Community health services: our position

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Part of The King's Fund position

The NHS long-term plan offers an opportunity to finally deliver on the longstanding ambition to provide more care closer to home, but only if commitments to increase funding and give more priority to community health services are honoured and severe workforce shortages are tackled.

What we think

Despite the vital role they play in helping people to maintain their independence, manage long-term conditions and treat acute illnesses, longstanding ambitions to strengthen community services and shift care from hospitals into community settings have not been realised.

These services have not been given the priority, funding or support they need, and they remain poorly understood compared to other parts of the NHS. Frequent reorganisations have proved distracting, while procurement rules have allowed services to be retendered on a regular basis. This has sometimes resulted in a confusing patchwork of providers and services.

There is a growing disconnect between the rhetoric of ‘care closer to home’ and the pressures community health services face. The recent financial squeeze on the NHS local authorities has put budgets for community health services under significant strain. This, along with severe shortages among key groups in the community workforce such as district nurses, has left providers struggling to meet current demand, let alone make a reality of plans to deliver more care in the community.

The NHS long-term plan has placed a renewed emphasis on community services, backing up ambitions to boost services with additional funding and national leadership. This provides a real opportunity to put services on a more sustainable footing and to deliver joined-up and proactive care in the community.

As part of this, community health services will need to collaborate more closely with general practice, social care and other parts of the health and care system. Much will depend on the successful development of primary care networks (PCNs). While their initial focus has been on building partnerships between groups of general practices, PCNs now need to broaden their focus to partner with other community-based services, and providers of community health services need to work constructively with their local networks.

Workforce shortages are likely to be the major limiting factor to these plans. Addressing the shortfall will require local systems to draw on the skills of the full range of community-based professionals – including nurses, pharmacists, allied health professionals and others – as well as efforts to improve retention of current staff and attract new staff by increasing exposure to community settings during training.

The number of qualified district nurses fell by 42 per cent between 2010 and 2018.
Source: NHS Digital 2018

The context

Community health services include an extensive and diverse range of services and activities – from those targeted at people living with complex health and care needs such as district nursing and palliative care, to health promotion services such as school nursing and health visiting. They play a vital role in enabling people to remain living independently in their own homes and communities, and can reduce the need for hospital or residential nursing care.

National data on community health services is patchy, but previous estimates suggest that they account for around 100 million patient contacts each year, and make up approximately twenty per cent of the NHS workforce and around 12 per cent of the NHS budget.

Delivering ‘more care closer to home’ has been a longstanding policy ambition, and attempts by successive governments to transform community health services have resulted in multiple reorganisations. The current organisation and delivery of community health services is varied and complex. There are many different types and sizes of providers (including standalone NHS trusts, combined trusts, and independent providers) and complex commissioning arrangements (spanning NHS and local authority commissioners and involving frequent retendering of contracts).

In a survey by NHS Providers, 52 per cent of trusts said that the income for community services in their local health economy had decreased in real terms in 2018/2019.
Source: NHS Providers 2018

Despite their vital contribution, community health services are poorly understood compared to other parts of the NHS and there is a lack of robust national data on cost, activity, quality and outcomes of care. This is set to improve since the introduction of a national community services dataset, but there are currently large gaps in this data.

While it is difficult to accurately quantify spending on community health services because of gaps and inconsistencies in national data, there are indications that budgets have fallen in recent years. At the same time, reports suggest that demand for some services is increasing as a consequence of the growing and ageing population, rising levels of multimorbidity and efforts to deliver more care closer to home.

These pressures have been compounded by severe workforce shortages – most notably in district nursing, where numbers have almost halved – presenting a significant challenge to plans to expand community health services. Workforce issues are all the more significant given the staff-intensive nature of services in the community.

While many community providers are managing to provide high quality care in spite of these challenges, there is evidence that the availability and quality of care is being compromised in some cases. There is a risk that the impact on people relying on services will go unnoticed due to a lack of robust data and the fact that care is often delivered behind closed doors.

The NHS long-term plan committed to ‘boost “out-of-hospital” care’, and finally dissolve the historic divide between primary and community health services’. Under the plan, community services are required to increase the capacity and responsiveness of their crisis and reablement services, to develop expanded community multidisciplinary teams aligned with PCNs, and to configure services in line with PCN footprints. These requirements have been formalised through changes to national NHS contracts for community services.

The ambitions in the long-term plan are supported by a commitment to raise the share of the NHS budget going to community and primary care services, increasing annual spending by £4.5 billion by 2023/4. Implementation will be supported by a new national community health services programme, and the appointment of the first National Director for Community Services, helping to fill a longstanding vacuum in national leadership for community health services.

Key spokespeople for community health services

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Anna Charles

Senior policy advisor to the CEO

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Richard Murray

Chief executive