Nearly 20 years ago, the then Labour government published a bold new vision for community services. Care, they said, would finally move closer to home. Where others had stumbled, this strategy would spark “the beginnings of a profound change”. Hospitals would no longer attract the bulk of resources and political attention. More money would flow to community and social care providers – representing a “fundamental shift” toward locally delivered, integrated care.
History is both a mirror and a window. It reflects past ambitions while challenging us to ask why the same ideas would succeed now when they have failed in the past. Politicians have long pledged to shift the NHS’s gravitational pull away from hospitals towards the community. Few have delivered.
We now have a new Labour government in the driving seat, working on its own plan to fix the NHS and finally tip the scales towards community care. But now the stakes are even higher. The Prime Minister has warned that the NHS must “reform or die” to meet the mounting challenges it faces. So the question remains: what will be different this time?
While the objective to move care closer to home may well be the right one, previous attempts have lacked a clear understanding of what is being shifted and why, and realism about how much would improve as a result. Right now, it’s not certain which of the NHS’s many problems the government intends this shift from hospital to home to solve; why it is the right solution to prioritise; or how the factors that hampered success in the past will be mitigated.
With the government’s consultation for the 10-year plan now closed, three unresolved questions have arisen from the current debate that the government needs to answer to avoid repeating the mistakes of the past.
What does shifting care into the community actually mean?
Community care spans a diverse and complex set of services. These range from general practice, pharmacy and dentistry to district nursing, health visiting, rehabilitation, social care and beyond – many of which sit outside of the NHS itself.
Shifting more care into any one of these services involves everyone in health and care doing something differently, from patients to staff, managers and commissioners – including changing their attitudes towards managing risk. This will need to be carefully thought through, but right now it’s unclear what the government means by more care happening outside of hospitals, both in terms of the services to be shifted, and where in the community they should be placed. The only thing that does seem clear is that this won’t mean social care, which has been sidelined once again and excluded from the scope of the 10-year plan.
The government risks oversimplifying the shift from hospital to the community, treating it as one thing when it covers a whole range of possibilities. The graphic a few paragraphs below highlights this diversity. On one end of the spectrum, change might involve specialists delivering the same services but in different, non-acute settings, such as respiratory clinics for people with COPD led by pulmonologists, or intravenous drips and chemotherapy delivered in a person’s home.
It could also mean more transformative changes, like staff with different skillsets taking over the diagnosis, treatment and ongoing care of patients previously cared for in hospitals – with the aid of digital technology and more collaborative ways of working. The breadth of options demands a clearer vision and understanding of what it is we want to achieve, and why.
But it’s also important we don’t reduce ‘moving care closer to home’ to a grab bag of separate, shiny initiatives. Any one of these approaches on its own would not move care as a whole closer to home. They need to come as a package, with a clear understanding of how each intersects and works together, with thought about ways to really tackle the things that perpetually get in the way.
What is moving care out of hospital likely to improve, and what is it unlikely to improve?
Many have argued that shifting more care into the community is a good way of ensuring that patients have a better experience of care, reducing costs and making health care more accessible to people – in part by freeing up more hospital capacity for the patients who need it most. It’s also viewed as a way to boost prevention and reduce inequalities by integrating services that are better equipped to address people’s broader needs for living well and independently. But the available evidence makes it difficult to say whether moving care closer to home will deliver on those expectations.
Several studies have found that shifting services out of hospital can improve access to specialists and ease demand on acute hospitals without compromising quality. Crucially, this depends on community providers – for example, district nurses, physiotherapists and advanced care practitioners working in rapid response teams – to have the skills and spare capacity to take on more responsibilities. But other evaluations have had mixed results: while some care models reduced unplanned hospital admissions, others had the opposite effect.
It's also unclear whether moving more care out of hospital will achieve loftier goals like reducing health inequalities and improving population health. Community services can improve access and deliver more culturally competent care for marginalised people, by being more embedded in the communities they serve and therefore more responsive to the cultural nuances and social factors that influence a person’s health. But this won’t happen automatically just because care moves into the community. Achieving this requires careful planning, thoughtful service design and intentional staff recruitment and training. Without these, care in the community risks being just as inadequate as poor care delivered in hospitals.
The mirage of cost savings
When it comes to costs, the evidence is more discouraging. While community services can sometimes be cheaper to deliver, this has rarely resulted in overall savings. Expanding community care often uncovers unmet need or leads to new spending elsewhere. Other reviews confirm that while moving care out of hospital can improve patient experience, it typically hasn’t saved money for the NHS, at least in the short to medium term. Some international evidence suggests that moving care into the community can boost hospital productivity by reducing waiting times and freeing up capacity. But these successes often come from countries already in a better position to provide more care out of hospital in the first place.
While reducing costs may be a reductive way of considering the benefits of moving care closer to home, it has often been the lens through which governments and NHS leaders have judged the success of previous efforts. It’s this wishful thinking regarding the benefits that often drives policy, without adequately dealing with what sits behind the NHS’s continued reliance on hospitals. And it’s also where many of those strategies have fallen short. For example, the 2014 Five Year Forward View failed in its promise to deliver 2 to 3% in efficiency savings – a promise which relied in part on expanding new models of care that would move more services out of hospital. The reasons for this are complex, but possible reasons could be that initiatives weren’t sufficiently scaled up or given enough time to achieve results.
This is not a systematic review of the evidence, and even if it was, it would be difficult to say for certain how beneficial moving care out of hospital is, given all the different ways it can be achieved. People will also be affected differently, depending on their individual health and care needs. The uncertainty around the evidence doesn’t mean that delivering more care in the community isn’t worthwhile. But given the mixed results, the government should be clear about what it expects to achieve and how, while avoiding the over-optimism that has marked past efforts.
Why have previous efforts failed, and what needs to be different this time?
One of the biggest issues that has undermined previous attempts to shift care out of hospital is that we have routinely underinvested in the services required to move care closer to home. Despite consistent rhetoric to the contrary, the proportion of total spending by NHS services on delivering community care has steadily fallen relative to acute services. In the six years between 2016/17 and 2022/23, acute spending rose by about 4.4% on average each year in real terms, while spending on community services grew at a much slower rate – only about 0.5% each year in that same period.
The recent Autumn Budget had little within it to tilt this balance, with most funding seemingly targeted at hospitals. There’s hope that the significant boost to capital (with average increases of 11% this year and the next) may support things like buying more diagnostic kit and upgrading GP surgeries to be able to absorb more capacity – but there are still big questions about how this will all play out in terms of what gets prioritised.
And we cannot talk about underinvestment in the community without discussing the failure of successive past governments to place social care on a sustainable footing. Social care services deliver a large proportion of the community care needed to help people live independently and keep people well, and services have been beleaguered for decades by insecure funding, variable access to support, high workforce turnover, and heavy reliance on unpaid carers. Here too, the recent Budget offered very little by way of righting these wrongs – and in fact will push many social care providers deeper down a financial abyss once new changes to national insurance come in.
Not just a lift and shift
The Darzi review clearly laid out these challenges, but they bear repeating. Without addressing the broader financial context, it’s hard to see how the 10-year plan will yield better results. An uneven distribution of resources has left community services woefully underfunded and understaffed, and poorly placed to take on additional responsibilities or deliver more care.
The government has been adamant that the NHS shouldn’t expect new money, and that it will be the job of reform – not investment – to do the heavy lifting in delivering this shift. But given where we are, it’s pretty implausible to assume that community providers will be able to deliver more care without some upfront boost to funding or double-running. The money certainly won’t easily come from hospitals – at least in the short term – without risking progress on waiting times and adding to the enormous strain that hospitals are already under.
This is also a key learning from other health systems. Denmark has managed to move more care out of hospital over time, but it has done so with significant upfront investments that have been used to upgrade hospitals and data infrastructure while building up step-down and rehabilitative care in the community. The government has also recently ring-fenced funding for community services by capping future hospital expenditure after more resources have started to creep back towards the acute sector. Following these reforms, Danish local councils will be able to move money from hospitals to community providers, but not the other way around.
Insufficient funding is far from the only barrier to shifting more care out of hospitals. Previous efforts have also failed when reforms threatened local hospitals, and communities feared this meant missing out on vital services. To bring the public on board with care closer to home, the government needs to focus on what patients will gain, and not what they might lose. Surveys have shown that the UK public are open to new care models like virtual wards, but this support is closely divided, with 45% in favour, 36% opposed, and 19% unsure. Hospitals are deeply symbolic physical spaces associated with safety and expert care for many people. So to make this shift, the government must clearly communicate what is being proposed and why, and indeed why hospitals are often not the best place for patients to be.
It’s encouraging that the government has centred a public dialogue in shaping its 10-year plan, but engagement alone isn’t enough. Listening without a willingness to act on public input is a familiar failure from history – and one they cannot afford to repeat.
Conclusion
Shifting care closer to home continues to be a worthy ambition. But to succeed where past efforts have failed, the new plan must go beyond ambitious rhetoric and be clear about what moving care out of hospital actually means, what it will achieve, and how.
Making this shift is a generational change. It will likely take the full 10 years to see progress. But only with clarity, realism, and a willingness to address foundational challenges will it have a chance of changing how – and where – care is delivered.
Shifting more responsibilities from acute hospitals to community providers
Avoiding use of hospitals for elective care or routine care
Shifting more management of chronic conditions (e.g. COPD) to primary care and community providers
Expanding the numbers of GPs with extended roles or ‘special interests’
Avoiding hospital admissions and accelerating discharge
Hospital-at-home
Two-hour urgent community response teams/paramedic triage
Better supporting at-risk communities or people with complex needs
Enabling primary and community care to take on more responsibility for care planning and management, including replacing outpatient visits with community follow-ups
Physically re-locating consultants/specialists into community or home (including through remote technology)
Avoiding use of hospitals for elective care or routine care
Consultant clinics in the community (e.g. for orthopaedics, pain management, etc)
Easy digital access to rapid consultant consultation
Avoiding hospital admissions and accelerating discharge
Community-based rapid access clinics for urgent specialist assessment, e.g. for suspected cancer
Remote monitoring of people with long-term conditions
Better supporting at-risk communities or people with complex needs
Providing additional clinical support to people within care homes
Virtual wards/home-based multidisciplinary care
Improved joint working between community and acute providers
Avoiding use of hospitals for elective care or routine care
Improved GP access to specialist advice
Referral management
Shared care models for managing chronic disease
Avoiding hospital admissions and accelerating discharge
Community-based rapid response teams
Integrating primary and acute care services
Better supporting at-risk communities or people with complex needs
Multidisciplinary team-based care
Case management or care coordination
Building up existing community capacity to ensure comprehensive delivery of services
Avoiding use of hospitals for elective care or routine care
Community diagnostic hubs
Improving continuity of care
Avoiding hospital admissions and accelerating discharge
Boosting community rehabilitation capacity for specific conditions, e.g. stroke, COPD, etc
Increasing intermediate care beds/step-down beds
Expanding urgent care centres and minor injury units
Better supporting at-risk communities or people with complex needs
Improving end-of-life care in the community
New types of workers focussing on preventing escalation of long-term conditions, e.g. social prescribing