Demand for community services continues to increase as a result of the growing ageing population and burden of chronic disease. Funding constraints on the NHS and local authorities have exacerbated the challenge trusts providing community services face in terms of having enough capacity to meet this demand. In addition to demographic changes, other factors contribute to this increased demand, including medical advances meaning more care can be conducted in the community, increasing patient expectations and pressures on other sectors such as primary, social and acute care.
Community services cannot absorb any extra demand in the current context of financial pressures and workforce shortages. As one trust leader that we interviewed said: "The community sector is being squeezed from all angles". In our survey, trust leaders reported that demand is already outstripping current capacity and resources (figure 10). For example, 59% of all trusts said their local community service provision was not able to meet the current demand for adult community services. Half of respondents also said the demand for planned community services such as physiotherapy and podiatry was not being met. One trust leader that we interviewed said that demand for some services had gone up by almost 50%.
The way that trusts deal with this increase in demand depends on the type of community health provision. For example, waiting times have increased for planned community services that are based in clinics (e.g. dentistry, musculoskeletal services [MSK]). The median waiting time for any first outpatient appointment is on average three days longer for a standalone community trust (32 days) than across all trusts (29 days) (QualityWatch, November 2017).
It is also harder to manage increases in demand for services that do not have a fixed number of beds or appointments. Home visiting services, such as adult community nursing, use clinical prioritisation to ensure people are not left waiting for care when they really need it, which means that staff feel the pressure in their increased caseloads. While technology has enabled multiple interventions to be carried out at home or in community settings rather than in hospital, and innovations such as telehealth and mobile wards enable staff to help patients manage their own care needs, these advances cannot stem the growing tide of demand.
Demand for community healthcare is rising primarily due to the shift in disease burden, as people live much longer with long-term conditions that cannot be cured by episodes of acute hospital treatment. Demand is largely, but not exclusively, driven by this growing, ageing population who are living longer in poorer health, with frailty, multiple long-term conditions and complex co-morbidities on the rise. The ageing population puts pressure on the NHS as a whole due to the costs of delivering health care increasing rapidly with age. Long-term conditions now account for 70% of the total health and care spend in England (Department of Health, May 2012) and it costs three times more to look after a 75 year old and five times more to care for an 80 year old than a 30 year old (NHS England, March 2017).
Demand for community healthcare is rising primarily due to the shift in disease burden, as people live much longer with long-term conditions that cannot be cured by episodes of acute hospital treatment.
Given that there are half a million more people aged over 75 than there were in 2010, and there will be two million more within the next decade, helping older people stay healthy and out of hospital is not only better for them but also crucial to the sustainability of the NHS (NHS England, March 2017). There were over 1.6 million emergency admissions for people in the last year of their life in 2016, costing the NHS £2.5bn and amounting to around 11 million days in hospital (Marie Curie, March 2018). Potential savings are therefore often associated with less acute care and more community-based support.
However, more often than not it is not the volume of patients but rather the complexity and acuity of care needs that is most challenging for community services. In our survey, increased complexity of care needs and unplanned capacity constraints in social and acute care were the top reasons all trusts, regardless of whether they provide community services or not, felt demand will increase for community services (figure 11).
These results demonstrate that the strain on community services is compounded by pressures to other services. The community sector is particularly interdependent with other parts of the health and care sector, particularly general practice, social care and the voluntary sector. The House of Lords Select Committee, on the long-term sustainability of the NHS, described pressures in social care as "the greatest external threat to […] the NHS", due to demand outstripping funding, the cuts in the number of people who are eligible to access local authority-funded social care, high vacancy rates and retention issues (April 2017).
The impact of unplanned rises in demand on community services due to constraints in social and acute care is particularly great over winter. In our 2017 Winter warning publication, trusts reported that in winter 2016/17, demand overwhelmed available capacity across all parts of the health and care system, with 76% of respondents to our survey highlighting a lack of community capacity (NHS Providers, June 2017).
Pressures on the acute sector have led to more patients being discharged into the community with increased levels of acuity and a greater range of medical and support needs. For example, patients who used to be looked after in nursing homes are now being looked after in residential care, and nursing homes are doing the job of palliative services. While assistive technology and a highly skilled workforce have enabled care that used to be delivered in hospitals to be delivered safely in the community to a certain extent, the current provision of services in the community is struggling to keep up.
Community service providers are clear that, properly staffed and funded, they can manage complex cases with higher acuity than many hospital consultants believe is possible. But it is important that there is a careful, agreed, definition of what level of acuity can be treated by community service providers and that they are appropriately funded and staffed to cope with this demand.
The community sector does not currently have the capacity or resources to meet demand increases in a sustainable way. In our survey, 91% of trusts think that, based on current trends, the gap between funding and demand for services will increase or substantially increase over the next 12 months (figure 12). Insufficient capacity in the community can lead to worse patient outcomes; it is widely stated that a person over 80 who spends 10 days in bed in hospital, loses the equivalent of 10 years of muscle ageing and often, subsequently, their independence.
A lack of community capacity can also lead to growing unmet need, which has a huge impact on the wider health and care system; insufficient funding of and capacity in community care means that people who should be cared for at home or in the community are presenting at acute services. At a time when investment in prevention should be increasing, demand and acuity are driven back into the acute sector. Demand pressures arising from demographic changes create an imperative for the NHS to adapt through transforming the way services are delivered. Community services have a crucial role to play in providing care in the community that not only reduces avoidable NHS activity but improves quality of life and keeps people well for longer.
Community services have a crucial role to play in providing care in the community that not only reduces avoidable NHS activity but improves quality of life and keeps people well for longer.
Significant demand increases, and the increased complexity of care needs, are making the task to strengthen and expand community services more challenging, as trusts cannot keep up with current demand within the funding envelope. Trusts providing community services need to be appropriately funded and staffed to keep up with this demand in a sustainable way. They therefore need national recognition that demographic and disease trends necessitate a renewed focus on prevention, health improvement and self-care, to ensure a sustainable NHS now and in the future. Instead of seeing the changing profile of disease as a burden, community services are keen to take a more positive approach to good health and wellbeing, and see it as a community asset.