Bramwell Donna, Goff Mhorag, Allen Pauline, Meacock Rachel, Checkland Kath
Centre for Primary Care and Health Services Research, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
Centre for Primary Care and Health Services Research, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.
BMJ Open. 2025 May 31;15(5):e098159. doi: 10.1136/bmjopen-2024-098159.
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.
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.
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.
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.
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.
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.
增加社区卫生服务（CHS）的使用，是英国政策愿景的核心，即把更多护理服务从医院转移出来，以减轻整个医疗系统的压力，特别是减轻二级医疗（医院服务）的需求压力。社区卫生服务研究不足，对于它们如何能最好地实现这一目标，人们了解甚少。英国国家医疗服务体系（NHS）最近经历了重大重组，更加注重协作式服务提供。在这次重组之后，本研究的目的是探讨社区卫生服务的委托方和提供方如何看待服务需求，以及如何就资源的委托和分配做出决策，以促进院外护理。
对来自英格兰四个案例研究地点的参与者进行定性的半结构化访谈研究。半结构化访谈通过线上方式进行，访谈记录采用反思性主题分析法进行分析。
成人社区卫生服务，其中包括两个将社区卫生服务提供方纳入急性医院信托机构的地点、一个独立的社区卫生服务信托机构以及一个社区卫生服务提供方协作组织。选择这些地点是考虑到地理因素（英格兰北部两个地点，南部两个地点）以及组织模式的多样性。
在所有四个案例研究地点共采访了40名参与者（A地点，n = 10；B地点，n = 17；C地点，n = 10；D地点，n = 3）。要纳入本研究，参与者需在提供或委托成人社区卫生服务方面担任管理角色，和/或在综合医疗系统内的战略层面上对其有所了解。
利用当前关于委托（组织、需求评估、服务设计与开发、合同与资金、绩效管理与支持）的文献主题来构建数据。所有地点的参与者都报告称，英国国家医疗服务体系从临床委托小组向综合医疗委员会的重组，导致委托职能方面出现混乱，当前的角色和职责不明确。所有地点都在进行某种形式的服务审查。然而，参与者强调，当前的人口健康和社区卫生服务数据不足以支持积极主动地规划服务以满足不断增长的需求。社区卫生服务发现很难证明其对避免住院的贡献。当前的整体合同资金模式也限制了社区卫生服务在避免住院方面提供所需灵活服务的程度。我们还发现，在实施额外的避免住院服务（例如“虚拟病房”）方面存在一些矛盾，这些服务不一定与核心社区卫生服务相整合或互补。
我们对社区卫生服务委托的关注凸显了这样一个事实，即综合医疗委员会创建所体现的服务设计和提供的新协作方法，导致决策方面出现了一些混乱。此外，缺乏适当的数据以及用于采购社区卫生服务的资金和合同模式，影响了它们为在社区治疗更多患者这一政策议程做出贡献的能力。如果社区卫生服务要实现预防住院的目标，就应解决这些因素。
