Something has been strangely absent from discussions about shifting care ‘from hospital to community’. Something so fundamental that we could not make, or assess, progress without it. Something widely agreed to be essential to policy making, strategic commissioning and the provision of care.

That something?

Numbers.

Multiple reports, proposals, articles and commentaries have been produced on shifting care without a number in sight. The only number featured in some reports on the subject is the ‘number of decades the NHS has failed to make this shift’. Or the related ‘number of policy documents that this ambition has been mentioned in’.

Quantitative data has not played a central role. This is odd. Quantity fundamentally affects quality. It matters whether we are talking about shifting care for 10 people, or 10 thousand people, or 10 million people. Are we shifting half of current hospital-based care into primary and community settings? Or are we after marginal changes? Or something in-between?

Scale therefore determines the nature of the task. Does ‘shifting care’ require root and branch reform? Or are we pruning existing growth?

Knowing this, NHS England’s Primary and Community Services team commissioned analysis from the Strategy Unit. This work is ongoing, but the report below sets out results to date – with some arresting headlines.

Over the next decade, we estimate that:

• Retaining current patterns of care and ‘simply’ accommodating demographic change means that demand for community contacts will increase among adults by 25%. The rate for those aged 65+ is just under 35%. And the rate for the over 85s is around 50%. Growth in demand for community contacts from population change is roughly twice that for acute admissions.
• A ‘steady state’, without significant changes in service patterns, would see hospital activity grow from the current 55 million bed days to around 77 million. Replicating the shifts in care planned by Trusts in the New Hospital Programme (a reasonable proxy for likely ambitions across the NHS) would contain this growth to around 64 million.
• These shifts in care would require a shift in resource from hospital to community of around £3.7 billion a year (compared to current annual investment in community services of £11.9 billion).

The scale of this task reveals its nature. This will require wide-ranging policy efforts of an ambition and effectiveness that defies recent history. This is more like reforesting than pruning.

Readers interested in the methods used should consult the report. But it is worth noting that our estimates combine several sources:

• We began with demographic projections. There is set to be a significant growth in those aged 65 and over - and incredible growth in the 85+ group. (We have a related open-source tool to help local organisations plan for this).
• Older people make significant use of services provided in community settings. So we added in data on current patterns of service use. Projecting these patterns forward showed that growth in demand is likely to concentrate in services such as enablement, intermediate care, rehabilitation and district nursing.
• We then looked at activity currently provided in hospitals, to see what could be ‘shifted’. This drew upon our open-source demand and capacity model for the New Hospital Programme (NHP). Using evidence from published research, and engagement with NHP sites and independent experts, the model describes over 90 types of activity that currently take place in hospital which could – potentially and in part – be mitigated.
• Service areas with the most significant potential to mitigate activities include: frail elderly admissions and readmissions, ambulatory care sensitive conditions and falls related admissions.
• We based costings on detailed work done by Monitor. This showed that community services are comparable in cost to the hospital services they replace – but that there might be savings from down the line capital costs.

This exercise revealed significant uncertainties. Some of the estimates above have wide ranges on them. This is disappointing. After multiple decades of policy ambition to ‘shift care’ the NHS still lacks vital knowledge. One obvious area for improvement is evaluation.

Our work on this topic is ongoing. We are seeking to narrow uncertainties and sharpen the estimates. We are also looking to develop user-friendly tools for local organisations, to support them in formulating their plans. These will be essential to make strategic commissioning a reality.

But we already see value in the early results. We have a clearer sense of what needs to be done to accommodate demographic trends and to shift current patterns of care and achieve a less hospital-centric NHS. Sobering as our results are, this is good news - or at least a precondition for it.

David Hume, the great Enlightenment philosopher and historian, once articulated a test that he may have recommended for approaching policy documents and reports:

“Let us ask: does it contain any abstract reasoning concerning quantity or number? No. Does it contain any experimental reasoning concerning matter of fact and existence? No. Commit it then to the flames: for it can contain nothing but sophistry and illusion.”

The Strategy Unit would be too worried about the health impacts of poor air quality to recommend burning reports that lack quantification; but we agree entirely that numbers are needed. Equipped with this - and therefore stripped of illusion - the NHS is far better placed to shift care.