Shifting more care out of hospital and into the community has consistently been an aim of NHS strategy, intended to prevent unnecessary admissions and ensure timely transfer from hospital to free up beds for patients who need them the most.1,2 But even with clear policy intent, progress and delivery on these ambitions has been minimal, and insufficient capacity in community health and care services have beleaguered the system for years.
The crisis observed over winter with growing numbers of patients delayed in hospital are just one manifestation of this policy failure and indication that community capacity has been insufficient to meet demand. Data from England shows that in the 12 months between December 2021 and 2022, the number of patients in hospital who no longer needed to be there increased by 27%. Among the patients experiencing the longest stays in hospital (three weeks or more), 70% of patients were awaiting community health and social care services (i.e., rehabilitation, home care, nursing home care or step-down care).3
And it’s not just delayed discharges. Community health and social care services play a key role in keeping people well and out of hospital and avoiding admissions in the first place. Patients with long-term ill health and frailty, complex care needs and inadequate carer support arriving in hospital when there’s no immediately available alternative support often become the most complicated patients to discharge.4
So what policy choices do we have to address these capacity gaps outside of hospital? The NHS is far from alone in trying to move more care into community settings, but some other countries have had more success. In this briefing we look internationally to understand how our performance compares, how other countries have managed to build up community health and care services, and where there might be relevant learning for England. We propose five hypotheses as to what might set these systems apart and how their approach has been different – and where the NHS may need to focus next if shifting more services out of hospital is ever going to become a reality. We focus on countries that, like the UK, have similarly low numbers of acute beds and therefore may have similar pressures and incentives to reduce length of hospital stay.
Bed capacity and length of hospital stay: How do we compare?
The average length of stay in hospital is a commonly used indicator of efficiency in health service delivery. Longer stays in hospital increase costs and can reflect poor care coordination or lack of capacity, leading to patients waiting unnecessarily in hospital until rehabilitation, long-term care or other community services can be provided. Shorter stays can free up beds for other patients in need and shift care from inpatient to less expensive settings. Prolonged lengths of hospital stay can also have detrimental effects for patients – especially for older people and patients with frailty. Increased risks of falling, sleep deprivation, catching infections, and mental or physical deconditioning are all associated with long hospital stays.5 At the same time, discharging patients too early can increase risks for readmission and affect a patient’s health outcomes.
Looking internationally, the UK appears to perform favourably compared to other OECD countries in terms of average length of hospital stay. However, this picture changes when comparing with other countries with similarly low acute bed bases – and therefore may have similar constraints and incentives to free up hospital capacity as the NHS. Figure 1 below shows that the UK has slightly longer lengths of hospital stay than would be anticipated given its bed base and appears to perform less well than countries with similar baseline acute bed capacity (e.g., Ireland, Sweden, Denmark, Norway, Iceland, Israel and the Netherlands).
Looking at total average length of hospital stay may also mask issues in England’s comparative performance for specific patient groups. For example, a study looking at differences in use of health care among older, frail adults across 11 OECD countries found that English hip fracture patients spent 29.3 days in hospital on average in a year – second only to Germany and more than three times Dutch patients.6 Likewise, the UK’s relative length of hospital stay is higher when comparing different diagnostic categories such as mental and behavioural disorders where UK patients spend on average 35 days in hospital compared to the European average of 25.7
International comparisons of this kind, however, are fraught with complexity and often raise more questions than they meaningfully help to answer because performance indicators are measured and defined across systems in different ways. There are also different demographics and patient case mix across countries, as well as the broader socioeconomic, political and cultural context in which health systems interact that influence outcomes and affect each system’s relative position. For example, length of hospital stay in different countries may be influenced by variables such as the number of people who live alone and have access to informal carer support.
At the same time, these comparisons may also point to different strategies or approaches that might impact overall performance and offer a new way of thinking about the root causes of systemic problems and their potential solutions.
In the section that follows, we offer five reflections as to what might distinguish England from other countries that appear better placed to support timely discharge and provide more responsive care outside of hospital. These insights are based on a review of existing research, as well as discussions with country informants. We focus primarily on the countries identified in Figure 1 above that have similarly low acute bed bases but shorter average lengths of hospital stay than the UK, and therefore raise important questions about what might be different in these systems that English policy makers should take note of.
Learning and opportunities from international experience
1. Shifting the balance of spend towards non-acute and community health and care services
An important observation is that most countries with similarly low acute bed bases and shorter lengths of hospital stay have tended to direct more of their health care spend towards non-inpatient services. This is true in the Netherlands, Sweden, Denmark and Norway – all of which allocate a higher proportion of their health spend towards outpatient and out-of-hospital care, including both prevention and long-term care services. The available data does not allow for direct comparisons between hospital and community care spend in each country (see data notes for Figure 2 on definitions) but does provide an indication of the balance of resources between inpatient and non-inpatient services. This is also substantiated by policy reforms and context in different countries (see Lesson 2 below).
Figure 2 shows that the Netherlands, Sweden, Denmark and Norway spend 62%, 60%, 58% and 55% respectively on outpatient, prevention and long-term health care compared to the UK’s 52%. Ireland is an exception and allocates slightly less than the UK on outpatient, long-term care and prevention, though recent reforms have focused on shifting more spend away from hospital and into community delivery.8 In Ireland, out-of-hospital care also requires higher levels of out-of-pocket spend relative to these other countries – which may influence utilisation and relative distribution of spend. Iceland spends similarly to the UK on non-inpatient services.
Another way of understanding differences in community capacity and how resources are allocated is to look at differences in the availability of beds outside of hospital. Many OECD countries have had long-term strategies to reduce the number of acute beds while increasing nursing and residential home or rehabilitation beds to bring down length of hospital stay and rates of hospitalisation. We see this particularly in some countries with shorter length of hospital stay and relatively low levels of acute bed stock, like the Netherlands and Sweden. The UK has 7.9 long-term or residential beds per 1,000 people, ranking just below the OECD average.
Here again, the number of long-term residential and nursing care beds is only one barometer of differences in community capacity, which includes a much broader range of services and social supports. Some countries like Denmark and Norway have emphasised expanding social and nursing support for people living in their homes more than other systems, which may explain their low number of residential long-term beds relative to other countries.9,10 Other systems with younger populations (like Ireland and Iceland) may require fewer nursing home and long-term care beds overall.
England has also aspired to redirect more resources outside of hospital, but strategy has not been matched with investments to actually deliver on those plans. In fact, growth in spending and treatments delivered by hospitals between 2000/1 and 2017/18 outpaced that found in primary care and community services over the same period.11 Likewise, the National Audit Office found that the proportion of the NHS budget spent on primary care and community services fell between 2015/16 and 2018/19, despite policy commitments to the contrary to redirect spending away from acute services and towards new models that delivered more care in the community.12,13
2. Long-term, aligned policy thinking
In some countries, funding allocations reflect long-term reforms that have redistributed resources and capacity towards local community services. For instance, in 2007 Denmark dramatically reduced the size of its acute sector by consolidating hospitals into larger, regionalised units.
The government backed their plans with a DKK 40 billion investment over 10 years in health care capital (about £4 billion 2017 GBP) that went towards building new large-scale hospitals, refurbishing existing health facilities and implementing integrated electronic health care systems to support more joined-up care between hospitals and community partners. Capital investments also helped convert smaller hospitals into intermediate care or step-down facilities to expand community capacity and improve rehabilitation and post-discharge support outside of hospital. Over the past decade, the share of Denmark’s health expenditure spent on inpatient services decreased by 15% as more care has shifted to outpatient settings.14
Evidence on the productivity and quality benefits of Danish reforms have been mixed, but between 2007 and 2015 rates of waiting times and length of hospital stay both decreased.15 As well as shifting resources, Denmark has also strategically reshaped its workforce in this period to enable more community-based models of care. While total full-time employment increased in hospitals by 10% in this period, the number of social and health care assistants employed in hospitals fell by 17% as more of these roles were shifted into the community and out-of-hospital institutions.
While the pressures and demands on acute services in the NHS make it difficult to redirect more spend away from hospitals in the short term, the experience of other countries suggests that delivering more community-based care will take a long-term change in how resources are allocated.
When acute pressures rise, the tendency in the NHS is to reach for short-term solutions and inject time-limited resources to do things like bulk-buy care home beds or step-down beds without recognising the pressures and demands these services will face as a result. We see this in the way that the number of delayed discharges from community hospitals have steadily increased in England as the government has sought to free up more acute beds by boosting step-down care.16 This just moves gridlock further down the pathway and fails to build community capacity in a sustainable way that will shift more care closer to home over the long term.
3. Reformed social care
It cannot be overstated how deeply felt the failure to reform social care and constraints on its funding have been across services. Social care services are vital in their own right, and their interdependence with the NHS is well recognised.17 While data suggests that the NHS itself is responsible for about half of recorded delays in discharge, about 25% of delays this past winter were due to insufficient social care capacity.18 The inability to reform social care and do what it takes to place services on a sustainable footing has resulted in tight eligibility criteria and staff vacancies approaching 165,000 in 2021/2219 – all of which make it difficult to provide timely care to people who need it.
Here we might also learn from northern European countries. Sweden, Norway, Denmark and the Netherlands provide comprehensive social care services to citizens where access is based on need rather than the ability to pay. Each country allocates more of its total health spend towards long-term health services (see Figure 2 above) and all are ranked among the top OECD countries in terms of how much each spends on long-term health and social care as a share of GDP (Figure 4).
Netherlands was one of the first countries to implement a universal public long-term care insurance scheme with broad entitlements – covering nursing home care, home health, community-based mental health care and social assistance.20 In Sweden, Denmark and Norway, social care is primarily tax-funded and delivered through local councils with caps on maximum payments defined through law.21 One of the results has been that a large number of older people receive more formal care within long-term care institutions or at home in these countries relative to other OECD countries – and this is one attributing factor to these system’s relatively short length of stay in hospital.22,23
Of course, northern European social care systems are rooted in different political and historical contexts that may be less transferable to England. Nor has building sustainable social care capacity been without challenge in these countries. For instance, policy makers in the Netherlands and Sweden have had concerns about the over-reliance on institutional forms of support that do not necessarily reflect good value for money. This has led to reforms in each country that have tightened eligibility of services and increased reliance on informal carer support over time – though it should be said that social care entitlements in the Netherlands and Sweden are still generous by European standards.24,25,26
Challenges aside, what sets these countries apart is a willingness to reform and prioritise social care – acknowledging that social care services provide essential non-acute capacity needed for a functioning system. Reforms can have unintended consequences and involve trade-offs, but as we have learned in England, the alternative of doing nothing and failing to support a functional system will only make the issues driving system failure and sustainability more intractable and harder to resolve.
4. Genuine local autonomy
Another key feature of some health systems with greater out-of-hospital capacity and shorter lengths of hospital stay has been the degree of local control and accountability over community health and social care services and post-discharge support. In Denmark, Norway, the Netherlands and Sweden, higher levels of spend outside of hospital has also happened alongside greater devolved responsibility for community health and care services to local commissioners and municipalities.
In each country, local councils are responsible for providing and ensuring quality of social care services and post-discharge health services such as home care, rehabilitation, step-down care, community nursing and social assistance. They are autonomous in terms of how these services are provided, including how needs are assessed and care pathways are defined. In general, greater decentralisation affords municipalities greater control over how to design services that reflect their local communities, and therefore may be better able to deliver targeted and tailor-made support that reflects population differences.
Alongside greater ownership, in some systems localities also have strong financial incentives to reduce delayed discharges and support people outside of hospital. In Denmark and Norway, for instance, municipalities must cover the cost of hospitalised treatment or pay a fee to the state or regions if they are unable to accept patients otherwise medically fit for discharge.27 (Similar rules have also been applied in England under the 2014 Care Act, but these may be a more effective lever in systems without the same mismatch in supply and demand in long-term and community services – see discussions above).
But increased decentralisation has also involved trade-offs and here the experience of other countries is also instructive. For one, municipalities have greater policy discretion in other countries to define the type and extent of assistance to be delivered, and the extent to which co-payments apply. This will lead to greater local variation and ‘post-code lotteries’, which in the English context have been politically unpalatable and can contribute to health inequalities. However, in many systems localities have well-defined “must” tasks related to health nursing, rehabilitation and home care, which counteracts this somewhat.
It is also important that decentralisation happens alongside adequate support and preparation if localities are to take on greater responsibilities. This has been a lesson in Norway, where studies suggest that placing more accountability on municipalities to oversee out-of-hospital care has affected localities unequally. Those with greater budget constraints reported insufficient numbers of qualified staff and equipment to take on additional tasks needed to deliver high quality home care services.28 Likewise in the Netherlands, evaluations of long-term care reforms concluded that smaller municipalities had insufficient capacity to carry out their new responsibilities properly and that the government may have been over-optimistic about the efficiency gains of decentralisation as a result.29
In England, greater local control and accountability for service delivery and design has been consistent in policy rhetoric, but in reality the NHS remains an outlier in terms of the degree of centralised planning. There is hope that as integrated care boards (ICBs) become more established, local systems will assume more responsibility for the planning and funding of services – but in doing so it will also be important that they are sufficiently supported to absorb additional capacity. As in other countries, this has often been overlooked and has undermined ambitions to support genuinely devolved decision-making and delivery in our own context.
5. Alignment of incentives and joined-up delivery to enable integration
Another key distinction between these systems and England is that for the most part, accountability for both community health and social care services both fall to local municipalities, whereas in England accountability tends to be split between local councils and the NHS.
Having joint control over both health and social care community services may have made it easier in some contexts to align incentives, share data and deliver more integrated support. For example, in Denmark experts have cited this as a key enabler in being able to set up and sustain integrated multi-disciplinary teams based in the community. Municipalities, for instance, have full responsibility for determining the appropriate level of health and social support needed following discharge from hospital. Assessment processes will typically include follow-up home visits from GPs, nurses and different community-based staff to assess an individual’s health, functional and social needs – all funded and overseen by municipalities.
Most localities in Denmark have also set up community-based emergency teams that have been cited as a key tool in preventing admissions, reducing re-admissions and shortening hospital lengths of stay. These teams work across settings to treat acutely ill patients with short-term care needs at home or in acute beds based in municipal care facilities. They include nurses with specific training and equipment that make it possible to provide treatments like intravenous therapy and acute nursing in patient’s homes previously limited to hospitals.
The NHS has similarly sought to establish greater multi-disciplinary working and community-based rapid response teams to keep people well and out of hospital.30 And while positive innovations and well-established models of good practice exist,31 misaligned incentives and disjointed governance arrangements have made it difficult to scale more integrated and flexible models of care. Cultural differences and limited histories of joint working across health and social care have hindered integration in some areas, and have made things like joint needs assessment a challenge.32 The split between health and social care has also contributed to a fragmented and complex landscape for community-based support, with acute hospitals often having to navigate multiple routes that cut across health and social care (each with different requirements) to discharge patients – all of which can make it difficult to transition patients into intermediate and other step-down services.
But it should also be said that these other countries are not immune to coordination challenges. While health and social services may be more joined up in the community, accountabilities are still split among regional, national, and municipalities and private structures in the health systems discussed here.
In Denmark, this has at times undermined continuity of care between acute and community services, which are governed by different organisations and payment schemes. While some supporting tools have been put in place to alleviate this (e.g. greater shared data between regional and municipal health teams at time of discharge), health care planning has been disjointed in other areas. For instance, as policy has emphasised redirecting more care outside of hospital, the acute sector has struggled to retain staff and expertise in key roles. This has been especially problematic in the recovery of the pandemic when the number of nurses working in hospitals has flatlined as high numbers of staff leave public hospitals to work in other parts of the health sector, like community care.33
Conclusion: What does England get wrong that other systems seem to get right?
In this piece we raise different hypotheses that might explain how other countries with similar constraints have been better able to build community capacity.
It’s clear when looking to other countries that reforms and strategies in the NHS have not been backed to the same degree by long-term reallocation of resources and aligned policy making needed to support more community-led service delivery. Too often, the NHS has tried to fix problems in the middle of a crisis rather than invest over time in the staff and capital infrastructure needed to enable more integrated ways of working and deliver care closer to home. This short-termism and disconnect is exhibited in the way that the government has consistently failed to reform social care. It's also apparent in the way that the NHS is seeking to expand community models of care like virtual wards after years of cuts to community and district nursing staff needed to make any home-based delivery of care work.
Other countries have also more meaningfully enabled local integration and autonomy, which may have placed these systems in a better position to deliver out-of-hospital capacity. While these have been consistent aims of NHS policy, both have remained elusive – in part because reforms have concentrated more on changing administrative processes without aligning incentives and meaningfully delegating local control.
When we look to what sets other countries apart, what stands out are differences in how they have approached system fundamentals that might support more proactive and responsive care outside of hospital. While debates on how to fix the NHS have focused on things like whether its tax-based design is failing us (systems described here represent both social health insurance and tax-based models), this misses an opportunity to interrogate more glaring issues that seem to hold us back relative to our international peers. Without getting the basics right – and backing ambition with long-term, aligned policy making that supports meaningful shifts of resources and delegations of power – it’s hard to see how we end up anywhere but where we’ve started.
Reed S and Dodsworth E (2023) Building community health and care capacity: Reflections from other countries. Briefing, Nuffield Trust.