To shift care closer to people’s homes, primary care and community services need to be firmer allies and work closely with local authorities, says John Copps and Matt Carter.
Moving care out of hospital settings into patients’ homes and the community has long been an ambition of the NHS.
Philosophical commitment to ensuring ill-health is tackled ‘upstream’ - with the right care delivered at the right time in the most appropriate care setting - is well established. In practice this means more care in the community and at home and less in hospital, resulting in better health for the population and lower costs for the tax payer.
Successive policy statements over the years have called for the balance in where care is delivered to be changed. Back in 2019, the NHS Long Term Plan set out a direction of travel to redistribute funding from acute to primary and community care. The plan was categorical: ‘we commit to increase investment in primary medical and community health services as a share of the total national NHS revenue spend across the five years from 2019/20 to 2023/24… This is the first time in the history of the NHS that real terms funding for primary and community health services is guaranteed to grow faster than the rising NHS budget overall.’
But despite these words that committment hasn’t been delivered. Instead, as a recent King’s Fund report found, spending on acute care has grown faster than any other area. The authors brand this ‘one of the most significant and long-running policy failures of the past 30 years’.
This failure is acknowledged in NHS boardrooms across the country. We were in a meeting of executives at the end of 2023, where an analysis on what the overall balance in the system budget should look like was presented. It was greeted with nods of recognition. But less easy was the next question: what can we do about it?
How do we shift the balance?
Everybody knows that the NHS is working in crisis mode. Short-termism rules as systems and Trusts seek to balance budgets, tackle waiting lists and, in some cases, keep the roof from falling in.
The King’s Fund’s assessment of the reasons for failing to deliver on the shift in resources includes criticism that progress has been hampered by the misconception that moving care into the community will result in short-term cash savings. Given waiting lists for hospital treatment and the trend in demand we currently see, it won’t.
One ingredient needed to help shift the balance towards out of hospital care is more robust action from central government. The King’s Fund report calls for a ‘national vision’ and ‘political will’.
A national mandate to redistribute resources is all well and good but what does it mean at a local level? It needs to be something that places buy-in to and has support within systems. But what will that take to achieve?
Making change happen in local areas
First, a key influence on what happens in local systems is who shouts loudest. Primary and community care needs to find its voice and be granted the time and space to articulate the benefits of investment. This means local leaders – GPs, clinical directors, CEOs – stepping up and committing to making the case. Equally crucial is that the Chairs of ICB and ICP boards carve out that space and, in a greater number of cases, bring first-hand knowledge of primary care and community services.
Second, primary care and community services need to be firmer allies. In many areas, there is ample room to strengthen relationships. That will be challenging, given historical tensions, and can only be done through spending time together. One successful example is an existing formal provider collaboration between a Community and Mental Health Foundation Trust and a GP Federation in South Yorkshire working in partnership with the local hospital to tackle health inequalities, address workforce issues and to drive the prevention agenda along the local frailty pathway..
Third, local government is an important part of the equation. Councils control many of the levers that impact the social determinants of health through their investment in housing, social care, education and economic development, as well as the public health grant. Like primary care, local government is embedded in communities in a way acute care isn’t and often thinks in terms of ‘neighbourhoods’. They need to be in the conversation and have the power to apply resource in a way that benefits the whole system. For example, the work of Changing Futures Northumbria, based in Gateshead Council found that targeting individuals in council tax arrears and providing intensive person-centred accrued most benefit to the NHS.
Fourth, acute trusts need to see and feel the benefit. The reality is that the status quo favours investment in hospitals – in terms of current budgets, status, political influence, representation within systems and public awareness. Clear arguments around preventing avoidable admissions and freeing up resource will be difficult to make in the short term but can support a long-term vision. For example, we have already seen the benefits of formal collaboration between a hospital in South West London and the local community providers, where blended teams are increasingly focused on outreach. There is no reason why acute trusts can’t be encouraged to deliver more in the community and contribute to a strong drive around prevention, at the same time as being able to focus more on care appropriate to an acute setting.
Shifting the balance in any system is never a quick fix. It takes time and effort. Investing in relationships, setting a clear joint vision, and sticking with it, is what is needed if places are serious about shifting care closer to patients’ homes and breaking through the current impasse.
Change has to be a shared endeavour – an alliance of all partners – if we want to achieve sustainable improvements in the health of the population.
To read our work on health and care click here.
To read more on MV’s work on how a focus on ‘place leadership’ can help areas work together click here.