Community matron - I didn’t know this was even possible.

whitestripedagain · 2026-10-10T12:55:43+00:00

My elderly dad is chronically ill and disabled and in the last 18 months he’s been in and out of hospital but often with relatively small issues, like needing fluid drained or IV antibiotics. As he’s quite frail, and his BP runs very low due to heart failure, they nearly always admit him and he often then picks up a new infection. When he is fit to go home, then usually have to fight to get him quickly reassessed for his state funded care package (it lapses after 5 days in hospital) On top of that I’ve been advocating for him to get a review of his drugs, get regular physio, support him hopefully to move into supported living and to get the GP to take us seriously about the many infections he’s picking him up. I’m grateful for the care he has received but wow sometimes it’s been utterly exhausting. But then one day a few months ago the community matron service entered our lives. Firstly I didn’t know there was such a thing - not until dad got a letter to say he’d been referred to them. This woman is an absolute marvel. She went to see my dad and got his permission to speak to me. She’s a band 8 nurse (as is her team), they can prescribe some medicines, act as an advocate, set up hospital appointments, deal with social services and basically cut through all the red tape and bureaucracy I’ve been dealing with. She’s even got the GP to finally listen to us which is extraordinary in itself. I don’t know who made the referral but I’m just mentioning this in case anyone is in a similar situation and doesn’t know this service exists. I assume it’s nationwide (if not, it absolutely should be) but apparently the aim is to keep people like my dad out of hospital unless it’s absolutely necessary. If you’re in the same situation, worth looking into whether your area has this service too.

CMOTDibbler · 10/10/2026 14:24

I think unfortunatly this sort of service is one of those things that is absolutely amazing, but get cut when budgets are squeezed and very local. At one point the area my parents were in had a 'keeping frequent flyers out of hospital' team which was multidisciplinary and were incredible - really working round my parents complex needs, finding ways to support correct decision making about admissions/ ambulance calls, falls prevention etc etc. Must have saved tens of thousands of pounds in hospital care just for the two of them. And then it disappeared again, I assume because they were costing the local community team money, and saving it from the hospital and ambulance service budgets.

Original poster

whitestripedagain · 10/10/2026 14:44

CMOTDibbler · 10/10/2026 14:24

I think unfortunatly this sort of service is one of those things that is absolutely amazing, but get cut when budgets are squeezed and very local. At one point the area my parents were in had a 'keeping frequent flyers out of hospital' team which was multidisciplinary and were incredible - really working round my parents complex needs, finding ways to support correct decision making about admissions/ ambulance calls, falls prevention etc etc. Must have saved tens of thousands of pounds in hospital care just for the two of them. And then it disappeared again, I assume because they were costing the local community team money, and saving it from the hospital and ambulance service budgets.

Ah, I’m so sorry to hear the service disappeared - that’s so disappointing. 😔

OP posts:

MysterOfwomanY · 10/10/2026 16:13

Mad isn't it.
My elderly relative has All The Things (ok, not diabetes. Yet...) and gets the district nurse out to dress leg ulcers. But when she was suddenly weak and stopped being able to walk At.All. and sleeping all the time... They didn't do anything.

Now she's in hospital being treated for an eye problem, and the GP will have had both a notification of this and an, "I'm really worried because XYZ, please go and visit her..." letter from me arriving on her desk last Monday.

A community matron might have forestalled all this...

Blushingm · 10/10/2026 16:27

MysterOfwomanY · 10/10/2026 16:13

Mad isn't it.
My elderly relative has All The Things (ok, not diabetes. Yet...) and gets the district nurse out to dress leg ulcers. But when she was suddenly weak and stopped being able to walk At.All. and sleeping all the time... They didn't do anything.

Now she's in hospital being treated for an eye problem, and the GP will have had both a notification of this and an, "I'm really worried because XYZ, please go and visit her..." letter from me arriving on her desk last Monday.

A community matron might have forestalled all this...

What do you think the district nurse could have done?

JHITRM77 · 10/10/2026 16:30

Community nurses used to be common, both my mum and auntie were on the circuit but most services have been cut now, it's awful.

FindingMeno · 10/10/2026 16:36

It's like a whirlwind when the Community Matron team are called in. Prescriptions, occ health needs, physio, incontinence- all evaluated/ re-evaluated.
It's amazing.
I think its a brilliant service to help those that are frail keep out of hospital.

Original poster

whitestripedagain · 10/10/2026 16:40

MysterOfwomanY · 10/10/2026 16:13

Mad isn't it.
My elderly relative has All The Things (ok, not diabetes. Yet...) and gets the district nurse out to dress leg ulcers. But when she was suddenly weak and stopped being able to walk At.All. and sleeping all the time... They didn't do anything.

Now she's in hospital being treated for an eye problem, and the GP will have had both a notification of this and an, "I'm really worried because XYZ, please go and visit her..." letter from me arriving on her desk last Monday.

A community matron might have forestalled all this...

Yes, agree! The issue is that a relatively minor health issue in a healthy adult, can absolutely floor an elderly person or make underlying conditions much worse, which means they need quick treatment. If my dad starts with a cold, it makes the Parkinson’s symptoms worse, it goes to his chest (it absolutely always does) which can impact heart failure/breathing and he will need antibiotics. But if it happens on a Friday, there’s no GP and so typically it’s off to A&E. All for the sake of getting a prescription. My dad is too frail to be transported in a car or sit in triage for upwards of 12 hours so we have to call an ambulance - at least if he’s on a corridor, he’s still on a bed. The point is, it’s a massive drain on ambulance time not to mention it’s very stressful for my dad. Despite it all, my dad still does have quality of life and is happy to keep going for as long as he does, but the health system bureaucracy is very very tough.

The matron service cuts through all of this - they contact the out of hours GP who makes an assessment as to whether he actually needs to go to hosp or not. 8 times out of 10, he doesn’t but if he isn’t treated, he most definitely will.

I think if the service was properly funded nationwide, it could transform the NHS. Elderly people (like my dad) are one of the biggest issues the NHS has to deal with - more care at home would free up beds and strain on acute services.

OP posts:

damekindness · 10/10/2026 16:45

Around 20 years ago I was involved with the Dept of Health in researching, setting up and training community matrons across the UK. It was a fantastic service, I went out a few times with them and saw how they worked. I remember one fixing a phone, diagnosing a chest infection, prescribing antibiotics and pumping up a wheelchairs wheels - all in one visit. What couldn’t be achieved in the visit was coordinated to be done later. An admission to hospital avoided. One person to case manage care - a conductor for the healthcare orchestra.

I remember working through costings that showed how much cash was saved ( never mind the increased patient satisfaction). However there just isn’t enough investment into community services so the services withered away in a lot of places.

PermanentTemporary · 11/10/2026 07:59

We still have ours locally thank goodness. I agree they are literal lifesavers and a hugely efficient use of funds (and experience - speaking as an HCP who loved hospital work for over a decade and then hit a wall with it, but has got my mojo back working in the community - retaining experienced nurses at this level is a win all round).

Lzzyisgod · 11/10/2026 08:51

damekindness · 10/10/2026 16:45

Around 20 years ago I was involved with the Dept of Health in researching, setting up and training community matrons across the UK. It was a fantastic service, I went out a few times with them and saw how they worked. I remember one fixing a phone, diagnosing a chest infection, prescribing antibiotics and pumping up a wheelchairs wheels - all in one visit. What couldn’t be achieved in the visit was coordinated to be done later. An admission to hospital avoided. One person to case manage care - a conductor for the healthcare orchestra.

I remember working through costings that showed how much cash was saved ( never mind the increased patient satisfaction). However there just isn’t enough investment into community services so the services withered away in a lot of places.

Absolutely agree with all this. You cant reduce A and E and hospital pressures (and for many elderly people prolonged admissions because inevitably they are vulnerable to picking up more infections in hospital) unless you put measures in place to prevent them needing A and E in the first place .........and that means investment in community services. This is what the 10 year plan was supposed to focus on but whether it's happening is another matter sadly........

You can't prevent every admission but you could atleast give people a fighting chance of avoiding hospital and to stay as well as possible at home and free up resources for those that do need admitting.

MysterOfwomanY · 11/10/2026 09:05

Blushingm · 10/10/2026 16:27

What do you think the district nurse could have done?

Show quote history

I mean, fair question.
My relative is currently being treated and the treatment appears to be ... Drugs given a couple of times a day, some injected, some orally.
I can't help thinking that with sufficiently responsible oversight, this could be done at home (where the carers she pays for already look after her, feed her, make sure she has her regular meds).
Moreover her infection markers had shot up since summer - possibly if a closer eye had been kept on that, the current problem might not have kicked off.
That's where I'm coming from.
She's definitely the sort of hospital frequent flyer that these schemes are trying to keep tied down to the launch pad ;)

FindingMeno · 11/10/2026 09:17

It's also such a win in as far as so many elderly or frail people not only pick up infections in hospital but even short stays can contribute to decreased mobility and cognitive decline going forward.

LadyGardenersQuestionTime · 11/10/2026 09:18

We talk about “The NHS” but there is no THE singular NHS - it’s a complex web of not-very-well joined up services funded by a postcode lottery. I live on the edge of two separate ICPs (funding areas, more or less).

West of me is a fabulous hospital at home service that will enable home IB antibiotics, runs very long hours, will take a referral from anyone. But it doesn’t do falls/occy health/day to day living or a falls service.

To my east there is a much less well funded and more limited urgent community care service; but it can do small wounds and seems to have a hotline to short term carers/occy health/home equipment. It also funds a falls service which whizzes out to care lines to check people are ok and pick them up if they are not hurt.

Things like dementia services, community respiratory nurses, Parkinson’s nurses vary wildly between the two.