Title: Understanding the role of adult community health services in avoiding hospital admissions
Funder: Department of Health and Social Care

Abstract: BACKGROUND_x000D_ Adult community health services aim to keep people well and support them to live independently at home. They provide a wide range of services including nursing, rehabilitation and end of life care. Providing care in the community may reduce the risk that people need to go to hospital, but the evidence on this is weak. The demand for community services is growing, putting services under pressure. We need to know more about this rising demand and the best way for the NHS to manage it._x000D_ _x000D_ AIMS_x000D_ We want to find out how rising demand has influenced the delivery of community services, how this affects hospital use, and whether there are inequalities by ethnicity, deprivation, and rurality. We can then set out a case for investment in community services to get the best outcomes for patients._x000D_ _x000D_ We want to understand:_x000D_ • How peoples’ needs for adult community health services are changing over time and how this varies across England_x000D_ • How services are changing to meet these needs, and if some areas are doing better than others_x000D_ • How the NHS makes decisions locally about which services to provide_x000D_ • If community services keep people out of hospital_x000D_ • The costs and benefits of providing care in the community compared to hospitals_x000D_ _x000D_ PATIENT AND PUBLIC INVOLVEMENT_x000D_ We talked with patients about our plans, and added inequalities to our overall aim based on what they said. They also told us services can be difficult to access, and so we will look at this. Our research team includes a patient co-applicant with lived experience of using community services. A dedicated PPI panel will act as critical friends, guiding our focus, interpretation, and dissemination._x000D_ _x000D_ WHAT WE WILL DO_x000D_ We will use two complementary methods; data analysis and staff interviews._x000D_ _x000D_ First, we will look at data on population health needs and see how these have changed over time in different areas of England. Next, we will examine how the number and mix of staff working in community services has changed over the same period and compare this with population needs. Until recently, there was no national information on the care people receive from community services. We will use a new data set on all the contacts that patients have with NHS-funded community health services in England, to see if there are differences in care between areas._x000D_ _x000D_ Next, we will select four areas of England with different population needs and numbers of community staff. In these areas, we will ask people who plan and fund services (commissioners) and people who deliver them (providers) about how they decide which services to provide locally._x000D_ _x000D_ We will then analyse data on hospital visits to see if the amount and type of community services provided is related to the amount of time people spend in hospital. Finally, we will examine whether providing more care in the community frees up NHS resources by reducing the need for hospital care. We will also explore how increasing community services affects other outcomes, such as patient access and NHS staff wellbeing._x000D_ _x000D_ WHAT DIFFERENCE THIS WILL MAKE_x000D_ People are living longer, and so need community services more than ever. Our research will check whether community services are keeping pace with increasing population needs, and whether these services can keep people out of hospital and improve their lives in other ways. This work will enable the NHS to consider the case for investment in community services, improving access and outcomes for patients

Lay abstract: BACKGROUND_x000D_ Adult community health services aim to keep people well and support them to live independently at home. These services interface with most of the wider care system. Provision may reduce the risk of hospital admission, but the evidence is weak. There is little evidence on how to organise and deliver these services to meet rising patient demand. _x000D_ _x000D_ AIMS AND OBJECTIVES_x000D_ Our overall aim is to examine how rising demand and limited investment in adult community health services has influenced their provision and affected hospital admissions, how this varies by ethnicity, deprivation, and rurality, and how to develop the economic case for investment._x000D_ _x000D_ Our five interlinked work packages (WPs) have the following objectives, to: _x000D_ 1. Estimate how demand for services has increased in each area of the country_x000D_ 2. Examine how supply of services in each area has responded to increasing demands _x000D_ 3. Understand how commissioners make decisions about investment in community services and how providers allocate resources _x000D_ 4. Analyse how gaps between demand and supply of community services influence use of hospitals_x000D_ 5. Summarise how investment in community services affects the costs of hospital care and a wider set of outcomes_x000D_ _x000D_ METHODS_x000D_ WP1 Demand: We will estimate how demand for community services has changed over time in each English local authority by identifying drivers of demand and combining these with data on changes in population composition._x000D_ _x000D_ WP2 Workforce and supply: We will identify relatively under-served areas by comparing time-series data on workforce to population demand from WP1, and by relating new national data on community services activity to population characteristics. These longitudinal and cross-sectional multivariable regression analyses will highlight areas with potential issues in patient access, variation in care provision, and workforce pressures._x000D_ _x000D_ WP3 Commissioning and planning: We will interview managers in four case study sites to understand how commissioners decide on investment in community services, and how providers allocate their resources. We will explore mechanisms by which supply reacts to demand and factors determining investment decisions. We will develop recommendations on how to improve allocation of resources for community services._x000D_ _x000D_ WP4 Impact on hospital use: We will relate community service provision to hospital use in aggregate and person-level multivariable regression analyses, taking account of local primary and social care provision. We will examine whether the relatively under-served areas identified in WP2 have higher levels of hospital activity, and whether community service provision affects hospital care at patient-level. We will use panel data and instrumental variable regression techniques to see if these associations are causal._x000D_ _x000D_ WP5 Economic case for investment: We will estimate the extent to which any reductions in hospital use identified in WP4 offset the costs of investment in community services. We will then analyse how community service provision relates to wider outcomes valued by patients, providers, and commissioners._x000D_ _x000D_ _x000D_ IMPACT _x000D_ We will produce detailed evidence on how community services can meet future population demands. We will show the impact on hospital use and develop recommendations for commissioning practices. This will help the NHS make a comprehensive case for investing in community services to improve access and outcomes for patients.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE