Taking the right approach to community-based health services

On Boxing Day, Professor Jane Cummings, Chief Nursing Officer at NHS England, wrote a letter to The Telegraph reflecting on what – on the surface – seemed to be a fairly standard NHS policy position, that the NHS should shift care closer to home and invest in community-based health care rather than hospital buildings.

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.

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#548876 jo

Managing budgets in mental health services, which have seen huge bed cuts over recent decades ,has shown me that to do aspects of community services properly ' tends to need at least as much resource as hospital care. However it is seen as a cheaper option. Therein lies the problem . It can of course be done much cheaper but invariably the patient experience will be way poorer than they would have received in hospital.

#548877 Angela M Cavill...
full time unpaid carer

Must include suitable housing please read my blog taken from recent letter to Simon Stevens http://onmybiketoo.blogspot.co.uk

#548889 Linda Gardner
Health Visitor
Community NHS Foundation Trust

Sadly community care particularly for the elderly hardly counts as care at all. If given in their own home is often rushed and based on a tick box approach and is not always what the person wants. The people providing the care are often driven by financial need for money not love of the job and it shows. There can be economies in scale if shared accommodation is thought through, learning disability have some good models as do Anchor. Being old, disabled and alone is not healthy.

#548900 Richard Simpson
Hon. Professor Health Sciences and Sport
Stirling University

As a retired GP, Psychiatrist who was a shadow Public Health Minister in Scotland for 9years I have been all too aware of the shortfall between rhetoric and reality in shifting the balance of care.The current shifts proposed are quite unlike the closure of long term learning disability beds where double funding made it easier to overcome the concerns of families. Such shift as has taken place to general practice has not been funded either at all or minimally. At the same time the underappreciated thrid sector has been cut and subject to annual funding rounds with substantial demoralisation of staff subject to repearpted provisional redundancy notices or short term contracts. Meantime here our Local Councils have not only had the cuts since 2011 but a freeze on council tax 2007-2016 which has been devastating to social care. Despite this the crisis is less than in England because we have more beds. So despite the fact that bed-occupied days have more than doubled since 2011 they are runnning at 45000 per month compared to 200000 p.m. In England when a comparable figure would be c.20,000. ten years after the Kerr report which should have led to increased community based services and closure of a number of local hospital based services the SNP have finally seen that this has to happen but are now faced with the opposition locally they whipped up in 2007 in order (successfully) to win power.

#548902 Mike S
pro NHS campaigner

I was pleased to see this column. I made very similar comments in a local HWB event last month to discuss our proposed place plan. To the views picked up by Beccy from the Telegraph and Jo's contribution above, I added the irony of 'services closer to home' when home itself is becoming increasingly insecure for a large proportion of vulnerable people. I also challenged the mantra that hospitals should only do what only hospitals can do. I suggested that criteria for progressing community services should include Visibility, Accessibility and Flexibility. Finally the weakest point in all my hospital experiences as a patient has consistently been during transition phases. Clinical care is notoriously poor in managing these; weaknesses apparent within a supposedly unified system (hospital) become magnified when the system fragments - especially when private providers without any commitment to flexibility become involved.

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