'We're not there yet!': a qualitative study exploring the commissioning of adult Community Health Services in England to support the avoidance of hospital admissions.

Objectives: The increased use of Community Health Services (CHS) is central to UK policy visions of moving more care out of hospital to reduce pressure across the healthcare system and, in particular, the demand on secondary care, hospital services. CHS are under-researched, and little is known about how they can best contribute towards this aim. The National Health Service (NHS) in England has recently undergone a significant reorganisation, with an increased emphasis on collaborative service delivery. In the aftermath of this reorganisation, the objective of this study was to explore how commissioners and providers of CHS think about the need for services and how decisions are made about the commissioning and allocation of resources in order to facilitate out-of-hospital care.

Design: A qualitative, semi-structured interview study with participants from four case study sites in England. Semi-structured interviews were conducted virtually and transcripts analysed using a reflexive thematic approach.

Setting: Adult CHS, which included two sites with CHS providers embedded in acute hospital Trusts, one standalone CHS Trust and a CHS provider collaborative. Sites were selected for both geographical (two sites in the north of England and two in the South) and organisational model diversity.

Participants: 40 participants were interviewed across all four case study sites (site A, n=10; site B, n=17; site C, n=10; and site D, n=3). To be included in the study, participants were required to have a management role in providing or commissioning adult CHS and/or their understanding of this at strategic level within the Integrated Care Systems.

Results: Themes from current literature on commissioning (organisation, assessing needs, service design and development, contracting and funding, and performance management and support) were used to structure the data. Participants from all sites reported that the reorganisation of the NHS away from Clinical Commissioning Groups to Integrated Care Boards has resulted in confusion around the commissioning function, with a lack of clarity about current roles and responsibilities. All sites were undertaking some form of service review. However, participants highlighted the fact that current population health and CHS service data do not adequately support proactive planning of services to meet rising demand. CHS find it particularly difficult to evidence their contribution to hospital avoidance. Current block contract funding models also limit the extent to which CHS can provide the flexible services required if hospital admission is to be avoided. We also found some tension around the implementation of additional hospital avoidance services (eg, 'virtual wards') which did not necessarily integrate with or complement core CHS services.

Conclusions: Our focus on the commissioning of CHS has highlighted the fact that the new collaborative approach to service design and delivery embodied by the creation of Integrated Care Boards has led to some confusion around decision-making. In addition, the lack of appropriate data and the funding and contractual model used to procure CHS impacts their ability to contribute to the policy agenda of treating more people in the community. These factors should be addressed if CHS are to fulfil ambitions of preventing hospital admissions.