Greater understanding of urgent community response services across system partners
At a local level, many community providers are actively engaging with colleagues from the ambulance sector and primary care to promote the urgent community response (UCR) services being delivered in their area, and boost confidence in making referrals.
Some providers are working with higher education institutions, hospices, GPs and the ambulance sector to outline their support offer through face-to-face meetings, sharing learning and resources to demonstrate the benefits of UCR for patients and system flow. Providers are also inviting key partners to attend weekly UCR leadership meetings to increase exposure to the service, which can help to improve understanding of these services and encourage partners to refer into them more routinely.
National guidance for the delivery of UCR services clearly outlines the clinical requirements for how and when the service should be used by the public and by health and care partners. But a degree of flexibility is built in and this can create challenges, especially for partners working across multiple systems.
For example, ambulance sector partners often deliver care across multiple integrated care systems (ICSs) with different UCR offers. Some UCR services deliver care from 8am to 8pm, as outlined in the national guidance, while others already provide care 24 hours a day. Promoting UCR services at both a national and local level with support for system partners to better understand different local offers, and how these services can be used, is key to boosting the number of referrals.
Understanding how clinical risk is shared between partners is another important part of the puzzle. For example, care home staff or ambulance call handlers might default to dispatching an ambulance if they do not have a clear understanding of the support UCR services can deliver, or confidence about the way that clinical risk is shared between key partners. Alongside leaders from community providers and ambulance trusts, ICSs can play a key role in encouraging system partners to work collaboratively to develop a vision and strategy for increasing referrals to UCR services. They can also facilitate open and transparent conversations about quality, patient safety and risk sharing between key partners.
Robust urgent community response data and a clearer national ask
At present, NHS England collects data on the number of UCR referrals, alongside the referral source and reason, as part of its UCR monitoring dashboard. While this represents an important step forward in the collection of national community data, there remains significant variation in the number of UCR referrals being recorded in each ICS. Some variation is to be expected, with rapid response services having been established for different lengths of time across the country, alongside different local geographies and demographics. However, the level of variation we see in the current national data indicates that providers are recording UCR referral activity differently.
Community providers would therefore welcome the opportunity to work with NHS England to clarify the activity that should be recorded as part of national UCR submissions. This would help create a more robust national dataset to support both providers and the national team to benchmark activity levels and understand where further work is needed to increase referrals into UCR services. Linked to this, a target for the number of UCR referrals an ICS should be aiming for based on population size could support a better understanding of local referral rates and capacity, as well as creating a clear vision and ambition for systems to invest in these services.
While greater national direction around developing more robust UCR data would be valuable, health and care support for patients who are frail or are managing long-term health conditions can be complex, as well as challenging to reflect accurately in a single performance metric. In the longer term, there is scope for a national evaluation of the benefits of UCR services for patients and other parts of the health and care system, taking into account the nuance and complexities of measuring the impact of ongoing care.
Trusted relationships and collaboration
Trusted relationships between community providers and colleagues in primary care and the ambulance sector are key to increasing confidence in making referrals into UCR services. Across the country, community providers are working effectively with ambulance sector colleagues to co-locate ambulance and UCR teams. This allows a multi-disciplinary team, often including a paramedic, to physically view the call stack together and determine which patients can best be supported by UCR services. This reduces duplication and streamlines the referral process, as well as supporting cross-sector collaboration and relationship building.
Some UCR teams have also developed a single point of access (SPA) hub, which patients and system partners can call to make a referral into their local UCR service. Patients are then triaged by the UCR team to determine which healthcare professional can best support the individual. SPAs support the seamless referral of patients into UCR services, again reducing the risk of duplication and supporting system-wide collaboration.
However, barriers to increasing referrals into UCR services remain. For instance, challenges around information governance and data sharing between key partners can make it difficult to increase referrals. While progress has been made around collaboration with partners, in most cases community teams cannot directly access calls made to 999 services and assess which could be appropriately diverted to UCR services. This means there is often an additional step between a patient requesting support and the call being diverted into a UCR team. Further work to develop local relationships, as well as national support to tackle issues around information governance and data sharing, are central to moving these processes forward with a view to increasing referrals to UCR services.
Finally, it's important to acknowledge that UCR services are operating at different levels of maturity and capacity in different parts of the country. Community provider leaders report that a dialogue about the role of UCR services in local systems is important, as are open and honest conversations about the challenges to scaling up services and what can be done to address them meaningfully.
Getting investment and staffing right
At a local level, community providers are considering how staff can play a central role in optimising UCR capacity. For example, one community provider reports recruiting more staff to deliver administrative support within their UCR team, with a view to increasing clinical capacity by 25%. Community providers are doing this in response to significant staff shortages across the sector, for example with the number of district nurses falling by almost 43% between 2009 and 2019. Despite the national policy shift towards providing more care in the community through initiatives such as UCR, the number of community staff has not kept pace with these ambitions or with increased demand for services.
The Community Network welcomed the NHS Long Term Workforce Plan's (LTWP) commitment to growing the community workforce, with the total community workforce expected to double in size by 2036/37. We also welcomed the focus on multidisciplinary teams, which play an essential role in delivering more integrated care for patients through services such as UCR. However, this ambition for the sector must be accompanied by a robust implementation strategy to break down the existing barriers to recruitment and retention in the community sector. Meeting the targets set out in the plan will require greater prioritisation of community roles, showcasing the rewarding work that can be delivered through new models of care including UCR services. We also look forward to confirmation from the government as to when the funding committed for the LTWP will be released for the sector.
In a financially constrained environment, and without ringfenced funding for the sector, there are concerns that the community sector will be squeezed out of system-level investments. However, to realise the potential of UCR services, funding for the community sector must be prioritised. There is a clear role for ICSs in directing resource at a local level to ensure community providers are properly resourced to deliver more care in the community. This will in turn alleviate pressures on the wider health and care system, and particularly urgent and emergency pathways.
It is clear that efforts to boost referrals into UCR teams and maximising capacity must be underpinned by having the right number and mix of staff, as well as sufficient investment in community services. Without this, it will be difficult to optimise the potential of UCR services and ensure that they can manage any increase in referrals effectively and sustainably.