Kings Fund - Call for radical refocusing of health and care system to put primary and community services at its core

• ‘Answer to over-crowded hospitals is not more hospitals.'

• 30 years of policy and implementation failure in moving ‘care closer to home'

• Need for clear vision, with funding, staff and political energy directed at general practice, pharmacy, community services and social care.

The health and care system in England must be radically refocused to put primary and community care at its core if it is to be effective and sustainable, according to a major new report published by The King's Fund.

The report authors argue that the failure to grow and invest in primary and community health and care services, despite successive governments stating a commitment to this agenda, is one of the most significant and long-running policy failures of the past 30 years.

The vast majority of interactions with the NHS are through primary and community services - such as general practice (GPs), community pharmacy and district nursing. On average there are more than 876,164 GP appointments in the NHS every day, an increase of 34,219 appointments a day since 2018/19.

Despite this rise in demand, and despite repeated pledges to boost out-of-hospital care, the proportion of Department of Health and Social Care (DHSC) spending on primary care has actually fallen (8.9% in 2015/16 to 8.1% in 2021/22).1 In 2021/22 the largest proportion of DHSC spending, £83.1 billion, went to acute hospitals, compared to £14.9 billion spent on primary care.

The NHS has received additional funding in recent years, but while acute hospital trusts saw 27% funding growth since 2016/17, community trusts saw just half that level of growth, at 14%.2

Trends in staffing reveal a similar pattern, with the number of NHS consultants growing by 18% between 2016/17 and 2021/22, but just a 4% increase in the number of GPs over the same period.3 There has also been a significant jump in social care staff vacancies rising from 110,000 vacant posts in 2020/21 to 152,000 in 2022/23.4

The authors outline how patients struggling to get appointments with their GP, are at risk of their condition deteriorating and having to seek urgent help from already over-stretched acute hospitals.

In their assessment of the key reasons for this longstanding policy failure, the researchers found that progress has been hampered by an incorrect belief that moving care into the community will result in short-term cash savings. Other factors include a lack of data about primary and community services leading to a ‘cycle of invisibility', funding flows that prioritise hospitals, and urgent challenges such as A&E waiting times and planned care backlogs becoming the priority for politicians tempted by quick fixes instead of fundamental improvement.

The King's Fund cautions that bolstering primary and community care should not mean closing hospitals, noting that England already has fewer hospital beds per capita than other nations.

Instead, the authors call for future funding to be directed into a comprehensive plan to refocus the health and care system towards primary and community care. They warn that a piecemeal approach of cherry-picking policies ‘will not miraculously unlock change'.

The report proposes several steps to begin the shift.

• Vision: A clear vision for bolstering primary and community services, with all policies aligned to achieving that vision, and the political will to stick to the vision over the long term.

• Funding: Future growth in health and care funding needs to be targeted at primary and community services

• Workforce: Incentivise more staff to work in primary and community services through pay, status, career progression, and by considering mandatory primary and community training placements for clinicians and leaders.

• Estate: Prioritise investment in primary and community care buildings and equipment, and cut red tape so organisations can better pool the space they have.

• Flexibility and accountability: Give local health and care leaders more flexibility to meet local needs and hold them to account for improving overall patient care, rather than waiting lists.

• Social care: Without reform of the ailing social care system, the ambition of ‘care closer to home' cannot be fully realised.

Sarah Woolnough, Chief Executive of The King's Fund, said:

‘The answer to over-crowded hospitals is not more hospitals. Despite this being well understood for many years, there is now a higher proportion of the NHS budget and staff going into hospital services. At the same time, there has been a slow erosion of capacity and confidence in primary and community care.

‘Many people across the country will have personal experience of struggling to get a GP appointment, trying to contact other services, and when all avenues have been exhausted, reluctantly going to A&E. It feels like all roads lead to the hospital, but our hospitals are already full.

‘To achieve an effective and sustainable health and care system, politicians and national leaders need to embark on a radical and wholesale refocusing of the health and care system towards primary and community services. Doing so will free up hospitals to treat the patients they are best placed to treat, thanks to many more people being diagnosed and cared for in the community.'

Beccy Baird, Senior Fellow at The King's Fund and lead author of the report, said:

‘Like other countries, England needs to bend the curve on the predicted rise in demand for high-cost, reactive and hospital-based care. That means supporting people to take care of their health and wellbeing, intervening early and keeping people healthy at home for as long as possible, which can only be achieved by bolstering primary and community services.

‘While these changes may not unlock the quick-fix savings many mistakenly expect, the alternative is to build more expensive hospitals to manage acute needs that could have been prevented or better managed in the community.'