The NHS must ‘cede power’ to deliver community health targets

Big announcements from NHS England about improving community services for older people are not common. So recent news about taking the next steps to implement the first waiting time standards for community care – of two-hours for older people in crisis and two days to receive reablement support – received overdue attention.

These standards are certainly needed. The last national audit of intermediate care found capacity was well below that required to meet the needs of older people trying to leave hospital. Waiting times for these community services means patients and hospitals have been losing valuable time.

The most recent audit in 2018 found patients were waiting on average nearly six days for reablement. Waiting to get older people out of hospital to recover in their home means their time is wasted; there’s more potential for harm; and adding to the hospital bed capacity shortfall.

On community crisis responses, a few hours waiting for services to arrive can make the difference between staying at home and an unnecessary emergency admission. Recent research suggests the patients most likely to breach the four-hour emergency department target are aged 75 and over, present at night, exhibit case complexity and are referred to hospital by other professionals. Lack of community capacity and responsiveness could well be an important factor in deciding to admit them.

Having been heavily involved in developing the new standards, and as an experienced geriatrician, I anticipate they will be among the most difficult to deliver that the NHS has seen.

However, importantly, they have not come out of nowhere for the service. They are derived from established evidence, focused on what is possible. 

Crucially, because they are intended to support existing services to improve, localities should not delay by waiting for new evidence to emerge from pilots.

These standards do not require incubation of new ideas in “vanguard” experimental systems. 

Intermediate care has been evolving and gathering evidence of efficacy for the last two decades. The policy and investment is set out in the NHS long-term plan to upgrade infrastructure which exists nationally, and this is something we should be getting on with right now.

Practical challenges

Doing so will involve tackling some tricky practical challenges. Older people with complex needs can present to the urgent care system at any time and to many different access points. 

Commissioners must resist the temptation to over experiment by changing things that are already working, instead supporting the existing intermediate care infrastructure to improve, innovate and evolve in partnership with urgent care

Multiple possible scenarios all require careful planning to ensure timely and accurate assessment of need followed by the right response. All parts of the system must work with clear service definitions which include what is meant by clock start and stop, from the point of initiation to the point of service commencement by providers working in a variety of ways which include community health, social care, voluntary and charitable sectors. Without this, sustained measurement for improvement locally and nationally will be difficult. This needs doing with great care, however: a new industry in burdensome data collection would detract from the underlying objectives.

At a local level successful implementation will require sustained collaboration with social care, voluntary and charitable organisations. This will involve strong local leadership to provide clarity, and support quality improvement building from what already exists.

There will be difficult decisions on shifting financial and clinical risk in several directions.

Acute sector providers may need to support their staff to work differently to bridge clinical pathways into community and primary care settings. Doing the right thing for patients and the system as a whole, may require sharing cost and governance burden for those staff without reciprocation between sectors.

Commissioners, meanwhile, may need to balance the risks of trading some established well-measured processes – for processes with benefits which are currently less quantifiable, particularly where this leads to the desired outcome of more people with complex needs being helped to recover in their own home.

In a truly integrated system, it can be expected that the NHS will need to cede some power and accomplishment in the health sector, by decommissioning some activities in favour of lower-profile but higher volume activities such as home-based rehabilitation after surgery. Some of this may end up being delivered beyond traditional NHS boundaries, in the social care sector.

This work cannot be driven from the centre of the NHS – but we are left with four big national challenges.

First, commissioners and providers across multiple sectors must quickly understand what is expected and plan accordingly. At the conclusion of my term as NCD, work had already commenced on generating evidence-based service definitions to support evaluation and improvement via the community services dataset. But all systems now need national guidance to help them understand precisely what is intended to help them plan for full implementation as committed to in the long-term plan.

Second, all systems need to know their starting position. Given that the last audit of intermediate care services occurred two years ago, up to date local baseline data and cross sector intelligence is required to set realistic trajectories for achieving the standards by 2023-24.

Thirdly, these standards will not be delivered without the workforce capacity, requiring system leaders to develop robust cross-sector partnerships to stand behind their operational plans.

Finally commissioners must resist the temptation to over experiment by changing things that are already working, instead supporting the existing intermediate care infrastructure to improve, innovate and evolve in partnership with urgent care.