There is clearly an objective here to relieve pressure on overstretched hospitals. But putting the needs of acute services aside, improving the availability of urgent care in the community makes sense for patients – there is good evidence that frail older people are at high risk of poor outcomes from even the shortest of hospital stays.
This announcement is also an indicator that the NHS is taking seriously the need to pay attention to community services and to accompany the rhetoric around care closer to home with the requisite resources and support (too often lacking in previous attempts at reform). These targets – due to be rolled out nationally by 2023 – will be the first ever national standards for community services. While there may be legitimate debates around whether these were the right standards to choose, their existence will surely help boost the profile and priority given to community services.
Delivering the standards will not be straightforward, and there will be major implementation challenges along the way. Clear points of access and acceptance criteria, information sharing, effective multidisciplinary teams and links into services for onward referral are just some of the features that will need to be in place. Like all new delivery models, their success will rest as much on relationships between individuals, teams and organisations as it will on the technical aspects of contracts or referral criteria. At the same time, community providers are being asked to work with their local PCNs to deliver the new anticipatory care and enhanced health in care homes service specifications. Like GPs, community providers have raised concerns that these risk destabilising services by expecting too much too soon, particularly as services are already overstretched and the funding growth promised for community services in the long-term plan will be back-loaded.
Realistic expectations are needed about the time it will take to develop and embed these new approaches, as well as what ‘success’ would look like. A review of similar rapid response teams by the Nuffield Trust found mixed results, highlighting the importance of local implementation and context. The temptation for national policymakers will be to look to readily available metrics such as data on hospital admissions, but properly evaluating impact will require a broader understanding of outcomes and patient experience. Robust and meaningful data on community services has long been notable by its absence, but there are signs that real progress is starting to be made.
It remains to be seen what the process will be for moving from the seven ‘accelerator sites’ to national coverage by 2023. In overseeing this process, the Ageing Well team at NHS England and NHS Improvement will have to strike a careful balance between national prescription and local flexibility. The current backlash against overly prescriptive national service specifications for PCNs provides a cautionary tale here. The new services will need to respond to local context – including the needs of the population, geography and highly variable existing community provision. A single, nationally defined model will not work. But the national team could usefully work with the seven sites to make their learning readily accessible to others, both in terms of the models they put in place and how any implementation challenges are overcome.
Finally, but perhaps most importantly, there are two major implementation challenges to resolve that go beyond the scope of local systems. The first is workforce. Community services have seen some of the sharpest reductions in staff numbers in recent years, including among community nurses. Put simply, these standards cannot be achieved without the staff to deliver them. The second major challenge is the availability of adequate social care support. It is intended that these new standards will be delivered by teams of health and social care professionals working together, and they may well need to refer people onto ongoing social care support. Without urgent action to address failings in the social care system, it is hard to see how these standards can be delivered.
What is the current position on reporting community nursing numbers? Are nurses not employed in NHS organisations still excluded? I worry that, by citing numbers for NHS-employed staff only, the true picture remains obscured, and it makes it more difficult to argue the case for additional staff.