The government should mandate the rebalancing of NHS funding towards primary and community services and overhaul existing hospital-focused performance targets in order to deliver its reform plans for a sustainable NHS, according to a new report from The King’s Fund.
The health and care charity is calling on the government to rebalance NHS spending towards primary and community care to make sure those services are able to provide the care and treatment the public need to stay healthy. This could be achieved through returning hospital spending to below 50% of the NHS budget over the medium term. The report authors also call on ministers to review the current, hospital-focused targets regime that they find hinders progress towards a more sustainable NHS that reduces people’s need for hospital treatment in the first place.
The King’s Fund has argued that the 76-year-old NHS is stuck in 1948 with a model of care based on patients getting sick, being patched up and sent home.
Latest figures show that 1 in 4 people in England live with one or more long-term conditions, many of which will never be cured but will require constant management and support. To meet this shift in patient need, the NHS needs to focus far more on services in the community, such as GPs, district nurses, pharmacies and occupational therapists, that support people to stay well and independent, not just those that treat them when they are acutely unwell.
The Labour government has committed to shifting the focus of the NHS towards primary and community services as one of its three ‘big shifts’ which will be delivered through the NHS 10 Year Health Plan, due to be published this spring.
This new report builds on previous research by The King’s Fund which found that over the past 30 years successive governments have failed to deliver this ambition of moving more ‘care closer to home’. Researchers at the charity studied past failed attempts to shift focus to primary and community services, analysed national and international research into what others have done to shift how health services are delivered, and interviewed national policy-makers and frontline healthcare leaders. The authors set out what this government needs to do differently to succeed this time, outlining the key policy ‘levers’ available to the Secretary of State for Health and Social Care if he is to deliver this change.
The authors highlight NHS funding flows that prioritise hospitals, and urgent challenges such as A&E waiting times and planned care backlogs becoming the priority for politicians and crowding out more fundamental improvement. This focus of money and attention on hospitals contributes to a vicious cycle of patients struggling to get appointments with their GP, risking their condition deteriorating and having to seek urgent help from already over-stretched acute hospitals.
The proportion of NHS spending allocated to acute hospital services has risen over the past decade, from 49% in 2010 to 58% in 2021. Over the same period the proportion spent on primary care has declined, decreasing from 28% to 18%. The King’s Fund is recommending the government rebalance the proportion of NHS spending on primary and community care to drive the shift towards delivering more care in the community, such as steadily reducing hospital spending to below 50% of the NHS budget.
The report authors also urge ministers to urgently review existing hospital waiting-time targets, arguing that the government’s dominant focus on reducing waits for elective care will distract from the much bigger prize of shifting to a more community-focused system.
The authors conclude that ‘what’s measured is what matters’ in government policy: current national targets overwhelmingly focus on hospital and emergency care, leaving little incentive for health care leaders to prioritise community-based services. As part of delivering this shift, ministers should address the current lack of meaningful national metrics for primary and community services, establishing a new, robust national data set to create accountability for delivering more care in the community.
Additionally, the authors warn that the government’s recent decision to cut integrated care board (ICB) operating costs by a further 50% this year risks perpetuating the dominance of hospitals in how health and care services are planned and delivered and will make the shift from hospital to community even harder to deliver. Ministers must ensure that local health and care leaders still have sufficient resources to drive the necessary changes.
Beccy Baird, Senior Fellow at The King’s Fund and co-author of the report, said:
‘The structure and focus of the NHS has failed to keep pace with changes in disease and ill-health. Hospitals in England are well-placed to support the most acutely unwell, but too often they are treating patients that could have had their condition better managed in the community. An increasing number of us are living with long term health conditions that require regular, ongoing support. Boosting out-of-hospital services can help avoid the need for hospital treatment, meaning better care for patients and better value for tax-payers.
‘For ministers to succeed where their predecessors have failed, they will need to take bold action. History tells us that warm words and soft ambitions won’t cut it – delivering this change will require hard targets, including the mandated rebalancing of funding towards primary and community services. Rebalancing NHS funding away from hospitals may sound counter-intuitive, and may even face some public criticism, but the truth is that the long-term solution to our over-crowded hospitals lies in boosting out of hospital services.’
The report recommends a number of other actions ministers in the Department of Health and Social Care (DHSC) can take to deliver the shift from hospital to community, including:
urgently reform adult social care: Without reform of the ailing social care system, the ambition of ‘care closer to home’ cannot be fully realised. The government should accelerate the timeline for its commission on adult social care to ensure social care services can effectively support the shift towards more community-based care.
empower local leaders with financial flexibility: An estimated 19% of GP funding is tied up in ‘micro’ funding incentives that only pay when a specific task is completed. Government and NHS England should allow GP practices more flexibility to spend funding on what matters to patients in their area. They should also allow ICBs greater autonomy to direct funding towards community services and remove restrictive financial constraints.
invest in infrastructure & technology: Community-based health services suffer from outdated technology and insufficient estate capacity. The report calls for capital investment to bring tech and kit up to date in primary care and changes to perverse financial rules that prevent better use of public sector estate.
