• There have been a number of national commitments, over many years, to shift care from hospitals into the community and give the community sector a key strategic role in improving the health and wellbeing of local populations. This argument has primarily been made because the NHS needs to move away from treating episodic illnesses to promoting health and wellbeing, as a way of coping with increases in demand caused by the changing disease burden and ageing population.
  • It is generally accepted that treating people in the community and in their homes is better for patient outcomes and experience, and the financial sustainability of the NHS. However, year on year, this ambition has not been realised. This report highlights seven reasons why this shift has failed to occur.
  1. Community services play a fundamental role in the NHS. However, there is insufficient understanding of these services at a national and local level, perhaps due to the diversity of services, organisations and commissioning arrangements involved.

  2. Community services have had insufficient profile and prioritisation at both national and local levels. Over nine in ten respondents to our survey of NHS trust chairs and chief executives said that community services receive less national-level focus, priority and attention than other sectors do, which means the expansion of care in the community has struggled to gain wider momentum, recognition or investment at a local level. There needs to be stronger leadership of community services at a national level to ensure ambitions for the community sector are realised.

  3. Community services need additional investment after a long period of under-funding, which is partly due to the general financial squeeze on the NHS, but also due to community sector-specific challenges such as the use of block contracts and the squeeze on local authority funding. Over half of trusts providing community services reported that their funding for these services has been reduced in 2018/19.

  4. Community services are struggling to meet increases in demand, which is already outstripping capacity. In our survey, nine in ten trusts think that the gap between funding and demand for community services will increase or substantially increase over the next 12 months.

  5. A set of workforce challenges has led to mounting pressure across community services. The supply of community staff has not kept pace with demand and trusts face worrying shortages in key staff groups, such as district nursing and health visitors. Trusts are also struggling to recruit and retain the staff they need to deliver high-quality care, due to the low profile of the community sector. Two thirds of trust leaders that responded to our survey are "worried" or very "worried" that they will not have the right numbers, quality and mix of staff to deliver high-quality care in one year’s time.

  6. Community service providers are being distracted from their core strategic task due to complex commissioning arrangements and frequent retendering of contracts. These providers are disproportionately affected by procurement rules compared to other parts of the NHS provider sector. This leads to a lot of wasted time and resource, and some trust leaders that we interviewed warned that this can risk the quality of care.

  7. A lack of robust national data, quality metrics and performance targets means that there is less national focus on, and no national improvement approach for, community services. Although national performance targets and quality indicators would be a double-edged sword for trusts, they would still welcome the opportunity to better quantify changes in demand, activity, funding and quality at a national level. Developing a standardised national dataset is crucial in this endeavour.

  • Community services are delivered by a diverse range of providers, and community interest companies (CICs) are a key component of that landscape. While much of their perspective on the challenges facing the community provider sector resonates with that of trust leaders, there are some nuances that should be taken into account when considering the overall provision of community services.
  • The drive to create integrated local care systems provides a great opportunity to invest in and develop community services. However, despite this opportunity, trust leaders responding to our survey generally felt that sustainability and transformation partnerships (STPs) were an acute-focused model of transformation, focused on the demand on and reconfiguration of acute services, rather than planning to strengthen and expand community services.  Only two thirds of trust leaders said community services in their local area were somewhat influential in shaping their STP. If new care models, STPs and integrated care systems (ICSs) are to flourish, it is vital that community services and the prevention agenda are at the centre of these plans.