How can national leaders balance investment in care closer to home with investment in other priorities?
Moving care closer to home requires investment across primary care, social care, public health and community health. So far, the numbers suggest this is not what is happening. Instead, the government and other national leaders are investing more and more in hospital and acute care – which are also important but unlikely to help achieve the vision of care closer to home.
Figure 1 shows the growth in NHS provider budgets and the overall Department of Health and Social Care budget over the past five years. While the budgets for all types of providers have grown, budgets have grown at the fastest rate for ambulance and acute providers, and least for community care providers. While acute and ambulance providers also contribute to ‘care closer to home’ (eg, 111 services), the key players are the community health providers. A National Audit Office report found a similar trend – between 2015/16 and 2018/19, the percentage of the total NHS budget spent on hospital care had increased by 2.5 per cent.
All this suggests that national leaders need to change how they invest in the health and social care system. However, it’s not as simple as moving money away from hospitals – especially with inflationary pressures, depleted capital budgets and growing waiting times to manage. So, the question is, how do national leaders invest in moving care closer to home without depriving hospitals of money?
How can national leaders grow a shrinking community workforce?
The health and social care system is facing workforce shortages and high vacancy rates . However, in general, the hospital workforce is still growing, whereas parts of the ‘closer-to-home’ workforce are shrinking. Figure 2 shows that while the number of hospital nurses has steadily grown over the past 10 years, the number of district nurses and health visitors has fallen.
The Long Term Workforce Plan has recognised this problem and promises action to grow in the community and primary care workforce faster than the acute sector (3.9 per cent and 2.7 per cent verses 2.1 per cent annual growth over the next 15 years). However, this is easier said than done. The current government is already struggling to meet its promises for extra nurses and GPs. So, the question here is, how can national leaders grow this workforce to provide care closer to home?
Are we sure we have the right data to understand what’s happening and what needs to happen?
Although there is lots of useful data on community health, primary care, public health and social care, there is not as much data as there is for hospital care. Care closer to home is often measured in number of contacts or appointments (eg, community services statistics or appointments in general practice), but there is limited data on waiting times, patient outcomes and quality of care.
The problem with this is that commissioners and providers (eg, integrated care boards, NHS England, local authorities, NHS trusts) make lots of decisions based on data. Data is used to predict demand, commission services, evaluate new models of care, benchmark standards of care, reimburse care and incentivise change. It’s easier to change the status quo if there is the data to justify changes, for example, providing more care closer to home.
That doesn’t mean systems necessarily need to replicate the data collected in hospitals. Data collection can be resource intensive and creating targets is not always helpful. The system also might not be able to collect the same data – for example, measuring the outcome of a hip operation is arguably easier than measuring the outcome of a weekly visit from a district nurse. So, the big question here is what data do national leaders need in order to change how they deliver care?
So, what we know so far is that, compared to hospital and acute care, national leaders are not investing as much in care closer to home and that the workforce in this area is growing at a slower rate. Also, that the system doesn’t have as much data on care closer to home, despite data being a useful enabler for change. Answering the three questions above might help the health and care system move care closer to home. However, there is no simple answer to how to do this. We hope to find the answers in the remainder of our project and share our findings at our annual conference in November 2023, with final findings published in early 2024.
As a social gerontologist I struggle with this term “Care Closer to Home’. We have adopted this in the regional partnership board in Gwent but apart from the odd change in practice such as a few CNS and geriatricians providing intensive support for a few days at a person’s home under the Frailty agenda not much has changed. No more employed community nurses and no more funded training for community nurses - so Care offered might be slightly closer but is still not AT HOME where it should be and can be now with technology opportunities. We are still building institutional care - Care Homes are not home and never will be.
Jackie’s Revolution has the vision and strategic plan to change this . Please contact me.
Although I am from Nigeria, from my observation of older people and people living with disability or the other, what they need best is having someone around them whom they care have a converse or talk with, laugh together and listen to them. By living alone for longer hours, the implication is brooding and thinking which will still contribute to their unwellness.
So, i think community garden can be established by local councils where they can have fun with their fellow friends. Loneliness is their number one enemy, which i believe can be arrested with having people around them.
Working in the US, where the system is very difference, we are working with patients discharged from hospital after a cardiac event and treatment. This is a US government initiated programme the object being to protect patient from another event requiring a return to hospital. We are engaged with hospitals and care homes each of which has say, hundreds of patients requiring monitoring. Each patient receives a kit that measures BP, oxygen, temperature, glucose for diabetics, spirometer and other remote monitoring additions. These are linked through a hub to an intelligent monitoring centre that raises flags for divergent reports. It’s very simple to set up and very effective in its purpose. Something like this would probably be adaptable to NHS. Costs are moderate and considered to save a great deal in Medicare/Medicaid and Insurance.
PCNs can justify more link nurses and PAs because they can be shared staff assets. One weekly visit over 70s patients living with a condition as monitoring/checking for even 10 minutes fulfills social and medical reporting needs, and saves GPs time. More of this spread thinly more frequently has potentially greater value serving your purpose. Initiatives like providing bicycles for very local work by MDTs would be PC!
More effort to correct hospital ward discharge forms that support carers immediately following leaving treatment would ingratiate people who maybe haven't performed the role before and equip them with necessary contacts in the hospital hub and community. Focus on community centres which either don't exist or have been closed because health Authorities have just pulled-out (example Fairway House by Southern Health, Basingstoke) would support ICBs 'integrate' to focus funds and make up the deficit there as you illustrate. The government's current emphasis on it's setting up of Diagnostic Centres, again saving time and costs to fast stream referrals and provide preventive care plans to older groups is so plausible, even as interim solutions while new hospitals are being built, but the one in Basingstoke just closed its doors, but was accessible in a central position in the town centre. Cost effective housing designed for a range of elderly people ranging from down-sized accommodation to assisted living scenarios, on to care and nursing care including dementia has been addressed by companies like Bollox (Swedish flat-packed crudely but custom built to high standards) include nearby surrounding community services and work out as less costly (about one eighth of the cost of a top care home). The lifestyle change is made less dramatic and normalises people's experience living longer but in acceptable ways with less extremes and more gradual transitions in twilight years.
How do these developments tie in with, and recognise, the role of unpaid carers?