Community services: How they can transform care

This paper looks at the changes needed to realise the full potential of community services for transforming care. The Transforming Community Services policy, launched in 2008, was mainly concerned with structural changes. While the emphasis on moving care closer to home has resulted in some reductions in length of hospital stay, it is now time to focus on the bigger issue of how services need to change to fundamentally transform care.

The paper is based on contributions from a working group of community providers convened by The King’s Fund, which was tasked with exploring how community services can help deliver the transformation in care that was promised by the 2008 policy.

Key findings

Comprehensive change is required in the nature of community services and how they relate to the rest of the health and care system. The key changes needed are as follows.

  • Simplify services and remove unnecessary complexity, creating larger multidisciplinary teams based around primary care and natural geographies and working in new ways with specialist services (community and hospital-based).
  • Community services need to offer a rapid and accessible response; significant numbers of patients occupying hospital beds could be cared for in other settings but only if suitable services are available and can be accessed easily. 
  • New ways to contract and pay for these services are needed, which means changes in primary care and hospital contractual arrangements; it also means changes in the infrastructure and workforce, to focus on providing whole person care and support.
  • Community services need to be better at reaching out – to harness the power of the wider community to support people in their own homes, combat social isolation, and create healthier communities.

Policy implications

Running community services in their traditional silos is no longer appropriate. They need to be more closely connected to all other parts of the health and social care system if they are to be a driving force in improving the health of individuals and communities. They need to be much more closely involved in key decisions about patients at an earlier stage in their journey through the system.

The changes proposed in this paper require leadership and investment, and require organisations to find new ways to work together effectively. There is also a need for fundamental changes in how primary care and hospitals are configured and in how social care is commissioned.

More on community services

Comments

Dr Peter Smith

Position
GP partner,
Comment date
02 February 2016
Intelligent and well observed comments from much under valued district nursing voice. Plus an international experience of just how badly other countries /systems can get it wrong . I have been championing a devolution of DNs to GP employment for years as can see great benefits to bringing them into the heart of the primary care team . Such plans flounder on the basis of smaller practices being unable to do likewise and a perceived inability to live with a redundant management system for these nurses , many of whom would jump at the chance to join us .

Noureddine Kenssous

Position
Librarian,
Organisation
Luton and Dunstable University Hospital NHS Trust
Comment date
14 October 2015
The report recommends the model to cover a population of 30,000 and above in rural areas and 50,000 to 120,000 in other areas. I will be very interested in evidence to support these recommendations. Can anyone direct me to the source, please?

Julie Ann Racino

Position
President and Principal,
Organisation
Community and Policy Studies
Comment date
01 October 2015
Community services involve in the US a substantial amount of health care financing, now with a layer of "managed care" on top of private, non-profit agencies. The latter do not even own health care patents, and the former do not either, claiming they "bought" the whole shebang to "better manage" it. In addition, the hospital sector in the US has taken in "behavioral in aging and mental health" as a psychiatry position, while the physicians involved with the general hospital will not even prescribe a sedative or a psychotropic!!

JYG

Position
District Nurse,
Organisation
Association of District Nurse Educators
Comment date
02 March 2015
As a lecturer, District Nurse practitioner and someone who is very supportive of the NHS (particularly it's community services), I was extremely disappointed that this piece does not mention District Nursing. Whether through a lack of understanding, or some misplaced aversion to the title, the crucial role played by District Nurses has been completely omitted. For example, when discussing 'Appropriate multidisciplinary skill-mix ...effective delegation of tasks to the right level' was the writer truly unaware that District nurses can and do, take on the roles mentioned?
- advanced nurse practitioners (many DNs are nonmedical prescribers)
- support patients with complex conditions, and provide appropriate supervision and training for other clinicians.
- act as integrated care co-ordinators who can support the management of patients with long-term conditions.
As a 24/7/365 service, they provide care when needed, and where needed (eg. community hospital, care home, clinics, patient homes, etc.) including of course, end-of-life care.
It would be wonderful to have recognition of the value of what the health service once had: DNs working closely with GPs (some are still 'GP attached'), co-ordinating care; providing holistic assessment and health promotion / prevention; quality assuring social and other services; and generally holding it all together for the greater good.
What's been created is a fragmented mass of individuals working in silos; getting paid much more as 'Advanced Practitioners' or 'Community Matrons' yet without the same overarching responsibility for a population, nor the accountability for a team and others' practice. Having worked in North America for the first 15 years of my career, I can assure you there is no need to look to Alaska to make recommendations for improvement. Very difficult to compare or translate services for the Innu patients I worked with in Northern Canada, to the populations I've nursed here. What I have encountered in the UK, is unparalleled elsewhere and it's a mystery why people keep looking to the USA as though they hold the key to great services. They don't. To improve primary and community care, it might be worth acquiring a better understanding of what worked well before this fragmentation / duplication of services set in and District Nursing numbers were decimated. We, and patients, are paying a very high price for quietly, efficiently working in the background, behind closed doors where research and policy doesn't seem to reach...

Brian Jarman

Position
co-director Dr Foster Unit,,
Organisation
Imperial College, London
Comment date
01 May 2014
What are the 'health risk groups' used in Table 1? It's not possible to properly interpret them without knowing what they are e.g. are they based on the IMD, Carstairs Index or some unpublished index of health risk?

Stephen Sellery

Position
Interim Business Development & Contracts Manager,
Organisation
NHS
Comment date
19 February 2014
Cogent report. Community services can improve services and save money but several barriers as the report notes: (1) power of the purse is strongest where there are high status individuals; (2) the medical model belies integrated working; (3) despite the rhetoric of QIPP and CQUIN the NHS does not invest to save. It returns savings back to the Treasury and then bemoans the lack of system wide innovation.

David Williams

Position
Trainee Advanced Nurse Practitioner,
Organisation
NHS
Comment date
17 February 2014
I agree with much of this paper, however, what is missing is an answer to how are policy & doh designers going to rein in and control all the mini businesses called GP practices? How can we expect to achieve seamless consensus while we have the gatekeepers of community care (GP's) running heavily incentive driven businesses? I don't have the answer folks but I've worked in the NHS long enough to see a big stumbling block.

Terry Roberts

Position
Member of the public,
Comment date
13 February 2014
Yes, could not disagree with any of the comments.
The problem is that what is said is nothing new and been the subject of many (many) commentators for years.....
An isolated project is heralded from time to time but no real overall improvement ever takes place.
Managers are just either incapable at grasping the problem, sharing it and being radical (if that is what it is) or reticent at putting their joint heads on the block.
Why do so I suppose, when you can remain safe and still earn a good wage?

Add your comment

You may also be interested in