Unlocking the power of health beyond the hospital: supporting communities to prosper

The NHS Confederation and CF have worked closely over the past 12 months to demonstrate the value of the NHS as an investment. To date, we have published the first national attempt at quantifying the positive relationship between increasing NHS spending, health outcomes and economic activity, and sought to understand where additional investment in a range of settings of care could deliver the most economic output.

This third report goes further still, exploring system productivity as it relates to spend. This issue is particularly timely: acute healthcare spending between 2020/21 and 2021/22 grew faster than any other form of NHS spending, despite performance continuing to be challenged with pressure on A&E, beds and discharges. Responding to these pressures requires a more holistic understanding of system productivity.

Our earlier reports demonstrated the important role primary and community care play in creating health value. For the purposes of this report, we have performed a deep dive into community care given the general ambiguity surrounding the services that make up this NHS setting, its broad links with other parts of the system and the wider economy, and what we believe to be significant potential to unlock significant system productivity gains.

Our analysis found: 1) Those areas that spent relatively less on community care in terms of population need have seen higher-than-average levels of hospital and emergency activity, compared to those spending relatively more. On average, systems that invested more in community care saw 15 per cent lower non-elective admission rates and 10 per cent lower ambulance conveyance rates, both statistically significant differences, together with lower average activity for elective admissions and A&E attendances.

2) Despite the increased focus on creating better health value and unlocking system productivity, there is currently no relationship between the amount invested by NHS organisations in community care and their population community care needs. The sheer variation in spend perhaps highlights a wider lack of understanding and prioritisation in community care.

3) The reduction in acute demand associated with this higher community spend could fund itself through savings on acute activity if a causal relationship were assumed, with an average 31 per cent return on investment and average net saving of £26 million for an average-sized integrated care system (ICS), exemplifying the power and potential of community care at a system level.

Each of these findings deserve attention and lead us to make a series of recommendations for national government, NHS England and ICS leaders that can collectively help create community health value and unlock the power of health well beyond the hospital.

Overall, we recommend that community spend is prioritised as a mechanism for reducing long-term pressure on the acute sector, as a crucial contributor to healthcare system productivity and as a direct lever to provide patients with the care they deserve. Improving impact tracking is also critical, and we recommend that providers of community health services work with their ICSs to report operational performance and data to ensure impact is adequately understood.

The report points to a wider challenge for community care. Given community needs are calculated nationally, it follows that certain findings and recommendations are relevant for national bodies, such as government and NHS England. However, since there is no national contract for community services, community spend is almost entirely at the discretion of local leaders. This analysis should equip leaders with the necessary focus, information and evidence base to navigate challenging decisions about how to allocate resources, making significant strides in evolving toward a more preventative system that is effective both in terms of cost and care.

Given this analysis, we strongly believe that community care can play a significant role in supporting system productivity and can provide ICS and NHS leaders with a direct lever of control that they can shape and use to deliver change.

To help leaders to put theory into practice, we have included a case study encompassing the five legacy CCGs that now make up North Central London (NCL) ICS. The place-specific example illustrates a need to streamline inconsistent service offers and develop a clearer community care offer for the wider system. It also provides tangible steps that systems can take to realise these ambitions, namely understanding the existing services, developing a refined offer, creating a means to track impact and building a plan for practical implementation.