interviews

Cutting complexity: a new vision for community services

NHE speaks to the King’s Fund’s Nigel Edwards about his major new report into community services, the need for closer relationships with primary care, and the ‘challenging questions’ for community trusts. 

Community services are complex, overly specialised, fragmented, neglected and poorly understood, according to a radical new report looking at potential future options.

Nigel Edwards, senior fellow at the King’s Fund – director with the Global Healthcare Group at KPMG LLP, former policy director of the NHS Confederation and incoming CEO of the Nuffield Trust – was the author of the new report, ‘Community services: How they can transform care’, which also had extensive input from a working group (see below).

He is scathing about the ‘Transforming Community Services’ programme, launched in 2008, which he says was almost entirely about structural re-jigging and outsourcing and can be considered a policy failure as far as the patient is concerned.

In his blog, he wrote: “…the programme led to some community services being privatised – and often set up to fail against hugely onerous procurement processes – with others transferred to whichever acute or mental health provider was available. Officials gave the strong impression that they would be happy to see the entire community service workforce moved off the NHS payroll…”

Edwards’ central recommendation is about simplifying the services on offer, based around primary care and natural geographies, with multi-disciplinary teams wrapped around GP practices or groups of practices. These teams would have to offer 24/7 services as standard, complemented by “highly flexible and responsive community and social care services”. Quality, accessible, responsive community services like this are the only way to improve patient care whilst simultaneously cutting unnecessary acute admissions and length of hospital stay.

This is one of seven interrelated steps identified by the working group:

• Reduce unnecessary complexity of community services;

• Forge much closer relationships with groups of general practices

• Build multidisciplinary teams for people with complex needs, including social care, mental health and other services;

• Support these teams with specialist medical input – particularly for older people and those with chronic conditions;

• Create services that offer an alternative to hospital stay;

• Build the information infrastructure, workforce, and ways of working and commissioning that are required to  support this; and

• Reach out into the wider community to improve prevention, provide support for isolated people, and create healthy communities.

Step-by-step

Although there are radical recommendations in the report, Edwards was keen to stress that he does not want more structural reorganisation for its own sake. Removing complexity is clearly a laudable aim, but we asked Edwards how this can realistically be done without it becoming just another reorganisation causing inadvertent fragmentation.

He said: “It’s a very good point, and the answer is that you do it in stages. There are all of these different small teams carrying out different functions, sometimes based around a disease area, or falls, for example. You still need people with those skills, they just need to work in new ways. Even if there’s fewer people working just on that specialist area, you are still going to need them – but you re-purpose them so they can join wider multi-disciplinary teams.

“That would have to be done step-by-step, not as a huge big bang. We’re increasingly finding that reorganisations of the ‘turn the switch on and it will all work perfectly’ type have their hazards, and this is certainly one of those areas.”

There are downsides to this, as the report notes: “Small incremental changes do not allow hospitals to make any significant adjustment to their cost base. This means that even where community services are cheaper than the inpatient equivalent, there may be an inflationary effect as overhead and other semi-fixed costs will remain stuck in the system. This may not be a problem if there is other work that the hospital can take on (and commissioners are willing to pay for it); but this is increasingly not the case.”

A new type of healthcare worker

Edwards’ ideas raise some very big issues about medical training and specialisation, especially the need for intermediate, middle-level clinicians working between health and social care – multi-skilled ‘generic’ workers who can take responsibility for looking after the whole person rather than performing individual tasks.

The report adds: “It is becoming increasingly obvious that there need to be significant changes in the health workforce. There are issues about the shortage of community nurses and the ageing of this workforce.”

Health Education England told NHE that its national workforce plan addresses these very issues. Spokeswoman Vicki Diaz told us: “HEE welcomes the report and the focus on workforce as a key lever for change. HEE recently raised similar issues in our first workforce plan for England that was published before Christmas and we will be setting out how we plan to address these in our 15-year strategy that we will be publishing in May.”

Cutting emergency admissions

Health Foundation research suggests about 20-30% of emergency admissions could be avoided if appropriate alternative forms of care were available, or if care had been better managed in the period leading up to the admission. “Relatively few admissions are identifiably inappropriate at the time of admission,” as Edwards’ report puts it.

There has been something of a paradox in these attempts to cut emergency admissions: noble efforts by teams of people who can point, anecdotally, to very many people they have managed to keep out of hospital, and emergency admissions avoided. But at the population level, there is little evidence of this happening.

Edwards’ report suggests this may be because admission thresholds are changed and other patients are admitted instead. Services need to be redesigned so that “only those frail older people who have evidence of underlying life-threatening illness or need for surgery are admitted as an emergency to an acute bed”.

He suggests a tough ‘gatekeeper’ role is needed: what he called “a very senior physician at the front door of the hospital”.

He told us: “It’s all about what happens at the point when someone’s got to the hospital, it needs someone to make a judgement about what should happen next. Larger [community] teams need to have the responsiveness and capacity to deal with those cases straight away. One of the criticisms of some community services response times – you need to be able to have a two-hour response time. Quite a lot of community services really couldn’t manage that consistently. The minute you can’t do it, people will start giving up on you, and think ‘this isn’t working’.”

Advocacy for community services from elsewhere in the NHS is important, Edwards says. He blogged about this recently: “…these services do not control many of the key points on the patient pathway, including referrals, admissions, discharges and other important transitions that they need to influence if they are going to reshape care effectively.

“[Q]uite a lot of community services are provided direct to patients; important though these services are, other providers may not be aware of them, which means that they have few advocates in other parts of the system. Crucially, they do not often employ
any of the key influencers in the NHS: consultant medical staff.”

Structures

Of course, there’s no getting away from the fact that the NHS is organised currently in a certain way, and structural upheavals affect people’s jobs and livelihoods. It can be easier to design a system that works entirely around the patient in theory than it is to actually make the changes that radically impact healthcare workers’ jobs and livelihoods.

We asked, for example, where in Edwards’ vision the existing community services trusts fit, if they exist at all.

He said: “It does raise questions. You start with wrapping these multi-disciplinary teams around practices, but then you probably
have another layer around three or four of those groups, where you have more of your specialist staff. There’s a whole task here of recruitment and training; community trusts are one model for doing that.

“But for the traditional community trust that only does community services, as opposed to maybe mental health and even social care too – there are some challenging questions that they need to think about, such as the shape of their organisation and how it works. We’re a bit agnostic on organisational structure here.

“There are some very nice examples of self-managing teams, but they do still need to be embedded in some wider structure with proper governance.”

On the right track

He said there was nowhere in England he could point to as an area that is doing everything right, or has the answer. Even the more interesting and progressive examples noted as case studies in his report – such as the Wigan Integrated Neighbourhood Teams project; Greenwich’s team-based approaches to supporting people at home; the community-based emergency medical unit (EMU) service in Oxford; Bedfordshire’s Partnerships for Excellence in Palliative Support service; Birmingham’s Healthy Villages programme; and the People Powered Health and Supported Self-Management initiatives in Leeds – have only got “bits” of the ultimate solution, Edwards told us.

“But I was very struck by the fact that everywhere I go, this kind of model [multi-disciplinary teams with a strong relationship
with primary care] is the one that people are alighting on.”

The genesis of the report

The report was commissioned by the NHS Confederation Community Trusts group. The research is based on a literature review, two workshops and a study network.

Nigel Edwards is the report author but it was developed with “extensive input” from members of the Foundation Trust Network’s group of aspirant foundation community trusts and two learning networks on integrated care. Data and ideas were also contributed by Dr David Oliver, Damon Palmer, Peter Spilsbury, the Symphony Project in Somerset, Dr Rebecca Rosen, and Dr David Maltz of the Oak Group.