One of the questions that is often not explicitly answered is that of why care needs to be delivered outside of hospital, and why we are trying to effect with this so-called “left shift” from secondary to primary and community care.  In the past, lack of clarity as to what constitutes success has caused huge problems with sustaining any efforts to make this happen.

The challenge is essentially an expectation from some that success is achieved when system savings are made.  This is based on the assumption that it is cheaper to deliver care in community settings rather than in hospitals, and therefore shifting care will result in lower levels of system expenditure.

The big problem with this in practice is that whatever care is delivered in the community is always in addition to the work carried out in hospitals.  The size of the waiting lists and (necessary) tolerances for admission based on bed availability means there is no way that carrying out work in the community will actually reduce hospital activity.  Hospital activity is more a function of hospital capacity than of demand, because the demand exceeds the available capacity.

As a result, initiatives that have been put in place get stuck in analyses of individual patients or cohorts of patients to prove lower hospital utilisation to demonstrate the value of the work.  This is ultimately futile because even demonstrating a reduction in expenditure at a patient cohort level does not produce an overall saving as there is no commensurate reduction in acute activity.  If the measure of success is short term system savings then shifting care out of hospital will inevitably fail.

Sometimes the aim (explicit or implicit) is not financial but to reduce the strain on hospitals by shifting routine work to local providers so that they can focus on the acute and complex cases.  Unfortunately, taking away the relatively straightforward work and leaving only the more acute and complex cases actually increases the strain on acutes.  It increases the pressure on staff as there is no balance between routine and complex work, and at the same time can create financial difficulties as often income generating procedures are replaced by loss-making ones.

So in the NHS world of increasing financial and workload pressure it is easy to understand why shifting care out of hospital has never actually happened.  But that is not to say it should not.

There are real benefits that this left shift of activity can realise.  Outcomes for patients can be improved by delivering care outside of hospitals, through offering greater continuity of care in community settings, through enhanced or proactive chronic disease management.  Care delivered in local communities is more accessible, convenient and personalised, which all contribute to improved outcomes for an important cohort of patients who otherwise will place increasing demands on the NHS in the future as their conditions worsen.

Ultimately, delivering care outside of hospital now can prevent the health needs of patients becoming greater in future, creating a more sustainable NHS.

But to have a chance of success, we need to be clear that this is the aim of shifting care from hospitals to the community.  It won’t save money within the financial year.  It won’t reduce short term pressure in hospitals.  It will require additional community capacity and it is a medium to long term investment in improving outcomes.  The explicit (and implicit) measures of success need to reflect this, so that expectations are managed accordingly.  If they are not, we will stay in the same cycle of failure that we have been in for at least the last 20 years.