What NHS England isn’t telling you, and more indispensable insight for commissioners. This week by HSJ primary care and community services correspondent Rebecca Thomas.
Last week, HSJ revealed that within the bowels of NHS England there had been an attempt to start developing a “forward view” for community health services – a document to sit alongside the 2014 original and 2016’s follow-ups for general practice and mental health.
The document never got to see the light of day, however, and in a belated response to my story, NHS England made clear it was definitely off the agenda. It said: “Thinking about traditional standalone community provision in isolation from the wider care integration agenda would be to reinforce the service fragmentation everyone now can see needs to change.”
The news was met with a significant backlash from community service leaders and concern about the sector being sidelined. No surprise there – what group in healthcare would not like its own forward view?
If Simon Stevens had chosen to detail his vision for NHS community service providers, it might well have been one this audience did not want to hear anyway. The implication of the Five Year Forward View’s new care models is that core community health services should blend into and be led by primary care (in a multispecialty community provider) and/or general secondary care (a primary and acute care system).
The difficulty with the forward view vision right now – and the reason that news of the quashed community services plan has resonated – is the widespread frustration that it doesn’t seem to be translating into reality.
More than three years after the first forward view was published, many areas are still being blocked on the journey towards integrated care. Most of those developing an MCP, PACS or “accountable care” have had to scale back their ambitions as they grapple with reality.
The forward view outlined the beginning and end of the journey, but Mr Stevens was always clear it was not a “plan” – it doesn’t answer the important question of how do we get from A to B?
Specifically, it is silent on how community services should be developed to enable that change.
While more detailed maps have been issued for GP and mental health, community services are referred to largely by their support for other sectors. Yet these services are pivotal for a wide range of patients – particularly for the aging and increasingly co-morbid population, which is central to the forward view’s challenge.
In the current context, the risks of not having a clearer community services plan, set out in the leaked NHS England document, are striking: sustainability and transformation partnerships will “not be able to achieve the full potential for service redesign”; and “expected efficiency savings associated with the shift away from acute bed based services will not be achieved”.
Of course, a further barrier to delivery has been investment. A separate community services strategy would have been another (entirely justified) call on transformation funds, which are already too thinly spread.
Leaving aside neglect in national policy, NHS England’s approach is emblematic of how many leaders and managers – at national and local level – see community services and why this is difficult.
Unlike general practice, community services can’t be easily defined by their workforce or the nature of their work. They have no especially powerful lobby group behind them.
Since they are split across different types of NHS provider, social enterprises, charities and private firms – and could well be shifted again in future – NHS community trusts have limited collective leverage.
The services are disparate and have a long history of fragmentation. There is little by way of common definitions, let alone descriptions of “what good looks like”.
This could be one reason for the centre’s reluctance to set out a specific improvement plan – how do you fight the monster if you don’t know what it looks like?
It leaves community services on the periphery, in the “too difficult” category. Making a reality of integrated care might require a more head-on approach.