Community health services explained

Community health services (also known as community services) play a key role in keeping people well, treating and managing acute illness and long-term conditions, and supporting people to live independently in their own homes.

However, compared with other parts of the NHS, community health services are often poorly understood by policy-makers, national and local health service leaders, and staff working in other parts of the system, and have not always received the same national profile as the rest of the NHS. The way these services are structured and delivered is complicated, and as a result, data about them is hard to aggregate. In this explainer we outline what we know about community health services in England.  

What are community health services?

Every day, community health services have about 200,000 patient contacts – about 13% of all daily activity in the NHS. Community health services cover an extensive and diverse range of activities, and hence can be difficult to define, with the precise range and configuration of services varying between local areas. They commonly cover a wide range of needs across people of all age groups and are provided by many professional groups. In the NHS the term ‘community health services’ generally excludes specialist community mental health services.

Figure 1: Where do NHS community health services fit within systems that support health and care?

Community health services are most often used by children, older people, people living with frailty or with chronic, multiple and/or complex health needs, and/or people who are near the end of their life. Due to this complexity, community services work closely with other parts of the health and care system, such as GPs, hospitals, social care and pharmacies. The increasing numbers of people living with long-term conditions means that more people are likely to need support from community health services in the future.

Services are delivered in a wide range of settings – including people’s own homes, care homes, community clinics, community centres, schools and hospices.

How are community health services organised?

Commissioning

Integrated care boards (ICBs) commission most adult community health services, while local authorities commission services for children and young people up to 19 years old and some public health services – for example, sexual health services. NHS England is responsible for commissioning some specialist or public health services, such as sexual assault services.

The way in which competition law was applied in the NHS during the 2010s resulted in disruption and uncertainty for community services, and disincentivised investment. Community services were often broken off into individual tenders and underwent frequent retendering, which was destabilising. The Health and Care Act 2022 made changes that give the NHS and public health commissioners greater flexibility over when to use competitive procurement processes.

Provision

In the past two decades, alongside changes to procurement rules, there have also been frequent reorganisations to how community health services are structured, resulting in a range of different provider types and sizes; this includes standalone NHS community trusts and combined community and acute or mental health NHS trusts. It has been estimated that NHS providers hold around half of the total value of community service contracts, with the rest held by providers including community interest companies, local authorities, social enterprises, private providers, GP practices and pharmacies. A single provider is often responsible for delivering most of the community services in an area, usually alongside other providers that deliver specific services under relatively small contracts.

Community services are delivered by a range of staff, including community nurses, district nurses, allied health professionals (such as therapists) and health visitors. There is limited reliable data about the community workforce, and NHS workforce statistics do not capture in a consistent manner where community-based staff work. This is a particular problem for staff groups that work across community and acute hospital settings, such as therapists. The Community Services Data Set does not contain the same level of detail as other NHS workforce statistics – for example, data on allied health professionals and health care scientists is not broken down into individual professions, settings and regions. From the data available for community nursing, there are worrying trends that their numbers reduced between 2010 and 2022: community health nurses by 8%, health visitors by 23.5%, and community learning disability nurses by 46%.

Funding

Due to gaps and inconsistencies in national data, it is difficult to accurately quantify exact spending on community health services. The diversity of services and complex patterns of provision and commissioning make it challenging to collect and aggregate data on how much is spent. A national community services dataset was introduced in 2017 but is incomplete, as there are few mandatory or standardised fields. This contrasts with the mandated data collection on activity in acute hospitals, where every patient episode has been recorded and nationally collated since the development of hospital episode statistics (HES) in the late 1980s.

In recent years, the proportion of spending on primary and community health and care has seen slower growth compared with the acute and emergency care sector, despite the majority of health and care activity happening within primary and community settings, and activity increasing both in terms of the number of people seen and the complexity of care provided. This is despite the ambitions set out in the NHS Long Term Plan to ‘boost out-of-hospital care’ by increasing the share of the NHS budget going to community and primary care services.

National standards

In contrast to the numerous targets for hospital and acute care, there is a very limited number of national targets for community services care. The focus of the current standards is on the responsiveness of community services to help prevent unnecessary admissions to hospital and residential care, as well as ensuring a timely transfer from hospital to community. These standards are a two-hour urgent community response from referral target and a target for reablement care to be provided within two days from referral.

NHS England’s 2024/25 operational plan included a commitment on community services waiting lists, with an expectation that ICBs would have developed a comprehensive plan by June 2024 to reduce the overall waiting times for community services, including reducing waits of over 52 weeks for children’s community services.

The lack of targets reflects a lack of data on community services. The data that does exist is mainly limited to the number of contacts with services; there is relatively little data on demand, patient and staff experience, patient outcomes, and quality of care. As a result, targets do not focus on community services themselves but on the impact of these services on hospital capacity, such as the number of delayed discharges or number of readmissions.

Future developments and trends 

More integrated working

Community health services are working ever more closely with other parts of the health and care system. By working closely with acute hospitals, virtual wards have been developed to monitor and care for patients remotely at home rather than in hospitals, and urgent community response teams have been established to help prevent unnecessary hospital admissions.

Community services are also working more closely with primary care, specifically through the creation of primary care networks (PCNs) and associated integrated neighbourhood teams. The NHS Long Term Plan initially set out a requirement for community services to be configured around PCN footprints, with expanded community multidisciplinary teams providing proactive and anticipatory care to people with more complex needs. This was further developed in the Fuller report, which set out a vision for integrated multi-professional neighbourhood teams to support people who need proactive care in the community. The teams bring together staff from across PCN areas, including general practice teams, physical and mental health community teams, secondary care teams, social care teams and care staff.

Workforce development

The NHS Long Term Workforce Plan identified the need to grow the community and primary care workforce faster than the acute sector workforce, with projections suggesting that the community health workforce needs to grow by 3.9% annually over the next 10 years. This means there would be 9,000 more community nurses by 2026/27. Addressing the shortfall will require local systems to draw on the skills of the full range of community-based professionals, alongside efforts to improve retention of current staff and increase exposure to community settings during training to attract new staff.

Technology

There is real potential for technological developments to support and change how community services deliver care – for example, greater use of remote monitoring of people’s health in their own home through wearable devices, or at-home diagnostics and the use of virtual consultations. Technology can also play a role in facilitating better collaboration between community health services and other partners in the health and care system. For example, more accessible shared care plans and virtual multi-disciplinary team meetings can mean better information flow and communication across organisations, people and places, bringing benefits for both patients and staff (such as fewer tests, saving both patients and staff time). However, the state of technology in primary and community health and care services is often underdeveloped, reflecting a lack of investment in hardware and software. Investment will be needed to ensure that the basic infrastructure is in place while giving community health services the opportunity to make the most of technological developments.

What next?

The latest commitments to strengthen community services are to be welcomed, but the real challenge will be to translate these ambitions into reality by giving greater priority and attention to community services at national and local levels.