Moving care closer to home: three unanswered questions

When trying to envision the future of the health and care system in England, the difficult question to answer is not ‘What do we do?’ – the vision for care has been outlined by multiple governments in countless policy documents –  but ‘How do we actually make it happen?’

The case for a health system that is proactive, provides personalised care closer to where people live and is embedded in communities – ‘care closer to home’ – has been well established. Our ongoing project, looking at the way forward for health and care, aims to untangle why it’s been so difficult to achieve across the board. So far, we have looked at the literature, spoken to key people, and crunched the numbers. All have provided interesting results, but from my work analysing the numbers, there are three particular questions that we need to work through before we publish our findings early next year.

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.