What are community health services?
Community health services cover an extensive and diverse range of activities and are difficult to define. Services are delivered in a wide range of settings – including in people’s own homes as well as in community clinics, community centres and schools – so are less visible than services delivered in hospitals and GP surgeries.
The precise range and configuration of services vary between local areas. They commonly include adult community nursing, specialist long-term condition nursing, therapy services, preventive services such as sexual health and smoking cessation clinics, and child health services including health visiting and school nursing. Some providers also deliver specialist services such as prison health care and dentistry.
Community health services provide support across a range of needs and age groups but are most often used by children, older people, those living with frailty or chronic conditions and people who are near the end of their life. Community services often support people with multiple, complex health needs who depend on many health and social care services to meet those needs. They therefore work closely with other parts of the health and care system, such as GPs, hospitals, pharmacies and care homes. 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.
Beyond NHS services, a much wider network delivers care and support to people in their homes and communities. This includes pharmacies, hospices, nursing homes, home care agencies, voluntary sector services and carers.
How are community health services organised?
Community health services are varied and complex in terms of how they are delivered, who provides them and how they are paid for.
Community services have undergone frequent structural reorganisations over recent decades, resulting in a range of provider types and sizes. This includes standalone NHS community trusts and combined community and acute or mental health trusts. It has been estimated that NHS providers hold around half of the total value of community service contracts, with the rest being held by providers including community interest companies, local authorities, social enterprises, private providers, GP practices and pharmacies (Gershlick and Firth 2017).
A single provider is often responsible for delivering most of the community services in an area, but usually alongside other providers that deliver specific services under relatively small contracts.
The commissioning of services is equally complicated. Clinical commissioning groups (CCGs) commission most adult community health services, while local authorities commission children’s 0–19 services and public health services such as sexual health and alcohol and drug services. NHS England is responsible for commissioning a handful of community health services, including dentistry, offender health, immunisations and national screening programmes.
On average, trusts providing community services are commissioned by more than five different organisations (NHS Providers 2018), and CCGs hold an average of 50 separate community service contracts (Gershlick and Firth 2017). Services also tend to be retendered on a more regular basis than those in other parts of the NHS.
What are the biggest challenges facing community health services?
It is difficult to accurately quantify spending on community health services because of gaps and inconsistencies in national data. Most estimates suggest that around £10 billion of the NHS budget is spent on community services each year.
While gaps in the data mean it is not possible to precisely track trends over time, there are indications that budgets have remained static or fallen in recent years despite growing demand. Community services are more vulnerable to cuts than some other parts of the NHS because they are paid for under block contracts (where payment is not based on activity) and are not linked to high-profile national targets. In a survey by NHS Providers, more than half of trusts reported that their funding for community services had decreased in 2018/19.
The £4.5 billion uplift to primary care and community health service budgets announced in the long-term plan could provide some welcome relief from these funding constraints, although it is not yet clear how this money will be spent. Encouragingly, and in contrast to previous plans to strengthen community services, this investment is not predicated on an assumption that it will reduce the need for hospital beds.
Growing shortages in key parts of the workforce present a significant challenge to plans to expand community services.
The total number of nurses working in NHS community health services fell by 14 per cent between 2010 and 2018 whereas the number working in acute adult settings increased by 9 per cent over the same period. The number of qualified district nurses has fallen particularly sharply, dropping by 42 per cent between 2010 and 2018.2 These numbers do not include information from all non-NHS providers; some (but not all) of the fall may therefore reflect staff transferring to non-NHS providers.
There are also worrying trends in other parts of the community workforce. Between 2010 and 2018, the number of community learning disabilities nurses employed by the NHS fell by 23 per cent and the number of school nurses fell by 25 per cent. The number of health visitors increased between 2010 and 2015 in response to a government commitment to significantly expand their numbers, but the increase has not been sustained and numbers have fallen by 23 per cent since their peak in 2015. Again, it is difficult to interpret these numbers as the employment of some health visitors and school nurses has transferred to local authorities.
Profile and understanding
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. This is partly because they are delivered ‘behind closed doors’ and partly because of the diversity of services and complex patterns of provision and commissioning described above.
The limited national data on activity, quality and spending in community services makes it difficult to make the case for their impact and value and almost impossible to accurately quantify changes in funding, staffing, demand, and availability and quality of care.
Community services have not had the same national profile, influence or leadership as other parts of the NHS – for example, there are no prominent national targets focused on community care, and there is no national director for community services as there is for mental health, for primary care, and for urgent and emergency care.
- 2. All figures are based on numbers from September 2010 and September 2018 as reported in NHS workforce statistics, September 2018 by staff group, area and level.
What does this mean for people using community health services?
There is evidence that the financial and workforce pressures described above are compromising the availability and quality of care. Our research on district nursing services highlighted the increasingly task-focused nature of much of the care being delivered, with less opportunity for thorough assessments and preventive care. There is a risk that growing numbers of people will be left without the care and support they need, although unmet need is very difficult to detect or measure.
This is particularly concerning due to the high level of needs and vulnerability of many of those receiving community services, as well as concurrent pressures on other services that support people in the community such as general practice and social care.
The result is a growing disconnect between the rhetoric and the reality of community-based care. Services are struggling to meet current demand, let alone to deliver ambitions of offering more care in the community.
How are services changing?
Despite the pressures, community services are not standing still. There has been a wealth of innovation in community services, with examples of local areas changing delivery models to improve co-ordination between services and to address people’s physical, mental health and social needs in the round.
Integrated community teams based in neighbourhoods or localities are a core element of the new care models being developed in many areas. These teams bring together a range of community health and social care professionals alongside groups of GPs to provide proactive and joined-up support for people with complex health and care needs.
Building on these developments, the long-term plan sets out plans for ‘a series of community service redesigns everywhere’. This includes a requirement for community services such as district nursing to be configured around new ‘primary care networks’. All areas are being asked to develop expanded community multidisciplinary teams aligned with primary care networks joined by social care and the voluntary sector, and services will be expected to increase the capacity and responsiveness of their community crisis and reablement services.
Innovation is also taking place through asset-based approaches, which seek to draw on the positive capabilities within communities that can promote health and wellbeing. This usually involves health and care services working with a wide range of partners, such as local voluntary sector organisations, community groups and other public services such as schools, housing and fire and rescue services.
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 level. Unless growing gaps in the community workforce are addressed, staff shortages may prove to be what limit plans to deliver more care in community settings.
What is the role of voluntary support groups in community services?
With central funding almost non-existing those third sector organizations that have survived in the "shark pool" that is the voluntary sector are looking at alternative sources of funding that will support future new services. Where does that leaves current services? Also, the third sector struggle for volunteers with so many community services e.g. libraries relying on volunteers and as the population ages and increases in number and as the statutory retirement age increases and more retirees acting as babysitters / carers / etc. where are the next generation of volunteers coming from
With less funding going into community services currently the VCS have adequately filled part of the role in providing first line services. However with the ongoing reduction in statutory funding and subsequent reduction in grants and commissioning from either health or social care these services are also at risk leaving very many people vulnerable. What plans are there for realistic commissioning of the VCS
"Innovation is also taking place through asset-based approaches, which seek to draw on the positive capabilities within communities that can promote health and wellbeing". I cannot reconcile in my mind the relationship between "asset-based approaches" and "positive capabilities".