Much of what is written about healthcare in England understandably tends to focus on what is happening in hospitals and GP surgeries. We hear a lot less about the provision of community health services despite the fact that shifting more care out of hospital and into the community is one of the ambitions outlined in the NHS Long Term Plan. NHS England state that community health services will “meet the changing needs of the country over the coming decade”. It is fair to say that community health services are poorly understood - so, to correct that balance, here is a brief but close up look at why they are such an important part of the healthcare system.
Let’s start with the obvious first question – what are community health services? Community health services are diverse and cover a wide range of services, from those targeted at people living with complex health and care needs such as district nursing and palliative care, to therapy services such as physio, to health promotion services such as school nursing and health visiting. Community services play a key role in keeping people well, treating and managing acute illness and long-term conditions, and supporting people to live independently in their own homes. Services are mainly delivered in people’s homes, including care homes, but also in community hospitals, intermediate care facilities such as reablement, clinics and schools.
Next question – how large a role do community health services play in the health system? Each year, community health services have approx. 100 million patient contacts and account for around £10 bn of the NHS budget. And with the commitments set out in the Long Term Plan, NHS England have committed to increasing the share of the NHS budget going to community and primary care services, raising annual spending by £4.5 billion by 2023/4.
Third (and fourth question) – how many people work in community services and who are they? The quick answer is a lot - estimates put it at one fifth of the total 1 million + NHS workforce. They include community nurses, allied health professionals, district nurses, mental health nurses, therapists and social care workers.
And next – who provides community health services? Provision of community services in England is delivered by a host of different types of providers. We know that 50% of providers delivering NHS funded community health services are non-NHS organisations, including those in the voluntary and social enterprise sector, and approximately 40% are independent healthcare providers. Of the £10 bn NHS budget, £2bn are delivered by non-NHS organisations and of that half are delivered by independent healthcare providers. This diversity is what makes community health services so unique. And independent healthcare providers are able to bring innovation, efficiency, great patient outcomes, high levels of safety, and deliver services that really meet and respond to the needs of local populations.
Final question – what is changing in the delivery of community health services? The attempt by the NHS to deliver more and better health services in the community is not new – over many years several policies have set out to strengthen and coordinate health services outside hospitals and deliver more care closer to home. Policies such as discharge to assess, virtual wards, and the expansion of urgent community response 2-hour care are recent examples. And in the diagnostic world, Community Diagnostic Hubs aim to move imaging services from hospital sites into the community.
Larger system changes will also have an impact. Most recently the move towards more integrated care systems (ICSs) and the Health and Care Bill will undoubtedly impact on how community services are commissioned and delivered. The challenges facing systems are great. Many community health services were paused during the first lockdown and then took a while to re-start. They now face similar challenges to the rest of the healthcare system in terms of staff shortages and a growing backlog of care. In addition, lack of clarity on funding for the second half of this year means it is difficult for commissioners to plan these services effectively for the long term.
This challenging environment means it is essential that ICSs engage and involve all types of providers of community health services in their geographical area. But as mentioned previously the size and variety of the non-statutory provider market is unique and may seem vast and impenetrable to ICSs, and it also may not be entirely obvious what the best ways would be to engage. IHPN, has recently published a briefing on this issue which outlines a number of practical steps that ICSs can follow.
But is this ambitious enough? IHPN are, therefore, inviting a small number of ICS who are interested in working with us to understand how partners can truly work together to achieve the best outcomes for patients, alongside delivering good value for money for the public purse. While responsibility for decision making should rightly sit firmly with public sector statutory ICSs, ensuring that system decision makers are fully aware of all the options at their disposal will surely maximise patient outcomes.
It is clear, by the recent planning exercises by NHS England’s Community Health Services team, that NHSE want to really understand community health services - what is being delivered and by whom. This is positive as will support better decisions to be made to ensure that community services are funded appropriately in line with developing policy. Perhaps it will also allow community health services to finally come out of the shadow of other parts of the NHS.
Danielle Henry, Head of Policy (Primary and Community Services), IHPN