Anna Charles: Reimagining community services

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  • Posted:Tuesday 23 January 2018

Anna Charles, Senior Policy Adviser at The King's Fund, presents the findings of our report Reimagining community services.

This presentation was recorded at a breakfast event at The King's Fund on 23 January 2018. 


Good morning, it’s really exciting for us to be launching the report today because it brings together 18 months worth of work from all the colleagues across the Fund that are listed on the slide behind me here.

So, as a starting point, why did we choose to do this piece of work and focus specifically on community services? Well, we at the Fund and many others, have long argued that changes in the population require the health and care system to do things differently, so we know people are living longer, they’re living with increasing numbers of long term conditions and increasingly complex health and care needs and a reactive health system that focuses on treating people in hospitals at points of crisis is not well suited to meet those needs. So instead we would want to see services joined up and able to keep people well in their homes and their communities.  

Now, those arguments I’m sure will be familiar to many if not all of you in the room and they’re reflected in many strategy and policy documents from over the years.  So the Five Year Forward View would be one recent example, and I think if you pick up any one of those strategy or policy documents or actually any of the 44 STPs published at the end of 2016 that set out local plans for the change, it’s absolutely clear that strong effective community services are critical to achieving those ambitions and the idea of strengthening and improving and coordinating community services isn’t new either. So, part of the work we did for this project was to take a real deep dive, look back at the long history of policy initiatives there in this area, and it stretches back over many decades. 

So, on this slide I’ve just picked a couple of examples from the last decade which again I’m sure many of you will be all too familiar with these and I could have filled many more slides with many more similar documents that contain similar ambitions to move care into the community.  

Accepting that we all know what the ambition is, how well does the reality live up to that? 

We took a comprehensive look both at the national picture of what we can see in community services and a deeper dive into services in three areas of the country to see how services are currently organised and delivered and how well we think they’re working, and what we found is a sector that is absolutely under pressure. So it’s very hard, I’m sure you may be aware, to get accurate and robust data on community services at a national level, but from our previous work on NHS financial pressures and this work too, everything indicates that funding for services in the community is under real strain and we also know that there are really worrying trends in key parts of the workforce, so most notably I think in district nursing where we know the numbers have halved. It’s also worth situating those pressures on NHS community health services in the context of pressures on other services that offer care and support in community settings. So, if you think there about general practice or about social care, they’ve got their fair share of financial and workforce pressures too. 

So in terms of then how services are organised and how they’re delivered, what we can see is a pattern where there are lots of small narrowly defined services, which often have different access and referral routes into them and between them and there’s often not very good joint working across those services and often they’re not well joined up with other services in the community. We heard examples of how that can lead to confusion and frustration for people receiving care, for their carers and actually also for the staff that are working in these services too, and all of that is despite those repeated attempts through the decades to strengthen and coordinate these services and with retrospect when we look back at what those policies have achieved, we can see that actually they’ve often exacerbated the situation by lots of reorganisation, lots of structural change and further fragmenting  provision. But, all that said, services aren’t standing still and despite those pressures and problems there is a wealth of innovation in community services and many, many examples of good practice that we can learn from and, while we absolutely recognise those challenges, what we really wanted to do, having recognised those, was to focus on what are the opportunities to improve these services? What can we see that could be done with what we have? 

So we looked at examples from across the country and from other countries too, to try and pull out what would a really good community focused health and care system look like and what would it take to make that happen in practice? What the examples show is that much more can be done with the resources that are available in communities if they were to work much more closely with each other, with wider health and care services and actually with a much wider range of assets in communities beyond a narrow definition of health and care services. 

I’m just going to give a few examples from the report. In Kent the Encompass, multispecialty community provider vanguard model, has introduced integrated community teams that bring together GPs, community nurses, social care workers, geriatricians, pharmacists, mental health professionals and others to wrap around patients’ needs and deliver care to people with complex needs and that sort of approach is mirrored across many of the new care model sites as part of the vanguard program across the pack, MCP and primary care home models.  

Some of the examples we talk about focus on bringing specialist expertise out of hospital settings and directly into the community where people are receiving care.  Now that might be directly by bringing a specialist into a community-based role or it might be by using technology in different ways to allow remote advice and supervision. So, one example we looked at was in Sheffield where specialists from a local hospice were delivering remote advice and supervision to community nurses who were then able to provide much more advanced palliative care interventions and help people to stay in their homes at the end of their lives. Many of the examples, as I’ve said, involve community health services working with a much wider range of partners, far beyond what we would consider as conventionally being the health and care system.  

So in Wakefield services are working with schools to promote healthy lifestyles for children, in Hull they’re working with fire services to provide a rapid response falls service for people who have fallen at home, in Erewash in Derbyshire again an example from the vanguard’s program, there’s a whole variety of schemes which include social prescribing scheme, an online directory of local voluntary and community groups, community connector roles to help people link in with local community resources and a time bank where people can offer their time and skills in return for support from others. In Wigan there’s a great example of a scheme led by the council which involves a whole variety of initiatives bringing together organisations and individuals from across the community to improve population health with a specific focus on addressing some of the wider determinants of health. 

So that’s just a small selection of the examples I could have picked and there are many more in the report, and we draw on those to distil what we see as the key elements of them into a list of design principles which lay out how we think services need to adapt and to change. I think what those principles and examples show more than anything is the great potential there is to use services in the community more effectively by bringing them together in a more systematic way and this isn’t a theoretical argument, it’s based on real life examples that are already happening where we can already see how this can make a difference.  

I think the examples also highlight that the challenges that we describe in the first part of our report can’t be addressed by NHS community health services working in silos or in isolation. So instead they need to sit at the heart of local systems of care that bring together all of the resources that are available in the community and bring those together in a much more cohesive way.  Now that might include services commissioned and provided by the NHS but it might also include services commissioned and provided by local authorities, by the voluntary and community sector and actually by communities themselves, and while there are many great examples of that starting to happen across the country, at the moment they are confined to innovative projects rather than being reflected across the system as a whole and that’s key. So the challenge is how to move beyond pockets of progress towards widespread adaptation and adoption of these sorts of community focused approaches to care.

So we make a number of recommendations in our report and there are lots of recommendations. So I’m just going to give you a flavour of some of those.  First if you think about the local action that’s needed, so what we can see is that to make these changes local organisations across an area need to come together and work together to bring their services together and integrate those around the needs of the population. If we look to services that have started to make a reality of that some of the key things that have helped are proper engagement of the public and of clinicians and staff in designing and implementing those changes. Now when you take a step back and think about the changes that are starting to happen at the moment with areas working together through STPs and the accountable care systems, there is a real opportunity for them to drive forward some of this work and provide the local system leadership that’s required, and we would argue that strengthening community services should be an absolute priority for all areas taking that work forward.

We also recommend that that local level leadership needs to be accompanied by national action and leadership too otherwise we’ll just continue to have lots of good examples of good practice across the country and not a widespread change.

So we think that there need to be some concrete commitments and plans around the resources that are needed to make a reality of these ambitions and importantly those commitments need to be realistic.  So in the medium term we would argue that more funding needs to go to NHS community services and wider community services by prioritising those services in the allocation of any new funds that become available. However, what’s not realistic is to expect that in the short term we can pay for significantly more services in the community by stripping resources from hospital and we know the pressures that hospitals are under at the moment, you only have to open the papers any day over the last few weeks.  

I think most importantly what we’re not arguing for here is further reorganisation or structural change.  So we know community services have had their fair share of top down reorganisations, we know that’s often been a distraction and has sometimes made things worse. So we would argue that what the focus needs to be now is on improving services for patients and users, learning from what we can see works rather than on making further structural change.  

So I’m going to leave it there, I’ll hand over to our other speakers and I look forward to taking any questions at the end.