trust board was told the capacity of the service was insufficient to match current demand.

James Benson, chief operating officer at Central London Community Healthcare Trust, one of the largest providers of community services, told The Independent his organisation was already seeing increases in referrals.

“We are now seeing a 20 per cent increase in referrals across our core community services, following a rise since August.

“Community services see more patients than people realise. Weekly contacts in Barnet for example, are 4,700 adults, not including children.

“We care for the most vulnerable people, so we just can’t walk away from them. To be on a community nurse caseload you have a significant need.

“We are working closely with our colleagues across the health and care system to try and manage the growth in activity and will be seeking a long term resourcing plan to support us to do this.”

NHS hospitals have faced an unprecedented crisis due to the effects of the pandemic and the thousands of sick patients needing help to breathe.

Research by Dr Puthucheary, published earlier this month, found 98 per cent of Covid patients who were admitted to intensive care at 26 English hospitals needed physiotherapy, with 100 per cent needing occupational therapy. More than nine in 10 needed support to help regain their speech.

In total, more than a third of the Covid patients who were discharged home, needed community rehabilitation.

Dr Puthucheary said around 100,000 patients survived ICU each year, with Covid likely to add 15,000 more. He warned many of those affected were of working age and without good rehabilitation would be unable to contribute to society.

He said: “We are going to push a vast number of patients out into the community. Britain survived the pandemic now it has to survive the recovery.

“People can lose 2 or 3 per cent of their muscle mass every day in ICU and Covid patients can be in ICU for 12 days or even longer

“A 5 to 10 per cent loss of your muscle mass is a life-changing amount. It changes your function, how you are able to walk, whether you can go shopping by yourself.

“The community care problems are so huge and people don’t want to talk about it.”

He said the chancellor, Rishi Sunak, should address the need for extra investment in his forthcoming Budget next month.

“This has been recognised as a public health issue since 2009 but there is still no commissioning of post-ICU rehab services.”

To help free up hospital beds, NHS England has launched a new faster discharge process with patients assessed in their own homes. New in-reach services for care homes have also been started in some areas during the pandemic as well as the large-scale vaccinations of housebound patients.

This is on top of the existing demand for community healthcare services.

Lesley Channer is a district nurse and lead for community nursing at Your Healthcare CIC, a not for profit social enterprise delivering care to residents in the Kingston and Richmond areas of London.

She told The Independent that community nursing was still largely invisible to the wider public but coronavirus had meant its services were even more in demand.

“The nurses are exhausted. They do not go home until the work is done. They meet the demand by working more hours, they don’t leave anyone requiring any nursing care at the end of the day. They do not go home on time and they do not take regular breaks. They are completely exhausted.

“We are the safety net. The demands are increasing and if you add in the effects of Covid the demands will increase further.

“We need a recognition of the essential role community nurses play in meeting people’s health needs in the community and we need the ‘cloak of invisibility’ removed from the work we do and the role we play in people’s lives.”

Crystal Oldman, chief executive of the Queen’s Nursing Institute, a charity which supports community nursing, said: “The virus affects so many parts of the body, many patients will have a lifelong illness. They will be cared for at home. These people are going to need a lot of support.”

She said those patients discharged from intensive care were only the “tip of the iceberg” in terms of the total demand on community services that needed to be considered.

Some staff were working six-day weeks in order to meet the increased demand, she said, adding: “That’s not sustainable.”

She said many families and carers have had to take on more caring responsibilities and been trained to do so by nurses.

Better data on the care that was being delivered was needed in order to plan the workforce and resourcing needed, she said, adding: “Community care is mostly a nurse-led service, we must find the resource that is going to be needed in the long term. There is going to be a legacy from Covid and long Covid and we don’t know what the size of that is yet.”

A Department of Health and Social Care spokesperson said: “This continues to be an incredibly challenging time and one that has put acute pressure on our NHS and care services. The government is doing everything it can to support vital health and care services through this time and is investing nearly £52bn this year alone.

“There are currently record numbers of NHS staff, including 11,000 more nurses and 6,300 more doctors than this time last year, but we are also offering new non-repayable training grants for eligible nursing, midwifery and allied health students, to make sure our health and social care sectors continue to have the workforce they need to deliver high quality care, now and in the future.”