Community-based care: an elusive strategy?

Community-based care: an elusive strategy?


Does anyone remember a time when shifting the balance of care into community settings and away from hospitals was NOT a strategic goal for the NHS? A new report from the Fund on the state of district nursing – due to be published later this month – will throw some light on the success (or lack of success) in delivering this goal.

This report follows others that have looked at the core building blocks of care outside the acute sector, including in general practice and mental health. Once you move out of the acute sector there are a number of common themes across all these areas, including a relative lack of data and oversight on the workforce, service capacity and quality of care. Most of these services also fall outside the iconic performance targets that apply in A&E, referral-to-treatment, diagnostics or cancer care. Even the post-Francis focus on quality of care has been framed to date mostly around the quality of inpatient services and all that entails – whether it’s debates about nurse staffing ratios or the Care Quality Commission (CQC) inspection regime. Perhaps it should come as no surprise that of the 63 providers picked out by NHS Improvement as having excessive paybill growth (however controversial the measure), only four were community or mental health service providers.

We seem to have a two-speed NHS. On one hand, acute providers who have been (and still are) performance-managed to within an inch of their lives on A&E and other access standards, while simultaneously trying to meet quality standards and satisfy the CQC. On the other hand, we have the rest of the NHS, so far largely free of aggressive national performance management and able to make more significant changes to services – which has often meant shrinking them in order to remain within budget constraints. Despite the fact that money has been re-directed towards the acute sector – whether proactively, or reactively by picking up the bill for deficits – this ‘freedom’ has allowed community and mental health providers as a group to remain relatively healthy in financial terms (or at least to avoid substantial deficits themselves), even if it has left general practice in the middle of crisis.

However, the impact on patients and staff of the relative operational neglect of these non-acute services has not been so positive. In recognition of widespread problems this has now prompted national bodies to try – perhaps rather late in the day – to re-balance the ship. In 2016 we have seen both mental health and general practice get their own Five year forward views packed full of commitments, not least on money. Although community services as yet remain outside this new drive, the sustainability and transformation plan (STP) process itself may ultimately help to focus attention on services outside the acute sector. Of course this is only an opportunity for the future, as the challenge for 2016/17 remains resolutely one of restoring acute sector finances and getting the old acute sector targets back on trajectory. As a result, £1.6 billion of the £1.8 billion transformation funding available this year has been ring-fenced for acute sector providers. In addition, lost in the annexes of the recent NHS reset on finance, it was interesting to see a number of non-acute providers refusing their control totals despite being in surplus. One wonders whether they are resisting pressure to run even larger underspends, intended of course to offsetdeficits in the acute sector. It would certainly be ironic if commissioners managed to increase spending on mental health and community services, only for those providers to hand the money back to the centre in order to offset acute sector deficits.

Assuming that 2016/17 does see the end of the net provider deficit (a rather big assumption), does this mean all the promises made on mental health and general practice will be delivered and that STPs deliver a step-change in community-based services? While NHS England has made some brave commitments, it remains the case that national targets and monitoring systems remain broadly the same. A&E and referral-to-treatment commitments remain at the heart of the NHS Constitution: staffing ratios are really about inpatient services, and basic data on the workforce and service quality remain poor outside of acute services – even if there are signs of action in mental health. If we look at NHS Improvement’s proposal on oversight for NHS providers this is still apparent: there are 16 indicators of quality of care specifically for acute providers, eight for mental health and four for community health services. Even more striking is that there are five indicators on operational performance for acute services. There are none on community health services.

Remembering that after 2016/17 the growth in NHS funding will dry up, perhaps we should not be surprised that a system that effectively treats the acute sector as the first call on resources (however uncomfortable that feels for all concerned, not least those actually working in acute hospitals), is not one that will easily deliver a strategic shift into non-acute services.
Kings Fund
Our Integrated Care Summit on 11 October will look at improving local population health and delivering integrated care.