For years an under-valued part of the NHS, community services are finally set to have their turn in the spotlight.
The NHS long term plan, published in January of this year, puts the sector at the forefront of the health service’s drive to deliver truly integrated care. For the first time, community services, along with primary care, will receive a greater than average funding increase. This comes with the expectation they will lead a reimagining of community-based urgent care, working alongside GPs, with whom they will be forging new working relationships via primary care networks (PCNs).
Raising the profile of the sector
Despite longstanding commitments to community services, the sector has had to develop its profile at a national policy level.
This may in part be due to a lack of data captured at a national level compared to other parts of the NHS. For example, a reliance on block contracting approaches within the community services sector has meant there has been less of an imperative to capture activity data than parts of the NHS where payment by results is in use. This has, in turn, led to a national policy and public focus on services with clear data on which performance against national targets can be measured – essentially, the services that can often grab media headlines.
Despite longstanding commitments to community services, for too long the sector has had insufficient profile and prioritisation at a national policy level.
Unlike the acute and primary care sectors, community services do not tend to have a clear physical presence locally that resonates with the public, like a hospital or an ambulance fleet. Instead, services are usually provided in community hubs and within the homes of patients, by a mobile workforce.
The combination of these issues, and the lack of a national figurehead for community services, means there is less awareness of how community providers operate at the national policy level.
In spite of this, community services have a distinct culture and identity, with flat operating structures and an often forward-thinking approach to focusing care around the needs of the patient. As Andrew Burnell, chief executive of City Health Care Partnership in Hull and a former community nurse, explains, "you come at it from a different angle. Get rid of hierarchy, get rid of yes sir no sir – it’s more about tenacity. Your value is your people – if you forget they’re your most important asset, you’re doomed".
Rob Webster is chief executive of South West Yorkshire Partnership NHS Foundation Trust, which provides both community and mental health services. He is also the integrated care system (ICS) lead for the West Yorkshire and Harrogate Health and Care Partnership. Rob highlights the complexity of the community sector patient base – which prefigures the demographic trend across the wider NHS: "Most of the people we look after have got one or more long term conditions, of which they’ll never be cured. Being older or having a special educational need or having chronic obstructive pulmonary disease, asthma, diabetes, dementia, means we’re going to be a partner in your care for the rest of your life. That means we start with the person and we deliver a team around the person".
Community services have a distinct culture and identity, with flat operating structures and an often forward-thinking approach to focusing care around the needs of the patient.
A sense of optimism
All of the leaders interviewed for this publication expressed a sense of optimism about the community sector in light of the NHS long term plan’s recommendations. As Siobhan Melia, chief executive of Sussex Community NHS Foundation Trust, puts it: "It feels as though we are at a really exciting juncture for community services and it feels quite motivating to know that services that make a real impact across the systems that they work in are receiving national focus and having some policy and investment decisions specifically targeted at them".
Alongside this enthusiasm for recognition of the sector in the long term plan, there is a sense that community providers have already built up significant momentum in moving towards the types of approach that the plan sets out. Robert Harrison, chief operating officer of Harrogate and District NHS Foundation Trust says: "The NHS long term plan backs up the direction we’ve been heading in ourselves – to work together across primary, social and community care in developing an ethos of prevention being better than cure, and to develop services that promote independence and support people throughout their life, including end of life".
There is a sense that community providers have already built up significant momentum in moving towards the types of approach that the plan sets out.
Workforce challenges
The widespread workforce challenges evident throughout the NHS are all too familiar to those leading community services.
In recent years, community providers have been forging closer relationships with primary care services in particular via locality-based approaches. These approaches see community services partnering with groups of GPs to offer more closely integrated provision, with community staff such as district nurses working out of GP surgeries.
These interrelationships between community services and primary care will become even more important as new primary care networks (PCNs) are rolled out across the country – one of the most significant demands of the NHS long term plan. In order to mitigate the risk that PCNs might duplicate activity already underway via locality teams and existing collaborative models of provision, there is an emerging consensus in both primary and community care that PCNs must be designed and implemented in a joined-up, collaborative way taking account of what is already in place and working well.
Royal College of GPs chair Professor Helen Stokes-Lampard says: "Primary care networks are a complement to community services. The whole point of this is to help us to work better to provide services for our patients. We could find we’re going to focus on particularly frail patients with a wraparound service focusing on a lot of the touch points they have with the service, making sure we’re all communicating, and then do more preventative work for them. There are plenty of really good exemplars of how that works. If PCNs end up in competition with community services, that would be a complete waste and a failure of the system".
The widespread workforce challenges evident throughout the NHS are all too familiar to those leading community services. In recent years, community providers have been forging closer relationships with primary care services in particular via locality-based approaches.
The need to ensure that community services and primary care can work in a harmonious way under PCN arrangements is one of the most pressing challenges facing the sector. Twenty thousand new community staff are to be recruited by PCNs under NHS long term plan proposals, and the existing community workforce skews towards older staff. Unless care is taken, there is a risk that community providers and expanded primary care teams could find themselves competing for the same staff, which might destabilise some aspects of provision.
Siobhan Melia points to the need to ensure that workforce decisions are joined up at PCN level: "While the development of primary care networks is a massive opportunity for the community sector, it’s also a risk in that if implementation of the networks is focused on money going directly to GP practices to choose how to expand the workforce, that could cause further fragmentation and some movement of staff from the community sector towards primary care. I would hope we will be able to ensure that we build new integrated workforce models that are resilient and don’t encourage a drift of clinical staff one way or another".
Faced with this workforce challenge, some community providers have adopted creative approaches to expand the pool of staff available to them. Northamptonshire Healthcare NHS Foundation Trust has started to use apprenticeships as a route to attract new people into the sector, as chief executive Angela Hillery explains: "Apprenticeship can give us an opportunity to encourage people to come into the NHS through community services, to get a foot in the door, to get a taste of what the NHS has to offer, whether through therapy apprenticeships, research apprenticeships, or whatever".
The need to ensure that community services and primary care can work in a harmonious way under PCN arrangements is one of the most pressing challenges facing the sector.
Driving integration forward
A further characteristic of both locality approaches and the PCN model is the emphasis on working effectively across sectoral boundaries. The community workforce tends to be highly aware of the role of other providers in caring for patients and service users. Often, people accessing community services have multiple conditions and receive social care support. When services are provided in patients' homes, community nurses and therapists can find themselves visiting alongside professionals employed by other organisations both within and outside of the NHS.
Rob Webster explains: "Community services are increasingly part of an integrated neighbourhood team. That team includes social workers, community nurses, occupational therapists, speech and language therapists, social care staff and GPs, all with a tailored offer which involves the patient and their carers as partners in delivery. That’s a very different ethos from what we’ve had in the past. I think across the whole country people are embracing joined up teams across sectors in the neighbourhood".
Association of Directors of Adult Social Services president Glen Garrod supports this view, pointing to three "big gains" to be had from "respectful, trusting and coherent" relationships between health and social care – these are a more coherent service for patients, more effective matching of supply and demand and a more financially efficient service.
However, the potential benefits of a more integrated service offer stretch beyond the relationship between community services and social care. Another major component of the long term plan is a move to expand the scale and coverage of urgent care provision out of hospital. A multidisciplinary clinical assessment service is planned, which will bring together ambulance services, NHS 111 and GP out-of-hours services, but also crucially provide access to community health crisis response services. This will be complemented by quicker access to reablement support in the community.
The community workforce tends to be highly aware of the role of other providers in caring for patients and service users. Often, people accessing community services have multiple conditions and receive social care support.
South Central Ambulance Service chief executive Will Hancock is clear in highlighting the wide variation in the types and nature of community services he sees across his patch, but also recognises the benefit for his own sector in improving access to community-based urgent care: "We’re trying to build a more inclusive offer quickly, which is why our relationship with the community services and out of hospital providers is so important. One of the big areas we’re interested in is integrated urgent care and working collaboratively with all out-of-hospital providers to populate a directory of services".
Policy commentator and former government advisor Paul Corrigan CBE shares this view that the sector’s future lies, at least in part, in providing services at the urgent end of the care spectrum, supporting people with significant levels of illness to stay in their own homes. He characterises this as providing a "place of safety" in the home for ill patients but warns there is a learning task for community staff to be able to operate in this way: "The staff that we’ve got that are doing community services at present are staff that are good at domiciliary care, and are not used to providing a place of safety. Even in residential care, people are being taken to hospital because the staff don’t feel they can create a place of safety".
Looking to the future
As the NHS as a whole begins to grasp the opportunities presented by technology and digital innovation, it is evident that some community providers have been quietly forging ahead in this field. The home-based nature of community provision lends itself to mobile technology and many providers have been adopting technology that enables their staff to view and update records remotely from patients’ homes, hot-desk in different office locations, and even begin to provide care using telehealth.
As the NHS as a whole begins to grasp the opportunities presented by technology and digital innovation, it is evident that some community providers have been quietly forging ahead in this field.
At Andrew Burnell’s organisation, which is a social enterprise, staff have embraced an even wider range of technological opportunities. He explains: "We're all on mobile working and we'll be using logistics management for community nurses very shortly. We're looking at how we develop our own app with others and we've got conversations with other providers around further digitisation of communities. We've just won an award with Amazon and our local university, developing a system to go into care homes around assistive technology using Raspberry Pi and an Alexa. It will probably cost around £50, but it's extremely interesting in terms of what it can and can't do".
Combining digital innovation with remote working can open up opportunities to achieve greater efficiency by enabling frontline staff to spend more time engaged in clinical activities. Here, community providers can learn from the experience of ambulance services, which are further along in their journey to implement remote working.
Will Hancock describes how in an attempt to optimise the efficiency of the deployment of their staff, ambulance services tested working patterns that had unintended negative consequences for staff: "We were driving a model which increasingly pushed a relatively unsustainable pattern of rotas into the working life - shorter rotas and then longer rotas and staggered rotas to match the peaks and troughs of demand and iron out underutilisation. Then we’d also asked staff to operate as lone workers as a part of their role. We’ve spent the last couple of years rowing back from that, because we’ve seen a huge exodus of staff and a lot of issues in terms of wellbeing, resilience and sickness rates. I think we’re in a better place now and a lot of work is going on around trying to improve the lot of ambulance staff".
Combining digital innovation with remote working can open up opportunities to achieve greater efficiency by enabling frontline staff to spend more time engaged in clinical activities.
As the sector looks to the future, another major challenge which is being addressed is the shortfall of data and evidence for the different approaches used in community services. Through efforts such as the work under the Carter review programme on addressing unwarranted variation in community services, and the creation of new nationally collected community services datasets, the range and quality of information about community services is set to improve.
Community Network chair Matthew Winn says over the next decade he wants to see the sector moving to a position where there is absolute clarity around the evidence base and outcome measures in use for the services community providers offer, and that this information should be provided with "the same rigour, science, intent and specificity as you’d expect in a hip operation, cataract surgery or a surgical intervention for a stroke".
He goes on to add: "We need to take out the variability that is unwarranted and shouldn’t be there. People have created barriers and mini-empires that need to be changed. We shouldn’t have a single provider setting criteria that stops people coming in to community rehabilitation beds, meaning those beds are empty, while hospitals are stacked to the gunnels with people who could really benefit from a rehabilitation bed-based programme. That still happens and is unacceptable".
Through efforts such as the work under the Carter review programme on addressing unwarranted variation in community services, and the creation of new nationally collected community services datasets, the range and quality of information about community services is set to improve.
Our time
Community services are now benefitting from a level of national policy focus not experienced in the last decade. This includes an emphasis on driving forward technological innovation that plays to the strengths of the sector and a renewed drive to integrate services with community provision at its heart. Alongside this is a sense that gaps in national, comparable performance data that have been tolerated in the past will no longer be accepted either by the sector or by its partners and commissioners.
Taken together, it is clear that the ingredients are in place for a step change in how the community sector both views itself and presents itself to the world. Community providers are tasked with implementing new approaches effectively and at a fast pace while responding to considerable challenges including a serious workforce shortage. Nevertheless, the advent of the NHS long term plan, combined with a renewed dynamism in the sector, means the sector is well placed to deliver on these increased expectations. As Paul Corrigan says: "We’ve got a crisis which isn’t just a crisis for the NHS - it’s a crisis for older people. We have people losing their independence sooner than they should, because the only way in which we deal with this is via hospital". The NHS long term plan acknowledges the scale of the crisis – the task is now for these forward-looking community services providers to work with their partners to resolve it.
Amber Jabbal
Head of Policy, NHS Providers
With thanks to
Helen Crump, Director, Cogency Analysis & Research
for additional research and input