Hospital and community services

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Reacting to a report from the Health Select Committee suggesting that the NHS faces ‘one of its greatest challenges’ dealing with patients with long-term conditions such as diabetes, Professor Stephen Peckham says that delivering care in the community may prove more expensive than hospital care.

He said: ‘Shifting services from hospitals to the community is difficult and complex but essentially the right thing to do for many people. Many patients would prefer community-based support -although as the recent Pilgrims Hospices saga has demonstrated – closing any in-patient beds (even outside of the NHS) is very contentious.

‘However, no one can say what the correct balance between hospital and community care should be. It will require additional investment in community services, which will first lead to an additional cost pressure – you cannot simply close down hospitals or parts of hospitals and then create community services. Delivering care in the community is not necessarily cost-saving and may be even more expensive than hospital care.

‘The UK’s track record on integrated care – whether between social services and health or within health services – is poor and we do not have good quality evidence to demonstrate that many community based initiatives are effective and provide better outcomes for people. There is currently a lot of support for looking at integrated services and there are models of good practice but these are rarely observed in practice.

‘A study on moving care closer to home concluded that that there is considerable potential to move care into the community and so improve access and convenience for patients. However, important issues of quality, safety, cost and staff training need to be considered as community based services are expanded. Public perceptions are also important. Research on public perceptions of high quality care suggests that people perceive that hospitals are ‘where the experts are’. The public is not convinced that the necessary skills are there in primary and community care for chronic disease management. Concurrent work is also needed to address this perception.

‘Finally attention needs to be paid to the financial and incentive structures in the NHS. Although the shift from acute to primary is difficult to envisage the work around outcomes-base commissioning particularly incentivising joint outcomes might be a building block in this. The Centre for Health Services Studies is involved in contract modelling work with the local NHS. For example, this envisages that the orthopaedic surgeon will get paid when a patient can walk three stairs at home after a hip operation.’

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