Improving access to out-of-hospital care

As political parties prepare for the general election, The King’s Fund has identified three priorities where national action from a future government will help ‘fix’ the NHS and social care and improve people’s health.

These are:

• improve access to out-of-hospital care

• make careers in health and social care more attractive

• tackle the biggest risk factors affecting people’s health.

This briefing focuses on how to improve access to out-of-hospital care, including GPs, social care, community services and community mental health services.

Summary

People are living longer with multiple, complex, long-term conditions but are struggling to access the primary care, social care and community-based services they need to manage these conditions. This means they may not receive treatment until their needs are more serious. Not only does this put increasing pressure on hospitals already struggling to be as productive as they were before the Covid-19 pandemic, it can be worse for people’s health and more expensive for the taxpayer. Action is needed to enable more people to access care in their community so that they can stay healthier for longer.

What’s the problem?

• People’s health needs are changing, with one in four adults living with two or more long-term health conditions, including diabetes, dementia or mental ill health. People living with long-term conditions need regular, ongoing support, which is often best provided by primary, community and social care services, rather than sporadic episodes of treatment, often focused on a single condition and provided at hospital.

• The most recent British Social Attitudes survey found that satisfaction with general practice had dropped to 34%, the lowest level since records began. Satisfaction with social care was just 13%.

• Patients unable to access primary and community care may see their health conditions worsen to the point they require hospital treatment, which places further pressure on already-stretched acute services. Each part of the health and care system should be freed up to provide the care it is best placed to offer. High-quality primary and community care can improve health outcomes through more effective diagnosis, monitoring, management and treatment of conditions. These earlier interventions also reduce the need for more costly care in the future and bring benefits for people.

• The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years.

• The National Audit Office (NAO) has reported that the proportion of the NHS budget in England spent on primary care and community services fell between 2015/16 and 2018/19, while the amount spent on acute care has grown faster than any other area. It is a similar picture in adult social care in England, where between 2015/16 and 2022/23there was a 10.6% increase in the number of people requesting local authority support, but the number of people receiving that support dropped by 2.1%.

• The same pattern emerges when considering the health and care workforce. The number of hospital-based nurses grew by 32% between May 2013 and May 2023, while over the same period the number of community-based district nurses reduced by 24%. The number of fully qualified full-time equivalent (FTE) GPs has fallen, while the number of doctors in other sectors has grown. And while social care staff numbers have been steadily increasing since 2009, there are still more than 150,000 vacancies.

• Meanwhile, the majority of health and care activity happens within community settings, with activity increasing both in terms of the number of people seen and the complexity of care provided. For example, latest data shows that there were an estimated 32.5 million appointments in general practice in January 2024 – a significant increase on the estimated 28  million appointments in January 2020.

• Voluntary, community and social enterprise (VCSE) organisations – many of which support people to live healthy and independent lives – are also reporting financial concerns. More than half of UK charities are worried about their ability to survive due to the rising cost of living.

• Despite progress in providing more mental health services in the community, there is still a sizeable gap between the number of people with mental health conditions and the number of people the NHS can treat. For example, the 2023–24 ambition for 1.9 million people in England to access talking therapy services equated to only around one-quarter of people with a diagnosed need. This has an impact on individuals but also on the economy. Across the UK, more than half (1.35 million) of the people economically inactive due to long-term sickness reported that they had ‘depression, bad nerves or anxiety’.

• Stretched and limited adult social care capacity is preventing people from accessing support, yet reform has been repeatedly delayed. The result is high levels of unmet need and providers struggling to deliver the quality of care that older and working-age adults who need care have a right to expect. Many people are also unable to leave hospital when they are fit for discharge as there is no appropriate care available to support them. In March 2024, among patients in England who had been in hospital at least 14 days, 1,843 a day (on average) could not be discharged due to there being no bed available in a residential or nursing home.

What can national government do?

Government should improve the provision of primary and community care by:

growing the community workforce and improving collaboration across community-based teams

The health and care workforce is currently hospital centric, with working in primary and community health and care settings often seen as lower status than working in the acute hospital sector. As such, key parts of the primary care and community workforce have been shrinking, leaving services unable to keep up with demand or move forward with plans to deliver more care in the community. Going forward, training providers need to explore how to increase meaningful experience of primary and community care, for example, through compulsory placements, and think through career paths that provide high-status roles in primary and community settings, reflecting the skills needed for working in these settings.

As well as growing the workforce, staff will need to work together differently to meet changing demand, with greater collaboration between teams of different professionals working across community-based services. Local health and care leaders will need more flexibility to meet local needs in this way and community services will also need to develop partnerships to make the most of the expertise of the VCSE sector in supporting people’s health.

modernising buildings and equipment in community health and care services, and taking advantage of innovations in data and technology

Investment in buildings and infrastructure for primary care and community services has not been a priority. This limits the ability of these services to transform how care is delivered or to make the most of all the services and organisations that can support health, for example, through sharing premises with services provided by local government or the voluntary, community and social enterprise sector.

People with long-term conditions need support from multiple primary and community services, making it even more important that those services can share data to provide more joined-up care. Lack of investment has left the state of technology in many primary and community health and care services very underdeveloped, reflecting a lack of investment in hardware and software.Taking greater advantage of the opportunities offered by technology could also support people to manage their own care.

increasing primary and community care budgets

Additional staff and improved buildings and infrastructure will require investment.

Despite rising demand, investment in primary and community services has grown more slowly than the investment in hospitals. While the whole health and care system will need investment to keep pace with demand, if people’s future care needs are to be met, future growth in funding and staffing needs to be more  proportionately directed to primary and community health and care services rather than to acute hospitals. This investment should be accompanied by a clear vision for bolstering these services, with policies aligned to achieving this vision.

Government should reform the adult social care sector by:

increasing funding to stabilise the sector and enable providers to attract, retain and train the staff needed to meet demand

Successive governments have neglected social care, and the lack of policy follow-through and investment has resulted in a social care system that is unfit for purpose and stretched to its limits. There is significant unmet need for social care; estimates suggest that fewer than half of older people with care needs are receiving support (including support from unpaid carers). Information from the Care Quality Commission’s social care Market Oversight scheme shows continued financial pressure on providers, and their analysis suggests that smaller providers are experiencing additional sustainability issues.

The financial pressures on local authorities have seen them try to limit how much they pay for social care despite providers being hit by increasing costs. This squeeze on provider finances is one reason behind the uncompetitive levels of pay seen in social care, which have contributed to high staff turnover. Large numbers of staff are leaving because they can find jobs with better pay, hours and working conditions outside the care sector.

implementing funding and eligibility reforms to make the system fairer

In the current system, everyone with assets of more than £23,250 must either pay for their own social care, rely on family or go without. In effect, successive governments have ‘made the means test meaner’ as it has not been increased to take account of inflation, so it has become harder for people to access publicly funded social care. There is also no limit on how much people pay towards their care, so people with ongoing care needs are exposed to the risk of spiralling costs. In 2014, parliament passed legislation allowing government to enhance the means test and introduce a cap on lifetime care costs, yet the changes have not been implemented.

Demand for care is likely to keep increasing due to an ageing population and rising levels of disability among the working-age population. Improving access to social care by extending the means test and providing free or subsidised care to more people are important factors in making the social care system fairer.

undertaking reforms to improve quality and outcomes

Around 18,000 organisations provide social care and one in six services remain below the Care Quality Commission standard, and there remains a problem with some services failing to improve over a long period of time. Reforming social care to improve quality is essential for the people, families and carers who rely on these services. Reforms should involve two core elements: regulation and support to drive improvement in service delivery; and measures to increase the number of social care staff as well as to provide them with proper training and development.