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Overview
The health and care system in England must shift its focus away from hospital care to primary and community services if it is to be effective and sustainable.
Despite successive governments repeating a vision of health and care services focused on communities rather than hospitals, that vision is very far from being achieved.
This research explored the underlying factors that have prevented change, and what might need to be done to achieve the vision; we analysed published evidence and national datasets, and interviewed stakeholders across the health and care system.
We found that to achieve the vision, political and other national leaders will need to completely shift their focus away from hospitals towards primary and community health and care – and all policies and strategies must align to that focus.
This report is not about closing hospitals or moving existing services from one location to another, although the latter option may sometimes be appropriate. Rather, it is about a wholesale shift in the focus towards primary and community health and care across the domains of leadership, culture and implementation. This will free up every sector to provide the care that it is best equipped to deliver.
Why did we do this work?
Despite successive governments repeating a vision of health and care services focused on communities rather than hospitals, that vision is very far from being achieved. 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. If this shift in focus does not happen, more expensive hospitals will need to be built to manage people with acute needs that could have been prevented or better managed.
What did we do?
We gathered perspectives from people across health and care, including people who use services. We carried out interviews with stakeholders across diverse roles relating to health and care. We also engaged with stakeholders, including practitioners, patient representatives, managers and policy-makers, throughout the project, holding workshops to test and refine initial findings.
We reviewed existing research and evidence from the past 30 years, both from England and internationally, and analysed national datasets.
What did we find?
Financial and workforce growth is not aligned to a vision of care focused on communities, with larger growth in the acute hospital sector than in the primary and community sector. There are many reasons for this.
There is a lack of agreement about the purpose underpinning the vision for the health and care system. In practice, there are several different sets of assumptions, aims and asks about why the focus of the system needs to shift to primary and community services. These include:
cost savings
reducing demand on hospitals (waiting lists, emergency admissions)
better experiences and outcomes for people who use health and care services
improved service alignment or integration
developing population health and prevention at scale, including wellbeing, and tackling inequalities.
There is a ‘cycle of invisibility’ for primary and community health and care services; they are hard to quantify and easy to overlook.
Hierarchies of care mean that urgent problems take priority over longer-term issues, for example treatments for urgent medical problems take priority over services that prevent the development of problems.
There are misconceptions about how the public think health and care services should be prioritised.
The financial architecture for health and care does not support a focus on primary and community health and care.
There are short-term approaches to return on investment.
The health and care system – including the way the workforce is trained and organised – is not set up to deal with the complexity of people’s needs.
Policies and strategies are not aligned with the vision of care focused on communities.
What next?
Because the health and care system is complex, so are the solutions. Although, in this report, we identify some specific actions that are required – for example, changes to training or to financial and incentive systems – it will not be enough to selectively implement only a few changes; a wholesale shift is needed, which helps to explain why the vision has not been achieved thus far. This wholesale shift in focus requires the following.
Leaders need to be clear about why a change in focus is needed: which is to deliver improved care and improved outcomes, and to ensure the health and care system is sustainable for the future, rather than to deliver cost savings in the short term.
All policies, including investment, workforce, financial architecture and performance management policies, must be aligned to the vision. If the focus remains on hospital performance, eg, waiting times and elective care targets, until performance recovers, this will reinforce the status quo and mean that the wholesale changes required will not be delivered.
The vision must be maintained over the long term – shifting focus will be an ongoing process and will need a consistent vision and dedicated investment that matches demand in the long term.
There will need to be differential funding growth. In a cash-limited system, and to avoid destabilising services, the solution is likely to be differential growth for each part of the health and care system, and a longer-term strategy for investing growth monies into primary and community health and care services.
The workforce needs to be equipped to deliver the vision. The health and care system is currently hospital centric, with increasing specialism and subspecialism of health and care. However, people are having increasingly complex health and care needs, which require an integrated, holistic response.
The system needs to increase generalism and multidisciplinary integrated teamworking, with practitioners able to hold risk and to enable people to live healthily in their communities. This will require pay and reward systems, workforce planning, education and training, and regulatory bodies to reflect the nature of this work.
Training for both practitioners and managers should focus as much on primary and community-based care as it currently does on hospitals, with most system and national leaders having expertise in, and experience of, primary and community-based care.
National leaders need to devolve responsibility and allow local areas to focus on what will meet the needs of their communities - a community-focused health and care system needs to reflect local need and circumstances. If integrated care boards (ICBs) focus on population health as originally intended, they have the potential to be able to deliver this change. In the main, ICBs should be held to account for their achievements in growing primary and community health and care services, rather than for the performance management of the hospital system.
We also identified some actions that should not be taken.
Only partially implementing the vision: individual policies, levers or initiatives will not miraculously unlock change. A total change in focus is needed to finally realise the vision.
Structural reorganisation: restructuring the current system is not necessary and risks reinforcing a hospital-centric health and care system.
Expecting short-term financial savings as a result of moving activity away from hospitals and abandoning plans if they do not materialise; given England’s already low acute-bed base, it is unlikely that money will be released from acute hospital closure, even if some activity moves from hospital to community.
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