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Moving care out of hospital – how far have we come?

To achieve the NHS’s ambition to move care closer to the home, focus needs to shift from commissioning reform to supporting providers to do things differently, says John Copps.

Over the last decade, ‘moving care closer to home’ is a mantra that has moved from the side-lines to being part of mainstream thinking in the NHS.

An essay competition run by the King’s Fund earlier this year asked entrants to imagine a ‘What if…’ scenario for the future of the NHS. The winner’s essay, entitled ‘What if… the NHS moved most care out of hospital?’ contained a striking image:

“There was quite a crowd cheering as the local MP drew a curtain over the door in celebration of another sign of the success of moving care closer to home. I’m old enough to remember it wasn’t always like this; years ago, the crowd would have been waving placards in protest. I tried to tell my grandchildren this but they didn’t understand. ‘You mean people wanted to be in hospital?’, they said, incredulous.” (Sue Brown 2017 – link)

The Five Year Forward View’s vision to dissolve the ‘classic divide’ between doctors and hospitals, physical and mental health, health and social care, and prevention and treatment is at the heart of local healthcare strategies across the country.

But how we achieve the historic shift in services is the real challenge.

What everyone agrees on is that it will take closer working between NHS-led clinical services and local authority-led adult social care. Moving care closer to the home requires integrated service delivery.

To date, the work on healthcare integration has focused on changes to commissioning and aligning decision-making processes linked to the way care is bought. For example, in Tameside, the local authority and CCG has appointed a single accountable officer and pooled their budgets. In Hull, the leader of the CCG now sits as a director on the management team of the council.

Changes to commissioning are to be welcomed but are not sufficient to get to where we need to be. Transformation will only be achieved if providers – those that deliver care at the front line – do things differently. Without this, the risk is that the experience of the service user will remain the same and outcomes will not improve.

By providers, that means everyone in the system – public health, adult social care, GPs, acute, voluntary sector, and community pharmacies. They all need to become ‘integration ready’ and be able to deliver more flexible services along joined-up pathways of care, closer to the patient’s home.

Commissioners have a role here to encourage and facilitate change, for example through competitive dialogue ‘market shaping’ exercises and helping to think through the ‘art of the possible’.

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As the NHS Five Year Forward View makes clear, the future means ‘new models of care’. The Vanguard programme is blazing the trail by testing new approaches but it has is a way to go to prove that the ideas are scalable. For example, the multispecialty community provider model on the Fylde Coast works to wrap health around the patient, delivering more in the community. Its ‘extensive care’ service supports older people to understand and manage their long-term conditions and general well-being and keep them out-of-hospital.

Elsewhere, there are other beacons of innovative practice outside the traditional NHS. Comprised of nine social enterprises and charities, The Health and Wellbeing Limited Liability Partnership is a vehicle for delivering integrated health and social care services. The LLP has been created to offer commissioners in the north of England a single entity to provide services along entire service pathways and across a wide geographical area.

So, in delivering care closer to the home, how far have we come? Not far enough. In 2017, it remains an aspiration, albeit one where there are areas of good practice emerging. In another ten years’ time NHS bosses hope that that it will become part of the everyday for all patients – and perhaps we might even hear those cheering crowds.

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