ICBs should be required to have executive-level leadership for primary and community health services to support the shift of care out of hospitals, a report from The King’s Fund recommends.
The report What should national policy-makers do to make care closer to home a reality?, published today, highlights that ICBs have higher representation from acutes and it called on the government to recommend proportionate representation of sectors rather than organisations.
‘Although each acute trust will be represented on ICBs, that is not the case for each primary care or community care services provider. While primary care representatives on the board are tasked with representing their whole sector, acute trust chief executives will represent each individual organisation.
‘If the focus of the system is to be primary and community services, then those on the board should reflect that focus and governance through rebalancing rather than expanding,’ it states.
Hospital spending should be reduced
The report also calls for hospital spending to be reduced to below 50% of the total NHS budget in the medium term. This, it says, would reverse a decade-long trend that has seen hospital expenditure rise from 49% in 2010 to 58% in 2021, while primary care funding has dropped from 28% to just 18%.
Beccy Baird, Senior Fellow at The King’s Fund and co-author of the report, said that without action from ministers, the NHS would remain trapped in a reactive cycle of care.
‘Hospitals in England are well-equipped to care for the most acutely unwell, but too often they’re treating patients whose conditions could have been better managed in the community,’ she says.
‘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,’ she adds.
Resource local leadership
As well as more funds, it says the Department of Health and Social Care (DHSC) should ensure that local leadership, planning and strategic commissioning functions have sufficient resource to drive the required changes in light of the 50% cuts now demanded of ICBs.
‘Without that counterbalance to the power of acute hospitals, it will be harder to deliver the shift needed,’ it states.
It recommends the introduction of new national metrics focused on primary and community care to ensure services are held accountable. This would replace the government’s current performance targets, which were criticised by the report as prioritising hospitals and emergency departments.
The authors argued that they created perverse incentives that diverted attention and funding from preventative and community-based care.
It criticised ‘micro-financial incentives’, which hinder local flexibility and innovation. Instead, financial decision-making should be devolved to ICBs and the GP contract used to allow practices and primary care networks (PCNs) to use funding to meet local needs, it states.
In addition, significant capital investment is needed to address infrastructure and technology issues in community services, said researchers.
Low status attached to working in primary care
The report also highlights that there is a low status attached to working in primary and community services with career paths focused on acute care settings, ‘which are seen to offer better opportunities for pay and progression, with large teaching hospitals considered the most prestigious places to work’.
‘If care closer to home is to be realised, it needs the best managers and clinicians to work in primary and community care settings, and pay and conditions need to reflect that,’ it states.
It recommends that government ensures staff doing the same roles have the same terms and conditions ‘particularly addressing the fact that staff directly employed in general practice, and settings other than NHS trusts, are not subject to Agenda for Change’. An issue that has been amplified by the additional roles reimbursement scheme. It calls for reform of the GP contract so that funding can reflect the changes in primary care.
It said that primary care contracts, particularly for pharmacy, optometry and dentistry, should reflect the funding needed to allow time for these professionals to be part of integrated working, including membership of ICBs.
