What should national policy-makers do to make care closer to home a reality?

Greater emphasis on primary and community care is one of the three ‘big shifts’ the Labour government wants to see in the health and care system.

In early 2024 The King’s Fund published Making care closer to home a reality, which examined why the long-term vision held by multiple governments to make this shift happen had not been achieved. So, having unpacked in our earlier report the reasons why it has been so difficult to make this shift, what does the government need to do differently to ensure that it happens this time, unlike the previous 30 years of attempts?

Here we focus on the policy levers available to any government wishing to reform health and care services. The King’s Fund has a long history of research in this area, including analysis of international experiences of developing and implementing long-term plans for health, understanding the levers for change in primary care, and the effective use of improvement approaches.

Drawing on this body of research, as well as a further analysis of national and international literature to understand what others have done to make these kinds of significant shifts in how health services are configured and delivered, we have developed a typology of policy levers. We tested and refined them through a series of interviews with national policy-makers and system leaders, and have set out which of these levers we believe the government should be using if it is serious about making the shift it has outlined.

The levers

Political leadership

In a national tax-funded health care system, political leadership is the necessary starting point for any plan for change, and it is this lever that provides the overarching framework for the use of all other levers.

Issue one: multiple government priorities mean this agenda is crowded out

The primary reason for previous failures to implement a community focused health and care system is a hierarchy of care that prioritises hospital services over community, primary and public health services. The prevailing view of national policy has been that care closer to home is the long-term goal but only after hospital waiting times are fixed, whether that’s elective care waits or A&E waits. As The King’s Fund has already argued, these decades-old targets are very unlikely to be met without the enormous injections of resource and focus that were seen in the early 2000s. And even at that time, when targets were routinely being met, the change of focus to care closer to home was still not realised because maintaining waiting-time performance took priority over everything else. Even though many staff are committed to the vision of a primary and community-focused health and care system, they are genuinely baffled over how it would be possible to do both at the same time. Politicians have been reluctant to describe explicitly the choices that will be needed in the absence of more money, and the implications of those choices, both in the short and long term, for patients and the public. As a result, acute hospital services remain the priority.

Issue two: the central narrative is muddled, with multiple definitions and interpretations 

There is no clearly understood single explanation for why a primary and community-focused health and care system is now the central vision, whether that’s for policy-makers whose implementation decisions remain inconsistent, commissioners who need to change the way they work, staff who need to change practice or the public who will experience the change in services. 

The way in which the terms ‘care closer to home’ or ‘neighbourhood health service’ are used has contributed to this muddled narrative. These terms are often used narrowly to describe moving existing hospital services to community or primary care settings, or the creation of local integrated health and care teams, both with a view to reducing pressures on acute hospitals. This narrow view means that the need for a wholesale change of focus for the system is lost.  

Issue three: national policy tends to hinder the development of effective local services rather than enable them

We know from our research that the most successful change is driven by the needs of communities, with a shared vision developed by local staff working with those communities. The many great examples of good practice in moving the focus of care closer to home demonstrate this approach. Care focused on local communities must, by definition, reflect the priorities of those communities.

In Fleetwood, for example, a long history of committed community engagement – empowering local people to develop and access resources to meet their needs, and encouraging local services, including housing, district council, education, police and voluntary sector services, to proactively come together – has led to significant positive impact on the physical and mental health of local people. 

However, these examples have tended to emerge despite national policy, rather than because of it. Moving care closer to local communities means having the flexibility to respond to those communities and trying innovative and creative solutions. The evidence is clear that when local teams, at any level, are able to set goals for themselves and be held to account for meeting them, they are much more likely to be successful. This means moving from an approach where single ‘hero’ leaders drive change on their own, towards a more structured and standardised approach to delivery, where national policy enables local leaders and communities to develop and implement a shared vision.

Issue four: the lack of a long-term plan for adult social care 

It is near impossible to see how this shift to a community-focused health system will be delivered successfully without similar attention and support for adult social care. A long-term plan for adult social care is essential, working alongside the shift of focus in health services. Without this, pressures on adult social care will continue to jeopardise any ambition for transformation. 

Issue five: there are no significant metrics that can demonstrate progress on moving the focus of care closer to home

A key policy lever for any government is to ensure the appropriate flow of information is in place to achieve policy goals – ‘what’s measured is what matters’. Our interviewees reported that as no significant metrics exist to demonstrate progress on moving the focus of care closer to home, there is consequently no pressure on system leaders to focus on it. This contrasts with the weight of pressure leaders feel around the elective backlog and A&E waiting times. ​

Despite recent improvements, national data on primary, community and mental health services is still not comprehensive, lacks quality and is mainly limited to the number of contacts with services. This lack of data translates into a very limited number of national targets for care ‘closer to home’, such as the two-hour urgent community response, whereas there are numerous targets for hospital and acute care.

Financial levers

Governments often look to financial incentives and control to drive change. The current financial architecture does not support a focus on primary and community care, and these services have seen less funding growth than acute hospital services, despite rising demand.

Issue six: the proportion of NHS finances spent on primary and community services has decreased over the past ten years compared with acute hospital services

The shift of focus in care will require a rebalancing of resources. In the decade before 2010 the proportion of the total budget spent on acute services hovered around 49%; by 2021 it had risen to 58%. Over the same period, the proportion spent on primary care services decreased from around 28% to 18%.

Issue seven: England is an outlier in its use of micro-financial incentives, which hinders local flexibility and innovation

England is an international outlier in its use of micro-financial incentives to drive change in health services, even though the evidence base for this approach is surprisingly thin. This is particularly apparent in the national contracts for primary care services, such as general practice and dentistry. Moving money from heavily regulated small discrete pots of funding (which are often hard to spend and at risk of being taken back by ICBs to balance system underspends) to core budgets and investing in local commissioning so that it can be targeted to local population need and strategy will be an important first step in promoting the kind of shared community-driven change that will be needed to make the shift.

Issue eight: national contracts for general practice and community pharmacy have competing incentives

Competing financial incentives and policies get in the way of collaboration. Uncoordinated changes to the GP and community pharmacy contracts often create unforeseen effects and cause challenges to joint working between these two sectors. For example, policies that shift the delivery of a service from general practice to community pharmacy can create additional co-ordination tasks that are not reimbursed and do not necessarily create extra capacity.

Issue nine: there are barriers to capital investment for estates and technology

If teams are integrated at neighbourhood level, there must be both estates and technological capacity to support that integrated working. In recent years, there has been a trend towards centralised community health services, particularly community nursing and allied health professionals, covering very large populations across wide geographical areas and multiple local authority areas. A different approach will be needed from NHS trusts that provide community services, which recognises that integrated neighbourhood teams will require much more local collaboration, allowing primary and community health and care workers to be based together. Even in advance of the NHS 10 Year Plan, the refreshed NHS Long Term Workforce Plan signals growth in both new and existing roles in primary and community care services which will require additional estates capacity.

These challenges require both capital investment and a better use of the current physical estate, including changes to financial rules that hamper collaborative use of the public sector estate, and requirements to charge market rent for the use of void space which prohibits that space from being let out at a discount, even to other parts of the NHS or local government.

Technology in primary and community health and care services is often very underdeveloped, reflecting a lack of investment in both hardware and software. For many interviewees, investment – at the minimum for there to be basic infrastructure in place in primary and community services – was a priority.​

Cultural levers

Although culture cannot be imposed centrally, the communication within, between and from national policy-makers defines the way in which the system operates and has a major impact on culture.

Issue ten: performance management culture is restrictive and risk averse

Integrated care system (ICS) leaders experience the performance management culture of NHS England and DHSC as restrictive and risk averse, and their own behaviours can pass that risk aversion down to those working at local level.

The NHS is a system dominated by centralised performance management. This ultimately leads to people within the system focusing on delivering what they are measured on nationally, rather than locally agreed strategic plans that reflect what their communities need. If that top-down message is ‘above all, hit waiting-time targets’ then that is where system leaders will put their focus. One of our interviewees reflected that they were never asked by NHS England or DHSC about progress on primary and community services, only about finances and performance targets.

Our interviewees echoed the findings of the Messenger review that the prevailing culture in the health and care system has led to a constant looking upwards for guidance, rather than downwards and outwards to patients and communities.

Issue eleven: there is a low status attached to working in primary and community services

Clinical and managerial career paths are often focused on acute care settings, which are seen to offer better opportunities for pay and progression, with large teaching hospitals considered the most prestigious places to work. If care closer to home is to be realised, it needs the best managers and clinicians to work in primary and community care settings, and pay and conditions need to reflect that.

Structural levers

The NHS is familiar with seeing major structural reorganisation used as a lever for change. Commissioning has been reorganised variously into primary care commissioning groups, primary care trusts, clinical commissioning groups and now integrated care systems. Community services providers in particular have seen multiple changes in past two decades resulting in a range of different providers, including standalone NHS community trusts, combined community and acute or mental health NHS trusts.

Issue twelve: ICBs have a higher representation from acute hospital providers than from primary and community services

The delivery of care closer to home does not require significant structural reorganisation. Across our interviewees, there was strong, consistent agreement that ICSs could be an appropriate structural vehicle to deliver care closer to home, particularly if ICSs are able to fulfil their underlying mission. However, there are changes that can be made to improve that capability.

Although each acute trust may be represented on ICBs, that is definitely not the case for each primary care or community care services provider as there are so many more providers in each area. If the focus of the system is to be primary and community services, then ICB boards should be clear that their membership reflects that focus and governance.

Issue thirteen: there is limited capacity and capability within integrated care systems to deliver care closer to home

There has been an erosion of capacity and capability when it comes to the leadership, commissioning and improvement of primary and community services within local systems. This started with the changes to primary care commissioning resulting from the Health and Social Care Act 2012 and has been compounded by the recent significant headcount reductions that ICSs are being required to make. In many cases, this means that remaining staff within ICSs are focused on acute hospital services, for the reasons we have outlined above. Without strategic leadership that is focused outside of acute hospitals, the power imbalance between acute hospitals and the rest of the health and care system is in danger of worsening, making it even harder to have a system focused on primary and community care.

Regulatory levers

Governments can use regulatory levers to implement change by setting standards and rules and ensuring compliance through monitoring and enforcement. These can include system regulation, such as the Care Quality Commission’s aim to enhance integrated care through its regulatory process, and professional regulators, who set standards for training and education.

Issue fourteen: the regulatory system, including system oversight, can sometimes act as a block to innovation and change

Much has been written recently about the capacity and capability of the Care Quality Commission (the health and care services regulator), and in an effort to drive change, government has often added additional functions to its remit, many of which do not fit with its core capabilities.

Local variation is a challenging concept for government, and regulation has been seen as a way of ensuring that all patients receive the same care, whatever the context, which can stifle local innovation and flexibility.

Issue fifteen: Professional regulators and professional bodies have struggled to adapt to the change of focus and emerging roles

The increasing focus on community-based care poses challenges for the professional regulators, such as the General Medical Council and the Nursing and Midwifery Council, and other professional bodies, such as the Royal College of General Practitioners and the Royal College of Physicians, requiring changes to training, regulation and ongoing professional development. This includes the challenges of regulating new roles, such as that experienced with physician associates. Training for many health and care professionals is focused on hospital care, which does not reflect the shift to a community-focused health and care system.

Conclusion

If the government is serious about the shift it wishes to make towards a primary and community focused health and care system then there are policy levers available to them to incentivise the system, with political leadership by far the most important. In short, our call to action for government is:

Prioritise, be consistent and be clear. It is abundantly clear that strong political leadership that prioritises this shift, and remains focused on it, will be critical. If this is pushed to the ‘nice to do once we’ve sorted waiting times’ column, then it will remain an unimplemented policy for another thirty years. Although people may be able to ‘walk and chew gum’, ‘running and chewing gum’ is what the health and care system is currently being asked to do. Government must provide clarity about its expectations for balancing the huge, urgent demand for existing services and making critical underlying reform and be clear about the potential impacts of those choices for patients.

Enable and support local innovation rather than dictate it. As has been amply demonstrated, staff, patients and communities can work together to deliver effective community-focused health and care. Government needs to provide clarity about its expectations for the outcomes systems should deliver, but it should recognise and support the real progress that comes from many individually relatively small changes made by staff at service level, rather than policy directives driven from Whitehall.

Focus on changing national financing, rules and culture within national bodies that impede local innovation. To date, innovation often happens despite national policy levers rather than because of them. Government and NHSE should concentrate on which levers within their control enable change and remove any barriers to it, rather than focusing on service specifications or directives.