Transforming community services: learning from previous mistakes

Community services make up a large part of NHS activity, from chronic disease management and intensive rehabilitation to health visiting and school nursing. Yet years of initiatives, policy ideas and fads have left a legacy of highly complex, narrowly focused and often poorly co-ordinated services, making the system difficult to understand and navigate, even for professionals. So, with an ongoing ambition to shift care out of hospitals and closer to people’s homes, what is needed to transform community services?

Launched by the government in 2008, the grandiosely named Transforming community services programme very noticeably did no such thing. Mostly concerned with structural changes rather than with service improvement, the programme led to some community services being privatised – and often set up to fail against hugely onerous procurement processes – with others transferred to whichever acute or mental health provider was available. Officials gave the strong impression that they would be happy to see the entire community service workforce moved off the NHS payroll, and policy changes were put in place to assist this. 

Since then, community services have remained neglected and poorly understood, and the commissioning of these services has also been poor, hampered by their complex and diverse nature. In the services themselves there has been a loss of direction and, more worryingly, a loss of staff from what is already an ageing workforce. Mergers and reorganisations have left hospitals and GPs confused about who to refer to, while community services often do not respond quickly enough when patients are discharged.

Transforming community services is not the only policy failure in this area. The equally grandiose Our health, our care, our say, which promised a once-in-a-generation chance to change the NHS, was also a damp squib. It lacked the machinery for implementation and was not actively followed up by later Secretaries of State.

And yet these are the services that are going to be asked to bear the burden of dealing with a growing and ageing population that, without other measures, will require an additional 13,500 hospital beds to soak up additional demand. The ambition to move care closer to home is not new –  it has been the agreed direction for years – but further significant changes are needed in the way care is delivered to achieve it. So it’s interesting to reflect on why community services have received more rhetorical support than actual support, which is what we explore in our new paper on transforming community services, published today.

First, they have lacked a story about what they can do – their complexity and the diversity of the services they run has not helped. 

Second, these services do not control many of the key points on the patient pathway, including referrals, admissions, discharges and other important transitions that they need to influence if they are going to reshape care effectively. 

Third, quite a lot of community services are provided direct to patients; important though these services are, other providers may not be aware of them, which means that they have few advocates in other parts of the system. Crucially, they do not often employ any of the key influencers in the NHS: consultant medical staff.

Fourth, the blanket application of cost improvements to services in which a very high proportion of costs are spent on staff has often reduced quality. This is because basic management practices, for example mobile working, work flow management and record keeping, have been adopted slowly and so efficiencies have been found by cutting staff.

Finally, quite a lot of the enthusiasm for community services seems to be because they are believed to be cheaper than hospital care. This is true only in particular circumstances. The funding model is based on a myth – that money can be easily taken out of the acute sector, that we know how to do this and that the mechanisms are in place to do so.  Most of the growth in community services has been from increases in funding rather than a shift of resources.

This area represents multiple failures of policy and process: failure to develop good metrics and effective commissioning; underinvestment in good management; ineffective implementation of policy – and general neglect.

Some providers are delivering fantastic and innovative care against the odds and new thinking and models are emerging. It will now be important that the mistakes of the past are not repeated and the opportunity to transform community services is seized.

This blog also features on the Health Service Journal website

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#41687 Peter Sharp
Head of Wellbeing
Cordis Bright Consulting

Excellent paper and particularly value the focus on a) the steps (p2) b) breadth - as e.g. Housing and Justice (p7) inclusion and the recognition that 'hot spots' need inclusive solutions. Surprised that there was no mention of culture (agency/organisational) and potential barriers to effective integration e.g. vested interests, protectionism and ownership - which are a real challenge in the transformation process.

#41689 Hugh Reeve
Clinical Chair and GP
Cumbria CCG

Transferring Community Services (which is all it was) was mostly a disaster, often transferring these services to organisations with little interest in and no experience of running them. The real opportunity that was lost three years ago was the opportunity of integrating services at the primary care level - general practice, community services, social care, and non traditional services (third sector etc). A number of areas are trying to deliver this level of joined up service despite the numerous obstacles now in place.
Here in Cumbria we are creating Primary Care Communities, based on natural communities, bringing together these community based services with the GP lists as the building blocks. This encourages a population approach to health and wellbeing as well as delivering family and individual centred care. To my mind this is the integrated platform we need to create, upon which the rest of the health and social care system builds.
This is not just a structural strange - it requires a major transformation in culture across all professional groups involved, it requires new business models, it requires joined up clinical information. It requires clinicians to lead not from self interest but from the interests of local people and populations.
Do we really believe this at least as important as sorting out local hospitals than are in crisis - time will tell.

#41690 roger kline
research fellow
middlesex university

Interesting paper. as with many such proposals it needs permission to innovate and top class leadership without which it will grind to a halt.

There was some stunning cutting edge work being undertaken with the elderly in a central London trust not so long ago. It came a grinding halt because the employer refused to reflect on its treatment of the black nurse manager leading it.

Tragedy for the work, for the patients, for the local GPs and, of course, for the nurse. That scheme had innovation and leadership, but the leadership was black. How many times has this happened?

#41698 Jocelyn Cornwell
The Point of Care Foundation

To add to the problems you describe, we know very little about patients' experience of community services, at the same time as also knowing that patients who receive care at home are amongst the most vulnerable. We should have exactly the same expectations of services in the community as we have for services in hospital - that is, that they should be safe, clinically effective and should meet patients' needs and preferences. We'd like to see investment in research into patients' experience and into quality improvement in community health services.

#41699 John Hill
Service Development Officer
Sefton Carers Centre

This thought provoking paper quite rightly calls for the development of the capability to harness the power of the wider community. Perhaps there is no greater single resource within communities than unpaid family Carers. In all local communities they act as the first line of prevention and frequently delay, minimise or even remove the need for high cost hospital or social care. However, as we all live longer Carers are ageing too, yet despite their own frailities they continue to provide more and more unpaid care at increasing cost to themselves. If Carers, particularly ageing Carers, are to continue to deliver care and support at home, if they are to continue to underpin our health and social care services, if they are to continue to save local authorities and the NHS money, then their own needs must be recognised and more support provided for them. Invest to Save - Keep Carers Caring

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