The state of community health services in England

Community health services provide essential support to help people stay healthy and live independently at home. There has been a long-standing policy ambition to deliver more services out of hospital and closer to home, although realising this has been challenging.  

The effort put forth by community providers goes largely unrecognised because it is not counted or documented in the same way that other NHS services are. As a result, community services are poorly understood by the public, policy-makers, and even other health and care providers. But it is widely recognised that NHS community services are critical to keeping the whole health system working effectively – not least from the impact that delays in discharging patients from hospital are having on emergency services.

In this explainer, we define community services, describe who uses and provides them, and who pays for them. We also highlight the opportunities and challenges facing community services now and in the future.

What are community services?

Community health services aim to improve the health and wellbeing of people of all ages, including from birth. They also treat and manage long-term conditions, bring care closer to home, and allow people to live independently in their own homes.

Some of the key services delivered include district nursing for older people; health visiting for children under the age of five; podiatry for older people; intermediate care for people recovering from illness or treatment; and speech and language therapy, mostly for children. These are delivered by a range of staff including community nurses, district nurses, allied health professionals (such as therapists), health visitors, dentists and GPs.

Community services are delivered in a multitude of settings, including in people’s own homes, community clinics, community centres, schools and care homes, as well as hospitals. Most services can be provided in a variety of settings. For example, phlebotomy services (drawing blood) can take place in patients’ homes but also in clinics. The way that care is provided varies across local areas based on historical decisions, and on providers’ physical facilities and workforce availability, among other factors. As a result, services can look very different across local areas.

Many community health services are provided by voluntary sector services. One example where voluntary sector provision is important is end-of-life care. Some areas have specialist palliative care services, run by independent hospices, which have significant charitable funding, whereas other areas are more reliant on end-of-life care from community nursing teams and GPs, with more limited access to specialist services at home.

Community health services work alongside social care services, but community health services are distinct from social care. Although both can be delivered to people at home, community health services address health needs and are delivered by clinicians, while social care focuses on personal care, such as washing and dressing, taking medication, preparing and eating meals, and household activities. Individuals may often have a combination of health and social care needs, and require support from both community health and social care teams.  

Who uses them?

It is estimated that over 100 million contacts are made with community services each year – these could range from a visit from a district nurse at home, a child attending a speech and language clinic, or a patient getting a blood test. People with more complex health needs may need care from several different community services, and in some cases services are provided by multi-disciplinary teams which aim to coordinate support required to meet a patient’s needs. 

Care can take place face to face, via telephone, or online. Typically, 60% of all contacts are made with older people and the rest are split evenly between working-age people and children and young people (see the table below).   

Who uses community services?

Source: NHS Digital. Not all providers submit to the community services dataset, and recording has increased over time.

One of the challenges faced by community providers, commissioners and analysts alike is how to account for the volumes and intensity of the care provided. The term ‘contact’ is interpreted differently across services and the country – creating room for error in estimates. Care providers’ contacts with the system are meant to be counted in a community services dataset, but currently only a proportion of providers are submitting data returns, and when they do submit data there are very few mandatory fields, leading to incomplete returns.

Services are organised in many different ways, which makes comparisons between services a challenge. What is recorded as community nurse contacts in one area may be a multi-disciplinary team contact elsewhere, if services are organised geographically. The data gaps make it difficult to understand not only activity, but also the workforce, spend and quality in community services.

Who provides community health services?

The organisations

The organisations that provide NHS-funded community services are often grouped into a few categories, including trusts (acute, mental health, community and combined NHS trusts), community interest companies, private providers, local government and the third sector. The varied organisational arrangements reflect the impact of successive NHS reorganisations, and community services being put out to tender.

Until data collection improves, knowledge about who is providing which services relies on snapshots captured in research studies or unpublished data. Information collected by NHS England, obtained by FOI, identified 814 providers of community services in 2020/21, which includes community interest companies as well as for-profit providers. Non-NHS providers outnumber NHS providers, but many are small organisations, and between them they provide about a fifth of services, based on contract value and number of contacts (see chart below).

The workforce

The organisations described above employ a broad range of health professionals such as community nurses, district nurses, allied health professionals (including physiotherapists, speech and language therapists, occupational therapists and podiatrists), health visitors and dentists. Medical input into care is most often provided from GPs, but other specialities are involved depending on the service provided.

Combined community staff make up an estimated one-fifth of the total NHS workforce. Information collected by NHS England estimates that, across providers commissioned by the NHS, 33% of community service staff are registered nurses, 25% are health care assistants and unregistered staff, 21% are allied health professionals, 18% are other non-clinical staff, and only 2% are medical¹. The make-up of staff groups will vary substantially between services.

The numbers of people working in community services are difficult to determine from NHS workforce statistics, which do not capture where staff work in a consistent way. This is a particular problem for staff groups that work across community and acute hospital settings, such as therapists. Even for community nurses (see the chart below), who can be identified more easily in workforce data, staff who work for non-NHS providers are not included in NHS statistics.      

District nurses manage teams of community nurses and support workers, as well as visit house-bound patients to provide advice and care, such as palliative care, wound management, catheter and continence care and medication support, particularly for people recently discharged from hospital or near end of life. In a patient’s eyes, district nurses are often the lynchpin between primary and social care, hospital teams and care homes. The fall in district nurses in 2012/13 is likely to reflect some community services moving out of the NHS. However, this is unlikely to explain the continued decline in district nurse numbers.

Health visitors are specialist public health nurses who typically work with families with children under the age of five years. There was a national target to boost health visitor numbers by 4,200 between 2011-15 but, while a rise was seen, the target was missed. Since the target was not renewed in 2015, the number of health visitors has fallen by almost 40%. In 2015, commissioning health visiting services became the responsibility of local authorities, and the fall in numbers of NHS-employed staff may in part reflect a shift from community interest companies or independent sector provision – estimated to be about 10% of health visitors in 2019 - but is also likely to reflect the lack of a national impetus to maintain health visitor levels.

The precise reasons behind these drops in numbers across community services can be difficult to pinpoint. With regard to district nurses in particular, a recent survey found challenges to staff sustainability such as unmanageable caseloads and insufficient time to provide care, regular unpaid overtime, lack of IT to undertake the job efficiently, and an ageing workforce heading for retirement. A lack of training and development was also reported as a key factor influencing those looking to leave. Signals are negative from wider community services staff as well.  

Community service providers have raised concerns about vacancies, recruitment and retention. Unless these can be addressed, it is difficult to see how the NHS can sustainably deliver safe services. The result of shifting services out of hospital without addressing workforce and funding challenges will mean increasingly task-focused crisis care with less opportunity for thorough assessments and preventative care, increased caseloads for staff (possibly leading to burnout), and longer wait times for services such as outpatient appointments.

How are community services regulated and how is quality assessed?

All health and care services are regulated by the Care Quality Commission. The most recent ratings (reported in October 2022) found that 75% of all core community services rated as good and 13% rated as outstanding.

Yet the fine print underneath these ratings suggests that the CQC finds it difficult to regulate community providers because they are often part of a pathway, but may not deliver a whole pathway. This makes it difficult to assess their impact on outcomes. From 2023, CQC will have responsibility for regulating integrated care systems, and not just individual providers.

At a national level, performance management of community services has been fairly limited until recently because of a lack of national data on community services, although programmes like the NHS Benchmarking Network aim to fill this information gap.

Two community response standards have been introduced: crisis response care within two hours from any referral source, and reablement care within two days from any referral source except a hospital ward/bed. The standards aim to support people to stay at home and reduce escalation of care to other settings. Reporting against the two-hour community response began in March 2022, although not all providers are yet reporting data consistently.

Reporting against the two-day reablement standard is expected to start from March 2024. The targets aim to determine where and to what extent crisis capacity should be enhanced and strengthened, so that people receive appropriate and timely care in their home/usual place of residence. It is possible that new measures will be added, in line with increased and improved data collection from providers.

There is a long history of community services designed to prevent hospital admissions. The new data flows on urgent community response may provide insight into activity and the numbers of people supported by services aimed at helping people to stay at home. However, within the context of an ageing population, it is not clear that there will be a significant impact on hospital capacity or reducing admissions.

How are community health services funded?

Comprehensive information on funding and spending by community services is as elusive as information on staff. 

Income data is available for NHS community trusts, but this will not include community services delivered by acute, mental health or combined trusts. Data collected by NHS organisations on the cost of services is more complete, but still does not cover services provided by non-NHS organisations. 

However, both of these sources suggest that the trend in spending on community services has been flat, which indicates a real-terms cut, once inflation is taken into account. Prior to Covid, spend on community activity was £5.44 billion in 2018/19, and £5.43 billion in 2020/21. This was around 7.4% of the £72.5 billion total spend by NHS providers on identified and costed forms of patient care. Spend increased to £6.4 billion in 2021/22, including Covid-related costs. The income of the 18 NHS provider trusts identified specifically in the accounts as “community trusts” (on the basis of their primary activity) was £3.2 billion in 2019/20, and £3.5 billion in 2020/21. Over those same years, NHS providers reported £7.6 billion and £7.7 billion respectively in income for community services.²

Neither of these sources take account of non-NHS providers – for which spend is about 20% of the total, based on data collected from NHS commissioners by NHS England (see the first chart above).

One of the largest challenges to the funding of community services on the NHS side is that the absence of routine data on activity makes it more difficult to make the case for increased funding. Historically community services were paid for under block contracts, unlike acute hospitals which had activity-related contracts and high-profile national targets. Nor do they have their own performance fund like primary care networks. On the local authority side, funding is being challenged because of the cost pressures of funding social care.

New community currencies aim to improve transparency in paying community providers (so they can be paid in the same way that acute hospitals are paid) by having community staff regularly assess people’s needs for care (which is especially important to do when needs are fluctuating), and assign the level of intervention required. Challenges may arise if the amount of work carried out by community providers exceeds allocated budgets.

What are the opportunities and challenges for community services?

Last July, integrated care boards were established in England, with the goal of improving coordination and collaboration of services, centred on the patient, and meeting population health needs. Community health services are central to this vision of integrated health and social care, working as they do with the most vulnerable patients and providing care at or close to home. 

Community services are also a critical building block of a number of service developments that aim to extend care outside of hospital, and are recognised in the latest recovery plan for urgent and emergency care. These include virtual wards – intended to enable patients to be monitored and cared for at home, rather than in a hospital bed. These also include a programme to enable discharge from hospital by assessing patients' ongoing care needs outside of hospital, as well as community diagnostic centres, which are aimed at speeding up diagnosis and getting patients to the right services more quickly.

But these initiatives are happening against a background of intense pressure across health and social care. There is a risk that dealing with immediate crises of ambulance delays and overcrowded A&E departments will squeeze out the time needed to establish new services and improve how services work together. Leaders of integrated care boards are already reflecting that their focus is on acute provider performance rather than broader work to improve population health. Despite the central role of community health services to ensure these initiatives are successful, the NHS does not have a strong history of shifting the focus of care away from acute hospitals, and very often the development of new community services identifies unmet needs, without reducing the use of acute care.

Better data about services provided in the community, staffing, and expenditure will be critical to enable local systems to prioritise how resources are deployed to meet the needs of populations. Looking ahead, services such as rehabilitation and end-of-life care, as well as the role of community services in reducing health inequalities, need to have a much higher profile.