The road ahead for community social and health care

On community health and social care, we can start by looking at data on GP’s surgeries.

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Gen Maitland Hudson

Head of Evaluation and Impact Measurement

What does a community business dedicated to health and social care look like?

As we publish our review into community-centred mental health, it’s worth having a think about what a community business working in this area could look like.

This isn’t a case study masquerading as a blog. Rather than look at one, or even several, examples, I want to think about the footprint that might make for a viable community business working in health and social care. This means considering two questions in particular:

  • How many people would it need to serve?
  • What would viable turnover be for a dedicated healthcare CB?

 

Typically, at the moment, if a community business is delivering care, it is usually through a small grant or contract with a local authority for social prescribing or green care. That might make a contribution to a mixed income model, but it won’t keep a business afloat.

There aren’t many existing models of community businesses that are solely reliant on healthcare budgets (mixed or otherwise), which means we have limited data on the turnover necessary for a health and social care community business to be sustainable.

There are, however, any number of independent businesses that operate entirely on their trade with the NHS in every local neighbourhood. We don’t typically think of them in that way, but every GP’s surgery is an SME paid by public sector contracts. And we know quite a bit about their numbers and business models, not least because much of this is fixed centrally through contractual agreement:

  • The average number of patients served by a GP practice in England is 7,500
  • The average payment for each patient in 2017-18 is £171.20
  • That makes average GP surgery turnover somewhere in the region of £1.3 million
  • The average GP has a personal list of 1,800 patients
  • That makes an average number of 4 full time GPs in every surgery

 

And these numbers are going up. The average GP list is about 15% larger than it was in 2004, when it was 5,500.

There has been a good deal of change in the last 13 years on establishing economies of scale in primary care: the footprint of community care is getting bigger, not smaller.

We also know quite a bit about the number of patients served by practice nurses, the number of administrative assistants needed for each GP’s surgery. There are even calculators for working out how much resource you need for managing phone calls.

Practice Index did some rough calculations on the numbers, and concluded that a GP practice serving 15,000 patients would need 3.75 practice nurses.

When considering that figure it is worth noting that a 2015 NICE evidence review failed to find any evidence that there is a given number of community nurses needed to guarantee safe staffing. This suggests that the numbers are driven not by evidence and need, but by commercial viability.

These ought to be sobering figures for any community business considering working in this area. It is certainly food for thought for us at Power to Change in thinking about a viable local neighbourhood, and the size of population that could sustain a health and social care community business that could compete with existing services.

If we translated these numbers directly into the Buurtzorg model of community nursing, for example, which typically works with a cluster of 11 nurses, that would mean a population of 45,000 served by each cluster.

Buurtzorg would be appalled by that figure, since their clusters usually work intensively with only 40 to 60 patients.

As much as half the Buurtzorg patient pool is made up of older people with dementia whose care would not be covered under an NHS, but under a social care budget, so that GP nursing figures are perhaps a bad starting point. Nonetheless, it is probable that a Buurtzorg pilot would need to draw its patients from a large population in order to fit into the current landscape of health and social care commissioning in the UK.

A follow up NICE workforce review in 2016, found that the “model of commissioning community services is activity based and does not consider shortfalls in the required workforce. Providers receive a fixed sum to deliver services irrespective of significant changes in demand for community care.”

There are two lessons here, as we embark on more work thinking about health, social care, and the role of community businesses.

Firstly, the current modelling of workforces and budgets is not likely to be helpful to a community business starting out, looking to meet the needs of its local population. Budgets are not modelled on need but on commercially-viable unit costs.

Secondly, and relatedly, it is clear that innovation is desperately required for those needs to be met at all.