Shifting care closer to home: slogan or solution?

As The King's Fund argued in Transforming the delivery of health and social care: the case for fundamental change, any discussion about developing new models of care must focus on shifting care closer to home. However, there is a danger of 'shifting care closer to home' becoming just a slogan and consequently not being examined sufficiently. It is not a step forward to relocate an activity that should really be stopped or redesigned, or to move care closer to home when this is less convenient for the patient or leads to a reduction in the quality of care. 

There are some key questions to consider: can changing the location of care act as a catalyst for developing completely new models of delivery, and will redesigning services lead to more convenient and cost-effective settings? Although moving care closer to home has been a policy  ambition for some time, non-elective admissions have continued to rise over the past two decades, and there are worrying signs that primary care is buckling under the current pressures of demand. This month's Time to Think Differently blog posts – and the responses to them – suggest that opinions on this policy continue to differ and that some of the evidence is still patchy.

Paul Corrigan's post concentrated on hospital strategy, claiming that radical new visions within the hospital sector will shift the location of care. However, as is often the case when you scratch beneath the surface, there is a frustrating lack of detail about these ideas and one wonders how truly radical they are. This may be because we need to move beyond thinking about the future of the hospital and how to move services into the community and begin to think of approaches that might fundamentally change the health and social care system. In many health communities these conversations start by looking at issues such as urgent care or individual long-term conditions and then quickly migrate to the development of new and imaginative approaches to dealing with frailty and the more effective management of population health. For example, the development of multi-disciplinary teams (including social care, mental health and other services) wrapped around groups of practices using a shared record and care plan and getting significant input from specialists that would previously have been confined to hospital. Many of these approaches are experimental, leading to evolutionary change that will be significant over time and could eventually be radically different.

The first step should be rethinking the operation of primary care, not having more conversations about hospital configuration. Hugh Reeve articulates some of the key issues that need to be dealt with. Hospital is the default option for many patients because we have failed to rethink how primary, community and social care currently operate. Primary care often operates on too small a scale, has inadequate access to specialist support and diagnostics, and has workflows and processes that are inappropriate for the types of patients it deals with (for example, the length of appointments are not sufficient for dealing with multiple morbidity and it is hard to provide continuity of care). Creating a strong primary care platform, as Hugh suggests, would allow the major change needed. Wrapping community services, mental health services and social care around groups of practices; giving those practices access to specialists and diagnostics; creating more systematic approaches to working collaboratively would provide continuity or rapid access to treatment depending on their patients’ needs. GP information systems are quietly helping to create the information infrastructure required for this. New technology offers hope as well, although more evidence and lower cost solutions are needed to make this viable.

But do we  need to be even more creative in our solutions? Listening today to a GP describing the difficulty of providing care in the homes of some of their patients made me realise that we need to think even more broadly about the care system. Jeremy Porteus makes the case for bringing housing design into the system not only at a strategic level but in thinking about discharge and care planning. Helping people to remain at home is very dependent on them having a home that is fit for purpose and Jeremy is right to draw attention to this and the need to make better links to health and other services. The same is true of private domiciliary care, residential care and nursing homes that have more beds and care staff than the NHS and can make a huge contribution.

With investment, these changes could lead to big shifts in the location of care. Moving outpatients, surgery, endoscopy and other diagnostics into the community might reduce some patient travel time, but this is just tinkering with the system and we will need critical examination to see if it is truly cost effective. The big gains need a much more strategic approach to the re-imagining of the whole system. Despite Paul Corrigan’s confidence that hospitals have new visions that might support this redesign, it will also need transitional arrangements and major changes in business models and payment systems. Is this why making the transition is so much harder than the policy commentators tend to think?

See more of our thinking on the relocation of care


#39903 Sarah Fraser

This debate has been excellent, not least of which has been the critical focus that talk and slogans don't make the difference - action does. As a patient I'd like to have telecast as the norm for me. It's available now.
I agree social design (of houses, roads, etc) impact health - the Victorians provided the evidence.
Advertising and promising me dinner at a fancy steakhouse - then taking me to the local burger takeaway is a disappointment, I hope, in my lifetime, care does actually come closer to my home.

And three cheers to The Kings Fund for hosting this debate.

#39904 Dr Helen Lewis
Lay representative in clinical commissioning group
Resident in Surrey

The arguments are well made. However, having listened and contributed to these debates over the last eight years, I think many of the problems in local health economies stem from the perverse incentives which mean that 'overheating' in the acute sector, through payment by results, leaves community health services starved of funding, and our commissioners struggling to cope with budget deficits. The answer must lie with the government who need to remove these perverse incentives, so that primary and secondary care can be integrated, and not compete for decreasing health resources.

#39906 Dr Malcolm Rigler
NHS GP with Special Interest in Public Health
Partners in Health ( Midland) Ltd.

It seems to many of us within the GP community that Primary Care Commissioning Groups are an attempt to re-arrange the chairs on a sinking ship and maybe even an attempt by GOvt. to shift the blame for the shortcomings of NHS services onto the shoulders of GPs rather than politicians.
I am quite sure that Nigel is right and that an entirely fresh look at Primary Care and Primary Care Services is required. In my experiance often "fresh eyes" and a mindset developed "outwith the NHS" can often lead to new approaches and creative solutions. That is why I was so interested to follow the blog on the Arts Council Website recently on the future of the Library Service. Reading the various , often inspirational , contributions I learnt that many of our librarians are troubled by the very significant mental health problems affecting so many people in the UK both those with "mental illness" and those with so called "long term conditions" ( now over 50% of our GP workload). I also learnt that within the library service there is a developing theme / project called "Libraries and Health" . Those involved in this work clearly have a strong interest in what is going on in the NHS and have started to develop some interesting responses to some of the things that are going wrong. As yet the NHS hospital managers and GPs developing an interest in NHS management within commissioning groups show little or now awareness of this very creative development . However if we study the "Planetree Hospital" approach to medicine and the "Kaiser Permanente" approach it is blindingly obvious that we should not be sidelining the Library Service and the Education Service as we continue attempt to improve both Primary and Secondary NHS services. Maybe the Kings Fund can create the right environment to bring together NHS managers and Arts People from the Library Service ( the Arts Council now being the lead agency for strategy development of the Community Library Service ) and the" Arts/Health" movement so that the opportunity that our current tight financial strictures offer to us are not missed.

#39910 Belinda Phipps

One service that is ideally suited to being provided at home is birth. There is even strong evidence that it and hospital birth are equally safe for the baby and more satisfying with fewer interventions for the mum .

Home birth costs less - not least because choosing home reduces the risk of a csection x4 even for those mums that transfer in. But only 2% give birth at home whereas 21% say they would if they thought it was safe. Clearly something is getting in the way.

That something is a bit the lack of awareness, understanding and acceptance of the safety evidence but it is also PbR and capital charges and the way CNST operates.

Those things are relatively easy to change - who has the power and the will to change them?

#39911 Jon Allen
Company Director
Value Care Ltd

Care closer to home is a nice warm slogan, but we have to ask what does this mean in practice in terms of what aspects of care by which professionals, how close to home, in what locations, for which conditions. We have seen over the years the erosion of GP home visiting, the exponential increase in community worker caseload sizes, the nearly scandalous arrangements in place for domicilary care, and the in and out of favour dance for community care resources such as community hospitals and health visiting. Vertical integration and removal of PBR us one strategy but where this exists as in mental health services there are perverse incentives to spend all you're energy gate keeping and denying service. Care closer to home needs to be thought through carefully in a prioritised fashion against conditions and care pathways where their would genuine economic and patient benefits. Then a carefully crafted incentive system to get existing primary, secondary and tertiary organisations to work together toreconfigure existing resources to deliver the benefits will be required if duplication of effort, and unhelpful competition is to be avoided.

#39917 Gerald Hudson
Milford Care

When it comes to studying the requirements of the Public over the last 30 years for Care provision for the Elderly it is blatantly obvious that Private Sector Care Homes both Residential and Nursing are ticking all the right boxes. In spite of many attempts by various factions to discredit these Care Homes, the Public continue to support them. Why is this NOT the case when it comes to the Authorities.
Since 1996 when Funding was passed into the Hands of The Local Authorities and Health Authorities the contributions towards Elderly Peoples Care in Care Homes has been continually depressed and is now below an economic level and Council funded clients are being forced into topping up to obtain the quality of care they themselves require.
I have essentially made this a very simple question as I think the Public deserve a clear simple answer.

#39922 Susan
Royston Hospital Action Group

the public do not have sufficient choice: it is either home, hospital or care/nursing home; it would be useful to have a halfway house from the acute hospital with full NHS medical care

#39923 Susan

My births needed medical assistance at the end, with one distressed baby now a marathon runner: the problem is how to also provide that assistance at home

#40191 Clive Bowman
Visiting Professor City University
City University

The problem is in the title, "Shifting". Our health and care system is based on archaic divisions of primary and secondary care rather than a structured Public Health approaches to preventative interventions and a seamlessly designed integrated solutions to long term conditions. "Shifting" perpetuates notions (real or imagined) of discharging responsibility.

#40211 Ed Macalister-Smith
NHS Leadership Coach, ex-NHS CEO

I have commented on this elsewhere, but this strand seems to have re-surfaced, so here's another (and I've had a personal bit of insight recently)...

We do need to shift care closer to home, why?

Firstly the positive reason... Because that is the model of care that we would expect personally to have ourselves, and we would expect for our families. We can imagine what this would look like, and as we or our parents get older and frailer, it would be reassuring to know that we can expect this kind of care in later years.

And the negative reason? Because we can't go on as we are, it is simply not sustainable, so we need to invent a new way of doing things which will be sustainable with relatively diminishing resources, and a population that is not getting any fitter...

Achieving this model will require change to the model of primary care that we now have. As it is currently structured, it does not support an at-home model of acute care for long term conditions, which is where we need to make the difference so as to reduce unaffordable non-elective admissions. Especially, the out-of-hours service in many parts of the country does not work, and this is the service that exists for 80% of the week. The standard GP service only exists for 20% of the week. Radical change is needed, but we have done this well before - remember when the best GP OOH co-operatives were providing an outstanding local service?

And my personal bit of insight? Having retired as a CEO, I have just trained to be a local Community First Responder, and it is frankly tragic to see how the ambulance service is repeatedly expected to pick up and transport to A&E elderly patients who could continue to be cared for in their own homes, with really simple support or interventions.

We do know that this is the right thing to do, we need local leaders of courage to integrate their services and resources with partner organisations and do the right thing for patients.

#40771 Guy Patterson
Project Manager
Age UK

Really simple support or interventions are actually quite difficult to organise and often take an inordinate amount of time to develop. Where they do develop they are often too localised and small scale to attract the attention of policy makers. This said, it is now up to the health and wellbing boards to see that local initiatives that have the potential to be scaled up are discussed, and i would hope that the CCGs are also sufficiently innovative in their thinking to recognise their value, or is this just wishful thinking?

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