For more than a decade, NHS policy has consistently pushed care away from hospitals and closer to home. The rationale is clear: earlier intervention, better patient experience, reduced pressure on acute services, and improved long-term outcomes. 

Few would disagree with that direction of travel. What is increasingly contested is the assumption that shifting care left, in and of itself, relieves pressure on the system. 

The experience of the past winter suggests otherwise. Where community capacity has not kept pace with demand, pressure has not disappeared, it has simply moved, accumulated, and in some cases intensified. 

 

The promise of shifting care left

The strategic case for shifting care left remains compelling. Community-based care can: 

• reduce avoidable admissions, 

• support faster discharge, 

• manage long-term conditions more effectively, 

• and improve continuity for patients. 

Successive national plans have reinforced this ambition, often positioning community services as the primary solution to acute flow problems. 

In principle, this is sound. In practice, it has relied on an assumption that capacity would follow demand. 

In many parts of the system, it has not. 

 

What winter has now confirmed

Winter acts as a stress test for system design. It exposes where assumptions hold and where they do not. 

The most recent period of sustained pressure has made one thing clear: shifting demand into the community without commensurate capacity does not relieve the acute sector. Instead, it creates congestion across multiple points in the pathway. 

Where community services are unable to absorb additional demand: 

• discharge slows, 

• hospital length of stay increases, 

• emergency departments become gridlocked, 

• and planned care is displaced. 

This is not a failure of the policy intent. It is a failure of sequencing. 

 

Pressure moves faster than capacity

One of the defining features of the current phase is how quickly pressure moves across the system. 

When beds are full, discharge becomes the priority. When discharge stalls, demand lands in community services that may already be stretched. When those services cannot respond, patients cycle back into acute care, often in worse condition. 

This dynamic has been particularly visible in areas such as: 

• intermediate and step-down care, 

• community nursing, 

• rehabilitation services, 

• and mental health crisis support. 

In these settings, capacity constraints are less visible than in acute hospitals, but no less real. Waiting lists lengthen quietly. Acuity rises. Risk accumulates out of sight. 

Shifting care left without strengthening these services does not flatten demand; it redistributes it. 

 

Workforce is the limiting factor

As with much of the NHS, workforce availability is the critical constraint on community capacity. 

Community roles face persistent recruitment and retention challenges. Teams are often small, geographically dispersed, and less able to absorb sustained surges in demand. Sickness absence or turnover has an immediate impact on access. 

At the same time, the complexity of community caseloads is increasing. Patients are discharged earlier from hospital, often with higher acuity and more complex needs. This raises workload intensity without increasing headcount. 

In this context, expecting community services to function as an elastic buffer for acute pressure is unrealistic. 

 

Visibility matters — and community pressure is harder to see

One reason community access pressure is underestimated is visibility. 

Acute pressure is immediate and public: ambulance queues, crowded emergency departments, and delayed handovers. Community pressure accumulates more slowly. Delays are measured in weeks rather than hours. Harm is diffuse rather than dramatic. 

This does not make it less serious. It makes it easier to overlook. 

By the time access problems in the community are fully recognised, they are often deeply embedded and harder to reverse. 

 

The risk of repeating familiar mistakes

The NHS’s experience with elective backlogs offers a cautionary parallel. 

For years, rising waits were tolerated as a manageable consequence of demand growth. By the time the scale of the problem was acknowledged, recovery required extraordinary intervention and sustained effort. 

Community services now sit at a similar inflection point. Demand is rising. Capacity is constrained. Variation is emerging. There is still an opportunity to act early, but only if the warning signs are taken seriously. 

Introducing access standards without aligning capacity risks formalising failure rather than preventing it. 

 

What a capacity-led shift would require

If shifting care left is to deliver its intended benefits, capacity must follow ambition. 

That means: 

• aligning workforce planning with the scale of demand being transferred, 

• investing in estates and digital infrastructure that support community delivery, 

• strengthening intermediate care to support flow, 

• and treating community services as core system infrastructure, not residual capacity. 

Most importantly, it requires recognising that community care is not a cheaper substitute for acute care. It is a different form of care that must be properly resourced. 

 

Shifting care left is a choice — shifting capacity is the test

The direction of travel in NHS policy is unlikely to change. Nor should it. 

But winter has confirmed a hard truth: shifting care left without shifting capacity simply relocates pressure. It does not resolve it. 

The success of this strategy will be determined not by ambition, but by execution. Where capacity follows demand, the system can rebalance. Where it does not, pressure will continue to migrate until it finds the next weakest point. 

 

References

1. NHS England – Integrated Performance Report, December 2025 
2. NHS England – Operational Risk Register and Medium-Term Planning Framework 
3. The King’s Fund – Shifting care closer to home: opportunities and limits 
4. Nuffield Trust – Community capacity, discharge and system flow 
5. Health Service Journal – Community services under rising pressure