It’s easy to ignore community services because they are ostensibly delivered in people’s homes behind closed doors. The people affected by them are not the most visible, unlike the photographs you see of people sitting in trolleys in an A&E corridor. National leaders have been slow to understand that this is a sector that can be of great benefit in providing solutions to the pressure the NHS is under, but it needs resources.
Providing care with rigour, science and specificity
The long term plan is good news for the sector but it still doesn’t help develop the model of care delivered at home – whether that’s integrated around adults, frail older people or children with complex needs. It doesn’t get onto the territory of really driving those new models forward, especially around health and care.
What is called community services in one area of the country can differ from other areas because of history and investment. In 10 years’ time, I’d like us to be absolutely clear on the evidence base, the data, the outcome measures that we are driving for the 10% and growing proportion of the NHS pot of funding that we have access to. To be able to describe how we help people to age healthily, how we give people a great start in life and help people live with incidents in their lives and with long-term conditions, and that all of that has the same rigour, science, intent and specificity as you’d expect in a hip operation, cataract surgery or a surgical intervention for a stroke.
The long term plan is good news for the sector but it still doesn’t help develop the model of care delivered at home – whether that’s integrated around adults, frail older people or children with complex needs.Chief Executive
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. In some areas, they don’t have these beds at all and it’s all done at home anyway. That variability needs to come out.
While clinical commissioning groups (CCGs) still have a role in saying how money should be spent, there should be a core offer, so that across the country there is one NHS approach and then there are variations according to the needs of local populations. We need identifiable clinical national leaders that will champion this, in the way that some of the progress that started in London on stroke care has now spread across the country.
Using data to improve children’s care and address wider determinants of health
There has to be an improved and more targeted approach for children and early years across health and care. That’s children centres, early health work from councils and nursery provision. We need to coordinate our approach around families, especially around healthy eating and diet, to avoid greater obesity and to support school readiness. We’ve had a siloed set of initiatives around early years support, very much focused around the healthy child programme. It’s not enacted in that integrated way that says "let’s use all our resources to really drive improvement in a targeted way".
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.Chief Executive
We’re beginning to see increasing use of data in older people’s care, triangulated across acute primary care and community and sometimes further afield in social care and mental health, but we’re not seeing that in children’s services at all. We really want to improve – some more predictive modelling of how we support children and family units in getting a better start in life is key.
It’s not segmenting people into an approach where you only pursue one set of interventions, but it is about allowing us to know what’s going on with local communities. We know the risk of adverse incidents creating problems for mental health later in life is massive. Taking what we know about risk factors, there is a much broader set of data around housing, domestic violence, poverty levels and using universal credit. All of these are potential alarm bells or issues, but if we don’t collect them together, we won’t get a composite view of how we support families, other than through door knocking.
We’re beginning to see increasing use of data in older people’s care, triangulated across acute primary care and community and sometimes further afield in social care and mental health, but we’re not seeing that in children’s services at all.Chief Executive
Prevention and wider determinants
There is a need for NHS organisations to take on a greater role in addressing prevention, wider determinants of health and public health, but often the focus is on the role of acute care. This is an area where there is untapped potential for community services.
There is a statutory healthy child programme that requires every child in every part of England to be seen a set amount of times pre-birth and post birth up until age five. My problem with describing it as a public health thing is it immediately pigeonholes it as a fluffy intervention. None of this is fluffy – all of this is really essential in preventing things from happening later on. Councils can’t afford to give universal children’s provision and a lot of families don’t need universal blanket support, but we do need to be targeting those who do need it.
There are five to six key issues that evidence shows are always prevalent when it comes down to safeguarding issues. They are risk factors that every single children’s clinician will be looking out for – for example drugs, alcohol and domestic violence. Community health care organisations are front and centre here because they do so much work with councils’ children’s services to improve children’s outcomes and get them ready for school. It’s not classic ‘prevention’ – this is hard edged action to drive improvements and take out some of the health inequalities that we’ve got. You could quite easily argue that is also true of comorbidity in adulthood and frailty as well.
There is a need for NHS organisations to take on a greater role in addressing prevention, wider determinants of health and public health, but often the focus is on the role of acute care.Chief Executive
Process data is probably not the way to go in the community sector. We do need to be talking about impacts on patients and getting into a level of detail about what’s appropriate for different groups. What you’d count as appropriate for a child with autism would be vastly different for a child who is just receiving universal children’s support and doesn’t need any specialist intervention. It is about dicing and slicing according to what’s appropriate.
Opportunities for the future
The NHS long term plan described the framework and the strategy for delivering care in vastly different and improved ways and had some investment attached to it. The sector needs to respond to that and say “our role is to make it happen”. We need some national leadership, focus and a national approach without being over-prescriptive. Chapter one of the plan, though, absolutely put community healthcare with primary and social care at the forefront of being the strategic change that will help the NHS to be sustainable. As long as we keep the focus on that, spend the money wisely and remember this is the start of an investment cycle, and there can be further rebalancing when the sector proves itself on data, the ground work is there and done.
I hope the Community Network will continue to agitate, to lobby and push for all the things I’ve been describing. Where there are gaps in national leadership, the strategy, the involvement of the royal colleges, the role of network is to be a single unified voice for sector.