Time to take community services seriously

Last week, we, alongside NHS Providers, NHS Confederation, Social Enterprise UK, the Local Government Association, and the Association of Directors of Public Health wrote to Steve Barclay, the Secretary of State for Health and Social Care, asking him to ensure there was central funding to ensure staff can get access to the same pay increase that colleagues on Agenda for Change contracts will receive.

Danielle Henry, Assistant Director of Policy and Programmes, says it’s yet another reflection of the community services sector not getting a fair deal.

Community health services often feel like the poor relation to the much higher profile services of emergency and elective care. If you monitor media and political coverage you would be easily forgiven for thinking that there’s no care being delivered in the community, it’s talked about so little. So why is there so little interest, given that for so many patients, the care given, in their home, or other convenient setting, is so vital?

Perhaps it is a matter of history. We are so used to talking about A&E waits and numbers of people sitting on an elective care waiting list, that it is the path of least resistance to keep talking about it. Everyone understands it, right? And it is certainly easier to measure.

Or perhaps it is easier to make sense of the episodic nature of elective and emergency care whilst community care is multi-layered and ongoing. Community care support is provided, often over the long term, and commonly to children, older people and those with chronic conditions, or those nearing the end of their lives.

It’s also not helped by the lack of a clear definition – when we talk about “community health services” we’re referring to a huge range of services including physiotherapy, podiatry, nursing, intermediate care, virtual wards, to name but a few.

This all adds up to a complex picture and because of that it isn’t always clear what the community services offer is to patients – do we know what we should all be expecting to get? And do we know what ‘good’ looks like when we get it?

This lack of clarity makes it harder to describe clear consistent messages around community services. And that’s where data comes in… or should come in. But again, this is where community services fall short. The data that underpins what we know about community health services is not as good as anyone would want it to be, despite some tireless work in the background which colleagues, in NHS England, and elsewhere, are committed to.

So, what do we know? Around £10bn is spent by NHS England each year on community health services, although the lack of clarity around defining community health services means that the actual spend and therefore reach is probably far greater.

Nevertheless, it is still a relatively small proportion of the total spend on health and care which sits at around £180bn each year – so that’s somewhere around 6%.

Every health commentator, policy expert, operational leader, politician or industry guru you can find will give you the same soundbite if you ask them about the long-term strategic direction that our health system needs to take: “less treatment in hospital, more delivered in the community or at home etc etc.” It’s stamped throughout NHS England’s Long Term Plan. So, where’s the investment to make that happen? 

Community services are unique, with such a varied group of providers delivering services. Obviously, NHS organisations are key, but independent providers alongside voluntary groups and social enterprises, play a massive role.

Approximately 40% of community health services are provided by non-NHS organisations who bring not only much needed capacity but also innovation, agility, and high-quality patient outcomes. CQC data shows that 91% of independent providers delivering community health services are rated good or outstanding.

But this brings us on to another issue. A very important part of the jigsaw when it comes to the delivery of community services is not within the NHS at all.

Local authorities directly deliver or commission a sizable chunk of community health services, most of which fall under the banner of “public health”.

About 10 years ago, these functions were transferred from the NHS to local government and are paid for by an annual direct grant from the Department of Health and Social. For many people, this move felt right and continues to feel right – local government is best placed to embed and extend health and wellbeing with local communities, across all the functions for which they are responsible, and through the extensive range of local and regional partnerships which they lead or support.

But therein lies a big problem. The Local Government Association recently stated that the public health grant (approx. £3.5 bn per year) has been cut by 24 per cent in real terms per capita since 2015 to 2016, equivalent to a total reduction of £1 billion. The greatest cuts have been in deprived areas with the highest levels of health inequalities. And we can all guess what is happening with demand for these services as well as the actual costs of delivering them.

The issue has been illustrated recently in the discussion around the (sadly still unresolved) Agenda for Change (AfC) pay discussions. Due to the historical context described above, and for other reasons, there are many thousands of workers who are contractually required to have terms and conditions which are the same as AfC. That is as it should be.

Unlike in the NHS, however, where there is additional money being made available to cover these costs, when it comes to local authorities, central government has said there won’t be any additional money – an estimated £66m – and they’ll have to find the money from existing budgets.  

You don’t have to be a rocket scientist (or indeed the Secretary of State for Health and Social Care) to realise that this is going to mean cuts elsewhere in their public health services.

We know these concerns are shared by key NHS representative groups as well as other organisations that represent the spectrum of providers of services. Recently, NHS Providers, NHS Confederation alongside the Independent Healthcare Providers Network, Social Enterprise UK, the Local Government Association, and the Association of Directors of Public Health co-signed a letter to Steve Barclay, which warned that “if unaddressed, an inequitable, two-tier system will be inadvertently created, impacting staff and creating significant risks and concerns”.

The letter highlighted that without “central funding to cover the uplift, many non-statutory providers will struggle to cover these increased costs and retain staff to sustain critical services”.

A lot of people clearly agree. At the time of writing this blog, an online petition which had attracted over 10,000 signatures – the threshold requiring government to respond.

So, what needs to change?

Policy makers, as well as national and local health leaders, need to update their thinking and better understand community health services.

Equally community health services leaders need to be engaging them all with this conversation. We understand that the services are diverse. Provision may seem complex, but we all need to do better at understanding the important role that community health services plays. And we need to treat all community health services with parity, whether they are funded by the NHS or local government.

The work on data must continue so that we have a national dataset which effectively shows the impact and value of community health services, and which leads to improvements in funding, staffing and quality of care.

And finally, perhaps the most difficult thing, but we need to find a way to create space on the national stage to give community services a seat at the table.