The purpose of our research was to understand the current state of community services and to explore how the health and care system needs to change to enable these services to meet the needs of the population now and in the future.
The policy context
Throughout the history of the NHS, a series of policies have sought to strengthen and co-ordinate services outside hospitals. The levers used to do this have often been structural and organisational, and community services have been subject to multiple reorganisations. Despite repeated attempts, ambitions to transform community services have not been realised.
How community services are currently organised and delivered
NHS community health services cover an extensive and diverse range of activities. There is no single model of provision; the range and configuration of services varies depending on the local population, geography and nature of other local services, and local legacy in terms of how services have developed and evolved.
Beyond the narrow definition of NHS community health services there is a much wider range of sectors and services that deliver care and support in the community. Patients receiving care in community settings often have multiple, complex health needs and depend on many health and social care services to meet these needs.
Figure 1: Where do NHS community health services fit within systems that support health and care?
Our research highlights both variation and complexity in how community health services are provided, who provides them and how they are paid for. Services are often fragmented, poorly co-ordinated, and not well integrated with other services in the community.
Current funding pressures are having a significant impact on community health services, and there are growing workforce shortages in key staff groups. Financial and workforce pressures are impacting on the availability and quality of care in some cases, and services are struggling to meet current needs let alone adapting to deliver the ambitions set out in the NHS five year forward view (Forward View). Concurrent pressures on related services such as general practice, social care, public health and mental health are exacerbating this situation. The result is a growing disconnect between the rhetoric and the reality of community-based care, with carers and families stepping in to fill the gaps left by statutory services.
Despite the complexities described, and the well-documented pressures that the sector is facing, community services are not standing still. Across the country there has been a wealth of innovation in community services stretching back over many years. But the potential to bring together the full range of community assets to improve population health is not being realised.
How services need to change
The elements of what community services should look like are well understood, and we summarise these elements in 10 design principles. How they are applied will vary from place to place depending on the population’s needs and how services are currently organised and funded. Many examples of these principles being put into practice are described in our report.
Organise and co-ordinate care around people’s needs
Community services need to be more closely connected to other parts of the health and care system to improve experience and outcomes of care and to avoid gaps and duplication between services. Shared records and interoperable IT systems can support better co-ordination by improving information-sharing.
Example: In Kent, ‘community hub operating centres’ have been developed to bring together multidisciplinary teams of professionals spanning health and social care.
Understand and respond to people’s physical health, mental health and social needs in the round
Future models of community-based care should take a ‘whole-person’ approach, addressing people’s physical health, mental health and social needs together. These factors are often closely related and interact to influence health and wellbeing.
Example: The Bromley by Bow Centre brings together health services and other community support, and health professionals can connect people to community resources through a social prescribing scheme.
Make the best use of all the community’s assets to plan and deliver care to meet local needs
Community assets are the positive capabilities within communities that can be used to promote health – this includes the full range of statutory services, voluntary and community sector organisations, private sector organisations, support groups, social networks, individuals, buildings and community spaces.
Example: In Erewash, an online directory of local community resources, community connector roles and a time bank have been developed.
Enable professionals to work together across boundaries
Professionals in the community should be able to work together across organisational and service boundaries. This may be through fully integrated teams or through regular communication, multidisciplinary meetings, or shared notes and care plans. Collaborative working should extend beyond the confines of the health service.
Example: In Nottinghamshire, there is a community in-reach service to older people’s acute wards, where GPs and community matrons work with hospital staff.
Build in access to specialist advice and support
Professionals in the community often manage high levels of clinical complexity, acuity and risk and should be able to draw on specialist input when required, without having to go through complex and indirect referral pathways.
Example: In Sheffield, community nurses are supported to provide advanced palliative care with remote supervision from specialists at a local hospice.
Focus on improving population health
Health care is only one factor contributing to health and wellbeing – others include individual behaviours, environment, poverty, education and employment. Improving population health requires collective action across different sectors to act on these wider determinants of health.
Example: In Wigan, there is strong focus on tackling preventable causes of ill health through a range of initiatives spanning local authority, voluntary and community sector and health and care services.
Empower people to take control of their own health and care
Future models of community-based care should support people to take control of their own health as far as possible. This might involve encouraging people to lead healthier lifestyles, improving their understanding of their health or supporting them to manage long-term conditions.
Example: In Bolton, health trainers are co-located within GP surgeries and can support people from certain high-risk groups to set health goals and promote behaviour change.
Design delivery models to support and strengthen relational aspects of care
Relational aspects of care are often the elements most closely correlated with good patient experience, and continuity is highly valued by patients, carers and families, particularly for people with complex health or social issues. Future models of community-based care should be designed to support these aspects of care.
Example: In the Netherlands, the Buurtzorg model involves self-managing community nursing teams providing the full range of care to their clients – from personal care to complex interventions.
Involve families, carers and communities in planning and delivering care
A significant amount of care and support in community settings comes from informal support networks of family, friends and communities. They can make a valuable contribution to future models of community-based care, both in identifying local needs and developing and implementing potential solutions. Community services also have an important role in supporting carers.
Examples: In Millom, the community has been closely involved in redesigning care. In Leeds, a local charity (Carers Leeds) has worked with commissioners to streamline carers’ support services.
Make community-based care the central focus of the system
There needs to be a shift in focus across the health and care system as a whole, from a system centred around hospitals to a system focused around communities and community services defined in their broadest sense. The changes described cannot be achieved by NHS community health services working in isolation – they require general practice, social care, hospitals and others to work differently too.
Examples: The Canterbury health system in New Zealand and the Southcentral Foundation in Alaska have both developed more community-focused approaches to care.
Making it happen
Services in the community comprise a wide range of assets, and there are many opportunities to use them more effectively to meet the population’s needs. Every area of England should exploit these opportunities. This should include pooling health and social care budgets, addressing the complex and fragmented approach to commissioning, redoubling efforts to integrate services, and investing in and changing the workforce.
Each area should identify leaders – including clinical leaders – to take this work forward. The third sector, the private sector and communities should be fully engaged in transforming care, and primary care – working at scale – should be at the centre of these efforts. There also needs to be a concerted effort to build capabilities for quality improvement among staff delivering care in the community.
STPs and ACSs offer a vehicle to drive the changes that are needed. Plans have already been developed to strengthen community services and improve population health. More work is now required to think through the detail of how these ambitions can be delivered, and to revisit plans to ensure that they are credible and will bring about the improvements in care that are needed. Every STP or ACS should identify leaders to take forward their plans for services in the community.
Local leadership needs to be combined with national leadership that identifies community services as a priority and provides the guidance and resources needed to translate plans into practice. National bodies should publish a plan for the future of services in the community, akin to the General practice forward view, setting out a compelling vision for the future and the resources that will be provided to make a reality of this vision. A team of experienced leaders should be appointed to oversee implementation of the plan at a national level.
The national bodies should work to align the regulation, commissioning and funding of health and social care with the changes that are needed. This should build on work by the Care Quality Commission to develop a place-based approach to assessing the quality of care and by NHS England and NHS Improvement to bring their work together. Work to join up information systems should be given priority in view of the importance of shared electronic care records in enabling more care to be delivered in the community. More work is also needed to collect and make use of data about community services.
It is not realistic to expect reductions in acute hospital capacity to pay for extra spending on services in the community at a time when hospitals are working under intense pressure. New and earmarked resources will be needed to invest in these services, and the proportion of the NHS budget spent on services in the community should increase over time.
The transformation of mental health services in England indicates that changes on the scale of those described in our report can be delivered, but they will take time, resources and sustained leadership to be realised. The goal should be to bridge the gulf between the rhetoric and the reality of care in the community by delivering a higher proportion of care at home or closer to home, reducing fragmentation in service delivery and improving overall population health. Now is the time for community services to come in from the cold alongside continuing efforts to improve hospital and specialist services.
What is the role of the Third Sector and Voluntary Groups in STPs ?
Clinical Commissioning Groups and other health and social care stakeholders need to engage now with Complementary Medicine practitioners and their professional organisations and regulators, including those accredited by the Professional Standards Authority. These practitioners provide a qualified, insured but 'untapped' workforce that is available to the public health (including the NHS) and social care sectors. Please refer to my "December 2017 Complementary Medicine Roundup" blog written for the 'Complementary' webpage of The College of Medicine, London, at: https://collegeofmedicine.org.uk/complementary-medicine-roundup-decembe…. Thank you.
It is a pity you are not proposing a single PHB to cover all proffessional organisations, it need to happen. Sharing is the way forward, it will save time, money and gives a better relationship with other bodies.
In order that change is effectively undertaken all levels of government and other public funded organisations need to demonstrate good management
Independent management accreditation is required to achieve this