2. An inconsistent priority

Despite longstanding top-level commitments to community services in national strategy documents, these services have lacked sufficient profile or recognition of their importance in both national and local debates, as well as in successive NHS planning rounds. The latest NHS strategy document, in the form of the FYFV, aimed to close the health and wellbeing gap, the care and quality gap, and the financial gap, by reducing hospital activity and shifting more care into community-based settings. However, these ambitions have proven hard to achieve due to inadequate sustained investment in transformation, the workforce, and lack of national leadership and direction for the community services agenda.

Subsequent planning documents have not upheld this ambition, with a continued focus on the acute sector and acute-focused targets. It is also disappointing that the plan to develop a forward view for community services was in development but then later dropped (Health Service Journal, February 2018), clearly illustrating the failure of national leaders to value and appreciate the vital role of community services.

Across the NHS provider sector, trusts recognise that the community sector is less of a national priority. As figure 3 shows, 93% of all respondents to our survey said that community services receive less national-level focus, priority and attention than other sectors do. The breakdown of responses shows a similarity between community service providers and non-providers, showing that both types of provider acknowledge this disparity. As one trust leader expressed: "The ambition is there and matched by the rhetoric, but the lack of the publication of a FYFV for community services is reflective of the value placed upon the services".

The themes from trusts’ comments on the survey question include concerns about a lack of national leadership on community services from NHS England and NHS Improvement, which is necessary to bring about change in the system.

While the national focus is on acute services, performance targets and constitutional standards, trust leaders have little confidence that community services will see any new investment or resources. Over three quarters of all respondents are worried or very worried that current resources and investment will not deliver the acute to community shift and move care closer to home for patients within the next five years (figure 4). The CIC leaders that we interviewed were similarly frustrated that national policy and rhetoric has not been matched with funding and resources.

It is clear that the NHS still needs to create a strong economic case for investment in community services, as has been done successfully for mental health services. Currently there is only a small evidence base that care in the community achieves financial savings. Research shows that financial benefits are at best only valid in certain circumstances and do not always reduce costs (Nuffield Trust, March 2017). However, even if community-based models of delivering care may not produce large financial savings, their primary purpose is to promote prevention and self-care, to best meet the needs of the population. The focus on the value of community services needs to shift from cost savings to improving patient care and benefiting society. It should be the case that the public is concerned when a patient is admitted to hospital in the first place, rather than about discharge delays. The narrative needs to be shifted.

The national policy focus on collaborative working, system-based planning and integrated health and care systems presents the best opportunity to transform the community sector. This is not just about reducing pressures on the acute sector, but rather about transforming the way that health and care is delivered. It is about population health, which includes preventing ill health by addressing the wider determinants of health and tackling health inequalities.

The national policy focus on collaborative working, system-based planning and integrated health and care systems presents the best opportunity to transform the community sector.

   

This national ambition is being delivered through STPs and ICSs that aim to provide more joined up care for their local population. However, much has already been delivered through the development of new care models, such as MCPs and PACS, that focus on population health by strengthening the provision of health and care services in the community. While the vanguards have seen lower per capita emergency admissions growth rates than the rest of England (NHS England, March 2017), their overarching focus has been on vertically integrating health and care services to improve patient care. Community services are central to these vertical models of integration, and their learning should be central to the development of STPs and ICSs.

Community services are central to these vertical models of integration, and their learning should be central to the development of STPs and ICSs.

   

STPs and ICSs are being used on the ground as a catalyst to plan and support discussions about day-to-day operational collaboration, as well as to help reconfigure services, share workforce and as a means of driving new models of delivering patient care. Strengthened community services can provide continuous and sustainable solutions to prevent further ill health by weaving patients into the fabric of community life. They not only provide continuity of care and deliver efficiency savings, but also ensure individuals are more connected with other community assets through their networks.

However there has been mixed progress in making community services and prevention a priority at STP or ICS level, despite their focus on integrated care. While prevention and strengthening community services were two prominent aspects in the majority of the initial STP plans, many partnerships have been tied up with operational and financial challenges that largely sit with the acute trust sector, rather than investing in prevention and transforming care to provide sustainable solutions in the community (National Audit Office, January 2018).

It is now widely acknowledged that initial targets of up to 30% reductions in hospital activity over several years will be difficult to realise (Nuffield Trust, March 2017). Figure 1 below shows how over half of respondents to our survey said that community services were very much included in local STP/ICS plans, but it is concerning that 34% of all trusts that responded to the survey described there being only "a little" focus on community services in reality (figure 5). If STPs and ICSs are to flourish, it is vital that community services and their prevention agenda are at the centre of these plans, operations and the integration process more broadly. However, local plans to reduce hospital capacity and increase community capacity have not been supported by national leadership or investment, and there needs to be a clearer national focus on prevention.

Our survey results highlight the variability in prioritisation of community services, as well as variation in the level of their engagement in STPs and ICSs, demonstrating how the strengthening and expansion of community services has not happened at scale. Around two thirds (65%) of all trust leaders felt that community services in their local area were "somewhat influential" in shaping their STP (figure 6). Given the prioritisation of transferring more care into the community that was integral to the original STP plans, it is worrying that only 18% feel that their own or other community services are "very influential" and 18% feel "not at all influential". This variation in STP engagement is comparable to the views of the CIC leaders that we interviewed.

Respondents generally felt that STPs were an acute-focused model of transformation, and were focusing on the reconfiguration of acute services or finding solutions to demand on acute services rather than planning to strengthen and expand community services. However, some trusts providing community services report being very involved in STPs/ICSs and feel that they are seen as an important part of the system architecture by the rest of the NHS provider sector. Some community service providers, such as Sarah Dugan from Worcestershire Health and Care NHS Trust, are leading their STP. Other trusts providing community services are leading STP workstreams, developing sub-STP place-based plans, and leading new models of care such as MCPs.

In addition, some STPs/ICSs are developing plans to share financial and operational risk across the system for defined population groups or reducing acute activity. Others are focusing on providing integrated care with acute, social care and GP colleagues, or developing primary care at scale. Although there are some success stories, others are grappling with big challenges, such as transforming care when double running services with non-recurrent funding and amidst unwavering demand. 

Where there is local recognition, it is, however, not supported by visible national leadership or strategic planning. There is real enthusiasm among community service providers about the major role they should play in developing and delivering new models of care, but there has been mixed progress in strengthening and expanding community services. There has also been widespread frustration amongst both trusts and CICs that the rhetoric of the FYFV has not been translated into reality on the ground. While local systems will want to develop their community services in different ways depending on the current landscape of provision and local population needs, STPs and ICSs provide an opportunity to apply a degree of consistency and standardisation to community services that has been lacking up till now.

Some trusts providing community services report being very involved in STPs/ICSs and feel that they are seen as an important part of the system architecture by the rest of the NHS provider sector.

   

Alongside the main seven barriers to strengthening community services that we cite in this report, there are some additional and more specific issues that are holding some community service providers back from driving the STP/ICS agenda, including:

• The centre focusing STPs on restoring financial balance and constitutional targets, rather than prevention and strengthening community services.
• Acute trusts tend to dominate STPs, both in leadership and issues such as their challenging financial situation and the reconfiguration of hospital services. It is difficult to innovate and develop new models of care when there is no financial headroom to do that at system level.
• Decades of structural reorganisation have led to the fragmentation of community health service provision across an STP footprint or across several STP footprints, so it is more challenging for a community trust to have a strong voice at STP level.
• Community services do not have a strong narrative and national voice to explain their service offer and role in the system. This is exacerbated by there being no visible leadership for the community sector within NHS England, NHS Improvement and Department of Health and Social Care.
• As some trusts providing community services do not employ consultant medical staff, there is no strong clinician voice to push forward their agenda.

The lack of visible national leadership and prioritisation of community services is epitomised by the fact that the FYFV on community services was abandoned.

There is a stark contrast between the stated strategic level commitment to strengthening community services in policy documents like the FYFV and the detailed planning required to make it happen. It is worrying that despite STPs offering an important opportunity to deliver strengthened community services, it is becoming increasingly clear that this is not being consistently delivered.

To achieve stronger community services, as the NHS has done in the mental health sector, there needs to be movement beyond the top level platitude of 'moving care closer to home' to create a concrete, detailed vision and plan of what is required to strengthen community services and how this will be achieved. This requires appropriate, well-resourced national leadership from the national bodies and the Department of Health and Social Care. It also means community services being given appropriate priority in all key decisions and policy and strategic frameworks.