Moving care into the community is a prominent feature of NHS England policy. The NHS Five Year Forward View envisages care traditionally provided in hospital being moved into primary care.
An important question has emerged from these plans: when is there benefit to the patient or the health system to moving hospital services into the community, and when are these services actually better provided in hospitals?
A recent study addressed this question, exploring how outpatient services could be made more efficient. The study included: the update of an earlier scoping review to make it relevant to the UK in 2016; four sub-studies to explore different types of interventions designed to improve effectiveness or efficiency of referrals; the review of a series of innovative approaches in other countries.
The scoping review showed that moving hospital outpatient services into the community could benefit patients. This included GPs with a specialist interest or specialist nurses providing additional services and giving GPs or nurses direct access to a wider range of diagnostic tests. Among the most effective interventions were strategies supporting improved communication between GPs and specialists, such as requests for specialist advice by phone or email, and use of telemedicine.
With some of these models there is a risk of increasing GP workload and demand for specialist care; however, in many cases, levels of patient satisfaction improved. This was mainly due to the increased flexibility of being able to visit a local practice rather than a hospital and the potential of shorter waiting times.
However, for all the approaches there was limited information on cost-effectiveness. It was unclear whether they would increase or reduce demand and whether they would cost more or less than traditional approaches.
Findings from the sub-studies and international comparisons unearthed further challenges. Referral management centres, an initiative that aims to reduce the rising volume of referrals from primary to secondary care, encountered administrative challenges and difficulty getting buy-in from clinicians. International evidence suggested that financial mechanisms and incentives to move care into the community were the most promising interventions, but evidence on their effectiveness was still lacking.
Moving outpatient services into the community can only be justified if higher value is given to patient convenience in relation to NHS costs. As the new models of care described in the NHS Five Year Forward View are rolled out, it is important to look at the costs, as well as the benefits of changes in care delivery.
Key points for future practice:
- Transferring care from hospital to primary care can be safe and effective for a range of diagnostics and treatments.
- Delivering more specialist services in the community is popular with patients.
- Nurses have a role to play in the redeployment of services to primary care, eg in the treatment of diabetes and mental health conditions.
- There is little conclusive evidence on the cost-effectiveness of the provision of more specialist care in the community.
-  NHS England (2014) Five year forward view (PDF).
-  Winpenny E et al (2016a) Outpatient services and primary care: scoping review, substudies and international comparisons.
-  Winpenny et al (2016b) Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary- secondary care interface. Journal of Health Services Research and Policy. May 10. pii: 1355819616648982.
-  Pitchforth E, Roland M (2015) Specialist services in the community: a qualitative study of consultants holding novel types of employment contracts in England. Future Hospital Journal; 2: 3, 173-179.
This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/135/02). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR HS&DR, NIHR, NHS or the Department of Health.
Céline Miani is a senior analyst at RAND Europe; Eleanor Winpenny is a career development fellow at MRC Epidemiology Unit & Centre for Diet and Activity Research (CEDAR) at the University of Cambridge.
This commentary originally appeared on Nursing Times on December 5, 2016. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.