Nothing new there, it's been a key component of much health policy for the past decade or more. But I started looking at readers’ comments on articles where her letter was discussed, and was taken aback by the strength of feeling from those commenters that the policy was wrong.
As I’m working on a project looking at a vision for the future of community-based health services, it seems important for me to reflect on the reasons for this strength of feeling. Some of the backlash against the letter was predictably about the focus on reducing acute hospital beds at a time when NHS hospitals are operating way over recommended capacity and the media is full of stories about pressures on A&E and hospital beds. However, there were a host of other interesting reasons.
The most notable comments were based on recent experiences of community health, primary care and social care services. When waits for some routine GP appointments are four weeks or more, then people may choose to go instead to a hospital A&E department. Commenters didn't feel confident that they could get access to health services in the community, such as district nursing, which are increasingly under pressure from growing demand and difficulties in recruiting and retaining staff. In order to have their health care needs met effectively at home, people must also have other basic needs met such as a clean, safe house and adequate nutrition. People needing community health services are likely to be affected by cuts in social care and voluntary sector services and so may struggle to get those needs met in an affordable way. It is easy to see that for many people being cared for in a 'safe' hospital, where professionals are available 24 hours a day, feels a better option. Many of the comments I read equated care in the community with no care at all. This was accompanied by a feeling that the lack of adequate services would increase the burden on family carers.
Some commenters were concerned that the move from hospital to community care was really about privatisation of services. It is true, of course, that community-based health services are far more likely to be subject to open procurement processes than hospital services, and some people were concerned about the impact of that on quality, as well as being opposed in principle to any potential shift towards more private providers. Communication and continuity between services was also a major theme – there were too many stories of patients’ needs falling between the cracks, with care packages increasingly hard to access and co-ordinate, and with complex referral pathways and criteria that seemed designed to keep patients out of services rather than to facilitate their care.
All of these issues go some way to explaining the strength of feeling people have for visible, tangible and accessible hospital buildings rather than what are perceived to be opaque and fragmented community services.
Clearly it’s not an either/or situation. Hospital care is, of course, sometimes necessary, and England already has a lower number of acute hospital beds than many other countries. But people increasingly live with long-term conditions for a significant part of their lives and need good-quality care where they live. If the ambition is, as the NHS five year forward view says, to ‘bend the curve’ on predicted trends and move from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, then health and care leaders at all levels must ensure that there is upfront investment in community services and that those services are clearly explained, visible and easily accessible. If the public don’t have confidence that community-based care will be able to meet people's needs and expectations, it will be hard to convince them that the proposals outlined in sustainability and transformation plans to move care closer to home are sensible.
We hope to address some of these issues in more depth in our work this year, thinking about how best to design and deliver community-based health services for the future.