CICs are a form of social enterprise and not-for-profit organisation; they exist for the good of their community and reinvest any surpluses into their services. Many CICs were spun out of primary care trusts (PCTs) in 2008 as the Transforming community services programme compelled PCTs to divest themselves of community services. CICs therefore play an important role within many local health and care systems as they provide all types of community services, ranging from district nursing to prison healthcare, primary care and care homes.
While some CICs provide health and care services in community settings only, others run community hospitals too, focusing on rehabilitation and reablement. CICs can hold both NHS and local authority commissioned contracts, and operate within a diverse delivery model. We held structured conversations with CIC leaders to identify their perspectives on the general and specific challenges facing community services.
There is some variation across the country around how CICs feel they are perceived by the rest of the health and care system. While some feel highly regarded and well understood, others said they face a double prejudice as the NHS at a local and national level does not appreciate community services, nor does it understand CICs as an organisational form. For example, CICs need to manage themselves in a commercial way, so attach great importance to their continued viability and balance sheet responsibilities. While CICs see this strong financial position and governance as a positive contribution to contracts and the wider local health economy, their budget discipline to innovate and meet increases in demand while remaining in the black, is often misunderstood or not recognised.
In fact, there are several benefits of a CIC delivering a community health service, given their non-NHS status. First, CICs are independent organisations that operate at scale, meaning they have more financial freedoms and can borrow money more easily. This financial flexibility can be used to help services or other parts of the local health and care system, but is often overlooked. Secondly, CICs are nationally regulated but locally managed, and exist for the benefit of the community so are well-placed to understand community issues and involve the community in system-wide decision-making processes. This makes them ideally placed to engage hard to reach communities and tackle health inequalities, which in turn can reduce hospital use and bring about cost savings.
CICs are nationally regulated but locally managed, and exist for the benefit of the community so are well-placed to understand community issues and involve the community in system-wide decision-making processes.
CICs feel that the differential between them and trusts is that they have retained NHS values and deliver NHS services, but do so working in a commercially sustainable model that drives innovation and high levels of employee engagement.
While the CICs we interviewed agree that strengthening and expanding community services is the way forward, they are similarly frustrated that national policy ambition and rhetoric have not been matched with funding and resources. CICs want to focus on changing care pathways, improving case management and maximising the opportunities of technology.
There is variation across England as to how engaged CICs are in STPs and ICSs. Some CICs feel like an equal strategic partner on STP decision-making boards as they are relied upon to alleviate patient flow throughout the system. As one CIC put it: "we are part of the machinery". However, some CICs can be wary of engaging with STPs as they are seen as driven by the NHS and the associated agenda of "big is best", which is not palatable for many CICs. Other CICs feel that although the wider health and care system sees them as part of the solution, in general there is a sense of not being "loved and valued" for what they offer in their footprint. One major issue for CICs in STPs is that they are excluded from any access to capital; only NHS organisations can access capital investment.
The CICs that we interviewed mentioned similar financial and funding issues to NHS trusts. CICs feel that their funding has been reduced under block contracts and they are struggling to meet demand pressures due to demographic changes. When CICs were spun out of PCTs, they were left with running costs and only a small amount of contingency money which has proved to be an unsustainable level of funding.
The CICs that we interviewed mentioned similar financial and funding issues to NHS trusts. CICs feel that their funding has been reduced under block contracts and they are struggling to meet demand pressures due to demographic changes.
CICs are having to deal with increased demand in different ways under their block contracts, including restricting access and making efficiencies. Short-term contracts mean that it is hard for CICs to unlock the long-term investment needed to ensure they have the right infrastructure in place to meet rising demand. Despite their ability to access capital and social finance, it is hard to convince an investor with a business case of anything less than five years. CICs therefore need contracts with a longer-term horizon to attain capital and transform on a bigger scale.
CICs also agree that the current payment systems disincentivise prevention and care in the community because payment by results awards admittance. They also support the development of well-designed, co-produced community tariffs. While CICs have worked hard to demonstrate their efficiencies, they find it difficult to translate productivity into cashable savings and there are usually only marginal gains.
In our interviews, the CIC leaders highlighted similar workforce challenges to NHS trusts. For example, CICs also struggle with recruitment and retention. They are losing nurses to general practices in particular, as primary care can offer a less pressurised working environment. While CICs are proud of their staff engagement and satisfaction scores, they flagged that these scores have started to decrease and sickness absence rates are starting to rise. These measures show that staff are feeling the pressure of increased demand on services, which potentially risks the quality of care. While technologies such as mobile working have relieved some of the demand pressure on the workforce, they can only have a limited impact and there needs to be greater investment in training to help staff make the best use of IT and technology.
CIC leaders also highlighted that the traditional routes into community nursing are not providing the supply of staff that is needed to meet demand for services. CICs would like to see a cohesive central function driving workforce strategy across the NHS, social care and public health; this could include a national target for health visitors and district nurses, or development bids specifically for community services. One CIC leader stated: "District nurses are the glue that holds the whole health and care system together".
While CICs are proud of their staff engagement and satisfaction scores, they flagged that these scores have started to decrease and sickness absence rates are starting to rise.
CICs report similar challenges around procurement rules, competition and frequent retendering for contracts as NHS trusts, including the associated transactional costs and resource intensive nature of re-tendering, as well as the more general cultural impact on the organisation of competing for business. In some areas this has created strong relationships between commissioners and CICs. For example, in an area with more than one CIC, commissioners have made a strategic decision to recommission all community services in a single contract and therefore push the CICs to bid collaboratively through partnership arrangements. However, in other areas, commissioners are retendering for services frequently and requiring more provision for the same or less money.
CICs want to maintain the quality of services but also have to deal with a substantially reduced contract value. Many CICs are now agreeing to limitations to specifications, reductions in services and decommissioning of services. However, it is hard to manage staff redundancies as there are no redeployment opportunities, as there are for an NHS organisation.
CICs are also affected by the lack of national performance targets and quality metrics for community services. Commissioners find it hard to compare different data sets on CICs and NHS organisations when deciding who to award a contract to. While CICs report on many key performance indicators through contracting arrangements, they feel they are over-measured for the services they deliver and warned that these measures are of more use internally than they are externally as each community service offer is different.
CICs report similar challenges around procurement rules, competition and frequent retendering for contracts as NHS trusts, including the associated transactional costs and resource intensive nature of re-tendering, as well as the more general cultural impact on the organisation of competing for business.
While high-level demand and activity data could be of use nationally, CICs warn it risks losing meaning further down in the organisation. For example, activity measures of district nursing visits are not useful as they could last five minutes for an insulin shot or three hours for a more comprehensive assessment. It would be better to focus on outcomes, such as the amount of time that services are keeping people well and out of hospital, or reducing readmission. Overall, CICs are extremely proud of the quality reports they produce and take their accountability to their community very seriously.
It is clear that while CICs face similar challenges to NHS community service providers, there are further nuances to these challenges that need addressing at both a national and local level to improve the integration of care for patients. CICs would like to see some clarity of national policy direction so that their businesses can understand the scope of health and care systems in the future. They would also like to see more alignment, and perhaps pooling, between local authority, NHS England and CCG commissioning. Finally, CICs would like to help the community sector as a whole to build the case for change and use savings for advancing the prevention agenda.