Shifting from hospital to community: delivering the promise of integrated care closer to home

In July, government unveiled its 10 Year Health Plan promising a shift from hospital to community. It set out a vision for a Neighbourhood Health Service, with a neighbourhood health centre (NHC) in every community. NHCs will be ‘one-stop shops’ bringing together ‘historically hospital-based services’ like diagnostics and rehabilitation with a wide range of other support such as smoking cessation and weight management – open at least 12 hours a day, 6 days a week.

 The RCP is a long-standing advocate of care closer to home. It is an opportunity to ease hospital pressures, improve patient outcomes, and address long waits for diagnostics and treatment.

We were especially pleased to see the plan commit to NHCs playing an important role in transforming NHS outpatient services after our campaign for outpatient reform earlier this year, and to see government adopting our call to make the NHS App the ‘digital front door to the NHS’. The plan says that by 2035, most outpatient services will happen outside of hospitals, and that through the NHS App, patients will be able to access automated information, digital advice, direct specialist input, and initiate follow-up.

Last month, government announced the National Neighbourhood Health Implementation Programme (NNHIP). There are now 43 areas rolling out the neighbourhood health model across England. Programme leads in each site are working with existing local services to set up new Neighbourhood Health Services.

The findings from these initial areas will clearly be key – local autonomy in design and delivery is key to ensure services reflect local patient needs and workforce makeup. But we also need to see more detail from the government on its neighbourhood vision, and how it will be realised. We need a clear implementation plan, with milestones and metrics for success.

From a physicianly perspective, there are several key areas government must consider to make it work. 

Prioritising integration

The ambition has got to be making sure patients get timely, high-quality care, from the right professionals at the right time, closer to home. As we said before the plan was published, delivering more patient-centred, equitable and sustainable care requires truly integrating the expertise of medical specialists – physicians – and primary care, supported by well-resourced community teams. Patients experience fragmented care and systems that are confusing in part because of a lack of integration between the professionals and teams who are providing care without communication or collaboration.

Government must focus on delivering integration. If the shift is seen as being about buildings, or a reorganisation of services, it will not succeed. It must be a rethinking of mindsets and healthcare delivery. It has to mean creating shared care models, embedding joint decision-making into clinical pathways, clear clinical accountability about which senior decision-maker is responsible at different stages of a patient’s care pathway. We need our digital systems to talk to each other so professionals across different parts of the system can easily work together to support patients more effectively. Investment in digital technology will also be needed to deliver the expansion of Advice and Guidance and patient-initiated follow-up (PIFU). We need local autonomy to design and deliver NHCs that reflect local patient need and workforce makeup, measuring performance based on outcomes and experience rather than just activity.

We have to think about how we can be ‘teams without walls’.

The importance of embedding medical specialist care

It is welcome that hospital doctors are cited as one of the professions that the leads in the 43 pilot sites will draw together to develop neighbourhood health teams, alongside others including community nurses and social care workers, using general practice as the cornerstone. Though often thought of as ‘hospital doctors’, there are many examples of physicians developing and delivering services in the community already.

Neighbourhood health should mean physicians have a more proactive role earlier in the patient’s journey, rather than after a patient’s condition has deteriorated. Without input from the right medical specialist at the right time in the right setting, neighbourhood health risks replicating current problems: fragmented services unable to meet the needs of patients holistically, particularly those with long-term conditions and complex needs.

The skillset of physicians as medical specialists will be critical to healthcare delivery, as well as in upskilling, educating and advising other clinicians in the community on specific conditions and diseases. Through case discussions, clinical supervision, joint clinics, and mentorship, physicians can better support patients to live well in the community. The government must consult with physicians as it develops its thinking on how NCHs will be staffed.

Bolstering the physician workforce will be key, requiring an expansion of postgraduate medical specialty places and the 10 Year Workforce Plan to project which medical specialty places we need to meet patient demand.

Working differently

As neighbourhood health expands, physicians’ roles are likely to evolve, with more work done remotely, and hopefully, more in collaboration with other healthcare professionals.

Many clinicians working in hospital outpatient departments also support acute care delivery. Government must ensure physicians are supported to work flexibly across hospital and community settings – and clearly investment in medical leadership and adequate training to work effectively in a neighbourhood health setting will be needed. The commitment to incorporate neighbourhood skills into the curriculum is welcome and should hopefully embed neighbourhood approaches within physician training. It is critical to ensure buy in from clinicians and that doctors’ day-to-day realities are reflected in how changes are envisaged and implemented.

Increasingly, physicians will provide advice through platforms like the NHS App, offering real-time, case-specific support without the need for an in-person hospital appointment. Again, serious investment in digital infrastructure, strong safeguards against digital exclusion, and adequate support for both staff and patients to use these tools confidently and effectively will be key.

Ensuring NHS care adds value to patients’ lives

There are several areas where we need to see more detail and thinking from government. One is the aim to replace two-thirds of outpatient appointments with services delivered through the NHS App. It’s not clear what evidence underpins this target. We need to understand that. As clinicians, we want to avoid unnecessary appointments, but targets like this risk prioritising the wrong thing. We need to focus on the value of appointments, not the volume.

Our prescription for outpatients highlighted that many don’t add value, leading to non–attendance. If test results can be conveniently accessed through the NHS App, we don’t necessarily need an appointment. And if patients have a clear care plan and understand how and when to get in contact with services, then PIFU is an effective alternative to having routine follow up appointments just because they have always happened.

We cannot underestimate the value of seeing patients in person that digital tools cannot fully replace – there is clearly therapeutic benefit in human interactions. With increased use of the App, we need to be alert to risk of – and take steps to tackle – digital exclusion and people bouncing between systems with unresolved issues so health inequalities do not widen.

Focussing on value is how we will best determine what activities still need to be in person, can be done via the App, or could be minimised or avoided altogether. A focus on volume is likely to result in unrealistic targets that don’t deliver what matters: clinical value to the patient in every NHS contact.

The other is PIFU as default. We must put in safeguards for patients who are unable to advocate for their own health needs, whether because of poverty, time, safeguarding concerns or not having the right knowledge or understanding. Patients will need a clear treatment plan, and clinicians will need to communicate the criteria or symptoms that mean an appointment is needed (rather than because it has traditionally just happened). It is critical that we avoid people delaying seeking necessary care or continuing to request and attend appointments that don’t add value, or becoming confused about how and when to engage.

These will need careful, nuanced thinking to get right.

What next?

We want to hear directly from physicians who are either already delivering care in the community, or who are involved in the 43 sites. How is the model is being implemented where you’re based? Tell us what’s working that we should champion, and what’s not working and worrying you. Send us an email!