Saving the NHS with Community Services

The NHS Darzi Investigation released last week (12/09) has uncovered nation-wide declining performance, with record lows of patient health and satisfaction. The report revealed that the ultimate cause of these problems is an over reliance on hospitals, and under investment in community-based services. In North Central London, we have already re-allocated millions of pounds into community services, but this is still just a drop in the ocean of what needs to be done.? To find out how we got here, why community services is the answer to many of the NHS’ problems, and how we at North London ICB are pushing forward this agenda nationally, continue reading the short article below:

How did we get here?

Waiting times for hospital procedures have ballooned, A&E departments are in crisis, people are struggling to get access to their GP and mortality for cardiovascular disease has increased.

There have been three key drivers of this at a macro level:

1. Austerity: Sustained underinvestment by the Tory government;
2. Health and Social Care Act of 2012: A "calamity without international precedent"; and
3. COVID-19 pandemic: Hitting an already weakened NHS system.

However, these macro drivers are being used to hide a deeper and more systemic problem within the NHS. The NHS system is set up to treat patients with episodic care in hospitals and not to prevent us needing such services in the first place. The NHS is built on reactive and not preventative care. Treating people in hospital is the least clinically effective and most expensive model of care. It worsens existing health inequalities through only responding to the demand you’re presented with, rather than the needs of underserved groups who are unable to actively seek out and access acute hospital services for a number of reasons.

With an ageing population and rising levels of chronic disease nationally, this model will only lead to worsening health outcomes and a level of cost pressures that no government will be able to justify. In other words, this would mean the end of the NHS as we know it.

What it will take to save the NHS

The solution for the NHS lies outside of hospitals and in the community. Community services may be the least understood part of the NHS, but they have over 200,000 patients contacts a day.? Community services target health interventions that allow patients to live longer and healthier lives and importantly, avoid hospital admission.

Systems that invest more in community services have seen 15% lower non-elective admission rates and 10% lower ambulance conveyance rates . The reduction in hospital demand associated with this higher community spend could pay for itself through savings on acute activity.

For society, for every ￡1 invested in community or primary care, there is up to a ￡14 return on investment back into the economy – a far greater return than if the same amount is invested in hospital services.

Lord Darzi in his report has called to move care out of hospitals and into our communities. Many people have come out to say such a shift is not possible. This has been NHS policy for the last decade, but investment in community services has shrunk while acute healthcare spend has grown faster than any other area. However, as we are faced with the continued crisis within the NHS, inactivity on the matter is no longer an option.

North Central London has proved that a shift to community care is possible

NHS North Central London ICB was the first system to create a ‘Core Offer’ of community services, describing the minimum threshold of community services available to residents regardless of which Borough they live in. We secured system-wide commitment to invest over ￡50m over 5 years. In 23/24 we were recognised by NHS Confederation as a national best practice example of community transformation and for 24/25 we agreed a ￡3m re-allocation of funding from acute to community services.

We have already progressed many of the areas that Darzi recommends as part of the 10-year plan. We have invested in muti-disciplinary working between community, mental health and primary care, improved data quality in the community, created a methodology to identify and quantify community productivity initiatives, and scaled community-based digital solutions such as Doc Abode which has increased productivity of our urgent response teams in Camden by 120%.

NCL have been leading a new forum of community services leaders from providers and ICBs across the country to share best practice across these topics. If you're interested in joining this group then please reach out to me on linkedIn or through email at [email protected] .

What is required to scale the solution

From the first two years of the ‘Core Offer’ programme, there are three key learnings that NHS England , the Department of Health and Social Care and The Prime Minister’s Mission Delivery Unit must recognise if they want to succeed where previous efforts have failed:

1. Agree a national core offer of community services with clear targets

This is essential to increase the visibility and understanding of the community services available in the system and sets consistent expectations across the system for service performance, access and outcomes. Crucially, it also makes it possible to make meaningful comparisons in productivity across providers and systems and inform investment decisions to address gaps in the offer. Other systems are starting to replicate the approach of creating a core offer, but NHS England needs to create a national community services core offer and set consistent and ambitious targets for performance and outcomes

2. Show the impact of community services on hospitals within a system

There are a number of barriers to shifting resources from hospitals to the community as a system. The primary of these is a lack of confidence in the impact of community services on hospital demand to justify reallocation of further funding. NCL is working with NHS Confed and NHS England to create a SLIDE (Shift Left Investment Decision Evaluation) Tool to overcome the barriers to change. The purpose of this tool is to demonstrate the impact of specific community services and the sector overall on specific acute sites. This will provide systems with the information needed to make the necessary decisions about the reallocation of resources out of hospitals into the community and identify the services with the largest impact per ￡ spent.

3.?Commit to a Community Investment Standard

?It is essential to commit to sustained, targeted investment in high-impact gaps in the core offer. There is a time lag on the impact of investments in community services on acute demand. Following a decade of austerity, many systems will not have the financial flexibility to increase investment in community services without taking funding away from hospitals that are already exceeding their capacity. Therefore, NHS England should create a Community Investment Standard that provides additional funding over 3 years (as we have seen with mental health). In conjunction with the SLIDE Tool, this would enable systems to demonstrate the impact these services are having on hospital pressures and sustainably fund the transition to community-based care afterwards.??

As we continue to push forward with out-of-hospital community services, the is a great need for collaboration, consultation, and belief that we can re-structure an effective NHS. If you are working in this space, want to further discuss the topic, or have ideas on how we can accelerate this transition then please reach out to me at ([email protected] ).