20/124 HS&DR Commissioning brief supporting information: Adult Community Health and Social Care services to avoid planned and unplanned hospital admissions
Closing date: 8 April 2021 (two stage – Stage 1 to Stage 2)
Please note; the following is intended to provide further information on the background of this call but does not constitute an exhaustive review of the literature in this area.
Health and Social Care Context
The NHS Long Term Plan  renewed attention on the importance of Community Health and Social Care Services (CHSCS) in helping to achieve a number of its ambitions such as; to increase community-based care, provide more personalized care, deliver care closer to the home and support people to live independently.
The delivery of community health and social care services has also been recognised for its potential to support other parts of the health and care system such as urgent care and unplanned admissions to hospital. Hospitals are coming under increasing pressure to maintain the flow of patients from admissions to discharge . In 2018-19 there were 24.8 million attendances at accident and emergency departments, an increase of 21% since 2009-10 . Research from the Health Foundation  indicates that the number of patients having to be admitted to hospital as an emergency has grown considerably, increasing by 42% between 2006-2017/18; people being admitted have increasingly complex needs with the largest increases seen in those with five or more health conditions and people aged 85 years of older. This has implications not only for the demand on urgent care services but also for other parts of the healthcare system such as the ability to carry out elective patient treatments due to limited availability of resources.
An important factor affecting the provision and delivery of caring services in the community, are changes in the makeup of the community health and care workforce. As people being cared for in community settings have increasingly complex health and care needs, the care being delivered has also changed significantly, requiring a different skill mix and developing the roles of the community workforce. This, along with the development of integrated care teams has led to a need to expand certain community health and care professions, such as allied health professions e.g. occupational therapy, physiotherapy and dietetics, as well as unregistered roles including healthcare assistants and support workers . Although, as highlighted in the recent NHS Benchmarking network report  on community integrated care teams (CICTs) the majority of care (69%) continues to be provided by nursing professionals, most often District and Community Nursing Teams, this workforce has seen a significant decline in key community roles such as District Nursing. The Queen’s Nursing Institute (QNI) estimates that the number of qualified District Nurses has fallen by 46% in the UK in the last 10 years . Vacancy rates also remain high in Community and District Nursing services at 10%  suggesting that there is greater pressure on teams to meet demand. As well as higher vacancy rates, according to the Royal College of Nursing (RCN) District and Community Nurses have a higher age profile than the wider nursing workforce which may put further strain on services as those nurses retire. Skills for Care, an independent social care workforce charity, estimates that across Adult Social Care 7.8% of roles were vacant in 2018/19, representing an average of 122,000 vacancies at any one time  and these vacancy rates were highest for registered managers at 11.4%, double the average of other managerial roles (5.3%). All independent health and care organisations (i.e. Non-NHS bodies) in England are required to have a Registered Manager under Care Quality Commission (CQC) regulations  and they play an important role in managing and coordinating people’s care.
CHSCS have undergone frequent structural re-organisation in recent years, resulting in a range of provider types and sizes. The majority of adult community health care services are commissioned by clinical commissioning groups (CCGs) who, on average, hold 50 separate community service contracts . With such a large and varied number of providers and health and care professionals involved in the provision of community health and care services, understanding how to integrate and encourage collaboration between services including community, primary care, social services and hospital care is important. This is needed in order to deliver high-quality care that is appropriate and timely to the needs of people and their families being cared for in the community and to avoid escalating health problems that result in a hospital admission. It is also important to ensure models of care are sustainable and able to meet future demand. This is especially important in light of the COVID-19 pandemic in which long term recovery amongst COVID-19 patients for example, particularly amongst vulnerable groups such as older people and those with multiple conditions, is likely to place even greater demand on community health and social care services.
Identified research need
A series of evidence reviews conducted by NICE  recognised the complex range of care delivered by CHSCS. It identified District and Community nursing teams as being well placed to notice a change in condition of a person at risk of an acute medical episode (AME) and the possibility that greater access to District and Community nurses could be cost effective or even a cost saving if it were to prevent an emergency hospital admission. However, there are few economic evaluations and further research is needed fully evaluate this impact. The role of social care services was also reviewed but no evidence was found which would help understand how access to social care services might support a reduction in hospital admissions. NICE recommends that greater access to community care is provided for those at risk of hospital admission or readmission and notes that further research is needed to understand the role of CHSCS in helping to reduce the number of people being admitted to hospital as an emergency which are potentially avoidable.
A 2014 evidence review  of interventions to reduce unplanned admissions from care home settings summarised evidence relating to community geriatrician services, case management, discharge planning, integrated working between primary care and care homes, medicines management, delirium and end of life care. It reported a lack of good quality evidence in all areas highlighting the need to monitor the impact of changes to the delivery of care home services in relation to resource use and patient experience. It would be timely to undertake an update to this review to include new evidence that may now exist in relation to the effectiveness of these interventions and how they can be best utilized in care homes and other community settings.
More recently, a 2018 systematic review  of the impact of integrated care models (including studies from primary, community and hospital based settings) on service outcomes in the UK and internationally found there were positive impacts on patient satisfaction with care, perceived quality of care and access to services, but the impact on hospital-based services (e.g. admissions) was unclear. The review also recommended a need for research to explore how individuals and carers experience integrated care models beyond just measures of satisfaction. This would help to inform how care models should be delivered for particular groups e.g. those with complex needs. A recent (2020) meta-review of systematic reviews  of community-based interventions involving community dwelling older adults found mixed evidence as to their impact on reducing hospital admissions, and highlighted the lack of a social care dimension in many of the systematic reviews and the need to understand the impact of fully integrated health and social care interventions  .
The 2018 Kings Fund report on reimagining community services  identified a number of local innovative projects taking place around the UK to improve community services but there is a lack of widespread change, highlighting a need to understand what is working and identify how successful innovations can be implemented across community services.
An evidence review  commissioned by the Local Government Association (LGA) identified six key enablers of delivering integrated care within community settings these include; co-production, person-centred, place-based, networks models of care, strengths based and prevention/early intervention . Whilst it found many examples of areas where these approaches were improving health and care outcomes at an individual and population level, it was not able to determine how widespread or embedded these ways of working are, or to fully evaluate the impact they are having on health outcomes in the community, due to the relatively short timeframe in which these integrated care systems have been in place. Further research is needed to understand the delivery and outcomes associated with existing models of community health and social care already being implemented in the UK, will help to identify which components are most impactful and understand how these services can be optimised or, in the case of entirely new models of care, which are likely to require greater investment of resources.
The NHS long term plan promises an expansion in the use of digital technology with an aim to increase the amount of time carers/staff spend in direct contact with patients, but poor connectivity in people’s homes and the use of multiple systems has made it difficult to implement and improve access to digital technology in community settings . The QNI Nursing in a Digital Age report  makes a series of recommendations for developing digital technologies for use in community settings and advocates that systems should be specifically designed for staff who work in community settings to ensure they are fit for purpose.
- NHS England. NHS Long Term Plan. 2019. Available Online. Accessed May 2020.
- NICE. Emergency and acute medical care in over 16s: service delivery and organisation. [NG94]. Available online. Accessed May 2020.
- NHS Digital. Hospital Accident and Emergency activity 2018-2019. 2019. Available online. Accessed August 2020.
- The Health Foundation. Emergency hospital admissions in England: which may be avoidable? 2018. Available Online. Accessed August 2020.
- NHS Digital. NHS Workforce Statistics - February 2020. 2020. Available Online. Accessed August 2020.
- NHS Benchmarking Network. Community Services benchmarking deep dive report for Community Integrated Care Teams. 2020. Available online. Accessed August 2020.
- The Queen’s Nursing Institute. Outstanding models of District Nursing. 2019. Available online. Accessed August 2020.
- NHS Benchmarking Network. Community Services benchmarking deep dive report for Community/District Nursing. 2020. Available online. Accessed August 2020.
- Skills for Care. The state of the adult social care sector and workforce in England. 2019. available online. Accessed August 2020.
- Care Quality Commission. Registration under the Health and Social Care Act 2008: The scope of registration. 2015. Available Online. Accessed August 2020.
- Gershlick, B. & Frith, Z. The Health Foundation. Provision of community care: who, what, how much? 2017. Available online. Accessed August 2020.
- Centre for Reviews and Dissemination. Interventions to reduce unplanned admissions from care home settings. University of York. Evidence briefings. 2014. Available online.
- The effects of integrated care: a systematic review of UK and international evidence. BMC Health Services Research, 18. 2018. Available online. Accessed: August 2020.
- Dawson, S., Kunonga, P., Beyer, F et al. Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed-method meta-review of systematic reviews. F1000Research,9. 2020. Available Online. Accessed September 2020.
- Kingsfund. 2018. Reimagining community services; making the most of our assets. Available Online. Accessed August 2020.
- Local Government Association (LGA). Stepping up to the place. Part B: Evidence Review. 2018. Available Online. Accessed August 2020.
- The Queen’s Nursing Institute. Nursing in the Digital Age: using technology to support patients in the home. 2018. Available Online. Accessed August 2020.
Relevant NIHR Studies
12/209/66. HS&DR. A multi-centre randomized controlled trial of comprehensive geriatric assessment in an admission avoidance hospital at home setting. Start; 01/07/2014 End: 30/09/2019. CI; Sasha Shepperd. In Editorial.
RP-PG-0612-20010 PGfAR. Reducing rates of avoidable hospital admissions: optimizing an evidence-based intervention to improve care for ambulatory care sensitive conditions in nursing homes. Start date: 01/03/2015 End date; 31/01/2019 Chief Investigator; Murna Downs
NIHR-RP-011-043 NIHR Professorships: Improve the health and wellbeing of older people and the quality of community care they receive, especially for people living with dementia. Start date; 01/05/2012. End date; 31/08/2017. CI; Louise Robinson.
15/77/34 HS&DR. From programme theory to logic models for multi-specialty community providers: a realist evidence synthesis. Start date; 01/07/2016 end date; 30/06/2017. CI; Rod Sheaff. Available Online.
15/77/25 HS&DR: Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis to inform emerging models of health and social care. Start date; 01/07/2016 End date; 30/06/2017 CI; Frances Bunn. Published Online.
15/77/15 HS&DR: An evidence synthesis of the international knowledge base for new care models to inform and mobilise knowledge for multispeciality community providers (MCPs). Start date; 01/06/2016 End date; 31/05/2017. CI; Alison Turner. Published Online.
12/130/33 HS&DR. Comprehensive Longitudinal Assessment of Salford Integrated Care (CLASSIC): a study of the implementation and effectiveness of a new model of care for long-term conditions. Start date; 01/04/2014 End date; 31/01/2017. CI; Peter Bower. Published Online.
12/209/02. HS&DR. Measuring quality in community nursing: a mixed methods study. Start date; 01/04/2014 End date; 31/12/2016. CI; Susan Horrocks. Published Online.
PB-PG-0712-28045. RfPB. Who knows best? older people’s contribution to understanding and preventing avoidable hospital admissions Start date; 01/04/2014 End date; 01/03/2016. CI; Jon Glasby.
09/1801/1054. HS&DR. Predictive Risk Stratification: impact on care for people with or at risk of chronic conditions. Start date; 01/09/2010 End date; 31/08/2015. CI; Helen Snooks. Published Online.
PB-PG-1208-18013 RfPB. Interventions to reduce unplanned hospital admissions: a systematic review. Start date; 07/06/2010 End date; 06/03/2012. CI; Sarah Purdy
PR-R10-1014-25001 PRP: Evaluation of the Integrated care and support pioneers programme in the context of new funding arrangements for integrated care in England. Start date; 01/07/2015 End date; 31/12/2020. CI; Nicholas mays.
16/116/43 HS&DR. The dynamics of frailty in older people: modelling impact on health care demand and outcomes to inform service planning and commissioning. Start date; 01/03/2019 End date; 28/02/2022. Chief Investigator; Bronagh Walsh
Other Relevant studies
On-going non-primary studies
Euan Sadler, Zarnie Khadjesari, Alexandra Ziemann, Katie Sheehan, Julie Whitney, Dan Wilson, Ioannis Bakolis, Nick Sevdalis, Jane Sandall. Case management for integrated care of frail older people in community settings [Cochrane protocol]. PROSPERO 2018 CRD42018107488 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018107488
Anna Thomson, Ros Kane, Paul Turner, Christopher Bridle. A systematic review of models and processes of integrated care services for older people. PROSPERO 2016 CRD42016043369 Available from:
Age UK. Behind the headlines: the battle to get care at home. 2018. Available online.
Lees, C., Hutchison, T., O’Brien, S. Introducing community integrated nursing teams: how one clinical commissioning group applied an evidence-based approach. 2017. British Journal of Community Nursing, 22 (6).
Kingsfund. Community health services explained. 2019. Available online. Accessed August 2020.