Introduction

For many years now, successive national NHS policies have stated that community services should play a more central role in the future health and care system than they do at present. The most recent iteration of this ambition was the Five year forward view (FYFV) (NHS England, October 2014), but this initiative was only the latest in a long line of NHS strategic plans that sought to strengthen the position of the community sector and deliver care closer to people’s homes [1].

This argument in favour of stronger, expanded community services has been made for three overarching reasons:

1. The NHS must radically improve its ability to prevent illness and support people to ensure their own wellbeing if it is going to be financially sustainable. As the Wanless report showed, the financial burden of the existing NHS model, which focuses primarily on treating illness, is in danger of becoming untenable. This is due to demographic changes, including an ageing population (Wanless D., December 2003). Strengthened community services are crucial to bringing the right focus on preventing ill health, improving the population’s health and wellbeing, and tackling health inequalities.
2. The disease burden is shifting as people are living much longer with multiple long-term conditions that cannot be permanently cured by hospital intervention. Conditions such as diabetes and hypertension require a very different type of interaction with patients and the public than, for example, a traumatic injury. Community services offer the most appropriate way to promote good health and prevention and provide joined-up care for an ageing population.  
3. Acute inpatient services, in both hospitals and mental health services, are under huge pressure and they are currently being used unnecessarily and inappropriately for patients who could and should be treated closer to home. It is better for patient care, better for performance outcomes, and better for the NHS budget to treat as many patients as close to home as possible, with community services once again at the heart of provision.

However, while the burning platform for this shift in the provision of care is the financial and operational pressures in the acute sector, the real driver for community services lies in good population health and prevention at scale. We have, for far too long, largely made the case for community services in relation to "moving care closer to home", when it is the combination of all three reasons that makes the case. Concentrating solely on this defines community services in relation to what they are not, rather than what they are. This then colours the debate around community services, which continues to be acute-focused and about shifting services between settings rather than acknowledging the positive reasons for strengthening community services. 

It is better for patient care, better for performance outcomes, and better for the NHS budget to treat as many patients as close to home as possible, with community services once again at the heart of provision

   

Our analysis for this report is informed by an online survey of NHS trust chairs and chief executives. We invited responses from all types of trust, regardless of whether they provide community services or not, seeking their views on the state of the community sector. We received responses from nearly a third of all trust leaders, representing 51 trusts that provided community services and 20 that did not. The contribution of these 51 trusts means that we heard from over half of all trusts that we define as currently providing a substantial amount of community services.

To complement our survey we carried out a number of interviews to gain a richer understanding of the issues facing community providers. As part of this we conducted five interviews with chief executives of community trusts and four interviews with leaders of CICs [2]. 

Despite the potential of community services, our survey and analysis found seven reasons why ambitions for the community sector have not yet been realised. And, in doing so, this report provides a clear manifesto for what needs to happen next if we are able to deliver the shift we all know the NHS needs to make. The seven reasons are:

1. There is insufficient understanding of community services and the community provider sector among the national bodies, the Department of Health and Social Care, commissioners, politicians, patients and the public.
2. Community services have been, and continue to be, an inconsistent national and local priority.
3. There needs to be greater financial investment in community services.
4. Demand for community services is outstripping capacity and supply.
5. Structural inequity means that competition and procurement disproportionately affect community service providers.
6. There are worrying staff shortages in key roles.
7. There is a lack of national-level data and a national focus on an improvement approach for community services.

The NHS has needed to make this fundamental shift to building up community health service provision for many years now and yet this ambition has not been achieved,despite having the extraordinary transformation of mental health care over the last 30 years, with the closure of inpatient facilities and the transfer of care to community provision, as a good example of the shift that needs to happen (The King’s Fund, February 2014).

With the current emphasis on population health at STP/ICS level and the recent report published by The King’s Fund (January 2018), the forthcoming Carter report on operational productivity and performance in English NHS mental health and community health services, and now this publication – the time has come to make the ambition for community services a reality.            

[1] The recent King’s Fund report Reimagining community services provides a comprehensive summary of how these attempts to reorganise the structure of community services provision have often been unsuccessful and merely fragmented the landscape of provision further, rather than improving services (The King's Fund, January 2018).

[2] CICs are a form of social enterprise and not-for-profit organisation that provide all types of community services. We have included their perspectives in this report as many CICs were spun out of Primary Care Trusts in 2008 under the Transforming community services programme and therefore play an important role in many health and care systems.