Last week we began a debate on Twitter to build on the lively social media activity around our recent report NHS Community services: taking centre stage. Our first topic was the impact of the gap between demand and resources in community services is having on both staff and patients. This issue came through in our recent survey of trust chairs and chief executives: 91% reported that, based on current trends, the gap between funding and demand for services will increase or substantially increase over the next year.
NHS Providers policy officer Georgia Butterworth pulls out the ten key points from this debate:
- Demand is about more than the numbers. The ageing population and changing disease burden mean an increasing number of people need care in the community. This demand is outstripping capacity as services have not been invested in to strengthen and expand. But the challenge facing community services is not simply the volume of demand. What is most challenging is the increasing acuity and resultant complexity of care. People are living longer with more complex conditions and patients are being discharged from hospital with greater medical needs, which places more pressure on community services.
- Planning for demand and capacity is key. Across the NHS, making plans to have enough capacity to absorb demand is essential. While this is everyday business for the acute sector, it is much more difficult for the community sector, given the challenges involved in collecting information about demand in the community. Robust planning needs to be supported by national demand assumptions and modelling.
- But the data isn’t there. We need investment in the data infrastructure. Information on the type, acuity and level of demand is not currently available for community services (which hasn’t been helped by the prevalence of block contracts in the community sector). This lack of data makes it harder to plan for demand increases. The national bodies need to improve the collection and understanding of demand, acuity and caseload data in the community.
- Trusts are reluctantly raising eligibility criteria as a way to cope. With demand outpacing current capacity, community services are being forced to cut staff, reduce service commitments or raise eligibility criteria for access (as in social care). Many community staff are concerned about the lack of visibility, consistency and formality around this, as well as the impact on patients and service users. Frontline staff clearly feel that many people who would previously have had access to services in the community are no longer getting it.
- And unmet need is hidden from view. While there aren’t patients physically waiting in corridors, community service providers and staff are worried that hidden demand for care in the community is growing. There is no national target or data collection to expose this – unlike in the acute sector – so delays remain invisible. Insufficient capacity resulting in unmet need has a huge impact on the wider health and care system as people end up presenting at acute services.
- All this puts pressure on staff. The mismatch between demand and resources inevitably puts pressure on staff, making the job more difficult, less rewarding and less attractive. There is a definite sense that the same number or fewer staff are being asked to do more to meet increases in demand, which is unsustainable. This is making retention and recruitment more challenging, particularly at a time of real competition for key staff groups such as district nurses.
- And impacts negatively on continuity of care. Research shows that continuity of care leads to better patient experience, reduced costs and improved health outcomes, for example in the treatment of pressure sores. But current pressures on services and staff mean continuity is harder to provide. Frontline staff raised concerns that this is adversely impacting patient outcomes and quality of care.
- Developing new models of care can provide solutions. The current mismatch between demand and resources in community services is therefore having a significant adverse impact on patients and staff. But many staff, organisations and systems are developing innovative, new and joined-up care models to counter this pressure. Collaboration, and often integration, is key.
- There are plenty of good examples out there. Changing the skill mix in teams can help tackle the mismatch between demand and resources (but this needs to be carefully considered). Some areas are integrating general practice and district nurses into single teams, overcoming the artificial divide between primary and community care. An important area that still needs to be addressed is the hand offs between community, acute, primary and social care services. These are getting harder as providers struggle to keep up with demand, but it helps to see patients as a whole person and pay more attention to patient flows.
- But innovation needs to happen at scale. This debate has thrown up a key question about how to deal with the growing gulf between demand and resources in community services. The solutions lie in how we can rapidly develop innovative solutions at scale, which often involve integrating care across organisational boundaries. In addition to support and leadership at a national level, local pockets of innovation need to spread more rapidly around the country to help begin to tackle the demand/resource gap collectively, and decisively.