There is no doubt hospital care is essential but community services must also be made an important part of the system. A new vision to recognise and expand its role in commissioning and governance is needed, writes Gill Morgan
Community health services used to be most people’s experience of healthcare. But one of the aspects of modern medicine’s wondrous advance has been that its technical and scientific achievements were concentrated in institutions.
Let us be in no doubt that the, at times, quite breathtaking quality and complexity of care that can only be provided by hospitals is an essential part of the healthcare system. But we must also recognise the breadth and sophistication of what can be accomplished by community and primary care services.
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Recognise community care
Healthcare in the latter part of the 20th century became so dominated by hospitals, bricks and mortar that we now struggle to explain to people the virtues of providing care outside of hospital. In fact, we now have a phrase for it – out of hospital or OOH – as the notion is so remarkable to some.
I think we should change OOH to out of home. Healthcare at home, in clinics, surgeries and pharmacies should be seen as the default and desirable place for most people’s healthcare with only intense need, high risk and specialist intervention requiring the unique abilities of a hospital.
Community health services lack the high public profile of other NHS services, and yet they often reach the deepest into our lives. They are part of our neighbourhoods, they come into our homes, and are with us for the long term.
We live longer now than ever before, but are more subject to frailty and long term conditions as a result. Community health services partner with colleagues across the NHS and in social care, education, charities and local government to personalise care packages which support people to maintain their independence for as long as possible.
Their personal, community based approach means they take many different forms, and are often organised to meet local patients’ and service users’ particular needs. Their underpinning philosophy is to help people live as independent and fulfilling a life as possible, for as long as possible.
‘Their philosophy is to help people live an independent and fulfilling life’
Yet their role has never been well defined or as widely recognised as other parts of the NHS. Partly, this is due to the various forms they take: working so closely with GP services, they are often assumed to be part of the surgery. They are also rarely in the spotlight, lacking the propensity to make headlines, impact elections or generate national controversy.
Consequently, their potential to provide the sustainable core of the NHS and drive new models of care can be under-recognised. In effect they are usually described in the context of other services, rather than in their own.
To deliver better and new models of care it is essential that we unleash the community health sector’s potential. This needs a new vision which explicitly recognises and encourages its role; new currencies to describe, measure and fund their work; and a language to explain, promote, measure and expand it.
Self-sufficiency, self-awareness and self-care (with the right knowledge, technology and local backup) will have a massive impact on keeping people healthier and helping them live with manageable conditions.
This will need commitment, leadership, and an NHS freed to develop and move to new models of community based, person centred care and provide the services that can only be delivered in a hospital at the same time. As part of this commitment we will publish Community Health Services – A Way of Life, a narrative to support and drive the conversations and plans for new models of care and sustainable NHS services.
We need to talk the language of community health so that we can benefit from its current and future potential.
A new language and context
Community services need to be described in their own language. The NHS must see its mission as being about people, not patients.
People live with increasing health needs and frailty, but we too often see patients for whom a health transaction is the necessary fix. Until the NHS is oriented around people and their needs, rather than episodes of care, it won’t be able to address challenges of quality or cost.
Currencies and timescales need to be fit for sustaining long term relationships in neighbourhoods, and across health and social care. Integration should be an outcome benefit experienced by the person; not simply an organisational design principle or administrative convenience.
A community approach
Commissioners will need to offer consistency and a long and integrated view in their commissioning and tendering behaviour.
Trust boards and commissioners will need to pioneer and use different forms of information to assure themselves that services provided in the home, away from a hospital, are safe and provide service users with a positive experience of their care.
‘Commissioners will need to offer consistency’
Regulators should seek to change their working models, to gain assurance that trusts providing community health services are well led and that agreed standards of care are met in different ways to the traditional hospital setting they are used to. This will require a new, sensitive approach to evaluating patient and service user feedback.
How will regulation and inspection processes change when the care setting is increasingly an individual’s private home?
Right workforce, skills, recognition and rewards
Providing support to stay healthy (or live more comfortably with ill health) needs additional and adapted roles and skills.
Different skills are needed to work in homes and high streets. Healthcare professionals will increasingly work alongside other care, support and advice professionals, using new approaches to relationship building and collaborative working.
Being locally responsive, neighbourhood based and person focused does not happen automatically. It requires:
- skilled professionals;
- well managed and led organisations; and
- strong and meaningful relationships between agencies and committed commissioners.
Community indicators that work for the NHS, but also are meaningful to its partners, will be a key element; as will core competencies of professionals and organisations.
The NHS seeks to be invited to be guests in the everyday lives of people, rather than only being there for when things go wrong. Community healthcare services excel at this.
It may seem odd that we are having to relearn an approach we were once good at, but this will become a way of life and a way of sustaining better, healthier, independent living for longer.
Gill Morgan is chair of NHS Providers